MMA - LOTO Procedure

• Site conducted

  Select

• Procedure Title:

• Conducted on

  Date

• Prepared by

• Equipment Name/Model Number:

• Photograph of equipment:

  Media

• 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 (as defined in our company's written lockout program) is responsible for all procedural steps.
  Enforcement: Failure to properly follow lockout/tagout procedures may result in disciplinary action.

NOTIFY AFFECTED PERSONNEL THAT LOCKOUT/TAGOUT IS BEING PERFORMED

LOCATE AND ISOLATE ENERGY SOURCES

Energy Source:

• Type of Energy:

  Select Electrical Hydraulic Pneumatic Steam Water Gravity Mechanical Heat / Thermal Chemical Natural Gas / Propane Wind Other

  • Electrical
  • Hydraulic
  • Pneumatic
  • Steam
  • Water
  • Gravity
  • Mechanical
  • Heat / Thermal
  • Chemical
  • Natural Gas / Propane
  • Wind
  • Other

• Describe hazardous nature of energy source (pressure, etc.):

• Describe where the energy isolation point is located:

• Photo of where the energy isolation point is located:

  Media

• Describe how to disconnect (de-energize) this energy source:

• Identify the device required for lockout/tagout:

  Select Lock & Tag Plug Lock Device 1/4 Turn Valve Cover Circuit Breaker Device Cable Device Other

  • Lock & Tag
  • Plug Lock Device
  • 1/4 Turn Valve Cover
  • Circuit Breaker Device
  • Cable Device
  • Other

• Voltage:

  Select Electrical 600V AC Electrical 480V AC Electrical 277V AC Electrical 240V AC Electrical 220V AC Electrical 208V AC Electrical 110/120V AC Electrical 90V DC Electrical 48V DC Electrical 36V DC Electrical 24V DC Electrical 12V DC

  • Electrical 600V AC
  • Electrical 480V AC
  • Electrical 277V AC
  • Electrical 240V AC
  • Electrical 220V AC
  • Electrical 208V AC
  • Electrical 110/120V AC
  • Electrical 90V DC
  • Electrical 48V DC
  • Electrical 36V DC
  • Electrical 24V DC
  • Electrical 12V DC

• Describe where the energy isolation point is located:

• Photo of where the energy isolation point is located:

  Media

• Describe how to disconnect (de-energize) this energy source:

• Identify the device required for lockout/tagout:

  Select Lock & Tag Plug Lock Device 1/4 Turn Valve Cover Circuit Breaker Device Cable Device Other

  • Lock & Tag
  • Plug Lock Device
  • 1/4 Turn Valve Cover
  • Circuit Breaker Device
  • Cable Device
  • Other

VERIFY THE DE-ENERGIZATION OF ALL ENERGY SOURCES (PUSH START/STOP BUTTONS, ETC.)

PERFORM REQUIRED MAINTENANCE/SERVICE

REMOVE LOCKOUT DEVICES

• Lockout Removal Process:
  1 - Inspect the work area to verify all tools, equipment, and materials have been removed
  2 - Verify that controls are neutral
  3 - Remove devices in reverse order
  4 - Notify employees that work is complete

RESTART EQUIPMENT

• Developed/Reviewed By (Name):

• Periodic inspection conducted by:

• Date of Lockout Creation / Update / Review:

  Date