EU RME LOTO Demonstration

• Instructions for use: Each trained and Authorized Person that completes and passes the RME - Global Hazardous Energy Control (LOTO) Authorized KNET eLearning module is required to demonstrate the ability to safely lockout equipment. This form shall document this demonstration of the Authorized Person and should be completed by the Authorized Person’ manager (who needs to be LOTO authorized as well) or, if such person is not available, a member of the RME team (L4+)

• The Authorized person’s manager (or equivalent as above) shall select a real equipment on site on which the authorized person being reviewed shall apply the LOTO procedure

• This document, properly filled and signed, shall be stored by the site for at least three (3) years

• Site

• Equipment

• Location

• Date

  Date

• Shift

  Select

• Authorized person’s name and Login

• Person who is reviewing the Demonstration (Manager or delegate)

• Date AUTHORIZED LOTO eLearning Successfully Completed

  Date

• Has the Associate verified that they have all the required Personal Protective Equipment (PPE) to perform the task? (Check all that apply for the task being performed reviewing the specific SOP/RA.)

  Yes

  No

  N/A

• Has the Associate performed the One Minute Risk Assessment (OMRA) and have them completed it correctly?

  Yes

  No

  N/A

• Does the Associate remove articles of jewelry or clothing such as watch, bracelets, rings, key chains, necklaces, metalized aprons, cloth with conductive thread, metal headgear or other articles that may not be worn when working with energized parts?

  Yes

  No

  N/A

• Can the associate recognize the all the energy sources that fed the asset chosen? Select those flagged by the Authorized Person VS those present in the asset

• Energy Source recognized by the Authorized Person?

• Electrical Energy

  Y

  N

• Hydraulic

  Y

  N

• Pneumatic Energy

  Y

  N

• Gravitational stored energy

  Y

  N

• Mechanical Stored Energy

  Y

  N

• Thermal

  Y

  N

• Other

  Y

  N

• Associate identified all energy sources present for the asset chosen?

  Yes

  No

  N/A

• Does the Associate notify any Affected Associates in the area that LOTO will be utilized?

  Yes

  No

  N/A

• Does the Associate reference the LOTO placarding or machine specific LOTO procedures? Have they also noted the number of energy sources and obtain the proper LOTO devices and number of locks?

  Yes

  No

  N/A

• If no LOTO placard is available or placard is not specific to section of equipment being de-energized, has the Associate accurately stopped and required a Permit to Work with the LOTO addendum module?

  Yes

  No

  N/A

• Does the Associate follow the de-energization procedure as outlined on the LOTO placard?

  Yes

  No

  N/A

• Does the Associate “STOP” the equipment / machine first using a push button or touch screen HMI?

  Yes

  No

  N/A

• Does the Associate place Lock and Tag correctly on the equipment, locking the device properly (switch lever/handle/valves/plugs etc)?

  Yes

  No

  N/A

• Once the equipment or machine is properly locked out, does the Associate take the key out of their lock and keep it on their person?

  Yes

  No

  N/A

• Once the equipment or machine is properly locked out, does the Associate try to restart the equipment to verify isolation? (This will not always ensure zero energy. There may be residual energy in the equipment and this step may require the use of a volt meter.)

  Yes

  No

  N/A

• I declare that I reviewed the LOTO application on the equipment indicated above with the authorized person and confirm that they demonstrated sufficient knowledge on the LOTO process and that are competent to carry out safely the LOTO procedure

• Name:

• Signed:

  Sign

• Date:

  Date

• I declare that a LOTO demonstration was carried out on the equipment stated above and that I have understood and will follow the Amazon LOTO procedure

• Name:

• Signed:

  Sign

• Date:

  Date

Training Documentation and Retention

• RME Department shall maintain a current list of Authorized Personnel

• The current requirement for Hazardous Energy Control training is as follows:

• Completion of the RME - Global Hazardous Energy Control (LOTO) Authorized KNET Training

  Yes

  No

• If KNET training passed, Completion of the Hands-on portion (this document)

  Yes

  No

• If demonstration passed, the person’s manager shall mark the KNET RME LOTO Demonstration as completed

  Yes

  No