		TITLE:	ES&H Manual

DOCUMENT ID:	6110 Appendix T5 Lockout/Tagout (LOTO) Forms and Templates

Part 1: Forms

a. Group Lockout/Tagout (LOTO) Forms

b. Lockout/Tagout (LOTO)- Multiple Energy Sources Form

c. Special Lockout/Tagout (LOTO) Form

d. Electrical Equipment Safety Inspection Form

e. Equipment Inspection Safety Form for LOTO

f. Energized Electrical Work Permit (EEWP)

g. Lockout/Tagout Periodic Inspection Checklist

Part 2: Creating an LOTO Procedure for a Template

Part 3: Complex LOTO Template Form

PART 1: FORMS

a. Group Lockout/Tagout (LOTO) Forms

b. Lockout/Tagout (LOTO)- Multiple Energy Sources Form

c. Special Lockout/Tagout (LOTO) Form

d. Electrical Equipment Safety Inspection Form

e. Equipment Safety Inspection Form for LOTO

f. Energized Electrical Work Permit (EEWP)

g. Lockout/Tagout Periodic Inspection Checklist

Group Lockout/Tagout (LOTO) for Single Equipment

Group Lockout/Tagout (LOTO) Form

for Single Equipment

(See ES&H Manual Chapter 6110 Appendix T3 Group Lockout/Tagout (LOTO) Procedure)

Group Lockout/Tagout Form For Single Equipment
Group Lockout/Tagout Form For Single Equipment			Date
Requesting Group		Building/Location

Authorized Group LOTO Coordinators (Minimum two required)		Title		Telephone#
PIC:



Description of Tasks Covered by this Form

INSTRUCTIONS: Work Coordinator performs Lock out/Tag out and verification according to the WRITTEN procedure.
Lock out/Tag out Performed by:					Date:
	Print Name:
Lock out/Tag out Witnessed and Verified by other work Coordinators					Date:
	Print Name:
	Print Name:
	Print Name:
	Print Name:
A personal LOTO lock belonging to at least one of the work coordinators listed on this sheet MUST be on the system at all times for this worksheet to be valid. At the beginning of each shift, individuals working on this system SHALL. · Verify that the system is locked out and that locks belonging to one or more of the work coordinators listed in this document are in place. · Verify that this work control document is still attached to the hasp or posted adjacent to the locked device (i.e. circuit breaker or switch). · Apply their personal LOTO lock to the hasp. At the end of each shift these individuals MAY remove their personal Lock. At the end of the job the work coordinator, who removes the last lock and this work control document, must verify that the system is configured in a safe state. This includes specific notes on the system as necessary.
System verified and de-posted by:					Date:
	Print Name:
	Print Name:

· Post this completed Group LOTO Form for Single Equipment at the area of the group lockout device for the duration of the work.

Form Revision Summary

Revision 2.0- 5/10/2021- Changed LTT to LOTO and Added PIC. Changed Manual name.

Revision 1.1 – 12/01/11 - Clarification of process steps and updates made to format. Qualifying periodic review, no substantive changes required.

Revision 1 – 04/04/09 – Updated to reflect current laboratory operations.

ISSUING AUTHORITY

FORM TECHNICAL

POINT-OF-CONTACT

APPROVAL DATE

EXPIRATION DATE

REV.

ES&H Division

Tim Fitzgerald

05/10/2021

05/10/2024

2.0

This document is controlled as an online file. It may be printed but the print copy is not a controlled document. It is the user’s responsibility to ensure that the document is the same revision as the current online file. This copy was printed on 6/6/2023.

Group Lockout/Tagout (LOTO) Form for Multiple Equipment

(See ES&H Manual Chapter 6110 Appendix T3 Group Lockout/Tagout (LOTO) Procedure)

Group Lockout/Tagout (LOTO) Form For Multiple Equipment

Date

Requesting Group

Building/Location

Authorized Group LOTO Coordinator/Person-in-Charge (PIC)

Title

Telephone#

Location of Lockout box:

No.

Energy Isolating/Draining Device

Device Location

Date Installed

Date Removed

Work Ready to Begin Authorized Coordinator/Person-in-Charge Signature:

Date:

Print Name:

Work Complete Authorized Coordinator/Person-in-Charge Signature:

Date

Print Name:

· Post this completed Group LOTO Form at the area of the group lockout device for the duration of the work.

Form Revision Summary

Revision 2.0- Rearranged format

Revision 1.2- 5/10/2021- Changed LTT to LOTO and Added PIC. Changed Manual name.

Revision 1.1 – 12/01/11 - Clarification of process steps and updates made to format. Qualifying periodic review, no substantive changes required.

Revision 1 – 04/04/09 – Updated to reflect current laboratory operations.

ISSUING AUTHORITY

FORM TECHNICAL

POINT-OF-COTNACT

APPROVAL DATE

EXPIRATION DATE

REV.

ISSUING AUTHORITY	FORM TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	REVIEW DATE	REV.
ES&H Division	Tim Fitzgerald	10/23/21	10/23/24	2.0

Complex Lockout/Tagout (LOTO) Form for Multiple Energy Sources


	Lockout/Tagout(LOTO) Multiple Energy Form (See ES&H Manual Chapter 6110 Appendix T1 Lockout/Tagout (LOTO) Procedure)

This procedure is for securing and controlling the hazardous energy and/or unexpected start-up of the equipment/system listed below.

