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Group Lockout Register / Issue Date: 6th April 2015
Approved by: Ian Powell / Review Date: 6th April 2017
Corps / Site: / Division / Department:
Work Area
Details of task to be performed / Plant or Equipment
Plant & Equipment Isolation Assessment
Energy Source Identification Actions / Proving Safe
Electrical points isolated / q / Hydraulic points blocked / q / Start buttons activated / q / “Jog” buttons activated / q
Pneumatic points blocked / q / Suspended equipment lowered / q / Moveable parts at confirmed at rest / q / Electrical circuit power off / q
Parts affected by gravity blocked / q / Air lines/steam drained/blocked / q / Potential (stored) energy released / q / Kinetic (motion) energy released / q
Spring energy released / blocked / q / Hazardous fluids / gas drained / blocked / q / Danger Tag(s) applied / q / All persons below have been shown & proven safe all identified isolation points / q
I hereby confirm that an assessment has been conducted, all applicable energy sources and associated isolation points have been identified for the purpose of performing the task(s) as described above and that each person has been issued with the necessary locks to isolate all energy sources.
Responsible Person: / Signature: / Date: /
Time Commenced / Applicable Energy Sources Isolated / Name of Person / Lock & Key Number Assigned / Signature
Lock On / Signature Lock Off / Time Finished
am / pm / am / pm
am / pm / am / pm
am / pm / am / pm
am / pm / am / pm
am / pm / am / pm
am / pm / am / pm
am / pm / am / pm
am / pm / am / pm
am / pm / am / pm
am / pm / am / pm
I hereby confirm that I have inspected the plant / equipment / machine which was isolated, that all locks have been removed, relevant Dept / site management have been notified and that the plant / equipment / machine can been returned to full operational status
Responsible Person: / Signature: / Date: /
All printed documents are uncontrolled