Template For Control Of Hazardous Energy Procedure (Lockout/tagout) Page 11
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16ATTACHMENT B
Equipment Specific LOTO Procedure Cont.
Equipment:
Model #:
Serial #:
Location:
Scope of Work:
Prepared By:
Date:
Signature:
C.
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:
D.
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:
E.
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
Page 2 of 3
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