Before beginning service or maintenance work, the following steps must be completed, by all qualified taggers, in sequence and in accordance to ESH manual chapter 6110T1. Include sufficient detail to allow for a safe and orderly shutdown and isolation of the equipment/system to be worked on.
Step #	Energy Isolating/Draining Device	Device Location		Method used to determine De-energized State






Reviewed and Signed by all Qualified Taggers					Date:
			Print Name:
			Print Name:
			Print Name:
			Print Name:
			Print Name:
Signature of the authorized person/Person-in-charge to this Form					Date:
			Print Name:

THIS FORM MUST BE POSTED NEAR THE WORK AREA UNTIL WORK IS COMPLETE

NOTES:

1. DO NOT PROCEED until this form has been completed and signed by an authorized employee.

2. Authorized employees are current in SAF104/ESC007 and ESC008 (LOTO training) and have equipment specific training for the equipment/system to be worked on.

3. This form satisfies the requirements of ESH Manual Chapter 6110T1.

Form Revision Summary

Revision 2.0- 6/02/2021- Updated to change link and terms. Changed LTT to LOTO and added PIC.

Revision 0.1 – 10/23/19 – Updated TPOC from T.Kujawa to T.Fitzgerald

Periodic Review – 03/09/18 – No changes per TPOC

Revision 0.0 – 03/09/15 – New form corresponding to ESH Manual Chapter 6110T1

ISSUING AUTHORITY	TECHNICAL POINT-OF-COTNACT	APPROVAL DATE	REVIEW DATE	REV.
ES&H Division	Tim Fitzgerald	06/21/2021	06/02/2023	2.0

Special Lockout/Tagout Form

Special Lock and/or Tag Removal Form

(See ES&H Manual Chapter 6110 Appendix T2 Special Lockout/Tagout (LOTO) Removal Procedure for instructions)

Only the Original Qualified Tagger may Remove this Form*
Requester’s Name:				Date
Signature:

I desire to remove the lock and/or tag presently securing the following equipment: (List equipment name and location)

Name of the original qualified tagger : (person who applied the lock and tag)
Department/Division of the original qualified tagger : (person who applied the lock and tag)
The tagger is unable to remove the lock and tag because:

I request authority to remove the lock and tag because:

I have considered the following safety items:


Approval Signatures**
(One signature required from this group)
Requester’s Supervisor/or TR				Date
Requester’s Department Manager				Date
(One signature required from this group)
Tagger’s Supervisor/or TR				Date
Tagger’s Department Manager				Date
Owner or Primary Manager of Affected Equipment:				Date

Post a copy of the completed form on or closely adjacent to the equipment that was locked/tagged out, and

Post a copy of the completed form on or closely adjacent to the area where the lock/tag was removed (if different from above).

(*If the original qualified Tagger is unavailable the equipment owner, with concurrence from the tagger’s supervisor, may remove the form.)

(**A verbal approval signature is an acceptable approval signature in critical situations. A verbal approval signature from the original qualified tagger does not negate this special lock and tag removal procedure. See ES&H Manual Chapter 6110 Appendix T2 Special Lockout/Tagout (LOTO) Removal Procedure Process Step 3: Affirm Management Agreement)

Form Revision Summary

Revision 1.4- 09/10/20- Updated LTT to LOTO from B. Rodriguez

Revision 1.3 – 10/23/19 – Updated TPOC from T.Kujawa to T.Fitzgerald

Periodic Review – 03/09/18 – No changes per TPOC

Revision 1.2 – 03/09/15 – Periodic Review; No substantive changes.

Revision 1.1 – 12/01/11 – Periodic Review; updates made to format. No substantive changes required.

Revision 1.0 – 04/04/09 – Update to reflect current laboratory operations.

	ISSUING AUTHORITY	FORM TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	REVIEW DATE	REV.
	ESH&Q Division	Tim Fitzgerald	10/23/19	10/23/22	1.4

Electrical Equipment Safety Inspection Form

Electrical Equipment Safety Inspection

(See ES&H Manual Chapter 6200 Appendix T1 Electrical Safety Inspection Procedure for Instructions)

Rectangle: Rounded Corners: Click
for
.pdf Form

1.0 Equipment/Installation Identification

	Equipment Description

	Unique Identifier #:	Manufacturer:

	Equipment Location:	Model Number:

	Division:	Serial Number:

	Equipment Owner:	JLAB Property #:

IF THIS EQUIPMENT IS MODIFIED, DAMAGED, OR UTILIZED FOR OTHER THAN ITS INTENDED USE, AFTER THE INSPECTION DATE, APPROVAL IS VOID, PENDING RE-INSPECTION.


