THE UNIVERSITY OF SOUTHERN MAINE

Lock-out Tag-out Program

(Zero Mechanical State)
Department: University Environmental Health and Safety 2
Document: Lock-out Tag-out Program (Zero Mechanical State) 02/21/2013

TABLE OF CONTENTS

Section Title Page

1.0 Scope and Responsibilities…………………………………………………………………………………………. 3
2.0 Examples of Potential Energy and Zero Mechanical State…………………………………………. 4
3.0 Who is Covered by this Program………………………………………………………………………………… 5
4.0 Lockout Tagout Procedures………………………………………………………………………………………… 5
5.0 Locks Removal Rule…………………………………………………………………………………………………….. 7
6.0 Responsibility at the End of a Work-Shift…………………………………………………………………… 7
7.0 Group LOTO………………………………………………………………………………………………………………… 8
8.0 Training……………………………………………………………………………………………………………………….. 9
9.0 Record Keeping…………………………………………………………………………………………………………… 10
10.0 Annual Inspections……………………………………………………………………………………………………… 10

Appendix
A Equipment Specific LO/TO Procedures Example & Form 11
B LO/TO of Simple Electrical Equipment or Machinery 13
C General LO/TO Procedure for Plug Connected Electrical Equipment 14
D General LO/TO Procedure for Motor Vehicle and Powered Industrial Equipment 15
E Annual LO/TO Self-Audit Form 17
F Extended Shift Form 20
G Daily LO/TO Activity Form 21
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Issued By: University Environmental Health and Safety

Effective Date: June 6, 1990

Revision Date: September 1999, August 2003, April 2004, January 2010, May 2011, February 2013

POLICY:
USM LOCK-OUT TAG-OUT PROGRAM

Statement of Purpose:

This program is intended to preserve the safety of those individuals involved with servicing or maintenance of
equipment or machinery. Department’s must ensure that anyone performing servicing or maintenance activities
are conducting these duties in a safe manner, utilizing lock-out tag-out guidelines. LOTO should also be thought
of as rendering something to a Zero Mechanical State (ZMS), as LOTO is not just concerned with electricity.

1.0 Scope and Responsibilities

The following departments have the following responsibilities:

1. University Environmental Health & Safety: Provide guidance to supervisors on how to implement
LOTO/ZMS procedures. University Environmental Health & Safety will offer LOTO awareness
training for employees to fulfill their responsibilities under the LOTO program and perform periodic
audits of the LOTO program.

2. Directors & Department Heads: Deans, Directors, and Department Heads are responsible for ensuring
that specific LOTO/ZMS procedures are developed for those pieces of equipment or machines that are
not covered by Appendix B, C, and D that are serviced by their employees.

Each department is required to perform an annual self-audit of the LOTO/ZMS procedures utilized
within their department.

3. Supervisors: Supervisors who have employees engage in servicing or maintenance of machines or

equipment shall ensure that employees follow LOTO/ZMS procedures, as outlined in Appendices B-D
and/or (Appendix A) specific LOTO/ZMS procedures developed by the department performing the
servicing or maintenance.

Supervisors must provide LOTO awareness training during annual departmental training for all non-
authorized employees and students who are in the area when LOTO activities occur.

Supervisors shall be responsible for ensuring that their employees/students receive Authorized
Employee LOTO/ZMS Training where required. In addition, the supervisor shall ensure that all
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Authorized Employees are trained on each Equipment Specific LOTO Procedure that the Authorized
Employees are required to perform for their department.

4. Employees: Employees who perform servicing or maintenance on machines or equipment may only
perform work for which they have been specifically authorized by their supervisor. Employees who
perform LOTO/ZMS of equipment are required to attend training and follow General or Equipment
Specific Lockout/Tagout Procedures, as appropriate.

5. Students: Students who performed tasks that require LOTO/ZMS must be specifically authorized by
their instructor and supervised by a competent person to ensure compliance with all of the requirements
of the program.

6. Contractors: An outside contractor must have a LOTO/ZMS program in place prior to starting work that
requires LOTO activities at USM.

