YEARLY LOTO PROCEDURE AUDIT

• YEARLY LOCKOUT / TAG OUT [LO/TO] PROCEDURE AUDIT CERTIFICATE

• FACILITY

• Conducted on

  Date

• Prepared by

• Location
  Address

• Instructions
  USE FOR YEARLY AUDIT OF LOCK OUT / TAG OUT PROCEDURES
  1. Answer "Yes", "No", "N/A" for the questions below
  2. Add any photos and notes by clicking on the paperclip icon
  3. To create a corrective action click on the paperclip icon then "Action", provide a description, assign to a member, set priority and due date
  4. Complete audit by providing digital signature
  5. Share your report by exporting as PDF, Word, Excel or Web Link

PROCESS

• FULLY REVIEW THE LOTO PROCEDURE AND INSPECT ALL LOTO EQUIPMENT AND MATERIALS TO INSURE THAT THEY ARE UP TO DATE AND ARE BEING FOLLOWED TO THE LETTER!

  Yes

  No

  N/A

• The Lock Out - Tag Out process is systematically applied when working on energized equipment

  Yes

  No

  N/A

• There is evidence / examples of recent LOTO

  Yes

  No

  N/A

• LOTO Procedure is well understood by Managers and Supervisors

  Yes

  No

  N/A

• LOTO Procedure is well understood by the crewmembers

  Yes

  No

  N/A

• A list of activities subjected to LOTO is visibly posted, the personnel are aware and understand the list

  Yes

  No

  N/A

• All LOTO certificates are formally authorized by the Person In Charge [ TRAINER ]

  Yes

  No

  N/A

• ALL Contractors are informed of and follow the proper LOTO procedure

  Yes

  No

  N/A

• A up to date list of all LOTO trained workers is always available

  Yes

  No

  N/A

LOTO DEVICES

• LOTO equipment (board) is readily available at all times? General conditions (how many, where, etc)

  Yes

  No

  N/A

• Check LOTO records to insure the program is being followed at all times

  Yes

  No

  N/A

• Tags are waterproof to prevent tag from deteriorating or becoming illegible due to wet conditions

  Yes

  No

  N/A

• Tags / Locks include legend such as Do Not Start, Do Not Open, Do Not Close, Do Not Energize, Do Not Operate

  Yes

  No

  N/A

• Plug bags or other locking devices are readily available along with proper locks etc.

  Yes

  No

  N/A

• A sufficient amount of the necessary LOTO devices are readily available

  Yes

  No

  N/A

• Check to insure every piece of electrical and pneumatic equipment at this facility can be properly isolated from all power sources!

  Safe

  At Risk

  N/A

TRAINING

• Insure all personnel know the purpose and the use of the LOTO procedure

  Yes

  No

  N/A

• ALL PERSONNEL ARE TRAINED IN PROPER LOCK OUT PROCEDURE AND KNOW NEVER TO WORK ON A MACHINE THAT HAS NOT BEEN PROPERLY LOCKED OUT!

  Yes

  No

  N/A

• Energy isolation incidents / lessons learned are commonly distributed to employees

  Yes

  No

  N/A

• All personnel are familiar with the LOTO checklists and proper records are kept

  Yes

  No

  N/A

• Personnel recognize all type of energy sources requiring isolation through LOTO

  Yes

  No

  N/A

Other Observations

• List any changes needed to procedures, record keeping, equipment etc. needed?

• Additional comments

• Add relevant photos

  Media

Sign-off

• A yearly audit of the LOTO procedures for this facility has been conducted on the following date

• Select date

  Date

• Auditor

  Sign

• Site Manager

  Sign