Lockout Tagout Steps Get Skipped: How Flagman Helps Confirm Machine Danger Zones Are Clear in NSW Manufacturing
Lockout tagout steps get skipped when jams and cleaning meet time pressure. What NSW prosecutions show, what the code expects, and how Flagman checks machine danger zones.
In brief
- The problem: NSW manufacturers keep being prosecuted after workers are caught in rollers and conveyors during feeding, cleaning and clearing jams, when machines should have been stopped and isolated.
- The requirement: plant should usually be isolated before maintenance or cleaning, and lockout tagout is the most effective isolation procedure, followed by a test that energy is gone.
- The gap: isolation depends on every person following every step, every time, and nobody sees when a step is skipped until someone is hurt.
- The outcome: Flagman restricted zone detection shows when people enter machine danger zones while plant is running and can alert before a restart with someone inside, adding evidence to your isolation system without replacing it.
A converting line stops with a jam ten minutes before the end of a shift. The isolation procedure is laminated next to the machine: stop, isolate, lock, tag, test. It takes six minutes. Reaching in to pull out a torn sheet takes six seconds, and the operator has done it before without a problem.
That gap between the procedure on the wall and what happens on the floor is where most machine injuries in NSW factories begin. From western Sydney to the Hunter and the Illawarra, the pattern in recent prosecutions is the same: the hazard was known, the controls were known, and the machine was still running when a hand went in.
The problem: isolation skipped, hands caught
Two recent SafeWork NSW prosecutions show the pattern. In October 2025, a tissue manufacturer was fined $150,000 after a worker feeding paper into a toilet roll machine had their left hand caught and crushed between rollers. SafeWork NSW described injury from unguarded machinery as “a known hazard and a preventable risk”. In February 2026, a boilermaking and welding business was fined $120,000 after a worker helping load and unload a blasting machine was caught between conveyor rollers and seriously injured.
These are not isolated cases. When SafeWork NSW launched a machine safety inspection campaign across Sydney, it reported responding to more than 540 machine safety incidents since 2019. It named clearing jams while machines are running, and cleaning or maintaining machines without safeguards or lockout tagout, as the most common factors in deaths and serious injuries. SafeWork NSW research also records 61 NSW worker fatalities between 2003 and 2023 caused by being trapped by moving machinery or equipment.
The requirement: what NSW law and the code of practice expect
Under the Work Health and Safety Act 2011 (NSW) and the Work Health and Safety Regulation 2017, a business must eliminate risks so far as is reasonably practicable and otherwise minimise them. The SafeWork NSW Code of Practice on managing the risks of plant in the workplace sets out what that means for machines:
- Isolate first. Plant should usually be isolated before maintenance, cleaning or clearing a blockage starts.
- Lockout is the most effective isolation procedure. Each person working on the plant fits their own lock, the plant is tagged, and stored energy is released or controlled.
- Test before work. A start attempt or test confirms the plant cannot move before anyone reaches in.
- Guarding stays in place. Guards follow an order of preference, from fixed guards to interlocked guards to presence sensing systems, and bypassing them should be made as difficult as reasonably practicable.
A tag on its own is not an isolation device. A procedure that exists only on paper is not a safe system of work.
Why existing controls leave a gap
- Isolation relies on behaviour. Locks, tags and tests work only when people use them. Time pressure, small jams and familiarity are the usual reasons they are skipped.
- Restart is a moment of risk. When a machine is restarted after a stoppage, the operator may not see a second worker still inside the danger zone.
- There is no record of the near miss. A hand that goes into running rollers and comes out safely is never reported, so the isolation system is never tested against reality.
- Supervisors cannot watch every machine. Night shifts and weekend runs often have the thinnest supervision.
The solution: how Flagman supports lockout tagout
Flagman is an AI vision platform that detects people, hands and personal protective equipment in camera footage, and processes video on site on the Flagman Neo edge device. For machine isolation, it adds a detection and evidence layer:
- Danger zone detection while running. Virtual zones are drawn around feed points, rollers, nip points and machine cells. When a person or hand enters a zone while the machine is running, Flagman raises a local alert and logs the event.
