Lock Out / Tag Out - Equipment/Machine

• Conducted on

  Date

• Prepared by

• Location
  Address

• Customer / GC has their own Lock Out Plan

  Yes

  No

• Lock Out Plan has been reviewed with Fliet Electric?

  Yes

  No

• Customer contact(s):

STEP 1: Locate Work Area & Identify Equipment/Machinery

• Please be sure to speak with machine operator, the worker, about the issues during these next 5 steps

• Identify and provide details of equipment, machinery or other system components to be worked on

STEP 2: Identify All Energy Sources

• Select applicable energy sources

  Select Electrical Mechanical Potential Pneumatic Hydraulic Thermal Chemical Steam Momentum Gravity Other

  • Electrical
  • Mechanical
  • Potential
  • Pneumatic
  • Hydraulic
  • Thermal
  • Chemical
  • Steam
  • Momentum
  • Gravity
  • Other

• Provide details on Other type of energy source

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

• Step 3: List the equipment/parts to be Locked Out

• Step 4: Determine Lock Out Method (ie: disconnect switches, line valves, blocks, blanks)

• What equipment/part(s) is locked out?

• What type of lock out method are you using?

• List the location of energy-isolating devices

• What equipment/part(s) is locked out?

• What type of lock out method are you using?

• List the location of energy-isolating devices

• All Lock Out points established?

  Yes

  No

STEP 5: Notify All Personnel Affected

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

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

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

  Yes

  No

• Does the individual notified normally use the locked out equipment?

  Yes

  No

STEP 6: Shut Down Equipment & Machinery

• Who shut down the Equipment/Machinery?

STEP 7: Install Lockout Devices, Locks and Tags

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

• Add signature

  Sign

• 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: blocked, bled, etc.)

• Check performed by:

• TEST

• List start buttons tested (attempt to start, then return controls to "Off" or "Neutral" position) and by whom?

• 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 equipment 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-Equipment Start Up

• Notify all people involved (listed in Step 5) in the area that re-starting the equipment 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