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HSE 14 Lockout and Tagout

This permit document outlines safety procedures for work requiring lock-out/tag-out. It requires contractors to identify energy sources that need to be disconnected and secured. The contractor must also ensure appropriate protective equipment is used and additional safety precautions are taken. Two signatures are required - one from the contractor to accept the provisions and safety precautions, and another from the approving authority to cancel the permit once work is complete.

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327 views1 page

HSE 14 Lockout and Tagout

This permit document outlines safety procedures for work requiring lock-out/tag-out. It requires contractors to identify energy sources that need to be disconnected and secured. The contractor must also ensure appropriate protective equipment is used and additional safety precautions are taken. Two signatures are required - one from the contractor to accept the provisions and safety precautions, and another from the approving authority to cancel the permit once work is complete.

Uploaded by

Ba N Nhim
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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LOCK-OUT AND TAG-OUT

This permit must be displayed prominently at the work area


This permit is valid from (a.m/p.m) to (a.m/p.m) on day of issued

SECTION A - WORK REQUEST


Contractor: Expected Duration of Work:
Location: Date: Time:
Specific Work Area:
Equipment to be worked on:
Description of work:
Equipment Tag No.: (if applicable)
JSA No: N/A

SECTION B - CHECKLIST YES N/A SECTION C: AUTHORIZATION


1 Have multiply shifts required? 10 Permissionics hereby given to the bearer of this permit to
Have electrical power sources been identified, carry out the above mentioned work under the provisions
2 disconnected with appropriate locks and tags applied, stipulated iun this permit and in accordance with the Work
and tested? Permit System
3 Do all disconnects have the capability of being locked
out?
Are there circumstances in the course of the job
4 where it is absolutely necessary to energize the
machine with their guards removed?
If yes to 3, have special instructions been provided to
5 do this job safely and controlling access to other
Signature by: Contractor Site Managers
persons?
SECTION D: AUTHORIZATION
Are there circumstances in the course of this job for 11 Permissionics hereby given to the bearer of this permit to
6 electricians to troubleshoot energized electrical carry out the above mentioned work under the provisions
apparatus? stipulated iun this permit and in accordance with the Work
If yes to 5, have special instructions been provided to Permit System
7 do this job safely and controlling access to other
persons?
8 Protective equipment to be used:
Rubber boots Hard Hat Safety harness
Gloves Face Shields Hearing protection
Safety Shoes Safety Glasses
Signature of Haskoning' representative
9 Additional Precautions to be taken: SECTION E: ACCEPTANCE
12 I understand the scrop of work to be done and safety
precaution to be taken. I agree and accept all the
provisions procedures and shall cease work should
condition affecting safety aspect of the work changes

Signature by: Authorized Contractor Supervisor


SECTION F: CLOSE OUT
13 Completion/Cancellation
I certified that the above mentioned work has been completed
has not commenced
(Tick as appropriate) has commenced but is not complete

Signed: Name: Time: Date:


(Performing Authority)
I declare that this permit is now withdrawn and cancelled.

Signed: Name: Time: Date:


(Approving Authority)

1st copy: Post At Job Site 2nd copy: keep to file 3rd copy: to HSE

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