Title Page
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Department
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Type of Lock Out:
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Date:
COMPLIANCE ACHIEVED
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1. Is the Lock out procedure available and understood by staff?
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1.1. Verify by asking questions
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2. Are "Lock Out" tags and locks and/or "Out of Service" tags in use?
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3. Are "Lock Out" tags and locks and/or "Out of Service" tags filled out correctly?
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4. Are spare “Lock Out” tags and “Out of Service” tags readily available?
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5. Do all employees use “Lock Out” tags and “Out of Service” tags correctly?
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6. Are lock out locks, scissors and tags being used for all isolations?
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7. Are all isolation devices labelled?
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8. Are keys removed from the lock out locks whilst personnel are working on the equipment?
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9. Is there a copy of the "Lockout/Tagout Quick Reference Guide" available on site? ( One Plan Lesson)
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10. Are all personnel and operators who is required to lock out, trained?
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11. Are all machinery or equipment capable of movement, required to be de-energized or disengaged and locked-out during <br> cleaning, servicing, adjusting or setting up operations, whenever required? (CAN IT BE LOCKED OUT? place to attach locks,etc.)
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12. Does the lockout procedure require that stored energy (mechanical, hydraulic, air, etc.) be released or blocked before equipment <br> is locked-out for repairs?
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13. Are employees required to keep personal control of their key(s) while they have safety locks in use?
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13.1 Is a register available and up to date?
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14. Is it required that only the employee exposed to the hazard, place or remove the safety lock?
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15. Is it required that employees check the safety of the lock-out by attempting a startup after making sure no one is exposed?
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16. Are employees instructed to always push the E - stop button immediately after checking the safety of the lock-out?
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17. Are there a means provided to identify any or all employees who are working on locked-out equipment by their <br> locks or accompanying tags?
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18. Are a sufficient number of accident preventive signs or tags and safety padlocks provided for any reasonably <br> foreseeable repair emergency?
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19. When machine operations, configuration or size requires the operator to leave his or her control station to install <br> tools or perform other operations, and that part of the machine could move if accidentally activated. Is such <br> element required to be separately locked or blocked out?
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20. In the event that equipment or lines cannot be shut down, locked-out and tagged, is a safe job the procedure <br> established and rigidly followed?
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21. Are all staff wearing correct PPE?
Sigantories
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Auditee
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Auditor