2.0 Examples of Potential Energy and Zero Mechanical State

Energy Form Energy Source General Guidelines

Electricity  Power transmission  Turn off power at machine first or point of
 Machine power cords operation switch & then at main disconnect
 Motors switch for the machine. Lock and tag the main
 Solenoids disconnect switch or remove fuses from box.
 Capacitors (stored electrical Then lock and tag the box.
energy)  Fully discharge all capacitive systems. For
 Generators example, cycle machines to drain power from
 Batteries capacitors.
 Photovoltaic Arrays  Install grounds where necessary.
 Bump test when appropriate.

Fluid Pressure  Hydraulic systems including  Shut off, lock with chains, built-in lockout
hydraulic presses, rams, devices or lockout attachments and tag valves.
cylinders or hammers Bleed off and blank lines as necessary.
Air Pressure  Pneumatic systems including  Shut off, lock with chains, built-in lockout
lines, pressure reservoirs, devices or lockout attachments and tag valves.
accumulators air surge tanks, Then bleed-off excess air. If pressure cannot be
rams and cylinders. relieved, block any possible movement of the
 Air actuated valves. machinery.
Kinetic Energy  Blades  Stop and block machine parts and ensure that
 Flywheels they do not recycle. Review the entire cycle of
 Materials in supply lines of bins mechanical motion and ensure that all motions
or silos are stopped.
 Block material from moving into an area of work
and blank as required.
Potential Energy  Springs  If possible, lower all suspended parts and loads
 Actuators to the lowest or rest position. Block parts and
 Counterweights might move due to gravity, release or block
 Raised loads stored spring energy.
 Top or moveable part of a press
or lifting device
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Pressurized liquids and gases  Supply lines  Shut off with chains, built-in lockout devices or
including steam and chemicals  Storage tanks and vessels lockout attachments and valves. Bleed-off
excess liquids or gases and blank the lines as
necessary.
1. Hazardous materials may require a double-block and bleed. These requirements must be noted in the
department specific LOTO/ZMS procedures.
2. The Lock-out Tag-out program (LOTO) will be considered complete when your department has
developed and implemented any specific procedures needed to render equipment safe for your
employees to perform maintenance and service work. Specific procedures will be needed for equipment
or machinery not covered by appendix B, C, or D. The specific procedures are to be added to your
department copy of this program, as part of Appendix A.
3. Individuals performing diagnostic work on energized-circuits must follow other applicable safety
protocols such as techniques used in the onsite appliance repair industry.
4. To prevent tampering with LOTO devices machinery or equipment, locks and tags with the name of the
employee that placed the locking device must be used.
5. A qualified person or employee is a person who has sufficient training and experience to safely work on
specific energized conductors. A person who designs LOTO/ZMS procedures must also be electrically
qualified.

3.0 Who is Covered by This Program

1. Any USM employee/student engaged in maintenance or servicing work on machinery or equipment

where unexpected energizing or start-up of the machinery or equipment, or release of stored energy,
could result in serious injury, death, or property damage or whom conducts activities in an area where
LOTO occurs.
2. Potentially hazardous energy sources include, but are not limited to; electricity, hydraulic, kinetic,
steam, pneumatics, and gravity. Day to day or routine maintenance activities, research projects, as well
as renovation or construction projects may involve the potential exposure to potentially hazardous
energy sources. It is an objective of UEH&S to control and eliminate the potential risk involved with
servicing or maintenance activities by implementing the LOTO/ZMS program.
3. Servicing or maintenance work which takes place during normal production operations (such as oiling a
gear via an oil lube port) is not covered by this program unless:
a. An individual is required to remove or bypass a guard or other safety device; or
b. An employee is required to place any part of their body into an area on a machine or piece of
equipment where work is actually performed upon the material being processed (point of
operation) or where an associated danger zone exists during a machine operating cycle (such as
moving gears, chains, etc).

