Sound On
This experience is narrated. Most of the story is told through audio.
Content note: this is a true account of a workplace fatality, drawn from a federal investigation. It is handled with care, but please give it your attention.
It's Never Just One Thing
- A serious tragedy is a chain of events — not one mistake.
- Each link in the chain is created over time, by different people.
- The chain only completes if no one breaks it.
A True Account · Federal Investigation
Break
the Chain
Read the options · make your call
February 8, 2021 · 1:15 p.m.
His open coat caught in the tail pulley of the bypass conveyor.
Every link in this tragic chain of events had to fall into place for this to happen.
Breaking the Chain
It Took All Six
Break any one link — and the tragic chain of events never completes.
▲ Tap any link to break it
Root Cause · MSHA Findings
What the Investigation Found
Training was never completed, and he worked unobserved.
The equipment was not properly guarded.
Power was never locked out and tested — and no locks were provided.
Why LOTOTO has three parts
Lock it. Tag it. Try it. A switch in the off position is a promise. Pressing start and watching nothing move is proof.
Prevention is invisible. On the timeline where any one link breaks, nothing happens — and no one ever knows a life was saved.
View the MSHA Fatality Alert (PDF)Read the full MSHA report →
The miner's name is withheld here out of respect. Events and findings are taken from the federal investigation.