Information

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Company Personnel on. Board

Job Setup

  • Barricade

  • House keeping

  • Pump Manned

  • Line of Sight

Personal Safety

  • Head

  • Eye & Face

  • Hearing

  • Hand

  • Clothing

  • Fall Protection

  • Respirator

Ergonomics

  • Straining

  • Over-extending

  • Lifting (back)

  • Line of Fire

  • Body Positioning

  • Safe Footing

Safety/Compliance

  • Per-job Checklist

  • Permits

  • MSDS

  • Pre/Post Trip

  • Lockout Tagout

  • Confined Space

  • Variance

Equipment

  • Use

  • Fittings

  • Ground

  • No Leaks

  • Chocks

  • Relief Valves

  • Guards

  • Hoses

Hazard Control

  • H2O Cuts

  • Trips/Slips

  • Chemical Exposure

  • Pinch Points

  • Spills

  • Heat Stress

Vehicle Use

  • Speed

  • Space Cushion

  • Land Guide

  • Seat Belts

Shotgunning

  • 66" Total

  • 6' Shroud

  • Whip Check

  • Guard Trigger

Chemical Cleaning

  • Job Plan

Air Machine

  • Safety "T"

  • Handle in Place

  • Flash Point Below 140

Liquid Vacuum

  • Cam Locks

  • Not Over Filled

  • Handling Hose PPE

Lance or Line Mole

  • Safe Hands

  • No Gap @ Tubesheet

  • Channel Head

  • Stabbed Controls

  • Stinger 1 1/2 X Pipe Diameter

  • Hose Marked 3'

  • Guard on Back

  • Foot Pedal

Tank Cleaning

  • Cam Locks

  • Hazard Signs

  • Sump Barricade

  • Temp Gauge

  • Hose Connections

COMMENTS

  • Additional Hazards Identified

  • Overall Evaluation of Job

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