4.0 Lockout Tagout Procedures

The following procedures are to be followed by all employees involved in the servicing or maintenance of
machinery, requiring the use of LOTO/ZMS procedures:

1. Preparatory Procedures: The following procedures are to be performed prior to servicing or maintaining
equipment or machinery covered by this program:
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a) Notify all affected employees that servicing or maintenance is required, that the machine or
equipment must be shut down and locked out to perform the servicing or maintenance, not to
attempt to remove the lockout device, and not try to start the machine or equipment.
b) Ensure that all of the tools and equipment necessary for you to perform the servicing and/or
maintenance have been obtained.
c) Shut down the piece of equipment or machinery using the established procedures.

2. General Lockout/Tagout Procedures: Simple Electrical Equipment or Machinery (Appendix B): If the
piece of equipment or machinery meets the following criteria, an Authorized Employee may implement
this general LOTO procedure:

a) Has no potential for stored or residual energy or re-accumulation of stored energy after
shutdown, which could endanger employees;
b) Has a single energy source that can be easily identified and isolated;
c) Isolating and locking out of that energy source will be completely de-energized/deactivate the
machine or equipment;
d) Is isolated from that energy source and locked out during servicing or maintenance;
e) A single lockout device will achieve a locked-out condition; and,
f) The lockout device is under the exclusive control of the authorized employee performing the
work and it may not be used, shared or removed by other employees.

3. General Lockout/Tagout Procedures: Plug Connected Electrical Equipment (Appendix C): In order for
an Authorized Employee to implement this general LOTO procedure, the piece of equipment or machine
must meet the following criteria:

a) The machine or equipment has no potential for stored or residual energy or re-accumulation of
stored energy after shutdown, which could endanger employees.
b) The machine or equipment has a single energy source that is powered from a cord and plug.

4. General Lockout/Tagout Procedures: Motor Vehicle & Powered Industrial Equipment (Appendix D):
An Authorized Employee may implement this general LOTO procedure when servicing a motor vehicle
or powered industrial equipment.

5. Equipment Specific Lockout/Tagout Procedures: When a piece of equipment requires servicing or

maintenance, but does not meet the criteria for Appendices B, C or D, then an Equipment Specific
LOTO/ZMS procedure must be developed and filed under Appendix A of the USM LOTO Program.
An Equipment Specific LOTO/ZMS Procedure must contain the following details:

a) A specific statement of the intended use of the procedure;

b) Specific steps for shutting down, isolating, blocking and securing machines or equipment to
control hazardous energy;
c) Specific procedural steps for the placement and removal of LOTO devices and the authorized
employee’s responsibility for them; and
d) Specific requirements of testing a machine or equipment to determine and verify the
effectiveness of LOTO devices, and other energy control devices (ZMS).
6. A qualified employee, as defined in the University of Southern Maine Electrical Safety Policy, is
required to review all Equipment Specific Lockout / Tagout Procedures that include specific steps for
isolating and de-energizing and electrical energy source(s). A qualified person or employee is a person
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Document: Lock-out Tag-out Program (Zero Mechanical State) 02/21/2013

who has sufficient training and experience to safely work on specific energized conductors. A person
who designs LOTO/ZMS procedures must also be electrically qualified.

7. Releasing Equipment or Machinery from LOTO/ZMS: When servicing or maintenance is completed

and the equipment or machinery is ready to be released from LOTO, the following steps, in sequence,
shall be taken by the employee who performed the lockout:

a) Check the machine and the immediate area around the machine to ensure that non-essential items
have been removed and that the machine guards and other components are operationally intact;
b) Check the machines and the immediate area around the machine to ensure that non-essential
items have been removed and that the machine guards and other components are operationally
intact:
c) Check the work area to ensure that all employees have been safely positioned or removed from
the area. Notify them that the machine or equipment is going to be released from LOTO;
d) Verify machine controls are in neutral or off position;
e) Removed lockout devices and re-energize the machines or equipment; and,
f) Notify affected employees that servicing or maintenance is completed and the machine or
equipment is ready for use.
g) Note the finish date and time in the appropriate daily or overnight activity form.
h) The tags may be reused by cleaning with isopropyl alcohol. Discard any tags that are damaged or
beyond reuse.

8. Alternative Procedures: When LOTO locks cannot be used, alternative procedures must be developed.
These alternative procedures must be reviewed by the Supervisor and UEH&S prior to implementing.