- Zone clear check before restart. Flagman can show whether a person is still detected inside a machine zone. Through relay outputs or programmable logic controller integration over Modbus and PROFINET, it can send a signal that holds or slows a start, where the machine’s control system is designed to accept it.
- Evidence for the isolation system. Time-stamped video of every zone entry lets supervisors compare entries against permits and isolation records, and find the machines, tasks and shifts where steps are being skipped.
- Works with existing cameras. Flagman supports ONVIF IP, USB and GMSL cameras, and the Flagman Neo device is IP69K rated and fanless for washdown and dusty areas.
Limitations: what Flagman does not replace
- Flagman is not an isolation or lockout device. It does not remove energy and cannot replace locks, tags, tests or permits.
- Flagman is not a guard and not a certified presence sensing safeguarding device. It must not be used in place of fixed or interlocked guarding.
- Flagman has no published Safety Integrity Level or Performance Level rating. Any start inhibit signal is not a certified safety function, and machine stopping time must still be considered by a competent person.
- Detection depends on camera position, lighting, steam, dust and line of sight. Each zone must be tested on site before it is relied on.
- In NSW, the Workplace Surveillance Act 2005 requires written notice before camera surveillance starts. Consult workers and health and safety representatives first.
A practical isolation improvement plan
- List every machine where people feed, clean, clear jams or adjust settings, and record the task and energy sources for each.
- Write machine-specific isolation steps, including jam clearing, and put the locks and tools at the machine.
- Fix guarding and interlocks first, and remove any bypasses.
- Pilot Flagman danger zone detection on two or three machines with the most stoppages or near misses.
- Review zone entries weekly against isolation records and talk through each one with the crew.
- Track whether entries without isolation fall as procedures, tooling and jam causes are fixed.
For the guarding side of this picture, read how Flagman AI vision supports the machine guarding hierarchy. For saws, rollers and presses, see hand and finger injury prevention in Australian manufacturing.
Fewer jams, fewer isolations: the case for predictive maintenance
Most isolation shortcuts start with a jam or a minor fault. A machine that jams several times a shift creates several chances a shift for someone to reach in. Worn rollers, misaligned feeds, failing sensors and loose guards all show up in maintenance and downtime data long before they cause an injury.
Predictive maintenance uses that data to fix the cause rather than clearing the symptom. Sharktech Global builds Business Intelligence dashboards for manufacturers that track downtime reasons, scrap and rework, and safety events by machine, including Flagman zone entries. A machine with rising jams and rising zone entries is the machine to fix first, and fixing it removes the reason to skip isolation.
Flagman in Australia: local delivery by Sharktech Global
Sharktech Global, based in Liverpool, New South Wales, is the exclusive Australian and New Zealand delivery partner for Perleybrook Labs, the developer of Flagman. Sharktech assesses production lines, installs and integrates Flagman with cameras and machine controls, and provides local business-hours support. It also backs up production software, recipes and machine configurations as part of managed IT for manufacturers. Details of its manufacturing machine safety, managed IT and data services are on the Sharktech website.
The outcome you can measure
- Alerts when a person enters a machine danger zone while it runs.
- A record of zone entries compared with isolation and permit records, by machine, task and shift.
- A falling trend in entries without isolation as procedures and tooling improve.
- Jam frequency and safety events side by side, so root causes are fixed first.
- Evidence for boards and regulators that isolation is working in practice, not only on paper.
Key takeaways
- Recent NSW prosecutions show workers still being caught in running rollers and conveyors.
- Isolation, lockout and testing come first, and guarding stays in place.
- Flagman adds detection and evidence at the moments isolation is most often skipped.
- Fixing jam-prone machines through predictive maintenance removes the temptation to reach in.
Next step
Request a Flagman safety assessment to review your machine danger zones and isolation points, or call Sharktech Global on 0468 017 373.
Sources: SafeWork NSW, Company fined $150,000 after worker injured in tissue manufacturing machine (October 2025); SafeWork NSW, Company fined $120,000 after worker injured on conveyor rollers (February 2026); NSW Government, SafeWork inspectors to target Sydney manufacturers and machine safety (August 2023); SafeWork NSW, Technologies for mobile plant (May 2026); SafeWork NSW, Code of Practice: Managing the risks of plant in the workplace (2022). This article is general information only and is not legal advice. Seek advice specific to your site.