Maintenance Pre-Startup Safety Review (PSSR) Checklist
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General Information
Records basic details about the PSSR process.
PSSR Date
Equipment/System Name
Equipment/System ID
Revision Number (if applicable)
Brief Description of Changes/Maintenance
Type of Change
Location of Equipment
PSSR Initiated By
Scope & Process Review
Verifies understanding of the changes, their impact, and the planned maintenance activities.
Brief Description of Maintenance/Modification
Reason for Maintenance/Modification
Type of Maintenance (e.g., Preventative, Corrective, Upgrade)
Estimated Duration of Maintenance (Hours)
Planned Start Date
Planned Start Time
Affected Systems/Areas (Select all that apply)
Reference Documentation (e.g., Work Order #, Engineering Change Order)
Hazard Identification & Risk Assessment
Identifies potential hazards associated with the work and assesses the level of risk.
Describe the changes made to the equipment or process.
List all potential hazards identified related to the changes.
Severity of each identified hazard (High, Medium, Low)
Probability of Occurrence for each hazard (High, Medium, Low)
Risk Score (Severity x Probability - calculated field)
Existing Risk Mitigation Measures (Select all that apply)
Describe any additional risk mitigation measures required.
Overall Risk Level After Mitigation (High, Medium, Low)
Attach any supporting documentation (e.g., MSDS, P&ID updates).
Engineering Controls & Safeguards
Confirms the implementation and effectiveness of engineered safety measures.
Are all safety guards in place and functional?
Emergency Stop (E-Stop) functionality verified?
Pressure Relief Valves (PRVs) inspected and tested?
PRV Set Pressure (if applicable)
Description of any modifications to safety circuits or interlocks (if applicable)
Attach photos/documentation of safety device inspection results (e.g., PRV test reports)
Are all interlocks functioning correctly and preventing access to hazardous areas?
Administrative Controls & Procedures
Evaluates the adequacy of written procedures, training, permits, and lockout/tagout processes.
Is a detailed, up-to-date maintenance procedure available for this task?
Which permits are required for this work?
Has all personnel involved received the required training for this task?
Describe any deviations from standard operating procedures and their mitigation strategies.
Is a Lockout/Tagout (LOTO) procedure in place and understood by all personnel?
Date of Last Safety Training for Task
Describe any specific safety briefings given before starting work.
Personal Protective Equipment (PPE)
Ensures appropriate PPE is available and used.
Required PPE for Task
PPE Condition Verification Notes
Quantity of Safety Glasses Available
Glove Type Appropriateness
PPE Inspection Sign-off
Equipment & System Verification
Confirms equipment functionality, safety devices, and system interlocks.
Confirm Lockout/Tagout (LOTO) Devices Installed and Verified?
Verify Safety Interlocks Functioning Correctly?
Pressure Test Results (if applicable - e.g., Hydraulic/Pneumatic Systems)
Verify Emergency Shutdown (ESD) System Functionality?
Describe Any Observed Issues or Deviations from Expected Behavior:
Confirm Guards and Safety Devices in Place and Functioning?
Date of Last System Calibration (if applicable)
Attach Calibration/Test Reports (if applicable)
Environmental Considerations
Addresses potential environmental impacts and mitigation measures.
Potential for Spills/Leaks?
Describe potential environmental impacts (e.g., water, air, soil contamination)
Estimated Spill Volume (if applicable, in gallons/liters)
Potential Contaminants Released (Select all that apply)
Describe mitigation measures to prevent/control environmental impacts.
Containment System in Place?
Supporting Documentation (e.g., spill prevention plan, waste disposal permits)
Review & Sign-Off
Records sign-off by responsible personnel, confirming the safety review is complete.
PSSR Review Date
PSSR Review Time
Maintenance Supervisor Signature
Operations Representative Signature
Reviewer Name (Maintenance)
Reviewer Name (Operations)
Comments/Observations
PSSR Approval Code (if applicable)
Overall PSSR Status
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