Representing what protects Us: From action to meaning in lockout-tagout procedures

Abstract

Lockout-Tagout (LOTO) procedures are a cornerstone of hazardous energy control in high-risk industrial settings. While regulatory frameworks prescribe clear sequences of actions, these procedures are often implemented through linear checklists that provide limited support for understanding underlying risks or managing systemic vulnerabilities. This article introduces a multi-level bow-tie representation of LOTO, developed through a research-action initiative in a SEVESO classified pharmaceutical facility. The model articulates four interdependent layers of protection: the primary level (direct energy isolation), the secondary level (protection of primary barriers), the tertiary level (organizational structures that sustain continuity and reliability), and a metacognitive level (the cognitive infrastructure that supports reflection, anticipation, and shared understanding). Each level corresponds to distinct causal and temporal dynamics that are often obscured in conventional procedural formats. Drawing on literature from cognitive science, safety culture, and organizational learning, we argue that such layered representations enhance procedural intelligibility, reveal critical points of vulnerability, and foster both adaptive training and cross-functional dialogue. While requiring a degree of cultural maturity, the model was positively received by operational teams and integrated into local training practices. Beyond LOTO, this framework offers a transferable approach to the representation of safety-critical procedures, such as confined space entry or hot work operations. Improving safety performance may ultimately depend not only on better procedures, but on better representations, those that make protection architectures visible, intelligible, and meaningful across time, teams, and contexts.