* To Be Completed by the Qualified Electrical Inspector*
Equipment is:			Equipment requires:
Under Warranty: Yes No	AND	Approved Rejected	No Action	OR	Corrective Actions See 3.0 Equipment Inspection Summary Code Equivalency*
			* Contact Jefferson Lab’s Electrical Authority Having Jurisdiction
Inspection Date:	Inspector Name: Inspector Signature:

2.0 INSPECTION CRITERIA
	Enclosure	Approve	N/A
	Operator not exposed to any hazard
	Not damaged
	Appropriate material used
	Protects contents from operating environment
	Adequate shock protection (components well secured)
	Will contain any arcs, sparks and electrical explosions

	Power Source – Cord and Plug	Approve	N/A
	Proper voltage and ampacity for plug and cord
	Grounding conductor included
	Not frayed or damaged
	Proper wiring of plug
	Strain relief on cord

	Power Source – Direct Wired	Approve	N/A
	Proper voltage and ampacity rating for wiring method
	Installation according to the NEC
	Proper loading and overcurrent protection in branch circuit

	Foreign Power Supplies and Equipment	Approve	N/A
	Connected to facility power with appropriate adapters
	Correct voltage, frequency and phasing
	Correct wire ampacity for United States use

	Grounding	Approve	N/A
	Ground is properly connected
	All non-current carrying exposed metal is properly bonded
	All non-current carrying internal subsystems are properly bonded
	Equipment ground is run with circuit conductors
	Auxiliary ground is permitted

Internal Wiring	Approve	N/A
Polarity correct
Phasing correct
Landing of ground correct
Separate line / high voltage from low voltage
Wiring terminals and leads ok (no tension on terminals)
Proper wire size
No loose parts (mechanical bracing)
Proper overcurrent protection

Marking Requirements	Approve	N/A
Power requirements (voltage, current, frequency)
Restrictions and limitations of use
Make, model and serial number
Hazards, including stored energy
Requirements for access (LOTO, stored energy, PPE)

Test Performed	Approve	N/A
Ground continuity
Leakage current to ground
Polarization of cord and plug
Functional tests (GFCI, Emergency shutoff)
Automatic discharge of high voltage capacitor

Other Issues	Approve	N/A
Neat workmanship
Proper management of conductors
Free from sharp edges
Proper cooling (review equipment owner’s tests or analysis)
Switches and controls readily accessible
Any safety issues with access and maintenance

	Secondary Hazards	Approve	N/A
	RF hazards
	DC electric or magnetic fields
	IR, visible or UV
	X-Rays
	Fire or electrical explosion

	Documentation	Approve	N/A
	Documentation adequate
	Operating procedures
	Training and qualifications requirements

3.0 EQUIPMENT INSPECTION SUMMARY If rejected, include any corrective actions that need to be satisfied before rescheduling an inspection.

Distribution: Equipment Owner, System Owner

Form Revision Summary

Periodic Review – 11/14/18 – No changes per TPOC

Revision 1.2 - 02/19/14 – Deleted Section 2 “Standards or Codes used for the Inspection”

Revision 1.1 - 11/17/13 – Deleted “Department Head” from “Distribution”

Revision 1.0 - 10/31/13 – Updated to reflect current laboratory operations; most notable - department retain records of inspections

Revision 0.0 – 10/01/09 – Updated to reflect current laboratory requirements

	ISSUING AUTHORITY	TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	REVIEW DATE	REV.
	ESH&Q Division	Todd Kujawa	11/14/18	11/14/21	1.2

Equipment Safety Inspection Form for LOTO

1.0 Equipment/Installation Identification

		Equipment Description

		Unique Identifier #:				Manufacturer:

		Equipment Location:				Model Number:

		Division:				Serial Number:

		Equipment Owner:				JLAB Property #:


	* To Be Completed by the Qualified LOTO Inspector*
	Qualified Person’s name and Division:				Qualified Person’s Inspection Results:
					Pass Fail OR
	Inspection Date:			Inspector Name: Inspector Signature:

2.0 INSPECTION CRITERIA
		Enclosure					Approve	N/A
		Operator not exposed to any hazard
		Not damaged
		Appropriate material used
		Protects contents from operating environment
		Adequate shock protection (components well secured)
		Will contain any arcs, sparks and electrical explosions
		Used an isolation or draining device
		Placed proper lock and tag
		Tag is legible with name, division, and phone number
		Performed correct LOTO (administrative, simple, complex)

		3.0 Barrier Requirements					Approve	N/A
		Are signs posted?
		Restrictions and limitations of use
		Posted monitor
		Barrier tape and/or other methods (ie. cones, wood barrier, etc.)
		Requirements for access (proper PPE)

		4.0 Test Performed					Approve	N/A
		Identified proper test points for each of the energy isolations including stored residual energy
		Provided a suitable method for dissipating the stored residual energy
		Zero Voltage Verification
		Zero Energy Verification

		5.0 Secondary Hazards (other hazards that may need extra PPE or access into other areas)					Approve	N/A
		RF hazards
		DC electric or magnetic fields
		IR, visible or UV
		X-Rays
		Confined Spaces
		Hazardous energies in combination
		Using trapped-key interlock system
		Fire or electrical explosion
		Understands the risks and hazards located around the LOTO/where work is being performed
		Alerted other personnel working in and around the area about the LOTO


		6.0 Documentation					Approve	N/A
		Documentation adequate (has documented LOTO and received proper approval)
		Operating procedures (has proper LOTO procedure for that equipment on hand)
		Identified hazardous energy sources and associated energy isolations (verified with drawings)
		Training and qualifications requirements