5.0 Lock Removal Rule

LOTO locks shall not be removed by anyone but the employees who placed the lock, unless the procedures
outlined below are needed and followed. Removing a LOTO device, belonging to someone else, could result in
fatality or serious injury.

If the person who applied a LOTO device is not available to remove the device in a timely manner, the device
may be removed by the authorized employee’s supervisor after the following procedures have been followed:

1. The supervisor must verify that the authorized employee who applied the device is not available;
2. The supervisor shall ensure that servicing or maintenance has been completed prior to releasing the
machine or equipment from LOTO, and procedures for releasing a piece of equipment or machinery
from LOTO are followed;
3. The supervisor must ensure the authorized employee (who placed the lock) knows that the device has
been removed before other employees engages in their work duties;
4. Verification by the employer that the authorized employee who applied the device is not at the facility;
5. Making all reasonable efforts to contact the authorized employee to inform them that their LOTO device
has been removed;
6. Ensuring that the authorized employee has this knowledge before they resume work in that area or
department; and,
7. The reason for the lock removal must be documented and maintained for one year.
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6.0 Responsibility at the End of a Work-Shift

Individuals not completing the servicing or maintenance of equipment or machines that they have Locked-Out
by the end of their workday shall:
1. Leave their attached locks until they complete their maintenance or servicing; and,
2. If another shift will be continuing the maintenance or service work, the authorized individuals from the
on-coming and off-going shifts will transfer responsibilities from the off-going to the on-coming shift.
The off-going shift will remove their lock and the on-coming shift will install their own lock and tags in
accordance with the lockout procedures.
3. Notification to Police and Safety of Extended Shift form shall be used whenever equipment and/or
systems are locked out for extended periods of time (overnight or multiple days). See appendix F
a. The form documents the particular equipment/system, location, start date /time, finish date/time,
and technician performing LO/TO on equipment.

7.0 Group LOTO

When equipment, machine maintenance or servicing is provided by individuals of more than one job class (i.e.
plumbers and electricians), a procedure shall be used that protects all individuals performing maintenance or
servicing. This is accomplished by providing all job classes with a lock which they control. All locks are
secured to a multiple hold lockout hasp. The hasp is attached to the equipment or machine cutoff switch, valve
or combination of both. Those employees assigned (by their co-workers) to control a lock have the same
responsibility as if they were performing the LOTO by themselves. Lock placement and removal shall be
coordinated between the differing job classes.

Group LOTO Guidance:

This guidance provides a sample policy template for group lock-out tag-out procedures.

1. Whenever a group of people perform LOTO work the Group LOTO procedure should provide the same
level of protection as if only one person is performing the work.

2. A lockout hasp should be used to allow each person to affix a lockout device to the energy isolating
device.

3. If two groups or more are involved, a coordinator shall be appointed to coordinate the work. A group
lock box may be used.

4. Once all energy sources have been isolated, residual energy released and locked out, all of the keys to
the locks are placed in the group lockbox and the coordinator or supervisor would then apply their lock
on the group lock box.

5. All group-lockout must be performed under the direction of an assigned or authorized employee as
designated by the manager or supervisor. The primary responsibility is to oversee the group lockout.

6. Each authorized employee involved in the group lockout shall affix a personal lockout device to the
group lockout device at the beginning of their work shift. The lockout devices are removed when work
on the machine or equipment is completed.
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7. During a shift change the authorized employee with the primary responsibilities of the group lockout
will coordinate the orderly transfer of lockout devices so that continuity of protection between off-going
and oncoming employees is maintained.

8. When more than one crew or group is involved, an authorized employee shall be designated to
coordinate the work forces and ensure continuous protection.

Where there are several lockout points to be secured and several authorized employees involved in the project,
group LOTO department specific written procedures must be in place and the following suggestions are made:

1. The primary trade or department obtains a lock box and secures it to the machine or piece of equipment.
2. Lockbox locks and tags are applied to all lockout points by the Authorized Employee from the primary
trade or department.
3. The keys are collected, verified and placed inside the lock box.
4. The lock box is then closed and a multi-lock hasp is affixed to it. This will allow for additional locks to
be added.
5. The last available hole should never be used for a lock. It should remain open to add another multi-lock
hasp, if needed, to create more space. (As many locks as needed for the task can be added to the
equipment.)
6. Each worker then applies their personal lock to the multi-lock hasp such that the box cannot be opened
until each personal lock is removed. Each of the workers personal lock remains in place as long as they
are actively working on the locked out equipment or machinery.
7. In all cases, the last lock to be removed should be that of the person supervising the lockout. This
responsibility should not be delegated to another person.

