Template For Control Of Hazardous Energy Procedure (Lockout/tagout) Page 10
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16ATTACHMENT B
Equipment Specific LOTO Procedure
Equipment:
Model #:
Serial #:
Location:
Scope of Work:
Prepared By:
Date:
Signature:
STEP 1: Identify energy sources: (check all that apply)
Identify all energy sources
Identify types of stored or residual energy
Electrical:
Pneumatic
Hydraulic
Stored electrical (capacitors)
Hydraulic/Pneumatic
110V
Mechanical
Other: - Specify:
Pressured Line
Suspended equipment
220/440V
Chemical
Spring
Other:
Other: (list)
Thermal
Yes – Explain:
Is there a possibility of energy re-accumulation?
No
STEP 2: Shut down equipment following normal procedures
(Consult equipment manual, manual location:
; or contact supervisor if shutdown instructions are needed)
STEP 3: Complete the following for each energy source (If more space is needed to document other energy sources, please list on back):
A.
Isolate energy source (list location):
Method:
Shut off manual electric circuit breakers
Disconnect switches
Remove fuses
Block hydraulic/pneumatic
Bleed pressurized line
Valves:
Close
Open
Ground electrical
Remove batteries
Release spring tension
Reposition suspended equipment
Other – Specify:
Apply lockout devices:
Lockout lock with identifier
Gate valve cover
Fuse lockout
Chain and lock
Lockout hasp
Block
Blank flange
Ball valve lockout
Pneumatic port valve lockout
Wall switch lockout
Cable and lock
Circuit breaker cover-up
Wedge
Slip blind
Butterfly valve lockout
Inline lockout valve
Plug lockout
Power cord lock
Lower item down to lowest state
Pins
None required
Tag and tie – describe reason lock cannot be used:
Other:
Verify Zero energy state by:
B.
Isolate energy source (list location):
Method:
Shut off manual electric circuit breakers
Disconnect switches
Remove fuses
Block hydraulic/pneumatic
Bleed pressurized line
Valves:
Close
Open
Ground electrical
Remove batteries
Release spring tension
Reposition suspended equipment
Other – Specify:
Apply lockout devices:
Lockout lock with identifier
Gate valve cover
Fuse lockout
Chain and lock
Lockout hasp
Block
Blank flange
Ball valve lockout
Pneumatic port valve lockout
Wall switch lockout
Cable and lock
Circuit breaker cover-up
Wedge
Slip blind
Butterfly valve lockout
Inline lockout valve
Plug lockout
Power cord lock
Lower item down to lowest state
Pins
None required
Tag and tie – describe reason lock cannot be used:
Other:
Verify Zero energy state by:
April 2015
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Parent category: Life