		7.0 Procedure Steps					Approve	N/A
		Isolated areas to properly LOTO and collect the proper locks and tags
		Disconnecting- identify all electrical disconnects, valves, latches, and other ways to disconnect and isolate hazardous energy sources)
		Stored Energy-identify all possible ways the equipment stores hazardous energy and the way to release the stored energy (confirm that no stored energy reaccumulated)
		Responsibility- understand how to identify the Person in Charge for implementing a complex LOTO (identify staff responsible for confirming that maintenance is done)
		Turn off equipment
		Testing- Verify zero energy including provisions for verifying that no one can restart or reenergize the equipment
		Place all LOTO tags and locks on equipment
		Shift Changes/Keys- understand how to create a plan to transfer LOTO responsibility if work extends beyond one shift or days (include how to transfer keys)
		Coordination- understand how to establish coordination with other jobs in the area or with tasks already in progress when a complex LOTO starts
		Have someone verify work was completed
		Warn others downstream that the work was completes and the LOTO is about to be cleared (so that nobody gets hurt during power up)
		Remove the locks and tags
		Verify that the equipment has returned to a normal operating state
		Document the removal of the LOTO

Inspection Date:			Qualified Person’s Name: Qualified Person’s Signature:
ESH Management Signature Date:			ESH Management Name: ESH Management Signature:

Form Revision Summary

Revision 1.1 – Updated header footer. No new approvals are needed.

Revision 1.0- New Form – 09/17/20 – New Form

	ISSUING AUTHORITY	FORM TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	REVIEW DATE	REV.
	ES&H Division	Tim Fitzgerald	06/26/2021	06/26/2024	1.1

Energized Electrical Work Permit (EEWP)

Energized Electrical Work Permit Form

(See ES&H Manual Chapter 6220 Appendix T1 Energized Electrical Work Permit (EEWP) – Instructions)

PART 1 – Description of Work (To Be Completed by the Requestor)(Include attachments as necessary)
Description of Circuit/Equipment and Location
Description of work to be performed
Justification to Perform Work while Equipment is Energized: (Attach Documentation) Conformance to OSHA 1910, OSHA 1926, and NFPA 70E (2015 Edition) requirements Include a preliminary Task Hazard Analysis and Risk Code
SIGNATURES	PRINT SIGNATURE	DATE
Requestor
Preliminary Approval (Laboratory Director)

PART 2 – Development (To Be Developed by Subject Matter Expert and Electrically Qualified Workers)
REQUIRED ATTACHMENTS
Description of Circuit, Equipment and Location
Means to Restrict Unqualified Workers from the Area
Results of Shock Hazard Analysis
Determination of Shock Hazard Boundaries
Results of Flash Hazard Analysis
Determination of Flash Hazard Boundary
Job Briefing and Hazard Analysis
List PPE to Perform Work Safely
Description of Safe Work Practices to be Employed


APPROVALS	PRINT SIGNATURE	DATE
Qualified Worker(s)
Electrical Safety Engineer
Associate Director/Division Manager (of group requesting the EEWP)
Laboratory Director
Associate Director, ESH&Q Division

Form Revision Summary

Periodic Review – 12/10/18 – No changes per TPOC

Revision 1.2 – 06/29/18 – Periodic Review; updated to include AD, ESH&Q approval per CATS#MOA-2018-02-01-01

Periodic Review – 01/20/12 – Updated format

Revision 1.1 – 10/19/10 – Updated to clarify content per P.Powers and T.Kujawa

Revision 0.0 – 02/23/09 – Initial Form

	ISSUING AUTHORITY	FORM TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	REVIEW DATE	REV.
	ESH&Q Division	Paul Powers	12/10/18	12/10/21	1.2

Distribution: Laboratory Director; Associate Director/Division Manager (of group requesting the EEWP); Electrical Safety Engineer

Lockout/Tagout Periodic Inspection Checklist

(See ES&H Manual Chapter 6110)

Date:
Audited Employee(s):	Training Current: ☐Yes ☐No
Auditor:
OSP or IC Number and Title:
Equipment Name:
Type of LOTO:	☐ Simple ☐ Complex ☐ Group

Was the procedure performed as written?	Comments:
Were safe work practices used?	Comments:
Focus areas from previous quarters	Comments:
Other Observations?	Comments:
Worker feedback	Comments:

Worker Responsibilities

· Maintain appropriate LOTO training (ESC001 for Electrical, but not necessary for Non-Electrical, ESC007 Lockout/Tagout and ESC008 LOTO Practical) and take LOTO refresher training every 3 years to maintain Qualified Worker status.

· If a qualified tagger finds a discrepancy between configurations depicted in drawings to those found for the equipment, the worker must report the discrepancy to their supervisor.

· Must be trained to understand the purpose and function of the LOTO program and energy control.

· Recognize applicable hazardous energy sources, types of energy, and ways to isolate and control the energy sources.

· Recognize how lockouts can hinder facility operations, especially when operations are needed when the remote controls are locked out.

· Understand simple, complex, and group LOTO procedures and the limitations.

· Demonstrate practical understanding and the ability to apply and remove LOTO tags. Requalify for On-the-Job Training (OJT) every year to maintain equipment specific qualifications.

· Obtain specific LOTO training on equipment being serviced.

· Perform LOTO process steps (in accordance with ES&H Manual Chapter 6110 T1 Lockout/Tagout (LOTO) Procedure (Simple and Complex)) only after authorization from the supervisor of the equipment which requires the securing of the hazardous energy source.