Before implementing a group lockout, a knowledgeable person, such as the primary trade or supervisor must
plan the procedure ahead of time and develop a written group lockout procedure. The written procedure must be
conspicuously posted at the place where the system is in use. The plan can be in the form of a checklist or a
simple bullet-item listing of the course of action for the group procedure.

8.0 Training

Workers who are to perform LOTO procedures are to receive training prior to engaging in their work. This
training is to be performed by authorized individuals in their departments. UEH&S will authorize department
trainers for LOTO training, and provide LOTO awareness training (as per 1910.147 (7) (i) [B]. The training is
to ensure that the purpose and function of the LOTO program is understood. The supervisor will also ensure
that the employees have acquired the knowledge and skill required for safe application, use and removal of
lockout devices, prior to having authorized employees perform Lockout procedures.

Initial training shall include at least the following:

1. Preparatory LOTO/ZMS procedures;

2. Recognition of hazardous energy sources, the magnitude of the available energy and the methods and
means necessary for isolation and control of the available energy;
3. Releasing equipment or machinery from LOTO/ZMS procedures; and,
4. Reviewing the Equipment Specific LOTO Procedures (provided by the Department Authorized LOTO
Trainer/supervisor).
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Re-training shall be provided:

1. Whenever there is a change in job assignments, change in machines, equipment or process, or whenever
there is a change in the LOTO procedures;
2. Whenever employees are unfamiliar with LOTO procedures, or appear to have inadequate knowledge
concerning what is required by this program, then the employee shall be re-trained prior to servicing or
maintaining the machine or equipment; and,
3. When the department supervisor believes that an employee is in need of the training.
4. Training shall be documented by each department. The documentation should include:
a. Subject of training;
b. Date of training;
c. Employees’ name;
d. Name of supervisor providing the training; and
e. Periodic Program Review Evaluation Information (See Section 10.0).

9.0 Record Keeping

Each department shall maintain records of the following:

1. A copy of this program;

2. Specific LOTO/ZMS procedures for equipment and machinery (found in their department);
3. Training records;
4. Corrective actions taken to address employees found violating the LOTO/ZMS program.
5. This documentation shall be reviewed annually by department and updated as new equipment or
procedures are added.

10.0 Annual Inspections

1. Each department shall perform an annual self-audit of the Equipment Specific, Simple Electrical, and
Motor Vehicle and Powered Industrial Equipment LOTO procedures used by their department.
2. The self-audit is intended to improve the LOTO procedures and to correct or improve any inadequacies.
3. Self-audits must include a visual evaluation of those workers performing the lockout procedures, and are
to be performed by an authorized employee who does not use the LOTO procedure(s) being evaluated.
4. Annual self-audits are to be documented using the annual LOTO Self-audit Form located in Appendix E
of the USM LOTO Program.
5. Completed self-audit forms shall be kept on file for a minimum of two years.
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Appendix A
Equipment Specific Lockout / Tagout Procedures Example

An Equipment Specific LOTO Procedure shall clearly and specifically outline the scope, purpose, authorization,
rules, and techniques to be utilized for the control of hazardous energy. The following four items must be
included in each Equipment Specific LOTO procedure:

1. A specific statement of the intended use of the procedure;

2. Specific step for shutting down, isolating, blocking and securing machines or equipment to control
hazardous energy;
3. Specific procedural steps for the placement and removal of lockout and tagout devices and the authorized
employee’s responsibility for them; and
4. Specific requirements for testing a machine or equipment to determine and verify the effectiveness of
lockout devices, tagout devices, and other energy control devices.

