Title Page
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Orora Site
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Location
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Department
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Conducted on
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Prepared by
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Machine
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Supervisor
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Lead Operator
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Is LOTO posted on machine?
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Where is LOTO posted?
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How many LOTO Points are listed?
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Is LOTO current?
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Types of Energy sources
- Electrical
- Hydraulic
- Pneumatic
- Potential Energy
- Kinetic Energy
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Are photos included of LOTO points?
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Are LOTO points marked at the source
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Does LOTO have signatures?
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Are LOTO devices available for the equipment?
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Are clear instructions posted how to Perform LOTO?
Team Members
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How many Team Members are assigned to the machine?
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Have the Team Members been trained in LOTO?
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Name of Team Member(s) involved in Audit
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When was Team Member last trained?
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What classification of training have the Team Members been trained for?
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Does Team Member understand the importance of Lockout Tagout
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Does the Team Member understand the 7 Steps for Lockout Tagout?
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1. Prepare for Shutdown
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2. Notify all affected employees
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3. Shut down the equipment
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4. Isolate the equipment from the Hazardous Energy Sources
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5. Disspate residual energy sources
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6. Apply applicable Lockout or Tagout devices
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7. Verify the equipment is properly isolated
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Does the Team Member understand how to isolate each Energy Source
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Have Team Members demonstrate knowledge of LOTO, hands on performance
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Does Team Member understand the procedures to remove LOTO devices
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Is further training required or any other weaknesses identifed
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Any other comments to add to this audit?
Verification
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Have Team Member training been verified by documented training records?
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Comments:
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Explain any identified issues to Operator and Supervisor. Acknowledge understanding by signature below.
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Operator Signature
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Supervisor Signature
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Auditor Signature
