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Isolation Work Instruction Template

This isolation instruction document contains: 1) Details of the work activity such as location and description that require isolation. 2) Procedures for isolating energy sources, testing that isolation is effective, and de-isolating. 3) Sign-off sections to confirm procedures were followed and isolations were put in place and removed appropriately.

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373 views5 pages

Isolation Work Instruction Template

This isolation instruction document contains: 1) Details of the work activity such as location and description that require isolation. 2) Procedures for isolating energy sources, testing that isolation is effective, and de-isolating. 3) Sign-off sections to confirm procedures were followed and isolations were put in place and removed appropriately.

Uploaded by

ppn
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Corporate Safety - Template

Isolation Instruction
Section 1 – Work activity details
This form must be completed in accordance with the requirements of the WHS Energy Tag and Lockout Procedure (PRO-00014).
Isolation instructions must be developed or reviewed by an authorised isolator for the site where the isolation is being performed. Work Order No.
Where required, the authorised isolator must also hold the appropriate qualification for the type of isolation being performed.

Location of work activity:


Description of work activity:
Work activity details

Date of isolation:

Name: Date:
Operations Y N/A
Signature:

Name: Date:
Isolation instruction
Electrical Y N/A
prepared or reviewed by
Signature:

Name: Date:
Mechanical Y N/A
Signature:

Documentation saved at Insert file path / TRIM Number / Q-Pulse Number

Section 2 – Isolation procedure


Isolation Codes
Low Voltage Isolation
LVI HVI High Voltage Isolation OWI Operations Work Instruction DCR De-contactor Removed AD Air Disconnected
(<1000V)
Tag Only (isolation point Spool Removed (Blank
VLO Valve Locked Open VLC Valve Locked Closed TO SI Spade Inserted SR
cannot be secured with a lock) Fitted)

Note: All HV Isolations require a High Voltage Access Permit (FRM-00439) and a High Voltage Switching Form (FRM-00438).
Devices not capable of being locked should, as far as reasonably practicable, be secured with a shroud, valve cover, chain, pin or other suitable means, or by the removal of the handle
or operating mechanism. As a minimum, an isolation tag must be affixed to any isolation point not able to be secured with a red isolation lock.
Doc no. TEM-00077 Version date: 21/03/2016 Trim ID:
Doc owner: J. Paige Doc approver: Manager, WHS Rev no. 1 Page 1 of 5
The controlled version of this document is registered. All other versions are uncontrolled
Corporate Safety - Template
Isolation Instruction
Step Isolation Point Number / Description Isolation Point Location Code Isolator name Initial

1 Access Officer / Duty Operator contacted before commencing isolation.


2

10

Section 3 – Test for dead / prove for dead procedure


Step Test Point Description Test Point Location Isolator name Initial

I confirm that all identified energy sources have been isolated, all residual energy has been dissipated, all isolation points have been locked or otherwise
secured to prevent re-energisation, and the isolations have been tested and proven to be effective.
I have demonstrated the effectiveness of the isolation to all workers who are working under the control of the isolation.

Name: Date:
Isolation Officer
Signature: Time:

Doc no. TEM-00077 Version date: 21/03/2016 Trim ID:


Doc owner: J. Paige Doc approver: Manager, WHS Rev no. 1 Page 2 of 5
The controlled version of this document is registered. All other versions are uncontrolled
Corporate Safety - Template
Isolation Instruction
Section 4 – De-isolation procedure
Step Isolation Point Number / Description Isolation Point Location Isolator Name Initial

1 Access Officer / Duty Operator contacted before commencing de-isolation.

10
5

Section 5 – Inch and test procedure


Equipment to be Tested: Type of Test: Reason for Test:

Step Isolation Point Number / Description Date / Time Re-energiser Name Initial Re-isolator Name Initial

Section 6 – Reinstatement
I confirm that all isolation equipment has been removed from isolation points, all isolated energy sources have been reinstated and the plant is available for normal operations.

Name: Date:
Isolation Officer
Signature: Time:

Doc no. TEM-00077 Version date: 21/03/2016 Trim ID:


Doc owner: J. Paige Doc approver: Manager, WHS Rev no. 1 Page 3 of 5
The controlled version of this document is registered. All other versions are uncontrolled
Corporate Safety - Template
Isolation Instruction
Notes and Drawings

Doc no. TEM-00077 Version date: 21/03/2016 Trim ID:


Doc owner: J. Paige Doc approver: Manager, WHS Rev no. 1 Page 4 of 5
The controlled version of this document is registered. All other versions are uncontrolled
Corporate Safety - Template
Isolation Instruction

Doc no. TEM-00077 Version date: 21/03/2016 Trim ID:


Doc owner: J. Paige Doc approver: Manager, WHS Rev no. 1 Page 5 of 5
The controlled version of this document is registered. All other versions are uncontrolled

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