Title Page
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Document No.
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Audit Title; Anuual Mandatory LOTO Observation
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Client / Site
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Conducted on
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Observer;
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Location: Dept; Bldg; Machine/Equipment process: Equip#
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Employee(s) observed
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Observation Questions:
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1. Has all energy-isolation get devices been located?
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2. Does the account provide devices specifically for LOTO procedures?
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3. Are LOTO devices durable enough to withstand work conditions?
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4. When only Tag out devices are used, are they self-locking and non-releasable with minimum unlocking strength of 50 lbs?
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5, Can person using a LOTO device be easily identified?
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6. AUTHORIZATION: is an authorized person performing the Lock-out/Tag-out?
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7. PREPARATION: Are affected employees notified when there is an application or removal of LOTO devices?
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8. SHUTDOWN: Are Normal "shutdown" procedures followed?
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9. ENERGY ISOLATION: Are energy isolating device(s) located and energy source(s) separated for the machine?
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10. LOTO DEVICE APPLICATION: Are LOTO device(s) placed on each energy-isolating device?
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11. STORED ENERGY: Are all potentially hazardous, stored or residual energy relieved, disconnected or restrained?
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12. VERIFICATION OF ISOLATION: Does the authorized employee verify that de-energization of the equipment has been accomplished?
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13. INSPECTION: Prior to removing Locks/Tags, has the work area been inspected, nonessential items removed and the machine components including guards, made operationally intact?
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14. EMPLOYEE NOTIFICATION: Prior to removing locks/tags, have all affected employees been notified and work area inspected to ensure all employees are in a safe position?
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15. LOTO DEVICE REMOVAL: Have all LOTO devices been removed by the person who applied them?
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Comments:
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Observer name and title:
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Observed employee name and title:
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