Example: #1 Waste Water Treatment Pump

Machine or Equipment Type: #3 Effluent Pump

Location: Basement Main Facility- Treatment ID # 003

Date Procedure Created 12/09/08 Verified By any authorized person

Date Verified12/12/08
1. Notify all affected employees in the area:
Plant Operator and personnel in the area.

2. Proper Shutdown Procedure:

a. Push “Stop” button in Control Room labeled “#3 Effluent Pump”

3. Isolation of Power Sources:

Energy Type Isolating Device Location Procedure

440 volt Electric Breaker Labeled “C-5” MCC 1st Floor Pull disconnect to the “Open”(Off)
position and place personal lockout on
handle.
Effluent Flow Inlet valve “Yellow” Right side of Pump Close by turning “Clock wise” apply
8 PSI #3. Chain and apply tag and lock.
Effluent Flow Outlet valve “Red” Left side of Pump Close by turning “Clock wise” apply
14 PSI #3. Chain and apply tag and lock.
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4. Bleeding of Potential Energy

Energy Bleed Down Points Procedure
Effluent Water Drain cock on volute. Open and drain

5. Blocking of Potential Mechanical Energy

Hazard Equipment Needed Placement Safety Devices

None

6. Verification Test
Lockout to Verify Controls to try: Process to verify Lockout
Electrical Control Room “Stop” Push “Start” button in Control Room labeled #3 Effluent
“Start” Pump, back to “Off”
All controls must be returned to the “Off” position after the “Verification Test” process.
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Equipment/Task Specific
Lockout Procedure Form
Machine or Equipment Type: __________
Location: __________ ID # ________
Date Procedure Created ___Verified By__________________________
Date Verified__________
1. Notify all affected employees in the area:

2. Proper Shutdown Procedure:

3. Isolation of Hazardous Energies

Note: This form can be compressed (rows deleted) or expanded (rows added) as the specific
procedure demands.

Energy Type Isolating Device Location Procedure

4. Bleeding of Potential Energy:

Energy Type Bleed Down Points Procedure

5. Blocking of Potential Mechanical Energy

Energy Equipment Needed Placement of Safety Devices

6. Verification Test
Lockout to Verify Controls to try: Process to verify Lockout

All controls must be returned to the “Off” position after the “Verification Test”
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Appendix B
Lockout / Tagout of Simple Electrical Equipment or Machinery
Lockout may be performed following the procedures outlined below, for electrical equipment or machinery
meeting the following criteria:

1. The machine or equipment has not potential for stored or residual energy or re-accumulation of stored
energy after shutdown, which could endanger employees.
2. The machine or equipment has a single energy source that can easily be identified and isolated.
3. The isolation and locking out of that energy source will completely de-energize and deactivate the
machine or equipment.
4. The machine or equipment is isolated from that energy source and locked out during servicing or
maintenance.
5. A single lockout device will achieve a locked-out condition.
6. The lockout device is under the exclusive control of the authorized employee performing the servicing
or maintenance and may not be used, shared, or removed by other employees.

Lockout of Simple Equipment or Machinery

General lockout procedures for simple machines or equipment are as follows:

1. Notify all affected employees that servicing or maintenance is required and that the machine or
equipment must be shut down and locked out to perform the servicing or maintenance, and not to
attempt to remove the lock or start the machine or equipment.
2. Ensure that all of the tools and equipment necessary for you to perform the servicing and/or maintenance
have been obtained.
3. If the machine or equipment is in operation, shut it down by following operating procedure (e.g. depress
stop butte, open switch, etc).
4. Isolate the energy source by securing a lock on the disconnect device (cut-off or breaker switch) used
isolate equipment on which work is to be performed. Lockout energy isolating device(s), in the open
position, with assigned individual locks (note: each authorized individual conducting maintenance or
servicing shall ensure that the lock has their name and work phone number attached).
5. Ensure that the equipment or machinery is disconnected from the energy source(s) by first checking that
no personnel are exposed, and then verify the isolation of the equipment by actuating the start button or
switch. Caution: Ensure that the actuation device returns to neutral or “off” position after verifying the
machine or equipment is isolated.
6. Perform maintenance and servicing of equipment or machinery.

