Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Is JSA/POWRA filled out and signed by company man and SPM employees?

  • Was a Safety meeting held stating all Safety Precautions, Muster Area, and Job Tasks?<br>(Use mapping to identify routes of exits and entrances,wind direction, and Respirators if needed.)

  • Is pressure OFF ALL LINES?

  • Has the Fall Protection been inspected and in good working order?


  • Do all swivels/wing nuts/hammer unions/middle ball races/swivels and middle of 10' joints have ribs? <br>(ONE RIB PER UNION)

  • Are all spines pulled tight with no slake and run through both ears of the ribs?

  • Does every main line have at least 2 anchor point ?

  • Do all shackles have nuts and pins installed and secured?

  • Is mainlines wrapped around any pipe? <br>( IF YES FIX, WRAPPING IS NOT ALLOWED)

  • Is all products picked up and loaded in truck/trailer?

  • Has the proper calculation for footage been done?


  • Is employee wearing Level 5 PPE.

  • Is the H2S monitor being worn?<br>Needs to be 9" from nose. ( i.e. - Outside of clothing on chest area.)

  • Has monitor been bump tested/ and or calibrated?

  • Does employee have Fall Protection on when above 4 feet?<br>Ensure employee is tied off when in man basket-Check to see if monthly inspection has been done.

Human Factor

  • Has the employee been given WX conditions prior to work?<br>Should be noted in POWRA.

  • Does employee have sufficient hydration and nutrition?<br>(When was the last time employee had water and meal)

  • Has the employee had rest?<br>Look for fatigue-Is employee checking in with supervisor every 2 hours.


  • Ensure trucks and trailer have current DOT regulatory documentation and signage.

  • Has the DVIR been properly filled out?<br>Pre & Post Trips.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.