Checklist · 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 · Last reviewed
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) | ||