This sample Lockout Tagout (LOTO) Program is provided by the Missouri On-Site Safety and Health Consultation Program. In order to comply with OSHA’s standard for Control of Hazardous Energy, 29 CFR 1910.147, this written plan must be site specific. Modify the template to reflect the policies and procedures at your company. Since OSHA regulations set minimum requirements, you may choose to add additional information to your site specific program. There is no requirement to follow this sample and its use does not guarantee compliance with the OSHA standard.
To prepare your plan, follow these steps:
2. The following information may be useful in developing your program:
3. Add information to make it site specific to your company.
4. For clarification or assistance, contact the Missouri On-Site Safety and Health Consultation at 573-522-SAFE.
(To customize, please complete and remove the highlighted areas of the program)
1. Company Policy
( Name of company ) is committed to providing a safe and healthful work environment for our entire staff. This program establishes the requirements for the lockout of energy isolating devices whenever servicing or maintenance is performed on machines or equipment. It will be used to ensure that the machine or equipment is stopped, isolated from all potentially hazardous energy sources, and locked out before employees perform any servicing or maintenance where the unexpected energization or start-up of the machine or equipment or release of stored energy could cause injury.
2. Program Administration
(Name of person or job title) will maintain, review, and update the Lockout Tagout (LOTO) Program at least annually, and whenever necessary to include new equipment or whenever major replacement, repair, renovation or modification of machines or equipment is performed, and whenever new machines or equipment are installed.
The LOTO Program will:
3. Program Review and Update
The LOTO Program will be reviewed or updated at least annually, or whenever there are new equipment, or personnel changes that might affect the program. Annually, authorized employees who are not involved with the procedures being inspected, will conduct a review of the Energy Control Procedures for all machines and equipment.
The annual inspection will include:
4. Responsibility
All employees (authorized, affected, or others) are required to comply with the requirements of our LOTO Program.
All employees, upon observing a machine or piece of equipment is locked out for servicing or maintenance work, shall not attempt to start, energize or use that machine or equipment. Employees shall consult with management whenever there are any questions regarding the Energy Control Procedures or methods. Management shall enforce the Energy Control Procedures including the use of corrective disciplinary action when necessary.
5. Methods of Compliance
Preparation for Lockout:
Lockout or Tagout System Procedure:
Group Lockout Procedures:
Shift or Personnel Changes:
Outside Service or Contractor Personnel:
Outside personnel or contractors shall be advised that the company has and enforces the use of Energy Control Procedures. They will be informed of the use of locks and tags and notified about the prohibition of attempts to restart or re-energize machines or equipment that are locked out or tagged out.
The company will obtain information from the outside personnel or contractor about their Energy Control Procedures and will advise affected employees of this information.
Testing or Positioning of Equipment during Lockout:
6. Training
Employees will be provided training to ensure they know the purpose and function of the LOTO Program are understood along with the knowledge and skills required for the safe application, usage, and removal of the energy controls.
Authorized employees will be trained on the following:
Affected employees will be trained on the following:
Other employees whose work operations are or may be in an area where Energy Control Procedures may be utilized will be instructed on the following:
Qualified employees (those permitted to work on or near exposed energized parts) shall, at a minimum, be trained in and familiar with:
Authorized and qualified employees will be given training prior to any initial involvement in the lockout procedures. Affected employees will be given training at the time of hiring.
Retraining will be given whenever there is a change in:
A list of employees trained, type of training, and dates of training will be maintained by (Name of person or job title) .
7. Energy Control Procedure
Energy Control Procedures shall be used to ensure that the machine or equipment is stopped, isolated from all potentially hazardous energy sources, and locked out before employees perform any servicing or maintenance where the unexpected energization or start-up of the machine, or equipment, or release of stored energy could cause injury.
LOTO Locks
LOTO devices will be standardized by either color, shape or size. These devices will be substantial enough to prevent removal without the use of excessive force (such as bolt cutters). The devices will also identify who had applied them by a tag or other equally effective means.
Sequence of Lockout
(Name(s)/Job Title(s) of affected employees and how to notify on the Energy Control Procedure Form.)
Restoring Equipment to Service
When the servicing or maintenance is complete and the machine or equipment is ready to return to normal operating condition, the following steps shall be taken:
Note: The removal of some forms of blocking may require reenergization of the machine before safe removal.
Compliance with this Program
All employees are required to comply with the restrictions and limitations imposed upon them during the use of lockout. The authorized employees are required to perform the lockout in accordance with Energy Control Procedures. All employees, upon observing a machine or piece of equipment which is locked out to perform servicing or maintenance shall not attempt to start, energize, or use that machine or equipment. Employees who fail to adhere to this policy will automatically be disciplined by our (Name of company) ’s progressive disciplinary policy.
(List the name(s)/job title(s) of "authorized" employees here)
Energy Control Procedure Form
Location:
Machine (Type, Manufacture, Model and Serial Number):
Date Created:
Date Revised:
Procedure Completed By:
Authorized Employees
Affected Employees
Energy Sources
Electric Hydraulic Pneumatic Mechanical Steam Gravity
Chemical Natural Gas Stored Energy Other (Explain)
Type of Energy Isolating Device
Location
Capable of being Locked Out? (Yes/No)
Shutdown Procedures:
Deenergization Confirmation Procedure:
Startup Procedure:
Annual Inspection Certification Form
Note: The Inspector must observe utilization of the procedure by the authorized employee(s).
Date of Inspection:
Inspector (Authorized Person):
Machine/Equipment:
Authorized Employee:
Were all the hazardous energy sources properly identified in the written procedure? YES NO If no, explain:
Were the energy isolation steps outlined in the procedure effective in isolating all the sources of stored energy? YES NO If no, explain:
Were the proper lockout/tagout devices (padlocks, plug locks, valve cover locks, blocks, breaker locks, tags, etc.) available to effectively perform the energy isolation procedure? YES NO If no, explain:
Did the authorized employee(s) deviate from the lockout/tagout procedure?
YES NO If yes, explain:
Did all authorized employees participating in the inspection understand their responsibilities under the procedure? YES NO If no, explain:
Was the procedure adequate to provide the necessary protection? YES NO
If no, explain:
Certification: I certify that this periodic inspection was performed in conformity with the information set forth herein.
Inspector’s Signature:
LOTO Training Roster
Training Performed By:
Employee Name
Employee Signature
Training Date