Auditor Signature:
I have been debriefed on the comments resulting from this audit, as well as reviewed my responsibilities under the hazardous energy control procedure.
Audited Employee Signature:
Audited Employee Signature:
Audited Employee Signature:

Revision History

Revision 0.0 – 06.06.2023 New form in accordance with CATS IA-2022-08-07-05

	ISSUING AUTHORITY	TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	NEXT REVIEW DATE	rev
	ES&H Division	Rick Adrover	05.11.2023	05.11.2026	0

This document is controlled as an online file. It may be printed but the print copy is not a controlled document.

It is the user’s responsibility to ensure that the document is the same revision as the current online file. This copy was printed on 6/6/2023.

PART 2:

CREATING AN LOTO PROCEDURE

FOR A TEMPLATE

1.0 Creating a LOTO Procedure

All complex LOTOs require a written procedure that is specific both to the equipment, machine, or system and to the scope of work. The procedure serves as the primary basis document for everyone involved in the LOTO, and contains the following information:

· All of the hazardous energy sources in the equipment.

· All hazardous energy storage elements and devices in the equipment.

· List of required PPE.

· The specific way to disconnect hazardous energy.

· The isolations that the LOTO establishes.

· All the steps for establishing the lockout.

For work planning and control purposes, the author of the LOTO procedure functions as the work planner and the procedure is a work control document (WCD), which may become part of a larger work package (for example, adding it to the Aware application). Jefferson Lab’s work planning and control (WPC) process explains how to complete the hazard analysis (see the Jefferson Lab ES&H Manual Chapter 3210 Work Planning, Control, and Authorization Process).and your local WPC manual). This section provides the work planner with specific details to include in the procedure.

If any possibility exists for workers to have direct exposure to an electrical component or wiring when performing a task, place the equipment, machine, or system into an electrically safe work condition according to the Electrical Safety Manual.

The table below provides an overview of the requirements for the written procedure.

Responsibility	The division director or department head must verify that procedures are developed, documented, and used to control potentially hazardous energy for the equipment under their purview.
Format	All LOTO procedures may follow the standard format in the Template for a Complex LOTO Procedure. You may use other formats specific to your division or user facility, provided they contain the required elements. You may make the plan part of a larger maintenance procedure or develop it as a stand- alone work control document.
Input	Develop the complex LOTO plan with input from affected employees and staff knowledgeable of the hazardous energy associated with the equipment.
Work planners (authors)	Only staff knowledgeable about the construction and operation of the equipment may develop LOTO procedures.
Approvers	Only someone knowledgeable on the equipment or systems may review and approve LOTO procedures. At least one LOTO approver must be an authorized person knowledgeable of the equipment, trained as a PIC, and designated by the division or department to approve LOTO procedures based on his or her level of technical knowledge and familiarity with the systems involved. Each division with LOTO procedures must designate one or more LOTO approvers to meet the LOTO needs of the division. If a division does not have the needed skills, staff from the Environmental, Safety, and Health (ES&H) division may assist in reviewing and approving LOTO procedures.
Record keeping	Division staff must keep LOTO procedures as records and for audit purposes.

Overview of Requirements for LOTO Procedures

To create a LOTO procedure, the work planner must do the following:

• Develop the scope of work by trying to anticipate all possible maintenance and servicing tasks for the equipment

· Perform a detailed hazardous energy analysis to establish the appropriate isolations

· Document the complete LOTO process

· Submit the final draft of the procedure for approval by an authorized LOTO approver Then the approver reviews the procedure and must sign off before work begins.

2.0 Developing the Scope of Work

Every LOTO procedure depends on a properly identified scope of work. To define the scope, the work planner follows these steps:

Step	Action
1	Contact the PIC for the job and have the PIC describe in detail the scope of work, including all preparations and testing required.
2	Walk the job site (perform a walk-down) to identify other hazards in the area that you may need to address.
3	Ask detailed questions to determine if there are other considerations.

3.0 Performing a Hazardous Energy Analysis

The work planner must perform a hazardous energy analysis to identify the isolations needed. The work planner must work with an expert on the equipment. Consult available documentation, such as equipment drawings, schematics, manuals, panel schedules, and piping and instrumentation diagrams (P&IDs). Use up-to-date drawings or an equally effective means to locate all sources of energy to the equipment. Also, inspect the system visually to identify all hazards, as follows:

· Identify hazardous energy sources and associated energy isolations

· Identify proper test points for each of the energy isolations (to verify the absence of energy)

· Determine PPE requirements for each of the energy isolations and zero energy verification (ZEV)

· Identify any source of stored residual energy

· Provide a suitable method for dissipating the stored residual energy

For equipment: If using multiple-lock hasps is impractical or there are too many authorized workers to use hasps, the procedure must also address how to provide workers protection equal to having a personal LOTO device. Examples of such methods are a group lockbox or the trapped-key interlock system.

3.1 Determining Suitable Energy Isolations

Energy isolations must be positive isolation devices such as a disconnect switch, circuit breaker, block valve, or blocking pin.

3.4.11 Do not use control actuators such as the emergency stop or the equipment controller as lockout isolation points.

3.4.12 Contactors, diodes, interlock switches, check valves, and automatically controlled valves are not positive isolation devices.

Energy isolations must be capable (or be made capable) of accepting an approved lockout device that physically prevents the actuation of the energy-isolating device. If the desired isolation consists of removing a spool piece, removing fuses, lifting electrical wires, or otherwise disconnecting an energy source without a lockable isolation.

