Information
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Procedure Title:
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Conducted on
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Prepared by
- Alanna Soukkala
- David Rumsey
- John Bestman
- Lindsey Hanson
- Mike Music
- Scott Rief
- Sean Antolik
- Shane Collins
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Equipment Name/Model Number:
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Photograph of equipment:
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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
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Energy Source:
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Type of Energy:
- Electrical
- Hydraulic
- Pneumatic
- Steam
- Water
- Gravity
- Mechanical
- Heat / Thermal
- Chemical
- Natural Gas / Propane
- Wind
- Other
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Describe hazardous nature of energy source (pressure, etc.):
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Describe where the energy isolation point is located:
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Photo of where the energy isolation point is located:
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Describe how to disconnect (de-energize) this energy source:
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Identify the device required for lockout/tagout:
- Lock & Tag
- Plug Lock Device
- 1/4 Turn Valve Cover
- Circuit Breaker Device
- Cable Device
- Other
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Voltage:
- 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
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Describe where the energy isolation point is located:
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Photo of where the energy isolation point is located:
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Describe how to disconnect (de-energize) this energy source:
- Turn switch to off position and apply lockout device
- Throw lever to off position and apply lockout device
- Other
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Identify the device required for lockout/tagout:
- Lock & Tag
- Plug Lock Device
- 1/4 Turn Valve Cover
- Circuit Breaker Device
- Cable Device
- Other
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Describe hazardous nature of energy source (pressure, etc.):
-
Photo of where the energy isolation point is located:
-
Describe how to disconnect (de-energize) this energy source:
- Turn valve to off position and apply lockout device
- Other
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Identify the device required for lockout/tagout:
- 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
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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
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Developed/Reviewed By (Name):
- Alanna Soukkala
- David Rumsey
- John Bestman
- Lindsey Hanson
- Mike Music
- Scott Rief
- Sean Antolik
- Shane Collins
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Periodic inspection conducted by:
- Alanna Soukkala
- David Rumsey
- John Bestman
- Lindsey Hanson
- Mike Music
- Scott Rief
- Sean Antolik
- Shane Collins
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Date of Lockout Creation / Update / Review:
