SMP-338 Attachment 1

HAZARDOUS ENERGY CONTROL PROCEDURE Control Number _____________

LOCKOUT/TAGOUT SHEET Sheet _______ of _______

IDENTIFICATION/LOCATION OF EQUIPMENT/MACHINERY/PROCESS TO BE MAINTAINED/SERVICED:

DESCRIPTION OF WORK TO BE CONDUCTED:

OTHER PERMITS IN EFFECT? YES ___ NO___ DESCRIBE PRODUCTION LOCKBOX/LOCKBAR METHOD TO BE USED? YES __ NO __

If YES, Designate Person(s) Responsible for Applicaiton/Removal of All Lockout/Tagout Devices:

Application: Date:

Removal: Date:
MAINTENANCE/SERVICING WORK RESPONSIBILITY (NAME):
IF NO*, Specify Name(s) of All Authorized Person(s) Applying/Removing Personal Lock(s)/Tagout Device(s)

Directly to Each Equipment Energy Isolation Control Device:

EQUIPMENT OPERATION/PRODUCTION RESPONSIBILITY (NAME):
Name: Date Applied: Date Removed:

Name: Date Applied: Date Removed:

EQUIPMENT/PROCESS SHUTDOWN AND ALL AFFECTED PERSONNEL NOTIFIED? Name: Date Applied: Date Removed:

YES__ NO__ DATE: Name: Date Applied: Date Removed:

PRE-JOB DISCUSSION HELD WITH ALL AUTHORIZED PERSONNEL? Name: Date Applied: Date Removed:

YES__ NO__ DATE: Name: Date Applied: Date Removed:

1 2 3 4 5 6 7 8 9 10 11 12 13 14
Energy Location and Type of Energy Isolation / ID Zero Energy Verification Lock If No, Describe what Tag Isolation Device Isolation Device Zero Energy Temporary Final Isolation Control
Type Control Devices, i.e. Disconnects, Valves, Number Measures To Be Taken - Must Installed additional Tagout measures Number Installed By Reviewed By Verified Changes Only Position Device Removed
Etc. (Also, Indicate the position that will make be verified in Column '10' Yes/No will be taken - Must be Initial/Date Initial/Date By of And Final
the device isolated. i.e."Close valve" verified in Column '10' Device Position Verified
Initial/Date Initial and Date

NOTE: SPECIAL PRECAUTIONS/PROCEDURES, SHIFT, AND/OR WORK STATUS CHANGES

ENERGY TYPE: E - ELECTRICAL C - CRYOGENIC P - PNEUMATIC S - STEAM H - HYDRAULIC G - GRAVITY M - MECHANICAL A-ACID CC-CORROSIVE T-TOXIC F-FLAMMABLE R-REACTIVE
 SMP-338 Attachment 1

HAZARDOUS ENERGY CONTROL PROCEDURE Control Number____________

LOCKOUT/TAGOUT SHEET Sheet _______ of _______
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Energy Location and Type of Energy Isolation/Control ID Zero Energy Verification Lock If No, Describe what Tag Isolation Device Isolation Zero Energy Temporary Final Isolation Control
Type Devices, i.e., Disconnects, Valves, etc. (Also, Number Measures To Be Taken - Must Installed additional Tagout measures Number Installed By Reviewed By Verified Changes Only Position Device Removed
Indicate the position that will make the device be verified in Column '10' Yes/No will be taken - Must be Initial/Date Initial/Date By of And Final
isolated, i.e.,"Close valve." verified in Column '10' Device Position Verified
Initial/Date Initial and Date

NOTE: SPECIAL PRECAUTIONS/PROCEDURES, SHIFT, AND/OR WORK STATUS CHANGES

ENERGY TYPE: E - ELECTRICAL C - CRYOGENIC P - PNEUMATIC S - STEAM H - HYDRAULIC G - GRAVITY M - MECHANICAL A-ACID CC-CORROSIVE T-TOXIC F-FLAMMABLE R-REACTIVE
 SMP-338 Attachment 1

LOTO Sheet Instructions

Control Number
The control number should be a unique number. If there is not a "SSOP" Site-Specific Operating Procedure, the ID number from the first HWP written for the job shall be used.
When subsequent HWPs are written, there is no need to change the LOTO sheet.

Sheet ___ of ___

Indicate the number of sheets used to complete the LOTO.

IDENTIFICATION/LOCATION OF EQUIPMENT/MACHINERY/PROCESS TO BE MAINTAINED/SERVICED:

Be specific as to the equipment that is being serviced.(e.g., BLAC #2).

DESCRIPTION OF WORK TO BE CONDUCTED:

Describe the actual work that will be performed (e.g., replacing the oil pump coupling).

OTHER PERMITS IN EFFECT? YES_____ NO_____ DESCRIBE:

Describe any other permit being used to perform the job (e.g., HWP, CSE permit, EEWP, etc.). The number of the permit is not necessary, but the type of permit must be listed.

MAINTENANCE/SERVICING WORK RESPONSIBILITY (NAME):

Indicate the name of the person actually performing the work on the equipment. This is to ensure that there is a contact person to determine if the work has been completed prior
to removing the locks/tags.

EQUIPMENT OPERATION/PRODUCTION RESPONSIBILITY (NAME):

Indicate the actual individual responsible for operating the equipment (e.g., The operator on shift or the technician responsible for the plant). This makes operations aware of the status
of the plant/facility.

