SAFE WORK PERMIT –ENERGY ISOLATIONATTACHMENT

Form 01456 Revised Feb. 242012

/

ID #:

Y N
Lock Box Used? Lock Box # ______Equipment/System ID ______Date Of Initial Isolation Activities ______
Contents of line/system PRIOR TO DRAINING OR CLEANING(i.e., chemicals, acids, steroids, etc.):______N/A
Type Of Energy & Location
(Chemical Names, Electrical, Pressure, Other) / Valve / Tag # / Open / On / Closed / Off / Lock # / Isolated
By (Initial) / Date / Lock/Tag Removed By (Initial) / Date
ADDITIONAL ENERGY ISOLATION INFORMATION LOCATED ON THE BACK OF THIS ATTACHMENT
ALL PERSONNEL WORKING ON THE SYSTEM MUST HAVE INDIVIDUAL CONTROL OF EACH ENERGY SOURCE IN ACCORDANCE WITH THE LOCKOUT/TAGOUT PROGRAM.
SAFE WORK PERMIT – ENERGY ISOLATION ATTACHMENT (CONTINUED)
Type Of Energy & Location
(Chemical Names, Electrical, Pressure, Other) / Valve / Tag # / Open / On / Closed / Off / Lock # / Isolated By (Initial) / Date / Lock/Tag Removed By (Initial) / Date
ALL PERSONNEL WORKING ON THE SYSTEM MUST HAVE INDIVIDUAL CONTROL OF EACH ENERGY SOURCE IN ACCORDANCE WITH THE LOCKOUT/TAGOUT PROGRAM.
All persons working on the system must initial that their personal lock has been applied before work is started & removed after work is complete.
LOCKOUT/TAGOUT APPLIED / LOCKOUT/TAGOUT REMOVED
INITIAL / INITIAL
/ CONTROL LOCK (OPERATING UNIT)
CONTROL LOCK # : ______
LOCK APPLIED / LOCK REMOVED
INITIAL / INITIAL
A control lock shall be applied by the Operating Unit to the Lock Box (or individual energy sources if a Lock Box is not used). This lock is for maintaining control of the in-progress Lockout and is NOT for personal protection.
LINE SYSTEM INTEGRITY ASSESSMENTNA(Initials _____) (MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Complete for process and service piping after Line Entry is complete and system is being restored
Y N
Pressure test not possible - completeLine Integrity Checklist
Pressure test is possible –contact operating unit for completion ofLine Integrity Pressure Test
Fugitive Emissions requirements apply – use MACTFUG Pressure Form or call 3-644 for OVA Monitoring on tagged equipment.
LINE INTEGRITY CHECKLIST (MAINTENANCE/CONTRACTOR)
Y NA
Spill kit is on hand & available
Replacement gaskets used
Replacement bolts used / Y NA
Flanges/connections are tight
Bolt threads extend nut
Drain/bleed valves are closed / Y NA
Operating unit positioned valves properly
Established and maintained flow/pressure
Confirmed integrity of system (no leaks)
Line Integrity Checklistperformed by ______Date:______
LINE INTEGRITY PRESSURE TEST (MAINTENANCE/CONTRACTOR or OPERATING UNIT)
Y NA
Pressurize system with gas and confirm acceptable pressure drop.
Pressurize system with gas and use liquid leak detectionfluid to confirm no visual leaks.
Pressurize system with fluid and confirm no visual leaks.
Pressure test performed by ______Date:______

Keep completed attachment with Lock Box or at job site during work

Attach completed Energy Isolation Attachment to last Safe Work Permit applicable to completed job and send to EHS - PORT-41-016