LOTO FORM

DOCUMENT APPROVAL INFORMATION

Document Number: Document Version: Document Title: Server Date Signed by / Reason for Signature

Server Date Signed by / Reason for Signature









eFOM-0002891.0

BP-002988: Lockout Tagout Permit Form

Kimberly Tavasoli05-Nov-2009 00:47:24 GMT Owner

Denise Bender05-Nov-2009 17:37:59 GMT Owner

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DOCUMENT NO.

STATUS EFFECTIVE DATE VERSION NO. PAGE NO.

TITLE

LEGACY DOC NUMBER: Amgen Confidential

eEntry Form

eFOM-000289

Effective 12-Nov-2009 1.0 1 of 8


FSS0024A

Effective

STEP 1: GENERAL INFORMATION (This permit is to be kept on the job until work is complete, or permit is revoked.) Primary Authorized Person (PAP): Supervisor: Date: WO #: Permit #:

Equipment ID or description:

Scope of work to be performed:

STEP 1A: HAND-OFF FOR LOTO ACTIVITES Hand-off not applicable for this LOTO This section must be completed by the user/operator/system owner (or designated PAP) of the equipment prior to physically performing LOTO activities. If hand-off is not applicable, justification must be made in the comments section at the bottom of the page. User/Operator/System Owner does NOT need to be LOTO “Authorized Employee” to complete this section. Which activities have been completed on the equipment in preparation for LOTO hand-off?

Drained

Rinsed

CIP’d

SIP’d

Vented

Other See “Comments”

NA

Is the equipment/system available for LOTO activities, and ready to be handed-off to another functional area? Yes No - see “Comments” Initials: Date:

STEP 1B: AFFECTED EMPLOYEES NOTIFICATION (The PAP is responsible for notifying affected employees of LOTO activities regardless if hand-off is applicable or not). Have affected employees been notified of the LOTO? Yes No, provide reason here: STEP 2: HAZARDOUS ENERGY IDENTIFICATION and MAGNITUDE

STEP 3: LOTO POINTS, ISOLATED ENERGIES, and EID POSITIONING STEP 4: APPLICATION OF LOTO

Hazardous Energy Type

(Enter value or use drop-down menu)

Magnitude (Enter value or use drop-down

menu)

Energy Isolating Device’s ID

Pre-LOTO Position

LOTO Position Lock #

Method of Energy Release

(Bleed, drain, vent, etc.)

Method of Verification (Gauge, try, visual, etc.)

Date of Lock/Tag

Application Initials Lock/Tag

Removed

Comments:

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STEP 5: AUTHORIZATION TO PERFORM WORK UNDER LOTO By signing, Primary Authorized Person (PAP) and Reviewer vouch that this LOTO was effective in creating a zero-energy state.

PAP’s Signature Date Time Reviewer’s Printed Named Reviewer’s Signature Date Time

STEP 6: GROUP LOTO (All personnel, including contractors, working under LOTO must enter their information here) Note: Authorized personnel documented under STEP 6 have done so acknowledging that they have been given the opportunity to verify that each EID has been de-energized.

Group LOTO not applicable to this LOTO

LOTO Authorized Person(s) Participating in Group LOTO (Printed Name) Lock box #/Hasp Lock #/Tag Initials Date Lock was Applied

to Group LOTO Device Date Lock was Removed from Group LOTO Device

Comments:

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STEP 7: TRANSFER of LOTO RESPONSIBILITY – SHIFT CHANGE Transfer of LOTO responsibility

not applicable to this LOTO LOTO Authorized Person Assuming Responsibility

(Printed Name) “I have verified all EIDs to be accurate and effective, and accept

responsibility of this LOTO.” (Signature) Date Time

STEP 8: AFFECTED EMPLOYEES NOTIFICATION OF LOTO COMPLETION and RELEASE FROM LOTO Have affected employees been notified of completed LOTO? Yes No, provide reason here: “We confirm that the LOTO work has been completed, and that all locks, tags, and devices have been removed, and the system verified to be fully reassembled and returned to pre-LOTO positions (Step 3). Final PAP’s Printed Name Final PAP’s Signature Date Time Final Reviewer’s Printed Named Final Reviewer’s Signature Date Time

