Lock Out Tag Out

k1218442Lockout Tag Out Protocol            Date: _____________________

Whenever workers leave area upon returning to work area recheck for voltage on the locked out system.

Workers only listen and take layout from their foreman and tell all outside personal to go to their foreman with all their ideas.

All outside sources are referred away and to the foreman.

NA means Not applicable to this LOTO procedure.

How many power sources are present in this Lockout Tag out procedure?

Possible Power Sources: One Two Multiple NA

AC Power Sources One Two or Multi Sources

One source of Utility Power Double Source of Utility Power Circle One

List all utility sources

___________________________________________________________________________________

Transfer Switches: Yes No NA Circle One

Equipment Number if Applicable

___________________________________________________________________________________

 

DC Voltage Yes No NA Circle One

Is DC Power from a panel, bucket or transformer!
Equipment Number of DC Voltage and where it is located if applicable.

_____________________________________________________________________________________

UPS Power Yes No NA

How many sources of UPS power?

Batteries Yes No NA

Battery Room Number

_____________________________________________________________________________________

Generators Yes No NA

Generator Equipment Number

______________________________________________________________________________________

Equipment Number of UPS and Circuits to Locked Out

______________________________________________________________________________________

Control Voltage Yes No NA

Control Voltage External or Internal Circle One

What is the voltage 24V 120V etc.
________________________________________________________

Internal power being inside the cubicle or switchgear or cubicle!

Where is control voltage located bucket, PLC, etc.?

_____________________________________________________________________________

Transformer Power: 12.4-13.8, 480-277 208-120

Does Transformer need to be locked out: Yes No NA Circle One

Transformer Equipment Number:

___________________________________________________________________________________

Do CT’s Need to be grounded out? Yes No NA

What is the Cal rating of suite to be worn during the shutdown and start up of system? ___________________________

When were the gloves to be worn during shutdown and startup calibrated?

Lockout Tag out personal doing the coordinating:

________________________________________________________

General Foreman giving instructions to his foreman:

________________________________________________________

Foreman giving the instructions to the workers is:

________________________________________________________

Are there any special procedures to be done to perform this lock out tag out procedure in safe and journeyman like manner? Yes No NA

____________________________________________________________________________________________

Main Panel or Equipment To Be Locked Out: ________________________________________________________

Where is Main Panel or Equipment Located: ______________________________________________________________

Load Side Panel to be Locked Out: ____________________________

Where is Load Side Panel located: _________________________________________________________________________

Circuit Breakers to be Locked Out:__________________________________________________________________________

Lockout Tag Out personal involved in checking out the system to be involved and their input?

 

Foreman and workers involved in checking out the system to be locked out:

What are the discoveries of people checking out the system to be locked out?

Are there electrical boxes involved in this lockout procedure such as 4 square boxes, 4 11/16 Boxes and etc.
_______________________________________________________________________________________________________

What circuits and circuit numbers inside the box that is involved in this lockout tag out procedure:

_______________________________________________________________________________________________________

Coordinate shutting down with system all people affected by shutting down system.

Who will be affected by the shutting down this system?

_______________________________________________________________________________________________________

Who does all the coordinating of shutting down this system?

______________________________________________________________________________________________________

What equipment computers and people will be affected by shutting down this system?

Name of Lockout Tag Out Person in charge of LOTO:

Color of Loto Personals Lock & Number of Lock being used by Loto Personal on this system: ________________________________________

Foreman Involved__________________________________________

Color of Foreman Lock & Number of lock being used by the Foreman on this task:

________________________________________________________________________________________________________

Journeyman Involved: _____________________________________

________________________________________________________

Color and Number on the Lock/Locks being used by Journeyman by the journeyman on this task:

________________________________________________________________________________________________________

PPE required to perform this task: _______________________________________________________________________________

Barricading work area required or not required.

Steps to shutting down the systems:

  1. _________________________________________________________________________________________________
  2. _________________________________________________________________________________________________
  3. _________________________________________________________________________________________________
  4. ________________________________________________________________________________________________
  5. _________________________________________________________________________________________________
  6. _________________________________________________________________________________________________
  7. _________________________________________________________________________________________________
  8. _________________________________________________________________________________________________
  9. _________________________________________________________________________________________________
  10. _________________________________________________________________________________________________

Name of person putting on the CAL Suite: _______________________________________________________________________

Name of Person with hook to pull working partner out of danger in case of emergency.

Person with hook must be outside of barricade and never involved in the process for checking of voltage on the shutdown system.

______________________________________________________________________________________________________

Company Voltage Meter to be used and Number of voltage meter: ________________________________________________________

What are the voltage readings of locked out system:

A Phase to B Phase _____________________________________

A Phase to C Phase ____________________________________

B Phase to C Phase ___________________________________

A Phase B Phase C Phase to Neutral ______________________

A Phase B Phase C Phase to Ground _____________________

Did workers check each circuit in panel for back feed? Yes No NA Circle One

___________________________________________________________________________________________________

Control Voltage _______________________Volts

UPS System Batteries __________________Volts

UPS System

A Phase to B Phase _____________________________________

A Phase to C Phase ____________________________________

B Phase to C Phase ___________________________________

A Phase B Phase C Phase to Neutral ______________________

A Phase B Phase C Phase to Ground _____________________

Whenever workers leave area upon returning to work area recheck for voltage on the locked out system.

The procedures to energize system:

As soon as workers finish their task remove locks tell their foreman allow the energizing of locked out system to be energized by authorized personal.

Are Journeyman to turn on system after completion? Yes or No

Energized Voltage Start Up

A Phase to B Phase _____________________________________

A Phase to C Phase ____________________________________

B Phase to C Phase ___________________________________

A Phase B Phase C Phase to Neutral ______________________

A Phase B Phase C Phase to Ground _____________________

Control Voltage _______________________Volts Yes No NA

UPS System Batteries __________________Volts Yes No NA

 

UPS System Yes No NA

A Phase to B Phase _____________________________________

A Phase to C Phase ____________________________________

B Phase to C Phase ___________________________________

A Phase B Phase C Phase to Neutral ______________________

A Phase B Phase C Phase to Ground _____________________

Are CT’s ungrounded Yes No NA

Was there any special instructions carried out and have to be turned on for system to operate? Yes No NA

Who is the authorized person to turn on system upon completions of the shutdown?

 

Who puts on the CAL Suite to check for voltage after system is energized?

____________________________________________________________________________________________

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