LOCK-OUT / TAG-OUT (L.O.T.O.
) PERMIT TO WORK
PERMIT TO WORK / REPAIR / INSPECT / CLEAN / MAINTAIN LIVE ELECTRICAL & MECHANICAL
EQUIPMENT / SYSTEMS
Work shall not commence until stages 1 to 4 are duly completed
PART 1: APPLICATION
Company / Department: Names of Workers Involved: Permit No.
Authorized Person: Date / Time:
Permit Receiver: Location:
Description of work:
PART 2: ENDORSEMENT BY AUTHORIZED PERSON
Confirmation of Lock-Out Practices Tick
1. All electrical points had been isolated & earthed
1. I have referred to the electrical installation layout
plan. 2. All isolated points had been securely lock-out
2. I have identified the electrical points to be isolated, 3. All isolated points had been displayed with
locked-out and tagged-out. ‘Danger! Do Not Operate!’
4. All locks are in good working conditions.
3. I have briefed all personnel involved in the work on
the Lock-Out Procedure. 5. All workmen using required PPE’s.
4. There are no Incompatible work processes being 6. I have briefed all the workmen
carried out.
7. Other safety checks / instructions:
________________________________________
Signature & Date
PART 3: ENDORSEMENT BY H.S.E. DEPT PART 4: ACCEPTANCE BY PERMIT RECEIVER
This above work is: 1. I understand the nature of work and all safety measures
instructed have been taken.
APPROVED 2. I have briefed the workmen on the ‘Part 5’ Safety
Briefing.
NOT APPROVED 3. I agreed and accepted the conditions and shall stop
work immediately should any of the condition changes.
________________________________________ ________________________________________
Signature & Date Signature & Date
PART 6: PERMIT-TO-WORK CLOSE OUT
I hereby inform the H.S.E. Department that the above work has completed on ___________ (Date) at ________ (Time)
I have inspected the work areas and have ensured that all ignitions have been put off and I have performed
housekeeping to the work area.
________________________________________
Signature & Date
Form No : P224-7 Rev0 Page 1 of 2
PART 5: SAFETY BRIEFING ON SAFE WORK PRACTICES
BEFORE Works / Repairs
1. Permit Receiver involved in the works / repairs / inspection / cleaning / maintenance on electrical equipment /
system / machinery / plant shall apply for permit to work from the Authorized Person.
2. Authorized Person shall identify the electrical points to be isolated through the site electrical installation plan.
3. Authorized Person, with the assistant of the electrical department, shall isolate and earth all power points
connected to the electrical equipment / system.
4. Authorized Person shall remove all ‘Equipment Alive!’ tags, then shall Lock-Out and display ‘Danger! Do not
Operate!’ tags for all isolated points.
5. Permit Receiver Locks-Out and display ‘Danger! Do not Operate!’ tags at all isolated points over the
Authorized Person’s safety tags.
6. Permit Receiver trains all personnel involved in the works on the Permit to Work procedure and instructions.
7. Permit Receiver acknowledges the Permit to Work and commences works / repairs / inspection / cleaning /
maintenance.
AFTER Works / Repairs
1. Permit Receiver notifies Authorized Person through Permit to Work that all works / repairs / inspection /
cleaning / maintenance completed.
2. Permit Receiver informs all personnel involved to confirm on the completion of works / repairs / inspection /
cleaning / maintenance.
3. Permit Receiver removes all locks and tags.
4. Authorized Person removes all locks and tags.
5. Authorized Person, with the assistant of the electrical department, re-energizes all power points to the electrical
equipment / system / machinery / plant and displays the ‘Equipment Alive!’ tag.
The keys to all locks shall only be held by the Authorized Person and the Permit Receiver.
The lock out method by Authorised Persons shall be in such a manner that no other person can energise the
electrical equipment / system / machinery / plant unless the lock is removed.
EMERGENCY Response Briefing
In the case of fire: Fight fire if possible and safe to do so.
Report to supervisor in-charge or if he is not present H.S.E. Department immediately.
Remove all flammable materials which can spread the fire.
Switch off all machinery and electrical supplies.
Evacuate and assembly at the Muster Point.
In the case of casualty: Do not touch victim unless you are sure that you will not be electrocuted
Perform CPR if you are trained and it is safe to do so.
Keep victim attended at all times
Report to the supervisor in-charge or H.S.E. Department immediately.
Clear all obstructions for effective emergency team access.
Barricade incident area.
ATTENDENCE RECORD
No. Name / I.D. Signature No. Name / I.D. Signature
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2 7
3 8
4 9
5 10
Form No : P224-7 Rev0 Page 2 of 2
