Information
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Location / Machine Name or ID
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Conducted on
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Prepared by
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Document No.
Equipment and Procedures
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Equipment needed
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other equipment needed
Machine Information
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Select all the hazardous energy sources for the machine.
- Electrical 120 Volt
- Electrical 240 Volt
- Electrical 480 Volt
- Electrical >600 Volt
- Compressed Air
- Compressed Gas
- Thermal
- Stored Energy (battery, capacitors-electrical)
- Stored Energy (hydraulic pressure)
- Hydraulics
- Mechanical
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Is there for a potential for Arc Flash
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NOTE: only trained and authorized personnel with proper equipment can work on machinery with arc flash potential
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List Arc Flash Equipment (PPE and tools) needed
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Location of ELECTRICAL 120 VOLT Disconnect/circuit breaker
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Add media
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Equipment Needed
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Location of ELECTRICAL 240 VOLT Disconnect/circuit breaker
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Add media
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Equipment Needed
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Location of ELECTRICAL 480 VOLT Disconnect/circuit breaker
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Add media
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Equipment Needed
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Location of ELECTRICAL >600 VOLT Disconnect/circuit breaker
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Add media
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Equipment Needed
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What is the pressure of the air line (psi)
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Location of COMPRESSED AIR Disconnect or shut off valve
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Add media
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Equipment Needed
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Location of COMPRESSED GAS Disconnect or shut off valve
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Add media
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Equipment Needed
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What is the temperature /of the energy source?
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Location of THERMAL Disconnect or shut off valve
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Add media
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Equipment Needed
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Location of STORED ENERGY (battery, capacitors-electrical) Disconnect, shut off valve, and bleed valve if applicable
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Add media
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Equipment Needed
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Location of STORED ENERGY (hydraulic pressure) Disconnect, shut off valve, and bleed valve if applicable
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Add media
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Equipment Needed
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Location of MECHANICAL Disconnect, shut off valve, safety blocks/braces, or machine locking mechanism
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Add media
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Equipment Needed
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Will blocks be required to prevent movement due to gravity?
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Location block is to be placed
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ARE THERE ANY OTHER ENERGY SOURCES THAT ARE NOT LISTED?
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List them here and show how to shut them off.
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Is this entry into a confined space?
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Is this a PERMIT REQUIRED confined space?
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Obtain Permit. DO NOT PROCEED
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Employee been trained on procedure for entry?
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Proceed with Lockout/ tagout Process
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Train employee - DO NOT PROCEED
CONTROL OF HAZARDOUS ENERGY - MACHINE SPECIFIC PROCEDURE
PURPOSE
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This procedure establishes the minimum requirements for the lockout of energy
isolating devices whenever maintenance or servicing is done on machines or
equipment. It shall be used to ensure that the machine or equipment is stopped,
isolated from all potentially hazardous energy sources, and locked out before
employees perform any servicing or maintenance where the unexpected
energization or start-up of the machine or equipment or release of stored energy
could cause injury.
ENFORCEMENT
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All employees are required to comply with the restrictions and limitations imposed
upon them during the use of lockout tagout. The authorized employees are required
to perform the lockout tagout in accordance with this procedure. Failure to follow
lockout/tagout procedures will result in disciplinary action and/or termination of
employment. The disciplinary procedures are maintained in the office.
STEP 1
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NOTIFY ALL AFFECTED EMPLOYEES
Ensure ALL EMPLOYEES are safely positioned away from Machine or Equipment.
NOTIFY -All affected employees of the “Machine” shut down intentions.
Ensure area is clear of additional hazards
STEP 2
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To shut off or shut down/ turn off the machine the machine the AUTHORIZED EMPLOYEE must:
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Add media
STEP 3
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Methods of isolation
Energy Source
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APPLY LOCKS AND TAGS TO ENERGY ISOLATION DEVICES ALL PERSONNEL WHOM WILL BE PERFORMING WORK ON THE MACHINE, DEVICE, OR SYSTEM, ARE REQUIRED TO PLACE THEIR OWN LOCKS AND TAGS ON THE ENERGY ISOLATION DEVICES.
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STEP 4
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RELEASE STORED ENERGY To RELEASE STORED ENERGY the AUTHORIZED EMPLOYEE must: Use
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Methods to release stored energy
Stored enegergy type
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STEP 5
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VERIFY THAT THE ENERGY HAS BEEN DEPLETED, RELEASED, OR BLED OFF TO VERIFY ENERGY HAS BEEN DEPLETED, RELEASED, OR BLED OFF THE AUTHORIZED EMPLOYEE MUST
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Add media
STEP 6
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PERFORM SERVICING, REPAIRS, OR MAINTENANCE ON THE MACHINE
Testing or positioning of machines, equipment or components thereof. In situations
in which lockout or tagout devices must be temporarily removed from the energy
isolating device and the machine or equipment energized to test or position the
machine, equipment or component thereof, the following sequence of actions shall
be followed:
1. Clear the machine or equipment of tools and materials;
2. Remove employees from the machine or equipment area;
3. Remove the lockout or tagout devices;
4. Energize and proceed with testing or positioning; Do not place body parts in
danger areas
5. De-energize all systems and reapply energy control measures to continue the
servicing and/or maintenance as detailed in this procedure.
Complete the assigned repairs, maintenance, or cleaning. If you need to restart the
machine for troubleshooting remember to follow the LOTO instructions precisely.
Do not release from LOTO until repairs or maintenance work has been completed.
CONTROL
STEP 7
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TO RELEASE FROM LOCK OUT TAG OUT THE AUTHORIZED EMPLOYEE MUST:
1. Remove all tools/equipment used for the repair process.
2. Re-assemble the machine.
3. Re-Install all safe guards, machine guards, and safety devices that were removed or disconnected due to the maintenance or repair activities.
4. Ensure ALL EMPLOYEES are safely positioned (away from Machine) NOTIFY -ALL affected employees of the Machine re - start intentions.
5. Remove the Lockout/Tagout device that was attached to the ENERGY ISOLATION DEVICES. NOTE—only the person who applied the Lockout/Tagout Device may remove it. Ensure area is clear prior to restart.
STEP 8
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RESTARTING THE MACHINE
It is critical that the operator of this machine follow the detailed and explicit instructions provided by the manufacturer or the company for restart and operation of this machine. The following are basic restart procedures: -
Restart Instructions:
STEP 9
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MONITOR THE MACHINEOR EQUIPMENT’S” OPERATION TO VERIFY IT IS OPERATING SAFELY
DISCLAIMER It is the AUTHORIZED PERSONS responsibility to VERIFY to ensure that all energy sources have been isolated and all energy has been released PRIOR to performing any maintenance, repair, or work activities on the equipment.
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Complete
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Name of preparer validating the procedure is correct and complete
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Name of manager validation
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Select date