Energy isolations must have an accessible test location to prove absence of energy. Do not position interlocks, contactors, diodes, check valves, or automatically controlled devices between the isolation device and the test point used for verification.

Label energy isolations clearly and uniquely (for example, use an alphanumeric designator or words to describe its function).

If the LOTO involves placing equipment into an electrically safe work condition, workers must follow the Electrical Safety Manual requirements for performing a Zero Voltage Verification (ZVV).

3.2 Document the method for performing ZEV and/or ZVV.

For more information on requirements for electrical matters, refer to the Electrical Safety Manual. For more information on requirements for pressure matters, refer to the ES&H Chapter 6151 Pressure and Vacuum Systems Safety Program.

3.3 Determining the LOTO Hardware and PPE

The work planner must include in the procedure a list of the appropriate lockout hardware and personal protective equipment to wear.

3.4 Addressing LOTO Sequences

The procedure may direct the PIC to work with FAC staff to determine who is responsible for applying the first lock. The procedure must also identify any need for specific sequences to isolate energy sources.

Unless specifically stated otherwise, workers may perform steps in the LOTO procedure in parallel or in series. This means workers either perform all steps in sequence for each isolation, completing all the steps for an isolation before moving to the next isolation; or, equivalently, perform each step for all the isolations before moving to the next step. Either way, instruct workers to use the LOTO procedure checklist to verify completion of all steps for each energy isolation. If the workers need to perform a specific sequence for any part of the LOTO procedure, describe this sequence in a written checklist.

If a complex LOTO requires a group LOTO, then the procedure must address the following:

3.4.1 At least one authorized worker from a group performs the ZEV or ZVV step, and the PIC determines how many additional authorized workers must observe and verify that the energy was isolated and the equipment was rendered safe.

3.4.2 The PIC must implement and coordinate locking and tagging out hazardous energy sources and verify that the steps taken, according to the written procedure, have actually isolated the equipment effectively from the hazardous energy sources.

3.4.3 The PIC must accomplish this before authorized workers participating in the group LOTO affix their lockout device to the group box and before work begins. The PIC must inform each authorized worker participating of their right to verify the lockout measures.

3.4.4 PICs must allow authorized workers to personally verify that hazardous energy sources were effectively isolated, if they so choose. Authorized workers who opt to verify the effectiveness of the isolation measures must do this after affixing their lockout device to the lockbox and before performing work.

3.4.5 Each authorized worker must affix a lockout or tagout device to the group lockout device, group lockbox, or comparable mechanism before beginning work and must remove those devices when done.

*If using a group lockbox, any more authorized workers adding their lock and tag to the group LOTO box must record their lock in the station logbook. Contractors may not make an entry in logbooks.

3.4.2 Documenting How to Dissipate Stored Energy

This section discusses documenting the means for releasing stored energy and preventing stored energy from accumulating again.

3.4.2.1 Releasing Stored Energy

For stored mechanical energy, use vent valves, spring releases, blocking devices, or equipment repositioning (as appropriate). For stored electrical energy, use approved grounding wands or discharge devices (for guidance, refer to the Electrical Safety Manual). Lock out or suitably control stored energy that cannot be released to prevent an inadvertent release that may cause injury or property damage.

3.4.2.2 Preventing Stored Energy from Accumulating Again

If it is possible for stored energy to accumulate again to a hazardous level, devise a solution for workers to install and maintain that continuously discharges the energy for the duration of the lockout. For guidance on electrical systems, refer to the Electrical Safety Manual. Other examples include the double-block-and-bleed method for high-pressure fluids where slow leakage past an energy isolation valve can result in undetected depressurization of a section of piping.

3.4.3 The table below shows various considerations for the work planner to address in a complex LOTO procedure. Also, the sections that follow provide detailed explanations for these considerations:

· Documenting how to inform multiple workers

· Accounting for confined spaces

· Accounting for other work area hazards

· Accounting for potentially hazardous energies in combination

· Using trapped-key interlock systems

Multiple sources, crews, or locations	Include any steps needed to account for multiple energy sources, multiple crews or crafts, or multiple locations.
Shutdown and startup	Identify the person or persons who shut down and isolate the hazardous energy, including where and how to de-energize the equipment. Identify the staff who power up the equipment. Specify the particular sequences for shutting down or powering up.
Disconnecting means	Identify all electrical disconnects, valves, latches and other ways to disconnect and isolate hazardous energy sources (there may be different or multiple means).
Stored energy	Identify all possible ways the equipment stores hazardous energy and the way to release the stored energy and confirm that no stored energy reaccumulated.
Responsibility	Identify the PIC for implementing the complex LOTO, and the staff responsible for confirming that maintenance is done.
Verify LOTO	For all hazardous energy sources, include provisions for verifying that no one can restart or reenergize the equipment.
Testing	Identify the test instruments to use, and points where workers verify a zero energy state.
Shift change and keys	Include a plan to transfer LOTO responsibility if work extends beyond one shift or may take several days. Include how to transfer LOTO keys.
Coordination	Establish how to coordinate with other jobs in the area or with tasks already in progress when the complex LOTO starts.
Accounting for	Explain how to account for all staff that could possibly be exposed to hazardous
staff	energy.
	Co-located work area hazards or introduction of new hazards resulting from
	applying the LOTO.
Tagout only	If the plan includes using only tagout on one or more energy sources, clearly delineate the sources to tag, the rationale, and any other way of achieving control equal to a lockout.
Removing LOTO devices	Provide a clear sequence for removing LOTO devices at the appropriate step in the procedure when the PIC verifies the work is complete, the equipment is inspected to confirm that it is safe, and employees are in a safe position. Document removing LOTO device if the person who applied the device is unavailable. Document how to release the LOTO and return the equipment to service.
Temporary release	Document how to temporarily release the LOTO for testing and positioning.

