Isolation Permit/ High Voltage Permit No

Rumaila Operating Organization
Isolation Permit/ High Voltage
ISOLATION PERMIT/ HIGH VOLTAGE PERMIT NO.

CONTRACTOR PROJECT/ SITE
PERFORMING AUTHORITY CONTACT NO.
AREA AUTHORITY CONTACT NO.
SCOPE OF WORKS:

DATE OF ISSUE / / DATE OF EXPIRY / /
ENERGY SOURCES APPLICABLE TO THIS EQUIPMENT ENERGY CONTROL DEVICES NEEDED

Electrical ☐ Compressed Gas ☐ Locks ☐ Plug Cover Box ☐
Hydraulic ☐ Radio Frequency ☐ Tags ☐ Pins ☐
Mechanical ☐ Water ☐ Chain ☐ Grounding Cable set ☐
Thermal ☐ Springs ☐ Hasps ☐ ☐
Pneumatic ☐ Air ☐ Block ☒ ☐
PRECAUTIONS (tick as applicable) YES NO NA YES NO NA
Identify all energy sources ☐ ☐ ☐ Apply lockout devices ☐ ☐ ☐

Notify affected employees/ Departments ☐ ☐ ☐ Reduce equipment to a zero energy state ☐ ☐ ☐
The equipment has been removed from service ☐ ☐ ☐ Test and Verify equipment isolation ☐ ☐ ☐
The equipment has been isolated ☐ ☐ ☐ Perform Task ☐ ☐ ☐
Notify Supervisor when equipment is available for
☐ ☐ ☐ Return all lockout devices to proper storage ☐ ☐ ☐
service
KNOWN HAZARDS & CONTROL MEASURES:
-
-
-
-
-
REQUIRED PPE (tick as applicable) YES NO NA YES NO NA
Hard Hats ☐ ☐ ☐ Hearing Protection ☐ ☐ ☐

Steel Toed Safety Footwear ☐ ☐ ☐ Fall Arrest/ Restraints ☐ ☐ ☐
Gloves or other Hand Protection ☐ ☐ ☐ Eye/ Face Protection ☐ ☐ ☐
High Visibility Clothing ☐ ☐ ☐ Respiratory Protection ☐ ☐ ☐
Screens ☐ ☐ ☐ Barriers and Signs ☐ ☐ ☐
ADDITIONAL PPE/ EQUIPMENT REQUIRED:
-
DRAWING/ SKETCH (if applicable):
RECOMMENDED SEQUENCE OF LOCKOUT:

1
Rumaila Operating Organization
Notify all affected employees that servicing or maintenance is required on a machine or equipment and that the machine or equipment must be shut down and locked out to
1
perform the servicing or maintenance.
The authorized employee shall refer to the procedure to identify the type and magnitude of the energy that the machine or equipment utilizes, understand the hazards of the
2
energy, and know the methods to control the energy.
3 If the machine or equipment is operating, shut it down by the normal stopping procedure (depress stop button, open switch, close valve, etc.).
4 Deactivate the energy isolating device(s) so that the machine or equipment is isolated from the energy source(s).
5 Lock out the energy isolating device(s) with assigned individual lock(s).
Stored or residual energy (such as that in capacitors, springs, elevated machine members, rotating flywheels, hydraulic systems, and air, gas, steam, or water pressure, etc.)
6
must be dissipated or restrained by methods such as grounding, repositioning, blocking, bleeding down, etc.
Ensure that the equipment is disconnected from the energy source(s) by first checking that no personnel are exposed, then verify the isolation of the equipment by operating
7 the push button or other normal operating control(s) or by testing to make certain the equipment will not operate. Caution: Return operating control(s) to neutral or “off”
position after verifying the isolation of the equipment.
8 The machine or equipment is now locked out.
RECOMMENDED SEQUENCE OF RESTORING EQUIPMENT TO SERVICE:

1 When the servicing or maintenance is completed and the machine or equipment is ready to return to normal operating condition, the following steps shall be taken.
Check the machine or equipment and the immediate area around the machine or equipment to ensure that nonessential items have been removed and that the machine or
2
equipment components are operationally intact.
3 Check the work area to ensure that all employees have been safely positioned or removed from the area.
4 Verify that the controls are in neutral.
Remove the lockout devices and reenergize the machine or equipment. Note: The removal of some forms of blocking may require re-energizing of the machine before safe
5
removal.
6 Notify affected employees that the servicing or maintenance is completed and the machine or equipment is ready for use.
CONFIRMATION BY PERFORMING AUTHORITY: I have been shown and understand all controls and I understand and accept the conditions and precautions detailed above.
I shall ensure that all personnel involved in the work described are informed of them.
SIGNED: NAME: DATE: / /
CONFIRMATION BY AREA AUTHORITY: I confirm that all controls have been checked and that the pre-conditions are met and work specified on this Permit may proceed
subject to the Work Party adhering to all pre-conditions and are aware of all safety precautions associated with the job.
CONFIRMATION BY PERMIT ISSUER: Authorization is given to commence work under the conditions prescribed within this Permit.
NB. IF FOR ANY REASON WORK CONDITIONS CHANGE, WORK MUST STOP IMMEDIATELY AND CONDITIONS REVISED WITH AREA AUTHORITY INFORMED.
PERFORMING AUTHORITY CONFIRMATION OF WORK COMPLETED & CLOSED. I confirm that all work for which this Permit was issued has been
completed, the area backfilled, barriers removed, and the workplace has been inspected and in a safe condition.

Isolation Permit/ High Voltage Permit No

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Rumaila Operating Organization

Isolation Permit/ High Voltage

ISOLATION PERMIT/ HIGH VOLTAGE PERMIT NO.

PERFORMING AUTHORITY CONTACT NO.

AREA AUTHORITY CONTACT NO.

ENERGY SOURCES APPLICABLE TO THIS EQUIPMENT ENERGY CONTROL DEVICES NEEDED

PRECAUTIONS (tick as applicable) YES NO NA YES NO NA

Identify all energy sources ☐ ☐ ☐ Apply lockout devices ☐ ☐ ☐

REQUIRED PPE (tick as applicable) YES NO NA YES NO NA

Hard Hats ☐ ☐ ☐ Hearing Protection ☐ ☐ ☐

DRAWING/ SKETCH (if applicable):

RECOMMENDED SEQUENCE OF LOCKOUT:

RECOMMENDED SEQUENCE OF RESTORING EQUIPMENT TO SERVICE:

SIGNED: NAME: DATE: / /

SIGNED: NAME: DATE: / /

SIGNED: NAME: DATE: / /

SIGNED: NAME: DATE: / /

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