Hazardous Energy Lockout/Tagout and Try

Performance Test Checklist

Trainee’s Name:Date:

Evaluator’s Name: Location:

Equipment:

Start Time: Ending Time:

Attempt No.12

Performance Objectives: Trainees will demonstrate/simulate the ability to safely de-energize and lockout/tagout identified equipment using appropriate materials and all applicable procedures. After completing all requirements with 100% accuracy, the trainee will be qualified to perform LOTO activities applicable to their job.

Performance Standards:

  1. L48 safety procedures will be followed during the performance test.
  2. Time allotted for the performance test is a maximum of one hour.
  3. Trainees will have two attempts to achieve satisfactory performance.
  4. A minimum of twenty-four hours is required between attempts.
  5. A maximum period of seven days is allowed between attempts.
  6. Remedial training (retrain or self-study) must follow if a satisfactory score is not achieved on the first attempt of the performance test.
  7. If unsuccessful on the second attempt of the performance test, see 2.1 under Guidelines for Testing in the Trainer’s Guide.

Instructions for Test Evaluator:

  1. Remind the trainee they are allowed to use the procedures as a reference document.
  2. Brief the trainee on the content and expectations of the performance test.
  3. Explain that coaching or prompting is not allowed during the test.
  4. Explain that questions may be asked during the performance test only to verify understanding of an expectation.
  5. Ask the trainee if they have any questions before starting the performance test.
  6. Place a check mark () in the box indicating ‘Satisfactory’ (‘SAT’) or ‘Unsatisfactory’ (‘UN-SAT’) for each step.
  7. Complete the Comment Section if applicable.
  8. Provide immediate one-on-one feedback after the performance test is complete.
  9. Sign the Approval Section.
  10. Obtain trainee’s signature and supervisor’s signature in the Approval Section.
  11. Forward a copy of performance test results to the Training Coordinator who will enter data in the Training Recordkeeping System (TRS).
  12. File original performance test.

This checklist format would be followed.

PERFORMANCE TEST CHECKLIST
SCORING SHEET / SAT
 / UNSAT

LOTO Procedures

  1. Identified and reviewed all applicable procedures for the LOTO task

Preparation for Shut Down of Equipment

  1. Conducted a pre-job meeting

  1. Notified appropriate personnel of equipment shutdown and LOTO

  1. Reviewed all applicable procedures for equipment shutdown

Equipment Shutdown

  1. Shutdown equipment safely using equipment shutdown procedures, if applicable

Isolation of Energy

  1. Identified all energy sources and isolation points

  1. Filled out lockout tags correctly

  1. Demonstrated how to correctly install locks on all isolation devices

  1. Ensured a lockout tag was attached to each lock.

Verification of Lockout Device and Tag Application

  1. Verified all isolation points were properly locked out and tagged out.

Release of Stored Energy

  1. Released “stored energy” by performing the following actions:

  1. Assumed safe body position while opening bleeders to relieve hydraulic, gas, or liquid pressure.

  1. Applied a grounding system to prevent static electricity, if applicable.

  1. Assumed safe body position while relieving tension on a spring, if applicable.

  1. Prevented mechanical equipment from turning, if applicable.

  1. Secured weights on pumps to prevent movement, if applicable.

  1. Bled down capacitors.

Verification of Isolation and Try

  1. Verified all isolation points have been locked out and tagged out using procedures, diagrams, schematics, or any other positive means.

  1. Verified equipment was at a zero energy state by performing the following action:

a.Tried all start buttons or selector switches to ensure that the equipment will not start.
b.Verified electrical switchgear could not be initiated to start equipment.
c.Opened bleeder valves

Release from LOTO

  1. Verified area and equipment is clear of nonessential items.

  1. Verified all employees are safely clear of area.

  1. Verified all controls are in neutral, if applicable.

  1. Removed all locks and tags. (non-owner lock removal)

  1. Notified all affected personnel that equipment is ready for use.

  1. Energized the equipment.

Verified Understanding of Group LOTO
  1. Correctly answered all of the following questions regarding group LOTO:

Note: Answers to the questions are in the Trainer's Guide.

  1. When is group Lockout/Tagout typically used?

  1. Where is the key for the isolation kept?

  1. Who attaches locks to the lock box?

  1. Whose lock goes on first and comes off last?

  1. When and how is a permit used?

  1. Who initials the permit?

  1. Who controls, keeps the permit?

Hazardous Energy Lockout/Tagout and Try

Evaluator’s Comments:

Trainee’s Comments:

Approval:

The trainee has met all requirements and is now qualified to perform LOTO activities.

The trainee has not met all requirements and requires additional training. A remedial training plan will be developed for the employee prior to the second attempt.

DateTrainee’s Signature

Evaluator’s Signature Supervisor’s Signature

December 30, 20031