LOCKOUT/TAGOUT PROCEDURE
Lockout tagout (LOTO) is a safety procedure that prevents the accidental release of hazardous energy from electrical, mechanical, hydraulic, pneumatic, or other sources during maintenance or servicing of equipment. LOTO can protect workers from injuries such as electrocution, burns, cuts, crushes, or amputations.
Ergon - Manor
12/14/2023
LOCKOUT/TAGOUT PROCEDURE
Lockout tagout (LOTO) is a safety procedure that prevents the accidental release of hazardous energy from electrical, mechanical, hydraulic, pneumatic, or other sources during maintenance or servicing of equipment. LOTO can protect workers from injuries such as electrocution, burns, cuts, crushes, or amputations.
FACILITY NAME:
LOTO PROCEDURE NUMBER:
EQUIPMENT:
DATE AND TIME ISSUED
WORK LOCATION:
DATE OF LAST PERIODIC INSPECTION:
PRIMARY AUTHORIZED EMPLOYEE:
NOTIFICATION OF AFFECTED EMPLOYEES
Notify all affected employees that servicing or maintenance is required and that the equipment must be shut down and locked out to perform servicing or maintenance.
AFFECTED EMPLOYEES
MEANS OF NOTIFICATION
AFFECTED WORK AREAS
SOURCES OF ENERGY
Place a *' by the type of energy sources associated with this equipment. When denoting type of energy, indicate the magnitude of energy in the space provided.
TYPE OF ENERGY
HAZARDS OF ENERGY
MAGNITUDE OF ENERGY
Volts)
Meter name
Unit
Amps)
Meter name
Unit
HP
Meter name
Unit
PSI
Meter name
Unit
PSI
Meter name
Unit
FLASH PT
Meter name
Unit
PPM
Meter name
Unit
PH
Meter name
Unit
DEG F
Meter name
Unit
PSI
Meter name
Unit
TYPE OF LOCKOUT DEVICES USED TO CONTROL THE HAZARDS
1. Describe in detail the sequence of steps used to SHUTDOWN equipment.
II. Describe in detail the sequence of steps used to ISOLATE and LOCKOUT/TAGOUT equipment
III. Steps needed for NEUTRALIZATION of stored or residual energy.
IV. Describe in detail the sequence of steps used to VERIFY ISOLATION.
AUTHORIZED EMPLOYEES
LOTO Authority was Acquired Date/Time:
Principal Authorized Employee Signature:
Click here to sign
Authorized Employees working under this LOTO
LOTO Authority was Released Date/Time:
TRANSFER OF LOTO AUTHORITY
Date/Time
Releasing Authorized Employee
Acquiring Authorized Employee
Personnel working under this LOTO
TEMPORARY REMOVAL
Clear machine or equipment of tools and materials
Notify and remove employees from machine/equipment area
Verify that the controls are in a safe condition
Remove LOTO devices
Energize and proceed with testing or positioning
De-energize and reapply energy control measures identified in Steps 1 - IV of this procedure
Primary Authorized Employee:
Time and Date
Click here to sign
Principal Authorized Employee:
Time and Date
Click here to sign
Primary Authorized Employee:
Time and Date
Click here to sign
Primary Authorized Employee:
Time and Date
Click here to sign
Principal Authorized Employee:
Time and Date
Click here to sign
RELEASE FROM LOCKOUT/TAGOUT
CONTRACTOR.
Inspect work area, remove non-essential items (tools), and replace equipment components (guards)
Notify and safely position all employees
Verify that controls are in a safe condition
Remove Each LOTO Device
Notify affected employees that LOTO devices have been allowed
Restart sequpment established procedures
RELEASE FROM LOCKOUT/TAGOUT
Operations
Inspect work area, remove non-essential items (tools), and replace equipment components (guards)
Notify and safely position all employees
Verify that controls are in a safe condition
Remove Each LOTO Device
Notify affected employees that LOTO devices have been allowed
Restart sequpment established procedures
Signature of each Principal Authorized Employee
Click here to sign
* Signature of Primary Authorized Employee
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Date and Time
Source: Ergon - Manor (Community Member)