LSR-Energy Isolation Audit

Life Saving Rules - Lock Out / Tag Out Verification

⚡ ENERGY ISOLATION AUDIT

👤 Auditor Information

Name of Auditor *

Date *

Company *

Location *

📋 Energy Isolation Plan & Verification

Life Saving Rule: Energy isolation is critical to preventing serious injury or death. All isolation points must be verified before work begins.

EIP completed on the appropriate form and approved? *

YesNoNeeds ImprovementN/A

Cold Eyes verification thorough? *

YesNoNeeds ImprovementN/A

Zero Energy verified by Affected Workers? *

YesNoNeeds ImprovementN/A

🔒 Personal Locks & Lockbox

Individual workers using personal locks? *

YesNoNeeds ImprovementN/A

Designated Worker attached personal lock to lockbox? *

YesNoNeeds ImprovementN/A

Designated Worker initialed beside each worker's name on log? *

YesNoNeeds ImprovementN/A

Are ALL device lock keys in the lock box? *

YesNoNeeds ImprovementN/A

🏷️ Tags & Color Designations

All locks have appropriate color designation? *

YesNoNeeds ImprovementN/A

All locks and isolating devices have tags? *

YesNoNeeds ImprovementN/A

Tags completely filled out and affixed? *

YesNoNeeds ImprovementN/A

If device can't be locked, is EI Tag attached? *

YesNoNeeds ImprovementN/A

EI tag stubs used in lieu of locks in lockbox? *

YesNoNeeds ImprovementN/A

Changes evaluated & verified zero and approved? *

YesNoNeeds ImprovementN/A

⚡ Electrical Isolation

Open breakers to electrical equipment? *

YesNoNeeds ImprovementN/A

Qualified Electrician confirms interlocks/permissive? *

YesNoNeeds ImprovementN/A

During Confirm. were ALL electrical sources ID'd? *

YesNoNeeds ImprovementN/A

🔧 Piping & Block Isolation

Are all flanges fully rated or misaligned (piping)? *

YesNoNeeds ImprovementN/A

For Double Block & Bleeds; are bleeds monitored for leakage past valves? *

YesNoNeeds ImprovementN/A

Are single blocks approved by 1st Line Authority? *

YesNoNeeds ImprovementN/A

All bleeds listed in EIL and monitored during work? *

YesNoNeeds ImprovementN/A

Workers walked down EIP & ID'd location of devices? *

YesNoNeeds ImprovementN/A

Single block isolation necessary? Explain ASH Compliance

💬 Audit Review

Was audit reviewed with crew? *

YesNo

Describe Needs Improvement or Non-Compliances

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