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Title Page

Audit Title

Client / Site

Conducted on 

Prepared by

Policy & Procedure

Have your employees read Pioneer's "Safety Principles" and agree to follow them?

Yes No N/A

Have your employees read Pioneer's "Rules to Live By" and agree to follow them?

Yes No N/A
 All PPE in use where & when required?

Yes No N/A

Are live electrical components de-energized prior to working on or near them?

Yes No N/A

Are JSA's being performed and documented?

Yes No N/A

Are Lock Out / Tag Out procedures being used and documented?

Yes No N/A

Are employees attending Pre-Tour & Safety meetings?

Yes No N/A

Do employees follow all lease or ranch posted speed limits?

Yes No N/A

Environmental

Are Berms in place & functional around all SCE?

Yes No N/A

Is the overflow on Torpedo Tank plumbed back into the Active System?

Yes No N/A
 Are drip pans being used?

Yes No N/A

Are all openings in drip pans properly plugged to prevent fluid from escaping drip pan?

Yes No N/A

Are drip pans empty at this time?

Yes No N/A

Is the work area clean of any excess oil & dirt?

Yes No N/A

Signs & Placards

Are "Fall Protection Required " signs posted in all location where needed?

Yes No N/A

Are "Danger High Voltage" signs posted where needed?

Yes No N/A

Equipment

Are all hand rails in place & properly secured?

Yes No N/A

Is grating on shaker tank secure?

Yes No N/A
Are brackets that secure shakers to tank in good condition?

Yes No N/A

Are all pins & keepers for hand rails and walkways in place and secured?

Yes No N/A

Is grating on Polishing Centrifuge Stand secure?

Yes No N/A

Do the legs on the Polishing Centrifuge Stand have proper pins and keepers in place?

Yes No N/A

Is grating on Active Centrifuge Stand secure?

Yes No N/A

Are motors and electrical panels free of excessive oil and dirt?

Yes No N/A

Do the legs on the Active Centrifuge Stand have proper pins and keepers in place?

Yes No N/A

Is the ladder on Polishing Centrifuge Stand properly secured to the stand?

Yes No N/A

Is the effluent line of Polishing Centrifuge secure?

Yes No N/A
Is the ladder on the Active Centrifuge Stand properly secured to the stand?

Yes No N/A

Has blue glue and tap screws been used on the Polishing Centrifuge effluent line?

Yes No N/A

Has blue glue and tap screws been used on the Active Centrifuge effluent line?

Yes No N/A

Is the effluent line of Active Centrifuge secure?

Yes No N/A

Has blue glue and tap screws been used on overflow line from Torpedo Tank?

Yes No N/A

Is connection from effluent discharge on Polishing Centrifuge to effluent line secure?

Yes No N/A

Are all hoses in good condition?

Yes No N/A

Are "goose necks" being used where hoses go over tank top edge?

Yes No N/A

Is connection from effluent discharge on Active Centrifuge to effluent line secure?

Yes No N/A
Are all connections Hammer Unions or Flanged?

Yes No N/A

Do all hoses with any pressure have Whip Checks?

Yes No N/A

Are all tank openings Bull Plugged or Blind Flanged?

Yes No N/A

Are all hoses Factory made?

Yes No N/A

There are no visible drips on effluent or overflow lines correct?

Yes No N/A

Is Fall Protection device in place where needed?

Yes No N/A

Is harness & lanyard readily available?

Yes No N/A

Is excavator being inspected for damages and documented prior to each tour?

Yes No N/A
Electrical

Is the Active Centrifuge grounded?

Yes No N/A

Is effluent tank grounded?

Yes No N/A

Are the VFD Panel doors secured, air & water tight?

Yes No N/A

Is the Polishing Centrifuge grounded?

Yes No N/A

Is the Polishing Centrifuge Pump grounded?

Yes No N/A

Is the Polishing Centrifuge Stand grounded?

Yes No N/A

Is the Active Centrifuge Stand grounded?

Yes No N/A

Do all electrical panels have "High Voltage" stickers?

Yes No N/A
Is the Active Centrifuge Pump grounded?

Yes No N/A

Electrical plugs to panel have no wire showing, correct?

Yes No N/A

Are all electrical panels grounded?

Yes No N/A

Are all electrical caps secured on all unused outlets?

Yes No N/A

Are all electrical plugs plugged in properly and securely?

Yes No N/A

Do Shaker stop / start panels have all bolts secured?

Yes No N/A

Are all electrical lines tied off with black zip ties or cable?

Yes No N/A

Do all ground rods have impalement caps?

Yes No N/A

Are Drying Shakers grounded?

Yes No N/A
 Is there sufficient lighting in the backyard?

Yes No N/A

House Keeping

Is office & equipment clean and in order?

Yes No N/A

Is living quarters clean and in order?

Yes No N/A

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.