LOCK OUT-TAG OUT PERMIT

Vessel Name: __________________________________

Location of Work: __________________________ This Permit is valid from ________Hrs to _________Hrs
1. Work Plan & Reason for Lock out / Tag out: _______________________________________________________
____________________________________________________________________________________________
Associated Permits (If any): 1. 3.
2. 4.

2. Sources of Energy (Please select appropriate energy source)

Electrical 110 V.A.C. Gas (Including Inert Gas) Hydraulic Thermal
Electrical 220 V.A.C. Steam Chemical Compressed Air
Electrical 440 V.A.C. Pneumatic Water Other (Specify): ________________

*3. Details of Isolation System to be Used: ____________________________________________________________

# 4. Identify Isolation Points
Tag-out / Lock-out Tag / Lock removed
Lock/ Tag No. System / Valve to be locked-out / Tagged-out
Date Time Date Time

5. What tests to be done ensure positive isolation prior to start to work (e.g. pressing start button after isolation)?
_______________________________________________________________________________________________

Original - To be kept at the work site and subsequently filed in the Permit To Work file upon completion of work. Rev. 1  03/20  S ‐ 9.5 C
Copy - To be kept at the Work Control Station (Ship’s Office / ECR) and destroyed upon completion of work.
6. Retest done to ensure positive isolation after breaks
Tested by
Time Location Type of Test Ensure Positive Isolation Signature
(Person In-charge)

7. Permit Issuance
The equipment and work area have been jointly inspected by the Person In-charge and the concerned crew members. The
Master or Chief Engineer warrants that the work described can safely proceed. The precautions and conditions have been
adhered to, and no attempt will be made by any persons to alter the conditions or carry out any other work other than that
specified.
Isolating Person Person In-charge Master / Chief Engineer
Name / Rank: Name / Rank: Name / Rank:
Date / Time: Date / Time: Date / Time:
Signature: Signature: Signature:

8. Instructions for returning to service (e.g. putting back a fuse in to the electrical circuit etc):
________________________________________________________________________________________________
9. Permit Closure
Completion of work Back to standby mode Closure of Permit
Work for which this permit is issued, I have physically checked the worksite and I hereby certify that the permit for
has now been completed and the can confirm that the work has been the job now stands closed.
worksite restored to a safe condition completed and the area restored to a safe and
tidy condition.
Isolating Person Person In-charge Master / Chief Engineer
Name: Name: Name:

Signature: Signature: Signature:

Date / Time: Date / Time: Date / Time:

Note:
* Valves where closed to be secured or lashed and suitably labeled to prevent inadvertent opening.
# Method of isolation: Breaker secured, Line blanked, valves closed, lines disconnected, vented to atmosphere, drained, purged, washed & others.

Original - To be kept at the work site and subsequently filed in the Permit To Work file upon completion of work. Rev. 1  03/20  S ‐ 9.5 C
Copy - To be kept at the Work Control Station (Ship’s Office / ECR) and destroyed upon completion of work.