MAINTENANCE PRE-STARTUP SAFETY REVIEW (PSSR)

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--- GENERAL INFORMATION ---
[ ] PSSR Date
[ ] Equipment/System Name
[ ] Equipment/System ID
[ ] Revision Number (if applicable)
[ ] Brief Description of Changes/Maintenance
[ ] Type of Change (New Equipment, Modified Equipment, Repair/Maintenance, Process Change)
[ ] Location of Equipment
[ ] PSSR Initiated By (Maintenance, Operations, Engineering)

--- SCOPE & PROCESS REVIEW ---
[ ] Brief Description of Maintenance/Modification
[ ] Reason for Maintenance/Modification
[ ] Type of Maintenance (e.g., Preventative, Corrective, Upgrade) (Preventative, Corrective, Upgrade, Other)
[ ] Estimated Duration of Maintenance (Hours)
[ ] Planned Start Date
[ ] Planned Start Time
[ ] Affected Systems/Areas (Select all that apply) (Mechanical, Electrical, Pneumatic, Hydraulic, Control System, Process Piping, Structural)
[ ] Reference Documentation (e.g., Work Order #, Engineering Change Order)

--- HAZARD IDENTIFICATION & RISK ASSESSMENT ---
[ ] 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) (High, Medium, Low)
[ ] Probability of Occurrence for each hazard (High, Medium, Low) (High, Medium, Low)
[ ] Risk Score (Severity x Probability - calculated field)
[ ] Existing Risk Mitigation Measures (Select all that apply) (Engineering Controls, Administrative Controls, PPE, Training, Other (Specify in Long Text))
[ ] Describe any additional risk mitigation measures required.
[ ] Overall Risk Level After Mitigation (High, Medium, Low) (High, Medium, Low)
[ ] Attach any supporting documentation (e.g., MSDS, P&ID updates).

--- ENGINEERING CONTROLS & SAFEGUARDS ---
[ ] Are all safety guards in place and functional? (Yes, No, N/A)
[ ] Emergency Stop (E-Stop) functionality verified? (Yes, No, N/A)
[ ] Pressure Relief Valves (PRVs) inspected and tested? (Yes, No, N/A)
[ ] 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? (Yes, No, N/A)

--- ADMINISTRATIVE CONTROLS & PROCEDURES ---
[ ] Is a detailed, up-to-date maintenance procedure available for this task? (Yes, No, N/A)
[ ] Which permits are required for this work? (Hot Work Permit, Confined Space Entry Permit, Lockout/Tagout Permit, Electrical Work Permit, None)
[ ] Has all personnel involved received the required training for this task? (Yes, No, N/A)
[ ] Describe any deviations from standard operating procedures and their mitigation strategies.
[ ] Is a Lockout/Tagout (LOTO) procedure in place and understood by all personnel? (Yes, No, N/A)
[ ] Date of Last Safety Training for Task
[ ] Describe any specific safety briefings given before starting work.

--- PERSONAL PROTECTIVE EQUIPMENT (PPE) ---
[ ] Required PPE for Task (Safety Glasses, Safety Shoes, Hard Hat, Gloves (Specify Type), Hearing Protection, Respirator (Specify Type), High Visibility Vest, Face Shield, Other (Specify))
[ ] PPE Condition Verification Notes
[ ] Quantity of Safety Glasses Available
[ ] Glove Type Appropriateness (Correct Glove Type Selected, Glove Type Requires Revision)
[ ] PPE Inspection Sign-off

--- EQUIPMENT & SYSTEM VERIFICATION ---
[ ] Confirm Lockout/Tagout (LOTO) Devices Installed and Verified? (Yes, No, N/A)
[ ] Verify Safety Interlocks Functioning Correctly? (Yes, No, N/A)
[ ] Pressure Test Results (if applicable - e.g., Hydraulic/Pneumatic Systems)
[ ] Verify Emergency Shutdown (ESD) System Functionality? (Yes, No, N/A)
[ ] Describe Any Observed Issues or Deviations from Expected Behavior:
[ ] Confirm Guards and Safety Devices in Place and Functioning? (Yes, No, N/A)
[ ] Date of Last System Calibration (if applicable)
[ ] Attach Calibration/Test Reports (if applicable)

--- ENVIRONMENTAL CONSIDERATIONS ---
[ ] Potential for Spills/Leaks? (Yes, No, Uncertain)
[ ] 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) (Oil/Grease, Solvents, Chemicals, Dust/Particulates, Noise, Other (Specify))
[ ] Describe mitigation measures to prevent/control environmental impacts.
[ ] Containment System in Place? (Yes, No, N/A)
[ ] Supporting Documentation (e.g., spill prevention plan, waste disposal permits)

--- REVIEW & SIGN-OFF ---
[ ] 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 (Approved, Approved with Conditions, Rejected)

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