Site Safety & Administration
Isolation & Lockout Record (LOTO)
Record of energy isolation and lockout / tagout for maintenance, cleaning or repair of plant and services. Lists each isolation point, lock and personal danger tag, stored energy release, test for dead and restoration.
33 checklist items
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Checklist Items
| Item | Pass / Yes | Fail / No |
|---|---|---|
| ISOLATION DETAILS | ||
| Isolation Record Number | ___________________________ | |
| Site / Location | ___________________________ | |
| Plant / Equipment / Circuit to be Isolated | ___________________________ | |
| Date | ___________________________ | |
| Reason for Isolation (work to be done) | ___________________________ | |
| Isolation Officer / Authorised Person | ___________________________ | |
| ENERGY SOURCES IDENTIFIED | ||
| Electrical | Yes ☐ | No ☐ |
| Hydraulic | Yes ☐ | No ☐ |
| Pneumatic | Yes ☐ | No ☐ |
| Mechanical (gravity, springs, flywheels, moving parts) | Yes ☐ | No ☐ |
| Thermal (hot or cold) | Yes ☐ | No ☐ |
| Chemical / process (pipelines, gas) | Yes ☐ | No ☐ |
| Other energy sources | ___________________________ | |
| ISOLATION POINTS | ||
| Isolation Point 1: location, device, lock number | ___________________________ | |
| Isolation Point 2: location, device, lock number | ___________________________ | |
| Isolation Point 3: location, device, lock number | ___________________________ | |
| Further isolation points | ___________________________ | |
| VERIFICATION | ||
| Plant shut down using normal stop procedure | Pass ☐ | Fail ☐ |
| All isolation points locked and danger tagged | Pass ☐ | Fail ☐ |
| Stored energy released or restrained (bleed down, block, chock) | Pass ☐ | Fail ☐ |
| Electrical: tested for dead by competent person using a proven tester | Pass ☐ | Fail ☐ |
| Attempted start (try-out) confirms plant will not operate | Pass ☐ | Fail ☐ |
| PERSONAL LOCKS & TAGS | ||
| Worker name, lock number, time on (each worker applies own lock) | ___________________________ | |
| Group lock box used (if multiple workers) | Yes ☐ | No ☐ |
| RESTORATION | ||
| Work complete; tools and materials removed | Pass ☐ | Fail ☐ |
| Guards and covers refitted | Pass ☐ | Fail ☐ |
| All workers clear and personal locks removed by the owner | Pass ☐ | Fail ☐ |
| Isolations removed in correct sequence | Pass ☐ | Fail ☐ |
| Plant tested and returned to service | Pass ☐ | Fail ☐ |
| Time Plant Returned to Service | ___________________________ | |
| SIGN-OFF | ||
| Isolation Officer Signature (isolation applied) | ___________________________ | |
| Worker(s) Signature | ___________________________ | |
| Isolation Officer Signature (isolation removed) | ___________________________ | |