Title Page
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Conducted on
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Prepared by
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Location
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HTTR PM Safety Checklist conducted for
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Audit Title
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HTTR PM
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Conducted on
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12/6/18, 1:30 PM
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Document No
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Prepared by
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Name
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Location
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Site location
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Personnel
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Company
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Score
Audit - 30/30 - 100%
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Question
Response
Details
Site Details
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Site / Project Name
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Location/ HTTR PM
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Use this audit to assess the following aspects of this site as Safe, At Risk or Not Applicable. Unsafe should be attached where appropriate, particularly to At Risk items
Work Areas
Score (6/6) 100%
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General Housekeeping (neat, tidy, dust free)
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Walkways (free of debris and obstructions)
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Work Surfaces (clear of clutter and dust)
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Sides or Holes (safety guards or covered)
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Impalement Hazards (none present, or adequately marked)
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Material Storage/Lay Down (neat and tidy)
Personal Protective Equipment (PPE)
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Hard Hats (available, worn by crew and in safe condition)
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Safety Glasses with Side Shields (available, worn by crew and in safe condition)
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Face Shield / Goggles (available, worn by crew and in safe condition)
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Respiratory Protection (available, worn by crew and in safe condition)
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Hearing Protection (available, worn by crew and in safe condition)
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Appropriate Clothing (in safe condition)
Score (8/8) 100%
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HTTR PM
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Score (30/30) 100%
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Question
Response
Details
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Gloves (available, worn by crew and in safe condition)
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Foot Protection (fit for task, worn by crew and in safe condition)
Fall Protection Equipment
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Suitable Anchorage Points
Ladders
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Proper Ladder for Task
Tools and Equipment
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General condition of tools
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Right tools are being used for tasks
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Crew members are trained to be competent in the tools appropriate for their work tasks
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Personnel
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HTTR PM
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Score (30/30) 100%
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Score (3/3) 100%
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Score (3/3) 100%
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Score (4/4) 100%
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Score (3/3) 100%
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Question
Response
Details
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Behavior is orderly and professional
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Proper lifting technique demonstrated
People Safety
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Score (3/3) 100%
Team Member 1
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Name
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Team member signature
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(to verify this interview knowledge)
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HTTR PM
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Score (30/30) 100%
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HEATER-TREATER - 15/15 - 100%
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Question
Response
Details
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Has the Chesapeake Representative drained and depressurized the Heater-
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Treater?
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Has an inspection been performed on the
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HTTR BMS (Burner Management System) which includes pilot line, gas inlet line,
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flame arrestor, orifice, burner stack,
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regulator, thermostat control, piping, and if
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any issues found, have they been
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addressed and cleaned/repaired/replaced if
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needed?
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Have the HTTR manway hatches been to specification when installing back on
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HTTR with new gaskets?
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Has the HTTR fire tube been removed for inspectioncleaning/replacing as per
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HTTR PM
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Score (15/15) 100%
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Question
Response
Details
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Has a visual inspection been made on
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HTTR PM
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Score (15/15) 100%
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General Comments
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Question
Response
Details
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Brief description of job scope
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Add any additional relevant photos
Sign Off
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Name and Signature of
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Pusher Name
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Name and Signature of
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Chesapeake
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Representative
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HTTR PM
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Score (0/0) 100%