Isolation and Lock Out Checklist

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Energy Isolation Certificate Number
  Address

• Personnel

Isolation and lockout process

Static Plant

• Identify equipment to be isolated.

  Yes

  No

  N/A

• Is Risk Assessment conducted and signed off?

  Yes

  No

  N/A

• General Permit to work issued.

  Yes

  No

  N/A

• Is the clearance book and filled and Isolation Certificate issued?

  Yes

  No

  N/A

• Is a qualified Industrial electrician performing the isolation process.

  Yes

  No

  N/A

• The main power supply disconnected at the isolation switch. Clearance book and isolation certificate issued

  Yes

  No

  N/A

• Do all employees involved have own lock.?

  Yes

  No

  N/A

• Test the lockout in order to verify that each energy source has been effectively locked out.

  Yes

  No

  N/A

Mobile Plant

• Was the park up principles followed as per procedure requirements ?

  Yes

  No

  N/A

• Is the ignition key removed and an isolation tag placed on controls and at isolation point (battery)

  Yes

  No

  N/A

• Only a qualified maintenance personnel to work on the mobile plant and also trained in site isolation procedure.

  Yes

  No

  N/A

• Was the plant properly locked out using the appropriate isolation locks and tags before any work commencement?

  Yes

  No

  N/A

• Is the work being conducted in a place in which it is safe to undertake maintenance activities.?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

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