Title Page
-
Site conducted
-
Plant/Area:
-
Employee/Contractor Name:
-
Conducted on
-
Prepared By:
-
Line Manager:
-
Location
-
Permit Number
-
Permit Issuer
-
Permit Acceptor
-
Higher Authority (if applicable)
-
Have all energy sources identified and indicated on the permit? (process isolation, electrical, kinetic: moving equipment and pneumatic: air pressure equipment)
-
Are all precautions specified in the permit/procedure in place?
-
Are the energy sources positively isolated? The level of isolation should be adequate for the risk
-
Are the valves immobilised? Locked with chain or do not operate notice attached
-
Where multi discipline work on the same equipment, each discipline must attached their lock/s.
-
Is the equipment tested for zero energy before starting with the work? (bump-test / stop/start)
-
Are the lock-out register completed when equipment are locked out?
-
Are locks and chains attached to the equipment before starting with the work? (process isolation, electrical, kinetic: moving equipment and pneumatic: air pressure equipment)
-
Are appropriate tags used to indicate in-place isolations? They are usually 'personal danger' or 'out of service' tags.
-
Are blanks installed and removed according to the blank list? (Where applicable)
-
Have all people involved in planning, approving and carrying out this isolation been authorised as competent to do so?
-
Comments: Where deviations have been noted, indicate the corrective action taken. Also report the matter to the supervisor. Look for other hazards that might have been missed in the risk assessment.
-
Auditor's Signature
