SPOT AUDIT: Lock-Out Tag-Out (LOTO)

• Conducted on

  Date

• Prepared by

• Location
  Address

Lockout Board

• Is the lockout board in good order?

  Yes

  No

  N/A

• Are there locks with missing keys?

  Pass

  Fail

  N/A

• Are there locks unaccounted for?

  Pass

  Fail

  N/A

• Is the LOTO whiteboard being used effectively?

  Good

  Fair

  Poor

  N/A

• Is the Long-Term Isolation book being used appropriately?

  Good

  Fair

  Poor

  N/A

Specific Lockout

• Name of Individual Performing the LOTO

• Is the individual conversant with the LOTO procedure?

  Good

  Fair

  Poor

  N/A

• Is there a Controlled Area Access Permit for the Isolation?

  Yes

  No

  N/A

• Is there a Risk Assessment for the Isolation<br>(Dynamic; RAMS; SOP; or other appropriate RA)

  Yes

  No

  N/A

• Is there an Isolation Standard for the Equipment that is Locked Out?

  Yes

  No

  N/A

• Should there be an Isolation Standard for this equipment?

  Yes

  No

  N/A

• Has the Isolation Standard been correctly followed in this case?

  Yes

  No

  N/A

• Does the individual have the Key to their Lock on their person?

  Yes

  No

  N/A

• Are others working on the equipment with the individual?

  Yes

  No

  N/A

• Are they named on the Permit?

  Yes

  No

  N/A

• Have they also Locked-Out the equipment?

  Yes

  No

  N/A

• Has a suitable method been used for multiple locks?<br>(Lock-Box or Multi-Hasp)

  Yes

  No

  N/A

• Feedback provided to the individual:

• Acceptance of Feedback

  Sign

• Feedback provided to the Shift Supervisor:

• Acceptance of Feedback

  Sign

• Feedback provided to the Process Manager:

• Acceptance of Feedback

  Sign