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Isolation Work Instruction Template
Isolation Work Instruction Template
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 1 of 4
The controlled version of this document is registered. All other versions are uncontrolled
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.
Where required, the authorised isolator must also hold the appropriate qualification for the type of isolation being performed.
Work Order No.
Work activity details
Location of work activity:
Description of work activity:
Date of isolation:
Isolation instruction
prepared or reviewed by
Operations Y N/A
Name:
Date:
Signature:
Electrical Y N/A
Name:
Date:
Signature:
Mechanical Y N/A
Name:
Date:
Signature:
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Section 2 – Isolation procedure
Isolation Codes
LVI
Low Voltage Isolation
(<1000V)
HVI
High Voltage Isolation
OWI
Operations Work Instruction
DCR
De-contactor Removed
AD
Air Disconnected
VLO
Valve Locked Open
VLC
Valve Locked Closed
TO
Tag Only (isolation point
cannot be secured with a lock)
SI
Spade Inserted
SR
Spool Removed (Blank
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.
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source: seqwater.com.au
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