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Energy isolation and equipment lockout procedure record
Mark each step as completed (P), not completed (F), or not applicable (N/A). All steps must be completed in sequence.
| # | Procedure Step | P | F | N/A | Notes |
|---|---|---|---|---|---|
| Energy Sources | |||||
| 1 | All energy sources identified (electrical, hydraulic, pneumatic, thermal, mechanical, gravitational) | □ | □ | □ | |
| 2 | Isolation points documented on equipment-specific procedure | □ | □ | □ | |
| 3 | Stored/residual energy hazards identified | □ | □ | □ | |
| 4 | Affected personnel notified of shutdown | □ | □ | □ | |
| Lockout Steps | |||||
| 5 | Equipment shut down using normal stopping procedure | □ | □ | □ | |
| 6 | All energy-isolating devices moved to OFF/SAFE position | □ | □ | □ | |
| 7 | Personal lock applied to each isolation point | □ | □ | □ | |
| 8 | Danger tag attached with worker details and date | □ | □ | □ | |
| 9 | Stored energy dissipated (capacitors, springs, pressure, elevated parts) | □ | □ | □ | |
| 10 | Multi-lock hasp used (if multiple workers involved) | □ | □ | □ | |
| Verification | |||||
| 11 | Attempted start-up to confirm isolation effective | □ | □ | □ | |
| 12 | Voltage/pressure/flow tested at zero | □ | □ | □ | |
| 13 | Controls returned to OFF after verification | □ | □ | □ | |
| 14 | Area safe for maintenance to commence | □ | □ | □ | |
| Removal Procedure | |||||
| 15 | Work completed and tools/materials cleared | □ | □ | □ | |
| 16 | Guards and safety devices reinstalled | □ | □ | □ | |
| 17 | All personnel clear of equipment danger zones | □ | □ | □ | |
| 18 | Each worker removes own lock only (one person, one lock, one key) | □ | □ | □ | |
| 19 | Danger tags removed by authorised person | □ | □ | □ | |
| 20 | Affected personnel notified before re-energisation | □ | □ | □ | |
| 21 | Equipment tested for correct operation after restart | □ | □ | □ | |
| 22 | LOTO register updated with completion details | □ | □ | □ | |
Declaration
I confirm that all energy sources have been identified, isolated and verified. I accept responsibility for maintaining lockout integrity for the duration of this work. No person shall remove another worker's lock without formal authorisation from the site supervisor.