MMA - LOTO Procedure Builder

Use this checklist before servicing industrial equipment. Record the nature of work, hazardous energy sources and the employees involved in the procedure. Do a site walkthrough to ensure that the area is cleared from unnecessary tools and check if employees are trained and notified about the procedure. Next check the quality and efficiency of LOTO devices being used. Evaluate if the step-by-step procedure was followed when applying and removing LOTO devices. Lastly, rate the overall LOTO process and provide recommendations.

Title Page

Equipment Name
Photo of equipment:
Scope: Utilize this procedure for any maintenance or servicing of aforementioned equipment:
Purpose: To protect authorized employees against unexpected activation of equipment or energy while servicing equipment.
Authorization: The plan administrator is responsible for all procedural steps.
Enforcement: Failure to properly follow lockout/tagout procedures may result in disciplinary action.

Procedure

1. Notify all affected personnel before starting to apply this LOTO procedure
2. Shut down machinery using normal procedures and operating controls
3. Isolate energy source at energy control points and apply LOTO devices
Hazardous energy source?
- Electrical
- Mechanical
- Hydraulic
- Pneumatic
- Chemical
- Thermal
- Gravity
- Other
Photo of where energy isolation point is located
Magnitude of energy source: (Include psi, voltage rating, or other pertinent information)
Describe how to disconnect (de-energize) this energy source
Type of LOTO Device (Reminder: One lock on each energy source per person)
Photo of where the energy isolation point is
Describe how to disconnect (de-energize) this energy source
Type of LOTO Device
Photo of where the energy isolation point is
Describe how to disconnect (de-energize) this energy source
Type of LOTO Device
Photo of where the energy isolation point is
Describe how to disconnect (de-energize) this energy source
Type of LOTO Device
Photo of where the energy isolation point is
Describe how to disconnect (de-energize) this energy source
Type of LOTO Device
Photo of where the energy isolation point is
Describe how to disconnect (de-energize) this energy source
Type of LOTO Device
Describe source of energy
Photo of where the energy isolation point is
Describe how to disconnect (de-energize) this energy source
Type of LOTO Device
4.Locks applied to isolation points must be personally identified and in the "secured" position
5. Authorized personnel must maintain possession of the key(s) for each personal lock applied
6. Do not work under the protection of a lock you have not personally applied

Testing and Verification Requirements

1. Test for full de-energization by turning normal operational controls to the on (or neutral) position and verify that no machine function or movement occurs.
2. if possible contact with exposed electrical conductors could occur, a qualified person must perform electrical voltage testing to verify zero energy condition.
*return all controls to the off position and complete necessary adjustments or repair work.
During testing and adjustment, Lockout must be re-applied when contact with hazardous area(s) is required.