Isolation System Assessment (GMR)

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

1.0 Risk Management

• 1.1 AMS/TRA Number & References:

  Yes

  No

  N/A

• 1.2 (GMR) Isolation and de-isolation must be planned, with the method for removal and restoration of stored energy or hazardous materials risk assessed and authorised by a competent person?

  Yes

  No

  N/A

• 1.3 (GMR) Prior to breaking contaminant systems, has a test for hazardous material/stored energy been performed with risk controls in place?

  Yes

  No

  N/A

• 1.4 (GMR) Are the Isolation controls and their effectiveness subject to ongoing monitoring?

  Yes

  No

  N/A

• 1.5 Are the worker/s able to identify the applicable hazardous/stored energy sources?

  Yes

  No

  N/A

• 1.6 Are the worker/s able to demonstrate how to isolate and control the hazardous/stored energy sources?

  Yes

  No

  N/A

2.0 Training

• 2.1 (GMR) Is the physical isolation and de-isolation completed by a competent and authorised person?

  Yes

  No

  N/A

• 2.2 (GMR) The isolation of electrical energy must be confirmed by a competent and authorised person prior to work commencing? The isolation status must be re-tested after any break or change in conditions.

  Yes

  No

  N/A

• 2.3 Has an isolation coordinator been assigned to the workplace and do they monitor the isolation process?

  Yes

  No

  N/A

3.0 Isolation Permit

• 3.1 (GMR) Has an Isolation Permit been obtained and in place for the isolation and de-isolation of energy sources. The permit conditions must specify the test requirements for the presence of hazardous materials/stored energy?

  Yes

  No

  N/A

• 3.2 Permit Number(If required):

  Yes

  No

  N/A

• 3.3 Issue Date/ Time:

  Yes

  No

  N/A

• 3.4 Expiry Date/Time:

  Yes

  No

  N/A

• 3.5 Do the names of workers undertaking the isolation appear on the isolation permit?

  Yes

  No

  N/A

• 3.6 Has their manager/supervisor communicated the isolation procedure to them and do they understand the procedure?

  Yes

  No

  N/A

4.0 Isolation Methods, Points & Equipment

• 4.1 All isolation points are clearly identified, proven, tagged and controlled to prevent inadvertent energising?

  Yes

  No

  N/A

• 4.2 (GMR) Have the appropriate guarding and safety systems been reinstated upon the completion of the work prior to de-isolation?

  Yes

  No

  N/A

• 4.3 Name of worker/s undertaking the isolation activity appear on the isolation (danger or out of service) tag?

  Yes

  No

  N/A

• 4.4 Has a method of testing to ensure that isolation is effective been established?

  Yes

  No

  N/A

• 4.5 Is a method in place to ensure that multiple isolation points have been checked and tested to ensure that isolation is effective?

  Yes

  No

  N/A

• 4.6 Are proper isolation methods being used for the isolation?

  Yes

  No

  N/A

• 4.7 Has the isolation activity been communicated to other worker/s in close proximity to the task location?

  Yes

  No

  N/A

• 4.8 Prior to the removal of the isolation, has the isolation coordinator ensured that all work is complete, all tools and equipment used during the isolation period has been removed, all persons clear of the operating parameter of the plant/equipment being re-energised, and they have been instructed that the plant/ equipment has been re-energised?

  Yes

  No

  N/A

• 4.9 Has the client specified mandatory project isolation requirements and are they being implemented as part of this isolation activity?

  Yes

  No

  N/A

5.0 Corrective Action / Remedial Action(s)

• Are there any corrective/remedial actions required to be raised as a result of this system assessment?

  Yes

  No

  N/A

6.0 Sign Off

• Person Conducting the System Assessement

  Sign