Follow procedures for “Releasing Equipment or Machinery from Lockout”:

1. Check the machine and the immediate area around the machine to ensure that non-essential items have
been removed and that the machine guards and other components are operationally intact
2. Check the work area to ensure that all employees have been safety positioned or removed from the area.
And, notify them that the machine or equipment is going to be released from lockout.
3. Verify machine controls are in neutral or off position.
4. Remove lockout devices and re-energize the machine or equipment.
5. Notify affected employees that servicing or maintenance is completed and the machine or equipment is
ready for use.
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Appendix C
General Lockout / Tagout Procedure for
Plug Connected Equipment

1. Plug Connected Lockout Procedure

The following procedure is appropriate when servicing equipment that can be isolated from its hazardous
energy source by the lockout of a single, readily identifiable isolation device, and there is no potential for re-
accumulation/residual/stored energy after the equipment has been locked out.

 The authorized employee shall inform affected employees that service or maintenance is required on
the equipment and that it must be shut down, locked out, and tagged.
 If the equipment is operating, the authorized employee will shut it down following the normal shutdown
procedure.
 The authorized employee will unplug the equipment and apply a clam shell type device to the plug along
with their lock and tag . The tag should have the name of the employee affixing the tag, the date and
time the tag was affixed, and work contact phone number .
 The authorized employee will ensure that stored or residual energy (such as that in capacitors, springs,
elevated machine members, rotating flywheels, hydraulic systems, and air, gas, steam, or water
pressure) is dissipated or restrained by methods such as grounding, repositioning, blocking, or bleeding
down.
 After confirming that no one is exposed to the hazardous energy source/machine, the authorized
employee will verify that the equipment is isolated and residual or stored energy is
dissipated/restrained by activating the start button/switch or other operating control(s), or by testing
the equipment with properly operating and/or calibrated equipment (i.e., voltmeter). Following
testing/verification, the authorized employee will return the operating control(s) to the neutral ("off")
position. Authorized employees must ensure the integrity of the lockout/tagout procedure following any
extended absence.
 When the equipment is ready to be returned to service, the authorized employee should check the
equipment and the immediate area to ensure that nonessential items have been removed, that all
components are operationally intact, and that all guards or other protective features are restored.
 The authorized employee will check the work area to ensure that all personnel are safely positioned
away from the equipment, and verify that the controls are in the neutral, off, or safe position.
 The authorized employee will remove the lockout device and tag, plug in the equipment, re-energize the
equipment, and notify affected employees that work is complete and the equipment is ready to return
to service.
 If the lockout device or tag must be temporarily removed from the energy-isolating device, the
authorized employee must follow the sequence of actions below:
i. Clear the equipment of tools and materials and have all non-authorized employees leave the
equipment area;
ii. Remove the lockout from the energy-isolating device;
iii. Energize the equipment and proceed with testing or positioning;
iv. De-energize all systems and reapply the energy control measures. Continue service and/or
maintenance activities.
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Document: Lock-out Tag-out Program (Zero Mechanical State) 02/21/2013

Appendix D
Lockout / Tagout for Motor Vehicles and Powered Industrial Equipment
(Example)
Machine or Equipment Type: All Fleet Dump Body Trucks

Location: Public Works Garage , Main St. Vehicle ID # 0085

Date Procedure Created: 12/05/08 Verified By: Guy Foreman Date: 12/09/08

1. Notify all affected employees in the area.

2. Hang “Out of Service” Tag on the driver’s side door or on the steering wheel.
3. Put your name, date, time and reason for lockout on the tag.
4. Place dump in position needed for repair if need.
5. Shutdown Procedure:
a. Put in “Park Gear” for automatic or “in gear” for Standard transmissions.
b. Set “Park Brake”
c. Turn engine “Off” remove ignition key.
d. Release air pressure if equipped.
e. See owner’s manual for special shutdown procedures for performing various tasks.

6. Isolation of Power Sources:

Energy Type Isolating Device Location Procedure
Mechanical Start Ignition Key Inside Vehicle Cab Turn key to “Off” position.
up

Electrical “Red” Battery Cable Battery Remove from battery terminal(s)

Compartment and secure from accidental contact
with battery.

