There’s a massive failure in maintenance and Operations’ culture here. This isn’t the exact sort of situation where you’d use LOTO, but you need something similar. Lock the engine in the off position until the removed part is properly reinstalled.

I want to call maintenance errors like this rookie… But they really aren’t. There’s plenty of plant incidents where people either don’t have a proper procedure or don’t follow it, and a welder tries to work on a live gas line. Or someone opens a valve without realizing it needs to be closed.

I still say we fine the companies and hold the CEOs personally responsible, because the buck stops there, and these mistakes are more likely to happen in an organization that doesn’t have a robust safety culture.