Lockout tagout permit template: base template and example

When to isolate plant

• Safe Work Australia's plant code says plant should usually be isolated before maintenance or cleaning starts, and calls lockout the most effective isolation procedure.
• Isolation is more than switching off. SafeWork NSW's energy isolation guidelines cover stored energy, personal locks and danger tags, and who can remove them.
• Isolation guidance differs between states, and electrical work has its own rules. See what applies in each state below, and use licensed electricians where required.

Isolating plant as part of a bigger job? Use a permit to work as well.

Isolation rules in your state

Every state expects plant to be isolated before maintenance or cleaning, but the guidance comes from different regulators. We're not a regulator, so check yours:

• New South Wales: personal locks, danger tags and stored energy are covered in SafeWork NSW's energy isolation guidelines

• Victoria: Victoria has its own OHS laws. See WorkSafe Victoria's isolate, de-energise, lockout and tagout guidance

• Western Australia: see WorkSafe WA's isolation of plant guidance note

• Queensland: WorkSafe Queensland

• South Australia: SafeWork SA

• Tasmania: WorkSafe Tasmania

• Northern Territory: NT WorkSafe

• Australian Capital Territory: WorkSafe ACT

For electrical isolation on low-voltage installations, electricians work to AS/NZS 4836:2023

Controls to think about

• Safe Work Australia's plant code lists the steps: shut down, identify every energy source and isolation point, isolate, control stored energy, lock out, tag, then try to restart the plant without putting anyone at risk.
• Give everyone their own lock. SafeWork NSW says to fit one lock for each person working on the plant, and that a tag on its own isn't an isolation.
• A failed restart doesn't prove all stored energy is gone. Release pressure, block moving parts and lower raised loads before work starts.

Isolation hazards and the controls to match

Every machine is different, but these are hazards that often get missed when plant is isolated, with the kind of control the permit should show for each:

• A second energy source nobody listed, such as air, hydraulics, a backup supply or a separate control circuit: walk the plant and check the drawings before isolating.

• Stored energy after the power is off, such as springs, pressure, flywheels or raised parts: bleed, block or lower it, and record how.

• Gravity: raised beds, rams or loads dropping when hydraulics are released. Prop or chock them mechanically.

• An isolator that shows off but hasn't opened, because contacts can weld together: test for zero energy, don't trust the switch position.

• Using an e-stop or a PLC as the isolation point: e-stops and standard control systems aren't isolation devices.

• Someone else restarting the plant: every person working on it fits their own lock and danger tag.

• Shift change with locks still on: hand over in person and record it on the permit.

• Guards or tools left off or inside when the plant is restarted: check the area and the guards before removing the isolation.

What to include in a lockout tagout permit

• The job, date, equipment or asset ID, and work order number
• Every energy source to be isolated, including stored energy
• Each isolation point, its lock or tag number, and who isolated it
• How the zero energy state was tested and verified
• Confirmation that all energy sources were isolated, locked, tagged and tested
• Sign-off by the isolator and equipment owner, and who removed the isolation

Common gaps in a lockout tagout permit

Before work starts, check the permit doesn't have these gaps. Your site's isolation procedure may ask for more:

• Only the main electrical isolator is listed, with no other energy sources or stored energy.

• Isolation points are listed without lock or tag numbers, or without who fitted them.

• The zero energy test is ticked but doesn't say how it was done.

• One lock is shown for the whole crew instead of one per person.

• Nobody signed when the isolation was removed and the plant was handed back.

Filled-in lockout tagout permit example

Example only, not for use as your own permit. This is the base template filled in for a fictional job: isolating a spiral dough mixer for maintenance, with four isolation points. Click the page to enlarge it.

Your own permit must list every energy source and isolation point on your actual plant. Follow the manufacturer's instructions and your site's isolation procedure.

How to fill one in

1. Fill in the job, date, equipment and work order number.
2. Tick every energy source, including stored energy like gravity or pressure.
3. List each isolation point with its lock or tag number and who fitted it.
4. Test for zero energy, record how you tested, and tick the confirmation.
5. Sign it off, and record who removed the isolation when the work is finished.

Get your lockout tagout permit into the app

This form is in the Shadow Forms app. Your team can fill it in on site, add photos and sign it, then send it straight to the office.

The PDF and Word versions are copies only. If you have your own branded version, or want this one adjusted to your business, we can add it to the app. Upload a form, or get in touch.

Need a permit for the whole job? Get the free permit to work template.

Working inside a tank or vessel? Get the free confined space entry permit template.