7. Blocking of Potential Mechanical Energy

Hazard Equipment Needed Placement Safety Devices
Falling Body or Dump Properly rated jacks, jack For raising body use jacks and back up blocking.
Stands, blocking and dump For dump body use 2 properly rated jack stands
Body pins. and dump body pins. Check owner’s manual for
recommended jack ratings.
Roll Away Wheel Chocks Set emergency brake and place chocks behind and
in front of both left and right wheels.
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Document: Lock-out Tag-out Program (Zero Mechanical State) 02/21/2013

8. Bleeding of Potential Energy

Energy Bleed Down Points Procedure

Hydraulics Bleed Valves Wait until oil cools then bleed off
line. Place oil in container and
dispose of properly.
Pneumatics Bleed Valves Open valve until pressure is relieved.

9. Verification Test
Lockout to Verify Controls to try: Process to verify Lockout
Mechanical Start Ignition Key Turn ignition key to the “Off” position remove from
up Ignition and place inside lockbox and each employee
involved in the vehicle maintenance must put a personal
lock on the lockout box.

Electrical Lights/Elect powered Check to see if the lights come on when switch is
equipment turned to the “On” position, the lights should not
come on.

Falling Body or Dump None Check back up blocking for stress. If none,
Primary jacks or pins are working to hold body
in place.
Roll Away None Try to push vehicle, it should not move.
Hydraulics Any hydraulic controls Controls that were activated, the parts should not
activate.
Pneumatics Any pneumatics controls Controls that were activated, the parts should not
activate.
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Document: Lock-out Tag-out Program (Zero Mechanical State) 02/21/2013

Appendix E
Annual Lock-Out Tag-Out Self-Audit Form

Department:
Location:
Equipment/System:

Inspection Topics Yes No

1 A) Has there been a change in job assignments, machines, equipment or processes?
B) If so, have employees been re-trained when job assignments, machines, equipment or
processes have changed?
2) Are the locks uniquely identified, uniquely keyed, and only used for the purpose of LOTO?

3) Does the tag used with the lock identify the worker servicing the machine or equipment?
4) Has equipment and machine-specific LOTO procedures been documented in writing?
5) Does the employee know where the written LOTO procedures are located?
6) Does the employee notify affected employees and all other employees in the area before
starting the LOTO procedure?
7) Can the employee identify all hazardous energy sources and associated hazards for the
equipment or machine to be locked out?
8) Does the employee follow the proper LOTO procedures for de-energizing the equipment or
machine?
9) Does the employee demonstrate the proper steps for the placement, removal and transfer of
LOTO devices?
10) Does the employee use the proper methods to verify the equipment or machine was de-
energized?
11) Before releasing the machine or equipment from LOTO, does the employee do the
following:
A) Inspect the machine or equipment to ensure it is operationally intact?
B) Ensure that all employees are safely positioned?

C) Notify affected employees and all other employees in the area that the LOTO devices
have been removed?
12) If you answered “No” to questions 2-11, has the employee been re-trained?
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Document: Lock-out Tag-out Program (Zero Mechanical State) 02/21/2013

Deficiencies Observed & Corrective Actions:

Inspected By__________________________ Employee ID________________ Date____________

* This Self-audit record must be maintained by the Department for minimum of two years.
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Document: Lock-out Tag-out Program (Zero Mechanical State) 02/21/2013

APPENDIX F

DFM LOCKOUT / TAGOUT OFFICE RECORDING _____________

CAMPUS ___________________ SCHOOL YEAR _________________

NOTIFICATION TO POLICE & SAFETY OF EXTENDED SHIFT

JOB LOCATION DATE STARTED FINISHED TECHNICIAN

Department: University Environmental Health and Safety 21
Document: Lock-out Tag-out Program (Zero Mechanical State) 02/21/2013

APPENDIX G

DFM LOCKOUT / TAGOUT OFFICE RECORDING _____________

CAMPUS ___________________ SCHOOL YEAR _________________

ROUTINE DAILY LOCKOUT / TAGOUT ACTIVITY FORM

JOB LOCATION DATE STARTED FINISHED TECHNICIAN