Considerations for Work Planner to Document in Procedure

4.0 Documenting How to Inform Multiple Workers

If the LOTO procedure involves multiple workers, the work planner must include the following in the procedure:

4.1 Identify the PIC.

4.2 Explain how the PIC ascertains the exposure status of individual workers (authorized and limited authorized) for LOTO and ZEV or ZVV.

4.3 If there is more than one crew, assign overall LOTO responsibility to a PIC designated to coordinate all of the affected work forces and determine continuity of protection. And specify the controlling organizational WPC process.

4.4 Document using a group lockbox or trapped-key interlock system.

5.0 Accounting for Confined Spaces

For work located in a confined space that requires LOTO, ES&H Manual Chapter 6160 Confined Space Program requires a minimum of two isolation methods (per hazard type) to control fluid, gas, mechanical, and steam.

Before disconnecting fluid, gas, or steam lines, isolate the lines by a minimum of two methods upstream combined with a method to bleed and isolate the downstream. In mechanical systems (for example, tank mixers), lock out the drive power source and disconnect the linkage between the drive and the power transmission shaft.

If the system is in total shutdown (hazardous energy sources were removed and all lines leading to the confined space were vented), it does not need isolation. Likewise, the system does not require isolation if all of the following are true: the liquid is not a hazard when not under pressure, the source of pressure is locked out, and pressure in the lines is reduced to a safe level. To determine if the liquid is a hazard under pressure.

If toxic materials or toxic, flammable, or inert gas systems are present in a confined space, workers may need a Confined Space Entry Permit. Locking out and venting the systems before line breakage in the space may not be adequate to remove the hazard. Workers may need to flush the system to remove the hazardous chemicals before opening the system in the space. Failure to properly flush and vent may result in serious illness or death. For more information on working in confined space to flush or vent systems, refer to ES&H Manual Chapter 6160 Confined Space Program.

6.0 Accounting for Other Work Area Hazards

Control concurrent and other area hazards through work planning and control. The work planner must analyze not only the hazards to remove by the LOTO, but also those hazards that workers may encounter while applying or working under the protection of the LOTO. The work planner also must identify the controls needed to mitigate those hazards. For more information on hazards analysis, refer to the Jefferson Lab ES&H Manual Chapter 3210 Work Planning, Control, and Authorization Process..

In complex process systems (for example, chemical or nuclear), procedural approaches can differ. Line breaking procedures, such as for contaminated or hazardous piping networks, must supplement the LOTO procedure if workers need to open, disconnect, or remove piping.

For lockouts and tagouts in areas that pose an unacceptable safety risk (such as radiological areas, hazardous chemical zones, or high overhead areas with strict access controls), the work planner may document alternative means for positive LOTO on the device. Such instances require concurrence from the HEC program manager and approval from the division director or department head for the LOTO procedure.

7.0 Accounting for Potentially Hazardous Energies in Combination

The work planner must consider controlling energy in combination with other situations that may increase the hazards. The following is only a partial list of dangerous combinations to consider:

7.1 Water and electricity: potential for shock or arc flash hazard when working on water lines over electrical components or when working on electrical systems in a wet location.

7.2 Compressed air and toxic materials: what are the results of inadvertent activation (will it generate toxic or radioactive dusts or aerosols that create contamination or personal exposure)?

7.3 Work on a ladder and unexpected energy or noise: consider the location of overhead water or air lines when placing the ladder; consider the effect of unexpected effect of air, water, or elevated noise level from release of compressed air (a startled worker may fall or drop tools).

7.4 Inert gas in a confined space: consider asphyxiation hazards in a work location with poor or no ventilation; include in the procedure to shut the gas source off and lock it out to avoid oxygen depletion.

7.5 Magnetic fields and metal: strong magnetic fields may propel ferrous tools.

7.6 Pneumatic and thermal: consider thermal and pneumatic hazards near live steam or pressure relief valves. Relieving highly compressed, nominal-temperature gases could create a blockage which prevents the needed, natural boil off (venting) of a cryogenic liquid. In this case, the pressure inside a dewar may rise until it reaches a dangerously high level.

8.0 Using Trapped-Key Interlock Systems

Trapped-key interlocks (also known as a Kirk^® key or sequestered key) use locking mechanisms and keys to sequentially control equipment for safe operation. A safe sequence of operations occurs by transferring trapped or released keys in a predetermined order. Some interlocks include a time delay or a rotation detector so that a machine has time to come to a stop before the next step of an interlock sequence proceeds.

The following list explains the requirements for trapped-key interlocks:

8.1 Multiple trapped-key interlock systems need a complex LOTO procedure specific to the equipment, machine, or system.

8.2 Workers must have equipment-specific training and be qualified, or working under an authorized worker.

8.3 The PIC must control the last single key, usually kept in a group LOTO box.

8.4 Perform ZEV and ZVV according to section 7.2 before authorized workers perform work on systems protected by trapped-key interlocks.

