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Inspection Form Lockout Tagout

The document provides a checklist for inspecting lockout/tagout procedures. The inspector must be trained and authorized. During inspections, the inspector identifies the area and task, interviews employees to verify training, checks that energy control procedures are being followed using the checklist, and examines lockout/tagout equipment. The inspector documents the inspection using a form that records the equipment, employees, inspection steps, and inspector information.

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Carina Kouamé
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
261 views

Inspection Form Lockout Tagout

The document provides a checklist for inspecting lockout/tagout procedures. The inspector must be trained and authorized. During inspections, the inspector identifies the area and task, interviews employees to verify training, checks that energy control procedures are being followed using the checklist, and examines lockout/tagout equipment. The inspector documents the inspection using a form that records the equipment, employees, inspection steps, and inspector information.

Uploaded by

Carina Kouamé
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Lockout Tagout - Periodic Inspection

Note: The inspector must be trained in Lockout / Tagout procedures and be an authorized
employee as defined in the Lockout / Tagout procedures.

A. Identify an area and task where Lockout / Tagout procedures are being applied.
B. When it is safe to interrupt the workers, identify who you are and the purpose of the inspection.

1. Print the names of the employees interviewed on the inspection form and check the
appropriate box to indicate whether the employees interviewed are authorized or
affect employees as defined in the Lockout / Tagout procedures.

2. Ask the employees if they have been trained in Lockout / Tagout procedures. If the
employees have not been trained stop the activities and contact Department
Management.

3. If the employees have been trained check the appropriate box and after the
inspection verify when the training occurred.

C. Determine if energy control procedures are being followed. Use the attached checklist to
record your findings. If energy control procedures are not being followed, stop the
activities and contact Department Management.

D. Examine the Lockout / Tagout equipment being used and verify that if meets the minimum
requirements of the procedure.

E. Print your name and sign and date the inspection form. Include the date you were trained
in Lockout / Tagout procedures.

1. EQUIPMENT OR DEVICE CONTROLLED (name, manufacturer, model, serial #, etc):

Building or Area: Room: Additional Information:

2. EMPLOYEE(S) INTERVIEWED:

1. Employee Authorized? Affected?


2. Were Authorized Employee(s) trained? Yes No
If No, stop the activities and contact Department Management

If Yes, after the inspection verify documentation is on file? Record the training date. _______________

3. ARE ENERGY CONTROL PROCEDURES BEING FOLLOWED? (Ask employee to describe the procedure.)

1. Are Energy Control Procedures being followed? Yes No


If NO, do this...

If YES, do this...

Employee Description of Procedure Correct? Yes No

4. LOCKOUT AND TAGOUT DEVICES:

1. Standardized Lock (singularly identifiable)? Yes No


2. Lock Out devices used? (i.e. multi- lock hasps) Yes No

3. If yes, are they substantial enough to prevent removal without the use of excessive Yes No
force or unusual techniques?

4. Standard Tags used? Yes No

5. If yes, did the information include: employee name, date, and activity description? Yes No

5. EMPLOYEE CONDUCTING INSPECTION:

1. Inspecting Employee Name: Training Date: Date:

Step 1: Before Beginning to Service Equipment Yes No N/A

Have the type and amount of energy source(s) on the equipment been
1.
identified?

Have the possible dangers related to the energy source being controlled
2.
been identified?

3. Are the steps necessary to control the energy source understood?

Have all affected employees been notified when the equipment will be
4.
shut down for service?

Step 2: Shut Down Equipment Yes No N/A

1. Have the company & RSQUO's Safety Procedures been followed?


2. Have the manufacturer & RSQUO's Instructions been referred to?

Step 3: Isolate the Machine or Equipment Yes No N/A

1. Has the main breaker or control switch been shut off?

2. Have the valves been closed?


3. Have process lines been disconnected?
Step 4: Attach Lock and Tag Yes No N/A
1. Have the lock and tag been attached?
Step 5: Control Stored Energy Yes No N/A

1. Has the electrical capacitance been bled?

2. Have the pressure or hydraulic lines from the work area been vented or
isolated?

3. Have tanks been drained?

4. Are switches or levers that could be moved into the start position blocked,
clamped, or chained?
5. Are lines containing process materials that are toxic, hot, cold, corrosive, or
asphyxiating cleared?

Step 6: Verify That the Energy State is at Zero Yes No N/A

1. Have the start switches on the equipment been tested?


2. Have the pressure gauges been checked to insure that lines are
depressurized?

3. Are blocks or cribs secure?

4. Have electrical circuits been checked to verify that voltage is at zero energy?

5. Are blanks, used to block feed chemicals, secure, and not leaking

Step 7: If you have answered yes (or N/A) to the above steps, then the correct procedures are
being followed. If not, describe the corrective actions taken:

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