• Location
  • Supervisor/Crew Leader

  • Job description

  • Conducted on

  • Prepared by

  • Personnel

Work order

  • JHA and Tool Box Safety meeting filled out correctly and all employees signed

  • All permits filled out correctly with customer Rep Signature and Circle S rep Signature in proper place

  • Crew is aware of all hazards and how to avoid them

  • Pre job inspection done on equipment/vehicles

Safety controls

  • LOTO done correctly


  • Is Job in Confined space

  • Has confined space air quality been tested?

  • Has monitor been bump tested with in 24 hours and in calibration?

  • All PPE present and properly used (Hard hat, safety glasses, ear plugs, steel toe boots (Lace Up where required)

  • Are ladders, scaffold, fall protection needed in use

  • Are the ladders, scaffolds, and man lifts being used properly

  • fall protection equipment in use in good condition and being used properly

  • Is Fall Protection being used

Confined Space

  • Is Confined Space permitted by customer

  • Verify Confined Space is in lock out procedure

  • Is a 4 gas monitor being used

  • Has monitor been calibrated in previous 12 months

  • Has monitor been bump tested within 24 hours and documentation on job site or (Job trailer)

  • Is Safety rope being used if only one person in confined space or if multiple entrants a safety rope at the entry point as needed for rescue

  • Confined space attendant present

  • Has Confined space attendant been trained and fully aware of his duties and expectations (emergency procedures)

  • Does confined space attendant have high vis vest and Radio and or Emg numb

  • Does Attendant understand the use and functions of the monitor being used

  • Are safety harnesses being used in the confined space

  • Confined Space Entrants been trained in confined space job task and PPE

  • Attendant Log sheet being used and kept current with entrants in the confined space

Hydroblasting General Safe Work Practices

  • 4.2.2 house keeping-Is the work area free of all removable hazards?

  • 4.2.4 Is pump properly barricaded to restrict unauthorized people from entering the work area.

  • 4.2.4 is area being cleaned properly barricaded to prevent unauthorized people from entering and using Signs

  • 4.2.4 is pre-printed barricade tags properly attached (Danger hydroblasting)

  • 4.2.5 Are wheel chocks in place on pump and truck

  • 4.2.6. Whip checks in place and tight on all hoses

  • 4.2.7 Is pump operator present and close enough to disengage pressure

  • 4.2.8 Is there clear line of site between pump operator and hose end equipment operator. If unable to do so is radio or third person in use

  • 4.2.9 Are hoses routed and protected in a manner that prevents vehicular damage and personnel exposure to hoses

  • 4.2.10 Are all personnel 6' or more away from hose connections while under pressure

  • 4.2.12 Are debris barriers in place

  • 4.2.15 Is a hard stop required. If so is it being utilized

  • 4.2.17 Is hose shroud in place

  • 4.2.18 Has back thrust been calibrated to 1/3 of operator and properly applied

  • 4.2.19 Is operator controlling the foot pedal

  • 4.2.20 Is foot pedal secure and free from obstruction

  • 4.2.21 If people working below is the water from foot pedal being redirected by using 3/4 hoses coming off foot pedal

Hydroblasting Equipment Requirements

  • 4.3.4 is stinger at least 1.5x the diameter of pipe being cleaned

  • 4.2.5 Is lance marked 24"or more from the end of the compression fitting

  • 4.3.6 Does shotgun have hose shroud

  • 4.3.6 Is the shotgun shroud 6' in length

  • 4.3.6 Has shotgun shroud been properly inspected for current qtr

  • 4.3.7 Is the length of the shotgun 66" from butt stock to end of the nozzle

  • 4.3.8 Are fittings rated for pressure being applied?

  • 4.3.9 Does shotgun have a double trigger lock

  • 4.3.10 Is entry point where 3D tool is in operation securely covered to prevent spray from exiting vessel

  • 4.3.10 Is 3D tool appropriately suspended (rope not allowed)

  • Blast hose inspected with metal tag in place

  • Blast hose in good repair

  • Hydro Blast unit level and wheels chocked

  • 10k

  • 20k

  • 40k


  • Has Vacuum check list been preformed and present on Job Site

  • If necessary, is vac truck properly bonded and ground meter being used and verified continuity

  • Is job on an elevated floor

  • Is vac hose properly tied off

  • Is product being vacuumed combustible dust

  • Is conductive hose being used

  • Is there a hose break in use and in close proximity of the work being preformed


  • Is fire extinguisher in place and inspected

  • Is vehicle/equipment clean

  • Does vehicle have current Inspection sticker, Tag, and current insurance card

  • Does vehicle have clear company logo's on side in good condition

Employee Appearance and Professionalism

  • Does employees have on Uniforms

  • Is the shirts of the uniforms tucked in with belt on

  • Are Employee's clean shaving to comply with company policy

Comments and corrections


  • undefined

Corrective Action

  • undefined

  • Auditor

  • Crew Leader/Supervisor

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.