ES-F0014-1B Lockout / Tagout Periodic Inspection

• Document No.

• Site

  Hoffman Estates

  Rochester Hills

• Conducted on

  Date

• Prepared by

• Personnel

Review LOTO hardware

• Do LOTO devices meet the following criteria? 1910.147(c)(5)(ii)<br> 1. Singularly identified<br> 2. Used only on LOTO<br> 3. Durable<br> 4. Capable of withstanding the environment<br> 5. Capable of becoming wet without deterioration<br> 6. Capable of withstanding acidic or basic environments where acids or bases are stored<br> 7. Standardized - Same color, design, shape, etc. Must meet one criteria<br> 8. Substantial/Heavy Duty<br> 9. Identifiable<br> 10. Provide a warning to employees

  YES

  NO

• Are they being maintained?

  YES

  NO

• Adequate supply on hand?

  YES

  NO

• Properly stored or located?

  YES

  NO

• Used only for LOTO?

  YES

  NO

• Do authorized employees have a good knowledge of use and location of devices?

  YES

  NO

Equipment

• Equipment inspected:

Equipment

• Equipment name

• Equipment Location

  Select Warehouse Maintenance Motor Repair Electronic Repair

  • Warehouse
  • Maintenance
  • Motor Repair
  • Electronic Repair

• Is a written machine specific isolation (LOTO) procedure available and posted?

  YES

  NO

• Does the procedure identify all energy sources?

  YES

  NO

• What types of energy does this equipment have?

  Select Electrical Hydraulic Pneumatic Thermal Steam Gravity Chemical Other

  • Electrical
  • Hydraulic
  • Pneumatic
  • Thermal
  • Steam
  • Gravity
  • Chemical
  • Other

Procedure Audit

• Employee observed:

• Did the employee notify affected employees that the machine was being shutdown and locked out?

  YES

  NO

• Did the employee shutdown the equipment properly?

  YES

  NO

• Did the employee isolate all energy sources?

  YES

  NO

• Did the employee apply locks and / or tags to all energy sources?

  YES

  NO

• Did the employee release any stored energy, if applicable?

  YES

  NO

• Did the employee verify that the equipment was locked out?

  YES

  NO

• Did the employee follow correct release from lockout procedures?

  YES

  NO

• Is the identification on the LOTO device correct?

  YES

  NO

• Auditor signature

  Sign

Recommendations / Corrective Actions :

• Are there additional recommendations / corrective actions?

  YES

  NO