Information
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Site
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Equipment / Machine:
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Conducted on
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Location
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Personnel
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This form complies with paragraph 3.6 of global EHS technical standard T23. Place a checkmark as each item is inspected in the “Yes” or “No” column. If “No” is checked, please make notes in the comments column to indicate the reason or action to be completed to correct the deficiency.
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As an authorized employee, I acknowledge the details noted during this inspection:
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Inspector:
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Authorized employee performing the work:
Inspection Topics
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1. Has the authorized employee’s LOTO training records been verified?
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2. Are written energy control procedures available?
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3. Are adequate supplies of locks and tags available to perform the procedure?
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4. Were all affected employees in the area notified that the LOTO procedure would begin?
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5. Were locks and tags applied in the order specified in the written procedures?
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6. Are the energy isolating devices for this machine labeled so as to be easily identifiable?
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7. If applicable, did the employee isolate any stored energy (i.e., bleed off pressure, block spring loaded valves, discharge electrical capacitors)?
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8. After applying the LOTO procedure, did the employee test the equipment to verify that it will not start and then return the controls to the neutral position?
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9. After completing maintenance, did the employee verify that all tools and items have been removed, and machine guards and components have been reinstalled and are operationally intact?
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10. Were all affected employees notified in the area that the LOTO devices will be removed?
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11. Did the employee verify that equipment/machine is operating properly upon re-energization?
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12. Did the employee follow the steps outlined in the LOTO procedures?
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13. Does the employee demonstrate knowledge of the LOTO program?
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14. Is the written energy control procedure for this equipment accurate?
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15. If applicable, were line breaking and jam clearing procedures followed correctly?
