Template For Control Of Hazardous Energy Procedure (Lockout/tagout) Page 12
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16ATTACHMENT B
Equipment Specific LOTO Procedure Cont.
Equipment:
Model #:
Serial #:
Location:
Scope of Work:
Prepared By:
Date:
Signature:
STEP 4: Verify zero energy state
Try to start the equipment using normal operating controls and return controls to “off” position
Try to operate panel
Other:
CHECK FOR:
Employees are located in a safe place
Observe, listen
Inspect movable parts to ensure they are immobile
No re-energization
No electrical energy
All operating circuits are off and cannot be reactivated
Control panel lights are off
If hazard is not in sight range of startup or energy isolation device, use buddy system
Check for a remote energy source
No pressure build-up
Other
STEP 5: Proceed with work on machine or equipment
Ensure that employees are protected from potential hazards if lockout devices must be temporarily removed to test equipment.
After testing equipment, lockout equipment again following the same initial equipment-specific procedure before putting yourself into a potential danger zone.
STEP 6: Release equipment from lockout
Remove locks, tags and blocking devices in their proper order
1
2
3
4
5
Equipment is operationally intact
Affected employees are notified
List the names and titles of the Authorized Employees qualified to service or maintain this machine or equipment.
Name
Title
Date
Name
Title
Date
April 2015
Page 3 of 3
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