Pipeline Risk Assessment Questionnaire
Complete this Pipeline Risk Assessment Questionnaire Form to evaluate and document key risks for your pipeline project. Please provide accurate and thorough responses for each section.
Pipeline Section or Asset Identifier
*
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pipeline Type
*
Please Select
Transmission
Distribution
Gathering
Flowline
Other
Location or Route Context
*
Please Select
Urban
Suburban
Rural
Environmentally Sensitive Area
Other
Current Condition/Status of Pipeline
*
Excellent (No known issues)
Good (Minor issues)
Fair (Some deterioration)
Poor (Significant deterioration)
Critical (Immediate attention required)
Operating Environment
*
Corrosive soil
High population density
Flood-prone area
Seismic zone
Remote location
Other
Key Risk Factors Present
*
Corrosion
Third-party damage
Material defects
Incorrect operation
Natural hazards
Other
Severity of Potential Consequences
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Probability of Failure
*
Rare
1
2
3
4
Frequent
5
1 is Rare, 5 is Frequent
Inspection & Mitigation Status
*
All recommended actions completed
Some actions in progress
No actions taken
Overall Risk Priority
*
Low
Moderate
High
Critical
Submit Assessment
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