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Lockout Permit Form - 1

This document outlines safety procedures for lock out/tag out (LOTO) plus permitting. It includes sections for: (1) isolating equipment energy by de-energizing, draining, locking out equipment, and installing necessary tags; (2) maintenance logging; (3) completion inspection; (4) return to service procedures; and (5) temporary removal of energy isolation. Sign-offs are required from equipment owners and maintenance at various stages to ensure safety.

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qamar sayed
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69 views2 pages

Lockout Permit Form - 1

This document outlines safety procedures for lock out/tag out (LOTO) plus permitting. It includes sections for: (1) isolating equipment energy by de-energizing, draining, locking out equipment, and installing necessary tags; (2) maintenance logging; (3) completion inspection; (4) return to service procedures; and (5) temporary removal of energy isolation. Sign-offs are required from equipment owners and maintenance at various stages to ensure safety.

Uploaded by

qamar sayed
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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LOCK OUT AND TAG OUT PLUS PERMIT PAGE ___ OF ___

SECTION I: ENERGY ISOLATION


Equipment: Lockbox#: Date: Time:
Description of work:
Equipment has been depressurized, drained, and cooled: Yes: N/A:
Equipment has been de-energized Yes: N/A:
Equipment has been locked or tagged (Tagout Plus) per equipment procedure: Yes: N/A:
Do blanks need to be installed prior to work activities? #Installed: Yes: N/A:
Necessary tags, warning devices (i.e., Barricade tape) and signs have been placed? Yes: N/A:
Have maintenance / service workers been briefed on process hazards? Yes: N/A:
Did line / equipment contain ANY of the following chemicals: Hydrogen, methanol, ethanol, ozone, Yes: N/A:
oxygen, propane, butanol, ammonia or natural gas?

SAFETY EQUIPMENT REQUIRED


Chemical goggles: Face shield: Rubber gloves: Rubber suit:
Safety harness: Fire extinguisher: Other:

ADDITIONAL PERMITS REQUIRED


Hot work: Confined space: Excavation: Other:

EQUIPMENT ISOLATION ID TAGS


Isolation device Tag number Isolation device Tag number Isolation device Tag number Isolation device Tag number

Electrical tags Tag number


MCC
Field
READY FOR MAINTENANCE (Equipment Owner): Maintenance / Service employee:

MAINTENANCE CRAFT SEALS*


Craft Seal number Craft Seal number Craft Seal number Craft Seal number

*Remove craft or contractor Maintenance Craft Seal when specified work for craft type is completed.

Sign on signature WO# Date Time Sign off signature Time Complete
Y N
Y N
Y N
Y N
Y N
Y N
Section II: Maintenance / Service Log (Continued)
Sign on signature WO# Date Time Sign off signature Time Complete
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N

Section III: Completion of Maintenance (Inspection by Equipment Owner and Maintenance)


Equipment and piping reconnected: Yes: N/A:
Insulation replaced: Yes: N/A:
Machine guarding replaced: Yes: N/A:
Tracing reconnected and tightly wrapped: Yes: N/A:
Electrical wiring reconnected and electrical energy isolation tags removed. Electrician:
Housekeeping acceptable: Yes: N/A:
MAINTENANCE COMPLETE (Equipment owner): Maintenance / Service employee:

Section IV: Return to Service


Lockouts / Tagout plus devices removed: Yes: N/A:
Equipment has been re-energized: Yes: N/A:
Blanks removed: Yes: N/A:
Tags, warning devices and signs removed: Yes: N/A:
Post testing of equipment required (i.e., System Leak Test): Yes: N/A:
RETURN TO SERVICE (Equipment owner signature required):

Section V: Temporary Removal of Energy Isolation Devices


Reason for temporary removal:
List of energy isolation devices removed:
Approved by (Insert equipment owner’s name): Maintenance / Service:
List of energy isolation devices re-installed:
Approved by (Insert equipment owner’s name): Maintenance / Service:

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