Isolation & Lockout

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Requirements

• Work Area

• Scope of Work - brief description of work task

• Isolation Officer

• Name(s) of Worker(s) performing the task
  

Worker

• Name:

• Has a risk assessment been completed for this task?

  Yes

  No

• What Type of Risk Assessment?

  Take 5

  JHA

  SOP

  Other

• Details

• Line of Fire - has the workplace been assessed for potential "line of fire" hazards during the work task in the event of a release of stored energy? e.g. Rigging, Piping, Gravity etc.

  Yes

  No

  N/A

• Have necessary Control Measures been put in place to inform and control people or equipment entering the work area? (e.g. Barricade Tape & Tag)

  Yes

  No

  N/A

Isolation Procedure

• Does the lockout involve Mobile Equipment?

  Yes

  N/A

• Is the equipment parked fundamentally stable prior to starting work?

  Yes

  No

• Has the Master Switch been locked out by the Isolation Officer?

  Yes

  No

  N/A

• Has the Tag been filled out with all required information?

  Yes

  No

• Have hydraulic and pneumatic systems been bled down of residual stored energy?

  Yes

  No

  N/A

• Are Booms, Blades , Buckets, Hoods, Boxes or other suspended attachments pinned, blocked or otherwise supported by stationary jacks to prevent accidental movement?

  Yes

  No

  N/A

• Does the Isolation involve Electrical Equipment?

  Yes

  N/A

• Regulation 10.21 (3) Electrically powered equipment or systems must have the main power source feeding the equipment/system disconnected, locked out and tagged out AND where necessary, the upstream and downstream equipment shall be disconnected, locked out and tagged.
  

• Have the RED lock(s) of the Isolation Officer been applied?

  Yes

  No

• Has the BLUE lock(s) of the worker(s) been applied

  Yes

  No

  N/A

• Has a YELLOW Service lock(s) been applied?

  Yes

  No

• Reason for Service Lock application

• Do all workers participating in the job have their personal locks applied?

  Yes

  No

• Are the KEYS for all applied locks securely controlled by the owner?

  Yes

  No

• Has a RED Isolation Officer Tag been applied on all lockout points and filled out correctly?

  Yes

  No

• Has a BLUE Personal Lockout Tag been applied on all lockout points and filled out correctly?

  Yes

  No

  N/A

• Has an OUT OF SERVICE tag been applied where necessary?

  Yes

  No

  N/A

• Have all workers been clearly identified in the Log Book and signed in correctly?

  Yes

  No

  N/A

• Has a Matrix been filled out for Multiple Point Isolation?

  Yes

  N/A

• Has a "Bump Test' been confirmed?

  Yes

  No

• Has Maintenance Mode been confirmed?

  Yes

  No

  N/A

• Have all Isolation points identified on the matrix been physically locked out?

  Yes

  No

• Do Equipment identification numbers on the matrix match the lockout points?

  Yes

  No

  N/A

• Has the Matrix been filled out as required?

  Yes

  No

• Is a Lock Box being used for 4 or more points of isolation?

  Yes

  N/A

• Lock Box has been locked with all keys inside?

  Yes

  No

• A copy of the matrix is INSIDE the Lock Box?

  Yes

  No

• A copy of the matrix remains OUTSIDE the lock box?

  Yes

  No

• Regulation 10.21 (6)
  All stored energy shall be safely released or contained.
  Pipelines shall be blanked where valves could leak. This includes water, steam, compressed air or any other substance
  All loose or freely moveable equipment must be secured against unintended movement.
  

• List any non-electrical isolation methods.

  Select N/A Valve Chain Pin Block & Bleed Other

  • N/A
  • Valve
  • Chain
  • Pin
  • Block & Bleed
  • Other

• Details

• Has a Zero-Energy State been achieved and proven for all non-electrical isolation points?

  Yes

  No

• Summary Notes