1. Information

  • Site conducted

1.1 Information

  • Document No:

  • Conducted On:

  • Prepared By:

  • Contact Number (auditor):

  • Pipeline:

  • Pipeline Description

2. Pipeline Exposure

2.1 Pipeline Exposure

  • Is the pipeline exposed?

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

3. Subsidence

3.1 Subsidence

  • Is there any pipeline subsidence?

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

4. Potential Active Erosion

4.1 Potential Active Erosion

  • Is there any potential active erosion near the pipeline?

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

5. Weed Infestations

5.1 Weed Infestations

  • Are there any weed infestations within the 3m pipeline easement

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

6. Fences & Gates

6.1 Fences & Gates

  • Are fences in good condition

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

  • Are gates accessible and in good working condition

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

7. Flooding

7.1 Flooding

  • Are there signs of flooding near the pipeline?

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

8. Explosives

8.1 Explosives

  • Is there evidence of explosives being used in the area?

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

9. Signage & Markers

9.1 Signage & Markers

  • Are there any damaged signs or markers? OR line of sight issues?

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

10. Vegetation & Re-Growth

10.1 Vegetation & Re-Growth

  • Is there any re-growth within 3m of the pipeline that requires attention?<br><br><br><br>

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

11. Gas Leakage

11.1 Gas Leakage

  • Is there any evidence of gas leakage on the TP main?<br><br><br><br>

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

12. Feral Animal Sightings

12.1 Feral Animal Sightings

  • Has there been any sightings of feral animals near the TP main?<br><br><br><br>

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

13. Coating Damage

13.1 Coating Damage

  • Are there signs of coating damage on the pipeline?<br><br><br><br>

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

14. Other

14.1 Other

  • Are there other events to note regarding the pipeline<br><br><br><br>

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

15. New 3rd Party Activity

15.1 New Third Party Activity Near Pipeline

  • Is there any activity by third party contractors near the pipeline?<br><br><br><br>

  • Incident
  • Company Name

  • Company Address

  • Site Supervisors Name

  • Contact Number

  • Location
  • Location description

  • Photos of incident/issue

  • Details of works in area

  • Has the contractor been notified of the TP main in the area?<br><br><br>

16. Construction

16.1 Construction

  • Is there evidence of construction/encroachment in the easement?<br><br><br><br>

  • Incident
  • Description of incident/issue

  • Location
  • Location description

  • Photos of incident/issue

  • Corrective actions required

16. Violation Third Party Activity

16.1 Third Party Violations Within 3m (or 30m for blasting)

  • Is there any third party activity within 3m of the pipeline which constitutes a non-conformance?<br><br><br><br>

  • Incident

16.1 Event Description:

  • Description of event

  • Location
  • Location Description

16.2 Activities Performed Onsite

  • Boring within 3m of TP Main:

  • Select from range

  • Blasting within 30m of TP Main:

  • Select from range

  • Excavating within 3m of TP Main:

  • Select from range

  • Road resurfacing within 3m of TP Main:

  • Select from range

  • Has heavy machinery been parked on TP Main:

  • Vehicle class/weight

  • Photos of vehicle in violation

  • Other:

  • Other - Description:

  • Select from range

  • Photos of People, Vehicles, Excavations:

  • Photos of TP signage within the area:

16.3 Company Details

  • Company Name:

  • Company Address

  • Vehicle Description (and Rego):

  • Photo of Vehicle (and Rego):

  • Operators Name:

  • Operators Contact Number:

  • Operators Email Address:

17. Special Zone Surveys

17.1 Special Zone Surveys

  • Bridge Crossing

  • Bridge
  • Location
  • Location Description

  • Photo
  • Photos

  • Description

  • River Crossing

  • River
  • Location
  • Location Description

  • Photo
  • Photos

  • Description

  • Road Crossing

  • Road
  • Location
  • Location Description

  • Photo
  • Photos

  • Description

  • Other

  • Other
  • Location
  • Location Description

  • Photo
  • Photos

  • Description

18. Sign & Submit

  • Signature:

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.