Lockout Tagout Isolation Permit Example
Example document for Lockout Tagout Isolation Permit. Use this as a reference when creating your own.
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Document: Lockout Tagout Isolation Permit
Example Document
Last updated 7/27/2026
LOCKOUT TAGOUT ISOLATION PERMIT
Permit Number: ISO-2023-045 Date of Issue: 24 October 2023 Time of Issue: 07:00 Valid Until: 24 October 2023 @ 15:00
1. JOB DETAILS
Company Name: Apex Manufacturing Pty Ltd Site Location: 12 Factory Road, Smithfield, NSW Work Area/Zone: Zone B - Packaging Line
Description of Work to be Done: Replace worn drive belt on Conveyor Belt 3 and repair jammed guarding on the roller assembly.
2. EQUIPMENT DETAILS
Equipment ID/Tag Number: CONV-03-B Equipment Name/Description: Main Packaging Conveyor Belt
Hazardous Energy Sources Identified (Tick all that apply):
- Electrical (Voltage: 415V)
- Hydraulic
- Pneumatic
- Mechanical (Kinetic)
- Chemical
- Thermal (Steam/Hot Water)
- Gravity (Raised loads)
- Other:
3. AUTHORIZATION
I hereby authorize the isolation of the above equipment for the described work.
Authorized Person (Manager/Supervisor): J. Smith Signature: J. Smith Time: 07:05
4. ISOLATION PROCEDURE
A. Shutdown
Equipment has been shut down normally by: M. Davis Time: 07:10
B. Isolation Points
| Energy Source | Isolation Point Description | Isolation Method | Isolated By | Time |
|---|---|---|---|---|
| Electrical | Main MCC Board Panel B, Breaker 5 | Circuit Breaker OFF | M. Davis | 07:15 |
| Mechanical | Drive Motor Coupling | Disc coupling disconnected | M. Davis | 07:20 |
C. Lockout / Tagout
Lockout Number: L-101 Tag Number: T-101 Lock Applied By: M. Davis Signature: M. Davis
D. Verification (Zero Energy Check)
I have verified that all energy sources are isolated and zero energy exists.
- Attempted to start equipment (Failed to start - SAFE)
- Measured voltage at test points (0V)
- Bled pressure lines to 0 PSI
- Dissipated stored energy (Fan stopped)
- Mechanical blocks installed
Verified By: M. Davis Signature: M. Davis Time: 07:25
5. WORKER SIGN ON
| Name | Trade/Role | Signature | Time On | Time Off |
|---|---|---|---|---|
| M. Davis | Mechanic | 07:25 | 11:30 | |
| S. Lee | Apprentice | 07:30 | 11:30 |
6. EXTENSIONS
Not applicable
7. COMPLETION & HANDOVER
I certify that the work described in Section 1 is complete.
- All tools and equipment have been removed.
- All safety guards have been replaced.
- All workers are clear of the machinery.
- Non-essential personnel have left the area.
Work Completed By: M. Davis Signature: M. Davis Time: 11:30
8. REMOVAL OF ISOLATION
I certify that I am removing the locks and tags listed in Section 4.
Locks/Tags Removed By: M. Davis Signature: M. Davis Time: 11:35
Authorizing Person (Sign Off): J. Smith Time: 11:40
Permit Status: [x] COMPLETE - [ ] CANCELLED
Notes
This example illustrates a standard mechanical maintenance task. Note that the verification step includes confirming the start button failed to operate. The isolation of the mechanical coupling is critical because simply turning off the power does not prevent movement if gravity or momentum could still move the belt.
About this Example
Part of the Lockout Tagout Isolation Permit document collection
Document Type
Lockout Tagout Isolation Permit
A formal document used to control hazardous energy sources during maintenance or servicing of machinery and plant to ensure worker safety.