Written Lockout/Tagout Procedure

(Department/Division)
Last Updated:

Type of Equipment:

Location:

ID# (if applicable):

Work to be performed

Employee(s) authorized
perform this work:

Purpose: This procedure establishes the minimum requirements for the

lockout/tagout of energy-isolating devices whenever maintenance or
servicing is done on the machine or equipment listed above. It shall be
used to ensure that the machine/equipment is stopped, isolated from all
potentially hazardous energy sources and locked out before employees
perform any servicing or maintenance where the unexpected energization
or start-up of the machine or equipment or release of stored energy could
cause injury.

Compliance: All employees are required to comply with the restrictions and
limitations imposed upon them during the use of lockout. Authorized
employees are required to perform the lockout in accordance with this
procedure. All personnel, upon observing a machine or piece of
equipment that is locked out to perform servicing or maintenance, shall
not attempt to start, energize or use that machine or equipment.

Notice : Failure to comply with all parts of lockout/tagout procedures may

result in immediate dismissal.

Checklists: A checklist is / is not required to be completed each time this procedure is

performed.
(circle one)

If required, appropriate checklists may be found

Location

Written description of required lockout/tagout procedures for the

machine/equipment listed above

LOCKOUT SEQUENCE

Step 1. Notify all affected employees that servicing or maintenance is

required on a machine or equipment and that the machine or equipment
must be shut down and locked out to perform the servicing or
maintenance.

Affected Employees:

Page 1 of 5
Methods to use for notification:

Step 2. The type and magnitude of the energy that the machine or
equipment listed above involves, the hazards involved and the method of
control that must be used to eliminate hazards are listed below.

Type of Energy Hazard

Method of
Control

Step 3. If the machine or equipment is operating, shut it down by the

normal stopping procedure.

Methods for shutting down the machine/equipment listed above:

(List type & location of switch(es), valve(s), etc. and, if applicable, sequence that
must be followed)

Step 4. Engage the energy isolating device(s) so that the machine or

equipment is isolated from the energy source(s).

Isolation Device
Location

Isolation
Method

Page 2 of 5
Step 5. Lock out the energy isolating device(s) with assigned individual
lock(s).

Step 6. Stored or residual energy (such as that in capacitors, springs,

elevated machine members, rotating flywheels, hydraulic systems, and
air, gas, steam, or water pressure, etc.) must be dissipated or restrained
by methods such as grounding, repositioning, blocking, bleeding down,
etc.

Type Present? Method of Restraint

Pressure ............... .........

Hydraulic ...............
.....
....

Pressurized..............
.....
....

Vacuum ...............
.....
....

Thermal ...............
.....
....

Springs ...............

Page 3 of 5
 .....
....

Gravity ...............
.....
....

Electrical ...............
.....
....

Capacitors...............
.....
....

Battery ...............
.....
....

Other ............
...

.....
....

Step 7. Ensure that the equipment is disconnected from the energy

source(s) by first checking that no personnel are exposed, then verify the
isolation of the equipment by operating the push button or other normal
operating control(s). Test as described below to make certain the
equipment will not operate.

CAUTION: Return operating controls(s) to neutral or OFF position

after verifying the isolation of the equipment.

Procedures/test equipment used to verify isolation:

Page 4 of 5
Step 8. Lockout is complete. Perform service/maintenance as required.

Restoring Equipment to Service

When servicing/maintenance is completed, and the machine or equipment

is ready to return to normal operating condition, the following steps must
be taken:
(Note: Add additional details/steps as needed to ensure safe start-up)

1) Check the machine or equipment and the immediate area

around the machine or equipment to ensure that nonessential
items have been removed and that all necessary components
are correctly re-assembled and intact.

2) Check the work area to ensure that all affected employees

have been notified of intention to start-up and are safety
positioned or removed from the area.

3) Verify that the controls are in the Aoff@ position.

4) Remove the lockout devices and re-energize the

machine/equipment.

5) Notify affected employees that servicing is complete and

machine/equipment is ready for use by using the same means
used to inform them of impending shut-down.

Special Considerations/Comments:

This procedure was reviewed and approved for use by:

Name/Title/Dept.

Date

Form Revision Date: 1/3/07

Page 5 of 5