Specific location / task:
Date:
Department(s):
Assessor:
Assessment guideline :
For this LIFEsaver Field Check, three independent employees / contractors must be interviewed. One
field observation, on a lockout and tagout energy isolation, beginning to end, must be completed to
verify program compliance.
Interview/Discussion items :
Do employee interviews verify LOTO
training? When was the last training?
Describe the procedure you follow
before performing maintenance on a
machine?
In the event that more than one
person was required to work on a
piece of equipment, how would the
equipment be locked-out?
Are there written equipment specific
procedures, which define how energy
is to be locked-out and isolated, prior
to any maintenance or servicing?
What are all applicable energy
sources related to this lockout?
What are the methods and means
necessary for energy isolation and
control?
Are there circumstances when you
cannot apply full lockout on
equipment/processes?
Expected Response Person - 1 Person - 2 Person - 3
Yes. Response verifies that
training is conducted
annually.
Identification of all energy
sources, LOTO in the field,
lockout verification done
(e.g. attempting to start
equipment, 3-way
communication with 2nd
person), each person applies
lock on disconnect or puts
lock on lockbox.
Each person working on the
equipment is to add a
personal lock on equipment
or lockbox
Yes, written procedures are
available that includes a
LOTO checklist, or LOTO
requirements are defined
using a Permit to Work.
Electrical, pipelines,
gravitation, springs,
hydraulic, etc.
Disconnect electricity,
closing valves, placement of
flanges, drain/purge/ vent to
zero energy state, etc.
If yes, be sure these
circumstances are noted in
the procedure or permit.
Field Observation Items : Processes / Equipment: …………………………….

Are all applicable energy sources identified (check P&ID/procedure)?  Safe  At-Risk
Comments:

Is LOTO being performed by trained and authorized persons?  Safe  At-Risk

Comments:

Is the field LOTO applied with lock AND tag?  Safe  At-Risk
Comments:

Are the LOTO methods completely discussed with all workers before starting
work?  Safe  At-Risk
Comments:

Is there a lock (field or lockbox) for all workers working on the equipment?
(and key of personal lock in workers own pocket)  Safe  At-Risk
Comments:

Did every worker verify that all energy sources are locked out and isolated
prior to starting work?  Safe  At-Risk
Comments:

Is the LOTO equipment robust and well maintained?  Safe  At-Risk

Comments:

If a lockbox is applied, are the keys of all energy sources in the lockbox?  Safe  At-Risk
Comments:

Follow up items Deep Dive assessment

required (yes/no)
1
2
3
4

Guideline for “Deep Dive” determination :

Two or more people indicated that they were not (re-) trained in the last 12 months.
One person indicated that a personal lock is not required or not applied.
More then 20% of the answers during the discussion are below expectation.
Field observation shows LOTO was not applied on all energy sources.