Comments:

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Hazardous Energy Control, Lockout/Tagout Permit (eFOM-000289) Instruction for Completing Permit

Additional information may be available in your site documents EXCEPTION CRITERIA – if all 8 conditions are satisfied, then a LOTO permit is not required: 1. The machine or equipment has no potential for stored or residual energy or re-accumulation of stored energy after shut down which could endanger

employees 2. The machine or equipment has a single energy source which can be readily identified and isolated 3. The isolation and locking out of that energy source will completely de-energize and deactivate the machine or equipment 4. The machine or equipment is isolated from that energy source and locked out during servicing or maintenance 5. A single lockout device will achieve a locked-out condition 6. The lockout device is under the exclusive control of the authorized employee performing the servicing or maintenance 7. The servicing or maintenance does not create hazards for other employees 8. The employer, in utilizing this exception, has had no accidents involving the unexpected activation or re-energization of the machine or equipment during

servicing or maintenance

Step 1: To be completed by Primary Authorized Person (PAP)

Enter the purpose and scope of the work being performed. Reference to a specific work order is acceptable.

Enter the main systems to undergo LOTO or provide a description of the system Identify the equipment # (if available) and type of equipment (e.g. heat exchanger, boiler, tank, gauge, pump, etc.)

Enter Work Order number and LOTO Permit number, if applicable. Note: Some sites use both WO # and Permit #.

Enter the PAP’s name.

Enter the name of PAP’s immediate Supervisor and date.

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Step 1A: To be completed by User/Operator/System owner of the equipment. If not applicable, check box.

Preparation for LOTO hand-off: Check off all activities completed on the equipment in preparing it for hand-off to other organization, i.e., F&E, for servicing/repair or maintenance. If “Other” is checked, provide explanation in the “Comments” section at the bottom of the permit. Some examples of “Other” are: Electrical equipment is shutdown, all chemicals removed from fume hood, and chromatography column disconnected from skid. Note: Hand-off is not applicable if the equipment/system to undergo LOTO is to be serviced/repaired or maintained by the organization that uses/operates/owns the equipment/system. For example, an air-handling unit is operated by F&E, and its maintenance is also done by F&E.

Equipment/system available for LOTO: Check “Yes” if the equipment has been prepared for LOTO. Residual hazards are not expected. Check “No” if the equipment cannot be prepared for LOTO. List any expected hazards in the “Comments” section at the bottom of the permit. This is to communicate any expected or potential risks to Authorized Staff performing service/repair or maintenance on the equipment/system. In these cases, a linebreaking procedure, or live-electrical work may be required.

Equipment user/operator/system owner,or designated PAP initials and dates permit.

Step 1B: To be completed by PAP

Check “Yes” to denote that all affected employees have been notified of the LOTO. This is a regulatory requirement. Check “No” if the PAP did not notify any affected employees. A reason must be provided.

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Steps 2, 3 and 4: To be completed PAP and any delegated LOTO Authorized Employees.

Step 2 Hazardous Energy Type: Enter value or use the drop down menu to select the type of hazardous energy to be isolated. If more spaces are needed, continue the permit by using another blank form. Magnitude: Enter the value or use the drop down menu to select the magnitude of each energy source. Unlisted value must be noted in the “Comments” section at the bottom of the page.

