Safe Work Permit: Life Energy Wheel Checklist

This checklist is designed to ensure that all necessary steps are taken to control hazardous energies before work begins on equipment or systems, in accordance with OSHA standards and best practices [1]. It applies to all individuals or groups requiring lockout/tagout protection while performing work on specific equipment [2].

I. Permit Information

• Permit Number: __________
• Date Issued: __________
• Equipment/System to be Locked Out: __________ [3]
• Work to be Performed: __________ [3]
• Location of Work: __________

II. Personnel

• Lockout Overseer: __________ (Print Name) [3]
  • Signature: __________
• Responsible Person: __________ (Print Name) [3]
  • Signature: __________
• Affected Employees Notified: __________ [4]

III. Pre-Shutdown Verification

• Type and magnitude of energy identified [5].
• Hazards of the energy to be controlled are understood [5].
• Method or means to control the energy is known [5].
• Ensure that a written list of names is available for every worker assigned a personal lock and a description of the unique mark or identification tag associated with each personal lock [6].

IV. Shutdown Procedure

• Equipment shut down using established procedures [5].
• Orderly shutdown performed to avoid additional hazards [5].
• Special shutdown procedures (if any): __________ [3]

V. Energy Isolation

• All energy-isolating devices located and identified [4].
• Equipment isolated from energy sources [1].
• Energy sources identified: [4]
  • Electrical [2]
  • Chemical [2]
  • Thermal [2]
  • Pneumatic [7]
  • Radiation [7]
  • Hydraulic [7]
  • Mechanical Potential [7]
  • Other: __________

VI. Lockout/Tagout Application

• Lockout/tagout devices affixed to each energy-isolating device [5].
• Locks are attached to prevent operation unless undue force/tools are used [8].
• Tags are attached to clearly indicate that operation is prohibited [5].
• Where used, tag attachment is fastened at the same point as the lock [5].
• If tag cannot be affixed directly, it is located as close as safely possible [5].
• Lockout devices and tagout devices indicate the identity of the employee applying the device(s) [9].
• Tags warn against hazardous conditions if the machine or equipment is energized and include a legend such as the following: Do Not Start, Do Not Open, Do Not Close, Do Not Energize, Do Not Operate [9].

VII. Stored Energy

• All potentially hazardous stored or residual energy relieved, disconnected, restrained, and rendered safe [5].
• Capacitors discharged and short-circuited/grounded [8].
• Stored non-electrical energy blocked [8].

VIII. Verification of Isolation

• Equipment operating controls tested to verify that equipment cannot be restarted [10].
• Qualified person uses test equipment to verify de-energization [10].
• Test equipment checked before and after use (if over 600V) [10].

IX. Permit Sign-On (Authorized Employees)

Employee Name	Time-On	Initials (Verification of Lock)	Time-Off	Initials (Lock Removal)

X. Return to Service

• Tests and visual inspections conducted to verify removal of tools/jumpers [10].
• Employees warned to stay clear of circuits/equipment [10].
• Each lock and tag removed by the employee who applied it [10].
• Work area inspected [4].
• Affected employees notified [4].
• Locks removed [4].
• Energy restored [4].
• Control returned to operator [4].
• Other: __________ [4]

XI. Permit Sign-Off

• Permit Returned To: __________
• Date and Time of Return: __________

XII. Additional Notes/Corrective Actions

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XIII. Training and Communication [11]

• Training has been provided to ensure that the purpose and function of the energy control program are understood by employees [12].
• Each authorized employee has received training in the recognition of applicable hazardous energy sources, the type and magnitude of energy available in the workplace, and the methods and means necessary for energy isolation and control [12].
• Each affected employee has been instructed in the purpose and use of the energy control procedure [12].
• All other employees whose work operations are or may be in an area where energy control procedures may be utilized, have been instructed about the procedure, and about the prohibition relating to attempts to restart or reenergize machines or equipment which are locked out or tagged out [12].

XIV. Periodic Inspection [9]

• The employer shall conduct a periodic inspection of the energy control procedure at least annually to ensure that the procedure and the requirements of this standard are being followed [9].
• The periodic inspection shall be performed by an authorized employee other than the one(s) utilizing the energy control procedure being inspected [9].
• The periodic inspection shall be conducted to correct any deviations or inadequacies identified [9].

XV. Approval

• Lockout Overseer Approval: __________
• Responsible Person Approval: __________