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Appendix II

Specific Instructions for Hazardous Machinery

Part I
Machine Name:_________________________________________________________________________
Machine Serial Number:___________________________________________________________________
Department Name:_______________________________________________________________________
Approved by:____________________________________________ Date:__________________________

Part II
a. What types of hazardous energy may be present?
Circle all that apply.

    Electrical   Chemical   Pneumatic   Hydraulic   Thermal   Other: ____________________

b. Complete Energy Check List (Reverse side of this form)

c. Special Locking and Tagging instructions:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Part III
Attach a diagram or photo identifying lock and tag locations:

 

                                                              Energy Control Diagram                                                                           

Energy Checklists

Energy Type Hazard Magnitude Control Method
Electrical Shock
Burn
Fire
___________		 110 VAC
220 VAC
208 VAC/30
___V____A		 Main Switch
Plug Control
Fuse Blocks
Shielding
Pneumatic Mechanical/
Pinch Points
Crush
Laceration
Flying Debris		 Moderate
Slight
High
___lb Force		 Air Line Valve
Gas Cylinder Valve
Gas Line Valve
___________
Chemical
(Gas)		 Flammable
Corrosive
Toxic
Reactive		 Slight
Moderate
High		 Cylinder Valve
Gas Line Valve
Chemical
(Liquid)		 Flammable
Corrosive
Toxic
Reactive		 Slight
Moderate
High		 Valve
Flange Plate
Mechanical Shaft in Motion
Moving Parts
Crushing
Laceration
Impalement		 Slight
Moderate
High
____ft-lb
____hp		 Main Electrical
   Switch
Plug Control
Shielding
Blocking
Anti-Motion Pin
UV Skin and Eye
Burns		 Slight
Moderate
High
___W/cm²@___%		 Shielding
Main Switch
Plug Control
Circuit Breaker
ElectroMagnet Strong Field Slight
Moderate
High
____Gauss		 Main Switch
Plug Control
Circuit Breaker
Thermal Burns Moderate
 Temperature
High
 Temperature
Cryogenic
____°C		 Main Switch
Plug Control
Steam Valve
Fluid Line Valve

*Chart adopted from the January/February 1995 issue of Compliance Magazine.

Appendix III

Using the LOTO Plan

  1. Preparing for Shutdown
    1. Identify the types of energy and sources
    2. Notify affected employees of intent to service machinery

  2. Shutting Down the Equipment
    1. Turn off equipment
    2. Deactivate energy
    3. Release all stored or residual energy
    4. Attach locking and tagging devices
    5. Test to make sure equipment has been deactivated

  3. Complete Work

  4. Preparing to Return Equipment to Service
    1. Remove all tools from the equipment
    2. Inspect the controls to verify they are in the "off" position
    3. Remove all locking and tagging devices
    4. Re-energize the equipment
    5. Notify affected employees when equipment is back in service


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