Patterson Lockout-Tagout Shut-Down Procedure Copy

• Client / Site

• Conducted on

  Date

• Prepared by

• Equipment Name/Model Number:

• 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 Patterson 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

Isolation Devices & Details

Step 1 / Appendix 1

• Type of Energy

  Select Electrical Pneumatic (Air) Hydraulic Chemical (gas/liquid) Potential/Kinetic Thermal

  • Electrical
  • Pneumatic (Air)
  • Hydraulic
  • Chemical (gas/liquid)
  • Potential/Kinetic
  • Thermal

• Describe where the energy isolation point is located

• 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

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

Step 2 / Appendix 2

• Type of Energy

  Select Electrical Pneumatic (Air) Hydraulic Chemical (gas/liquid) Potential/Kinetic Thermal

  • Electrical
  • Pneumatic (Air)
  • Hydraulic
  • Chemical (gas/liquid)
  • Potential/Kinetic
  • Thermal

• Describe where the energy isolation point is located

• 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

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

Step 3 / Appendix 3

• Type of Energy

  Select Electrical Pneumatic (Air) Hydraulic Chemical (gas/liquid) Potential/Kinetic Thermal

  • Electrical
  • Pneumatic (Air)
  • Hydraulic
  • Chemical (gas/liquid)
  • Potential/Kinetic
  • Thermal

• Describe where the energy isolation point is located

• 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

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

• Photos of the Steps / Appendix above in order

  Media

Verify the De-energization of all energy sources

• 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

• Periodic Inspection Date (Date of the Annual Review):

  Sign

• Date of Lockout Creation / Update:

  Date