9.0 Approving and Authorizing a LOTO Procedure

The LOTO approver must examine in detail every aspect of the written procedure and be familiar with its scope of work. Once the LOTO approver is satisfied that the LOTO scope of work is appropriate, believes that the procedure can be safely and successfully completed, and that all questions concerning the details of the LOTO are resolved, the LOTO approver can approve the LOTO procedure. This approval may be written or use electronic signatures.

Obtain authorization for this procedure according to your division’s process.

PART 3:

TEMPLATES

CREATING AN LOTO PROCEDURE

FOR A TEMPLATE

Complex Lockout/Tagout (LOTO) Template Form

Complex Lockout/Tagout (LOTO)

Template Form

You may use this form as a model to create a just-in-time procedure for a complex lockout/tagout (LOTO) for servicing or maintenance work on equipment, machines, or systems. Send an electronic version of this completed form to electricalsafety@jlab.org.

Use this form only for servicing and maintenance work on equipment. This form assumes you are familiar with the information in the Hazardous Energy Manual. See also the full instructions at the end of this form.

Section 1. Preliminary Information

Date:

Form completed by:

PIC:

Equipment type or description:

Location:

Asset No.

Other ID:

Scope of work:

Does equipment contain confined spaces requiring a LOTO permit? ☐ No ☐ Yes – PRCS number:

If yes, complete Confined Space Entry Permit

Section 2. Identify Why the LOTO is Complex

☐ Equipment has multiple sources of hazardous energy.

☐ Isolation and locking of a single energy source does not completely de-energize equipment.

☐ The equipment has the potential to store hazardous energy or, after the shutdown, the possibility of reaccumulating hazardous energy.

☐ A single lockout device will not establish an energy-safe work condition.

☐ Authorized workers do not exclusively control the lockout device.

☐ Shutting down the equipment for servicing or maintenance may create hazards for other employees.

Section 3. Identify the Staff to Notify for the Equipment Shutdown and Lockout

	Staff	Name	Contact Number
☐	Building manager:
☐	Operations and FM&L:
☐	Equipment expert:
ü	Person in charge (PIC):
☐	Affected researchers:
☐	EES/ES&H (if work affects fire protection systems):
☐	Radiation Facility Manager (if work affects radiation facilities):

Section 4. Identify Hazardous Energy Sources
Check the form of the hazardous energy, list the magnitudes of the energy, and the personnel isolating energy. If there are more than 6 energy sources, add more pages as needed.
Source 1 Form and Magnitude of Energy: ☐ Electrical ☐ Pressure ☐ Mechanical ☐ Gravitational ☐ Chemical ☐ Thermal ☐ Rotational ☐ Laser ☐ Vacuum ☐ Hydraulic ☐ Pneumatic ☐ Radiation Personnel Isolating Energy Source:
Source 2 Form and Magnitude of Energy: ☐ Electrical ☐ Pressure ☐ Mechanical ☐ Gravitational ☐ Chemical ☐ Thermal ☐ Rotational ☐ Laser ☐ Vacuum ☐ Hydraulic ☐ Pneumatic ☐ Radiation Personnel Isolating Energy Source:
Source 3 Form and Magnitude of Energy: ☐ Electrical ☐ Pressure ☐ Mechanical ☐ Gravitational ☐ Chemical ☐ Thermal ☐ Rotational ☐ Laser ☐ Vacuum ☐ Hydraulic ☐ Pneumatic ☐ Radiation Personnel Isolating Energy Source:
Source 4 Form and Magnitude of Energy: ☐ Electrical ☐ Pressure ☐ Mechanical ☐ Gravitational ☐ Chemical ☐ Thermal ☐ Rotational ☐ Laser ☐ Vacuum ☐ Hydraulic ☐ Pneumatic ☐ Radiation Personnel Isolating Energy Source:
Source 5 Form and Magnitude of Energy: ☐ Electrical ☐ Pressure ☐ Mechanical ☐ Gravitational ☐ Chemical ☐ Thermal ☐ Rotational ☐ Laser ☐ Vacuum ☐ Hydraulic ☐ Pneumatic ☐ Radiation Personnel Isolating Energy Source:
Source 6 Form and Magnitude of Energy: ☐ Electrical ☐ Pressure ☐ Mechanical ☐ Gravitational ☐ Chemical ☐ Thermal ☐ Rotational ☐ Laser ☐ Vacuum ☐ Hydraulic ☐ Pneumatic ☐ Radiation Personnel Isolating Energy Source:
	Section 5 Identify Isolation Points and Shutdown Process
	Describe the points of isolation for each hazardous energy source and the step-by-step process for isolating the energy source. Attach a photo of isolation point as needed. If there are more than 6 energy sources, add more pages as needed. Source 1: Source 2: Source 3: Source 4: Source 5: Source 6:

Source 1 Isolation Point Photo	Source 2 Isolation Point Photo

Source 3 Isolation Point Photo	Source 4 Isolation Point Photo

Source 5 Isolation Point Photo	Source 6 Isolation Point Photo

Section 6 Identify Points of ZEV and ZVV

Identify points of zero energy verification (ZEV) and zero voltage verification (ZVV), and any potential hazards at ZEV locations. If there are more than 6 energy sources, add more pages as needed.

Energy Source 1

Describe point of ZEV/ZVV: