PUB-3000 Chapter 18 | LOCKOUT/TAGOUT & VERIFICATION | Appendix 3: LOTO Inspection Form

LOTO Procedure Periodic Inspection Form

Date of Inspection_______________________________________________________________

Equipment Name/Identification_____________________________________________________

Procedure Number_______________________ Revision Number / Date___________________

Associated Documents (AHD, etc)__________________________________________________

Authorized Employee(s) Demonstrating the Procedure__________________________________

Authorized Employee Inspecting the Procedure________________________________________

Procedure Inspection Criteria:

Each equipment-specific written energy control procedure must be inspected by an Authorized Employee on an annual basis.
The procedure shall be demonstrated by (a) LOTO-Authorized Person(s) who uses the procedure.
The Authorized Employee performing the inspection must be familiar with the LOTO procedures utilized as well as with the equipment’s energy types and methods of controlling them.
The inspector must not be a person who is involved in the actual use of the procedure on the equipment or apparatus.
If the inspection scope was limited by operational demands, describe in Comments below

	YES	NO	N/A	SUBJECT	COMMENTS
I. Written Equipment-Specific LOTO Procedure:
1.				Written energy control procedure(s) available
2.				Procedure identifies persons to be notified
3.				Procedure identifies specific preparation steps
4.				Procedure identifies all steps of how to shut the equipment down
5.				Procedure correctly identifies and quantifies all hazardous energies to be controlled.
6.				Procedure correctly identifies energy isolation points and methods for all hazardous energies to be controlled.
7.				Procedure identifies any special LOTO devices to use for all hazardous energies to be controlled.
	YES	NO	N/A	SUBJECT	COMMENTS
8.				Procedure identifies how to release stored energy and prevent reaccumulation of all hazardous energies to be controlled.
9.				Procedure provides instructions to attempt restart of equipment to check effectiveness of LOTO
10.				Procedure correctly identifies how to verify that all hazardous energies are controlled.
11.				Procedure identifies how to release from LOTO.
II. Authorized Employee Knowledge:
1.				Can demonstrate knowledge about the LOTO program, purpose and employee responsibilities.
2.				Can demonstrate knowledge about the appropriate lock and tag devices to use for all hazardous energies to be controlled.
3.				Can demonstrate knowledge about the placement location of all energy-isolating devices.
4.				Can demonstrate knowledge about any (or all) secondary or residual energy.
5.				Can demonstrate knowledge about the energy-isolation verification procedures.
6.				Can demonstrate knowledge about the necessary procedures if the equipment does not have a lockable energy-isolating device.
7.				Has received the required classroom and hands-on equipment specific training.
III. LOTO Devices:
1.				Appropriate LOTO devices available for each type of hazardous energy to be controlled.
	YES	NO	N/A	SUBJECT	COMMENTS
2.				Appropriate support equipment/devices (grounding rods, measurement tools, etc) available for each type of hazardous energy to be controlled.
3.				Adequate number of LBNL approved locks available.
4.				Adequate number of LBNL approved tags available.
IV. LOTO Practices:
1.				Written energy control procedure(s) followed.
2.				Locks were placed and labeled.
3.				Tags were placed and labeled.
4.				All stored energy was released and prevented from reaccumulation.
5.				Control of all hazardous energies was verified.
6.				Procedures for release from LOTO were followed.
7.				Each Authorized Employee involved in the procedure was able to describe their LOTO responsibilities.
V. Effectiveness:
1.				Discrepancies found in procedure(s):
2.				Discrepancies found in knowledge:
3.				Discrepancies found in practices:
4.				Other Notes:

________________________________________________________________________
Signature of InspectorDate

Chapter 18 LOCKOUT/TAGOUT AND VERIFICATION

Appendix 3: LOTO Inspection Form

Chapter 18
LOCKOUT/TAGOUT AND VERIFICATION