Lock Out / Tag Out - Circuit Only

• Conducted on

  Date

• Prepared by

• Location
  Address

• Customer / GC has their own Circuit Lock Out Plan

  Yes

  No

  Not Available

• Lock Out Plan has been reviewed with Fliet Electric?

  Yes

  No

STEP 1: Locate Work Area & Identify Breaker

• Provide details of work area and breaker which controls electrical energy to area to be worked on

STEP 2: Identify All Energy Sources

• Confirm that only electrical energy is involved in the task

• Only Electrical

• Are there any forms of potentially hazardous Mechanical energy?

  Yes

  No

• Are there any forms of potentially hazardous Pneumatic energy?

  Yes

  No

• Are there any forms of potentially hazardous Hydraulic energy?

  Yes

  No

• Are there any forms of potentially hazardous Thermal energy?

  Yes

  No

• Are there any forms of potentially hazardous Chemical energy?

  Yes

  No

• Are there any forms of potentially hazardous Steam energy?

  Yes

  No

• Are there any forms of potentially hazardous Momentum energy?

  Yes

  No

• Are there any forms of potentially hazardous Gravity energy?

  Yes

  No

STEP 3 and 4: Identify the Parts to be Locked Out or Isolated and Determine Lockout Methods

• Step 3: List the circuit(s) to be Locked Out

• Step 4: List type of breaker lock used on locked out circuit(s)

• What circuit is locked out?

• What type of breaker lock are you using?

• What circuit is locked out?

• What type of breaker lock are you using?

STEP 5: Notify All Personnel Affected

• List all the people you have informed about the circuit being locked out.

• Provide name and company of individual(s) you have told about the locked out circuit.

• Is the individual(s) working in the immediate area?

  Yes

  No

STEP 6: Breaker Turned Off

• Who turned the breaker off?

STEP 7: Install Lockout Devices, Locks and Tags

• Locks and Tags Applied by whom? List each person by name, provide details on which circuit they have installed their lock & tag in the signature line.

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

STEP 8: Verify Zero-Energy State

• ****Use PPE as required based on potential incident energy (ie: Arc Flash PPE)

• List Arc Flash PPE worn/used:

  Select Arc Flash suit Arc Flash rated face shield complete with hardhat & balaclava Voltage rated gloves with leather protectors Insulated hand tools Rubber mat

  • Arc Flash suit
  • Arc Flash rated face shield complete with hardhat & balaclava
  • Voltage rated gloves with leather protectors
  • Insulated hand tools
  • Rubber mat

• Indicate method of release of potentially hazardous stored or residual energy (ie: Especially check for capacitors or possibility of back fed energy)

• Check performed by:

• Confirm your voltage meter is working properly by testing it on a know live circuit.

• Then test your Locked Out circuit to confirm zero energy.

• Re-test your voltage meter again on a known live circuit.

• If voltage was read on both known live circuits and not on the locked out circuit, you can now be sure that there is zero electrical energy on the locked out circuit.

• Individual who tested to confirm zero electrical energy

  Sign

STEP 9: Perform the Task

• List person(s) responsible for performing the work

STEP 10: Task is Complete - Removal of Locks

• Removal of Locks: Notify all people involved in circuit use or in the vicinity that removal of the Locks is going to take place

• List of individual(s) to be contacted for removal of Locks from Step 7. NOTE: Locks must be removed in the order they were placed, the last lock to be put on must be the first locked removed.

• Pre-Circuit Start Up

• Notify all people involved (listed in Step 5) in the area that re-starting the circuit is going to happen

  Completed

  Not completed

STEP 11: Restore Power

• Start up successful

  Yes

  No

STEP 12: Return Control to Operating Personnel

• Inform Supervisor that power is restored to circuit; provide name of Supervisor

STEP 13: Record Date & Time Lockout Was Removed and System is Restored

• Date & Time

  Date

• Signature

  Sign