In the event that a lock is left on an energy isolating device and the person to whom the lock belongs has not left the site, the person must be located to remove the lock. If it has been verified that the owner of the lock has left the site, this form must be completed and signed by the supervisor removing the lock. This form serves as evidence that the lock has been removed lawfully and is therefore NOT an act of gross misconduct
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Title Page
Conducted on
Prepared by
Cell No.
Machine Asset Number (CLxxxx)
Lock Removal Record:
What is the reason as to why the lock(s) must be removed?
Has an attempt been made to contact the lock owner by phone?
Has it been verified that the equipment is safe to operate?
Has the Plant Manager / Maintenance Manager approved the removal of the lock(s)?
Has the EHS Manager approved the removal of the lock(s)?
Investigation
What was the reason the lock owner failed to remove the lock(s)
Signatures
Supervisor Name:
Factory Manager / Maintenance Manager Name:
EHS Manager Name:
David Lucioni
Lock-out Tag-out Lock Removal Authorisation Form
In the event that a lock is left on an energy isolating device and the person to whom the lock belongs has not left the site, the person must be located to remove the lock. If it has been verified that the owner of the lock has left the site, this form must be completed and signed by the supervisor removing the lock. This form serves as evidence that the lock has been removed lawfully and is therefore NOT an act of gross misconduct
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