Step 4 Lock #: Enter lock # for each EID. The PAP has overall responsibility for accurate completion of the permit, but may delegate responsibility to other Authorized Employees to lockout individual EIDs. Method of Energy Release: Describe the method to be used to release any stored energy. Examples: Bleed, Drain, Vent, etc. or N/A if there is no stored energy. Method of Verification: Describe the method that will be used to verify the energy source is at a "zero-energy" state. Examples: Electrical = Try or Voltmeter; Pressure = Gauge or Open bleed; Valves = Try; Transfer panel ports = Visual. NOTE: "Qualified" electrical workers, as defined in 1910.333 shall use a voltmeter, appropriate for the voltage, to verify the zero-energy state. Date of Lock/Tag Application and Initials: All authorized personnel applying locks and tags to the EIDs shall initial and date for each lock they applied. Where a lock cannot be applied, the authorized person shall place a tag and then include a description of an additional safety measure (e.g. remove handle) in the comments section. Lock/Tag Removed: As each lock/tag is removed from the applicable EID, check the box corresponding to that EID.

Step 3 Energy Isolating Devices: List all Energy Isolating Devices (EID). An EID is a mechanical device that prevents the flow or release of energy. Pre-LOTO Position: Enter pre-LOT0 position of each EID. LOTO Position: Enter LOTO position of each EID.

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Step 5: To be completed by PAP and Reviewer.

Reviewer: A second Authorized Employee, who knows and understands tequipment/system to undergo LOTO, shall be designated as the Reviewer and shreview the information in Steps 1 – 4. The Reviewer must verify that all sources have been accurately identified, isolated, de-energized and locked/tagged ouaccordance with the HECP outlined in the permit. If all these conditions have bemet, then the Reviewer shall print their name, sign and date the permit.

he all

t in en

PAP: The PAP shall sign and date indicating that all of tEIDs identified in the HECP have been safely isolated, denergized, residual or stored energy relieved, blocked disconnected, verified and locked/tagged out. The PAshall stop all work if these conditions cannot be met acontact their Supervisor for assistance.

he e-

or P

nd

Step 6: To be completed by all Authorized Employees in group LOTO. If not applicable, check box.

All personnel working under the LOTO permit shall be trained as LOTO Authorized Employee. Participating Authorized Employees must affix their lock/tag to the group lockout device (e.g. hasp or lockbox) while conducting servicing/maintenance work under the LOTO permit. LOTO Authorized Person(s) Participating in Group LOTO: Print name, initial, and record the date their lock was applied and the date it was removed. If using a TRANSFER lock, refer to the transfer Lock procedures in sites DP. Lock box #/Hasp: Enter the lock box number or hasp. Lock #/Tag: Enter the individual lock number. Contractors must have their own locks/tags. Initials: Each Authorized Employees documented on this permit must enter his/her initials on the permit. All Authorized Employees have done so acknowledging that they have been given the opportunity to verify that each energy isolation device has been de-energized. Date Lock was Applied to Group LOTO Device: Enter the date which the individual lock was added to the lock box or hasp. Date Lock was Removed from Group LOTO Device: Enter the date which the individual lock was removed from the lock box or hasp.

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Step 7: To be completed by PAP assuming responsibility. If not applicable, check box.

Step 8: To be completed by Final PAP and Final Reviewer

STEP 9: RELEASE FROM LOCKOUT/TAGOUT

Before removing any LOTO devices and restoring energy, the PAP shall inspect the LOTO boundary and ensure that all staff are in a safe location, equipment is operationally intact, all tools have been removed. The PAP is responsible for notifying affected employees in the area of the completion of LOTO, and that the equipment is about to be re-energized. The Final PAP and Final Reviewer shall physically confirm that all locks and tags have been removed and the system is ready to be returned to service. The PAP and the Reviewer shall print and sign their name and document the date and time this was completed.

During a shift change/gap, the PAP can be transferred to another PAP, the new PAP must print their name on the line corresponding to the previous PAP, initial and date/time. Each time the PAP is transferred, this procedure must be followed. NOTE: For sites with TRANSFER lock procedures, in the absence of a new PAP to transfer the permit to, a TRANSFER lock shall be applied to the

group lockout device until a new PAP accepts responsibility for the permit under Step 7. Refer to specific procedures listed in your site’s procedure.

Completed permit must be kept at the site for 5 years according to Amgen’s record retention requirement. Failure to comply with this procedure may result in disciplinary action, up to and including termination.

LOTO FORM

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