EQUIPMENT/PROCESS SHUTDOWN AND ALL AFFECTED PERSONNEL NOTIFIED? YES_____ NO_____ DATE:
Ensure the process has been safely shut down and the affected personnel have been notified.

PRODUCTION LOCKBOX METHOD TO BE USED? YES ______ NO _______

Checking "yes" indicates someone will apply production/personal locks/tags on all the equipment and place the keys in a lockbox. The person attaching the locks will then place a personal
lock on the lockbox. Individuals wishing to work on the equipment will then place their lock on the lockbox prior to performing maintenance.

If YES, Designate Person(s) Responsible for Application/Removal of All Lockout/Tagout Devices:

1. Write the name of the individual responsible for attaching and removing the locks/tags. If there is a change in the responsibility for removing the locks due to shift change, vacation, or
work schedule, indicate these changes in the "SPECIAL PRECAUTIONS/PROCEDURES, SHIFT, AND/OR WORK STATUS CHANGES" box on the bottom of the LOTO sheet.
2. When the Lockbox method is used, the designated person responsible for the production Lockout/Tagout devices retrieves the key and removes the devices from the equipment.
The name of the person and the removal date is then written on the
Lockout/Tagout sheet where it states, "Removal." After removal equipment startup procedures can then be implemented as appropriate.

IF NO, Specify Name(s) of All Authorized Person(s) Applying/Removing Personal Lock(s)/Tagout Device(s) directly to Each Equipment Energy Isolation Control Device:
1. The individual listed in the shaded box is responsible for applying locks first and removing locks last and also ensuring that the LOTO is sufficient to protect all
personnel performing maintenance.
2. Individuals performing maintenance on the equipment will apply their own locks at each energy isolation point and print their name and date on the LOTO sheet

Column 1 - ENERGY TYPE

Ensure the type of energy you are isolating is understood, and indicated in this column by using the codes at the bottom of the sheet. If there is a source not indicated on the legend, explain.

Column 2 - LOCATION & TYPE OF ENERGY ISOLATION/CONTROL DEVICES, I.E., DISCONNECTS, VALVES, ETC.
Indicate the location and type of device (i.e., fan motor breaker in switch gear building 2, or BLOC #2 suction and discharge valves). Also, indicate on this column what you plan to do with the device; close it, open it,
disconnect it, etc.

Column 3 - ID. NUMBER

Using the SWD or P&ID, list the valve, breaker, or device number (DV-1 or CB-15).

Column 4 - ZERO ENERGY VERIFICATION MEASURES

Indicate how you verified "ZERO" energy. (Vent valve opened, no pressure; or checked for zero voltage with meter and push the start button). This verification must be confirmed in Column 9.

Column 5 - LOCK Y/N

Indicate whether or not a lock was applied to the energy isolation point. Use whatever means possible to place a lock on the isolation.

Column 6 - IF NO, ADDITIONAL TAGOUT MEASURES TO BE TAKEN

If you were not able to place a lock on an energy isolation point, indicate the additional measures you have taken to ensure the isolation points current position will not be changed. This measure must be verfied in
Column 9.
Keep in mind that with all the devices manufactured to assist in energy isolation, this option should rarely be used.

Column 7 - TAG NUMBER

Each tag is to have a unique and distinguished number written on the bottom corner below the space for initials. With multiple isolations in place, it is very improtant that all personnel are able to distinguish one
isolation from another by tag number. The tags must be tied to a specific isolation sheet.

Column 8 - ISOLATION DEVICE INSTALLED BY

The person isolating and installing the isolation devices must intial and date each isolation point listed on the LOTO sheet.

Column 9 - ISOLATION REVIEWED BY INITIAL/DATE

When it is possible, a second person should review the isolation sheet to ensure accuracy and completeness. They should review the P&ID, check isolations on the drawing, and verify that the correct isolation
position is achieved by personally inspecting each isolation point. As they complete their inspection, they should initial and date Column 9 for each point of isolation.
Note: There will be times when a second person is not available to complete this task. In these cases, column 9 will be left blank. However, the individual creating the isolation may have the option of
contacting a supervisor or other authorized employee to review the isolation.

Column 10 - ZERO ENERGY VERIFIED BY

The person responsible for installing the isolations must verfiy each isolation measure listed in Columns 4 and 6.

Columns 11 and 12 - TEMPORARY CHANGES

This section is to be used for testing only. If locks/tags need to be removed to check a motor for rotation or the tightness of a fitting etc., this column would be completed. The columns are split for multiple applications.

Column 13 - FINAL POSITIOIN OF DEVICE

The isolation device shall be removed, the valve, breaker, blind, etc. should be placed in the desired position for startup and then noted on Column 13. This step is done in conjunction with Column 14.

Column 14 - ISOLATION CONTROL DEVICE REMOVED AND FINAL POSITION VERFIED

Verify that the control device is in the correct position for start up as is indicated in Column 13, date and intial Column 14. Also, sign and date "Removal and Date" in 'Production Lockbox method to be used' section
of the form.

NOTE: SPECIAL PRECAUTIONS/PROCEDURES, SHIFT, AND/OR WORK STATUS CHANGES

1. This section is to be used when there is a change in the individual who may be required to remove the locks or tags due to shift changes, of vacation, or any other reason the
person applying the locks is not available. Note this section is not to be used in the case where an individual has forgotten to remove their locks at the end of a shift.
2. If an individual forgets to remove his/her lock and goes home, the local management must follow the "Lock and/or Tag removal procedure". A form must be completed and filed out.

Issued: 17 Sep 2014 Page 3 of 3