Serious Seven - S3 - Lock out & Tag out

• PREPARED BY:

• Date

  Date

• MANUFACTURING LINE

  Select Line 1 Line 2 Common System

  • Line 1
  • Line 2
  • Common System

• LOCATION / AREA

• NAME OF EQUIPMENT

• JOB DESCRIPTION (DESCRIBE SPECIFIC TASK)

• NAME OF ADDITIONAL OBSERVERS

• NUMBER OF IMERYS EMPLOYEES OBSERVED

• NUMBER OF CONTRACTORS OBSERVED

• Additional comments

• PICTURE OF THE SYSTEM / EQUIPMENT DURING THE INSPECTION

  Media

• Was a pre-job safety assessment properly completed for the job being observed?

  Yes

  No

  N/A

• The equipment locked out was identified by:

  Select Drawing / documentation provided Tracing the process Already labeled

  • Drawing / documentation provided
  • Tracing the process
  • Already labeled

• What energy sources have been identified? Select all that apply:

  Select Electrical Pneumatic Stored Other

  • Electrical
  • Pneumatic
  • Stored
  • Other

• Did each person performing the work have an individual lock with identifying tag on the energy source(s)?

  Yes

  No

  N/A

• Had the system been tried ?

  Select HOA Control Room Was not tried out Not applicable

  • HOA
  • Control Room
  • Was not tried out
  • Not applicable

• Is a lock box in use?

  Yes

  No

  N/A

• Are Contractors included in the observation?

  Yes

  No

  N/A

SAFETY VISIT CARD

• CHECKLIST # 1 - MARK ALL BEHAVIOURS THAT APPLY

  Select Climbing or Standing on Equipment Climbing through Equipment (Awkward Position) Ascending/Descending (Stairs, Ladders, Platforms) Ergonomics (Position/Posture) (Pushing & Pulling) Eyes on Task Line of Fire (Being Struck By Something) Electrical Hazards (Following Safe Work Practices) Isolation (Installation of Lockout/Tagout / Try) Ergonomics (Lifting/Carrying) Line of Fire (Caught Between Something)

  • Climbing or Standing on Equipment
  • Climbing through Equipment (Awkward Position)
  • Ascending/Descending (Stairs, Ladders, Platforms)
  • Ergonomics (Position/Posture) (Pushing & Pulling)
  • Eyes on Task
  • Line of Fire (Being Struck By Something)
  • Electrical Hazards (Following Safe Work Practices)
  • Isolation (Installation of Lockout/Tagout / Try)
  • Ergonomics (Lifting/Carrying)
  • Line of Fire (Caught Between Something)

• CHECKLIST # 2 - MARK ALL BEHAVIOURS THAT APPLY

  Select Stepping Over or Under Equipment (Awkward Position) Climbing Over Handrails Isolation (Securing or Bleeding Off Stored Energy) Personnel Protective Equipment (All Needed for Job) Vehicles & Driving (Securing Parked Vehicles) Vehicles & Driving (Maintaining an appropriate Speed) Proper Chemical Handling (Labeling, Storage, Use) Tools/Equipment (Correct For Job & Proper Use) Tools/Equipment (Good Condition or Properly Stored) Are Hazards Controlled (Eliminated/Barricading)

  • Stepping Over or Under Equipment (Awkward Position)
  • Climbing Over Handrails
  • Isolation (Securing or Bleeding Off Stored Energy)
  • Personnel Protective Equipment (All Needed for Job)
  • Vehicles & Driving (Securing Parked Vehicles)
  • Vehicles & Driving (Maintaining an appropriate Speed)
  • Proper Chemical Handling (Labeling, Storage, Use)
  • Tools/Equipment (Correct For Job & Proper Use)
  • Tools/Equipment (Good Condition or Properly Stored)
  • Are Hazards Controlled (Eliminated/Barricading)

• CHECKLIST # 3 - MARK ALL BEHAVIOURS THAT APPLY

  Select Reaching through Handrails Interaction with Vehicles Have Hazards/Risks been Communicated with Others Are there any Balance Traction Grip Issues Pre Job Safety Assessment Used Work at Heights (Protecting from Fall Hazards) Confined Spaces (Following Safe Work Practices) Work Environment (Hot, Cold, Wet, Etc.) Are Safe Work Practices being used?

  • Reaching through Handrails
  • Interaction with Vehicles
  • Have Hazards/Risks been Communicated with Others
  • Are there any Balance Traction Grip Issues
  • Pre Job Safety Assessment Used
  • Work at Heights (Protecting from Fall Hazards)
  • Confined Spaces (Following Safe Work Practices)
  • Work Environment (Hot, Cold, Wet, Etc.)
  • Are Safe Work Practices being used?

HAZARDS & RISK ASSESMENT

ASSESMENT

• Select the level of risk: Low, Medium, High

  Low

  Medium

  High

• Is there a way to do the job/task "Better" and/or "Safer"?

• Feedback Given:

• Follow Up Action required ? (if any, submit action plan)

  Yes

  No

  N/A

ENDING TIME

• ENDING TIME

  Date