PLANT SAFETY REGULATIONS DOCUMENTREFERENCE

GGR 0992
REV
1

PERMIT TO WORK
APPENDIX
I
Dept: Priority Job No: EWT: Location: No

UNIT PLANT CODE PLANT REQUIRING ISOLATION

APPLICATION

SPECIAL REQUESTS/ CONDITIONS/ WORK TO BE CARRIED OUT CROSS REFERENCE

DANGERS
PTW No

Workers' Register No

Gas Test Cert No

Potential
Production
Loss
Recommis-
sioning
Required
ISOLATIONS/INSTRUCTIONS
PLANT CODE COMPONENT/INSTRUCTION REQ LOCATION STATUS * KEY OPS
W O R K
T O
P E R M I T

PERMIT APPLICATION PERMIT ISSUED CLEARANCE

D T D T D T

APPLICATION COMPLETED BY APPOINTED PERSON SIGNATURE RESPONSIBLE PERSON SIGNATURE

NAME ** **

RESPONSIBLE PERSON SIGNATURE KEY SAFE NO SAFETY LOCK NO REVOCATION

SIGNATURES

** D T

PRODUCTION SCHEDULED PERMIT ACCEPTANCE APPOINTED PERSON SIGNATURE

D T **

PLANT SHUTDOWN AGREED RESPONSIBLE PERSON SIGNATURE RECOMMISSIONING COMPLETED

NAME ** D T

*SEE NOTES AND ABBREVIATIONS TARGET COMPLETION RECOMM.DEPT SIGNATURE

OVERLEAF
**SIGNATURE D T **
PTW PSR CPTWS TM
 IMPORTANT NOTE
PERMIT TO WORK
The appointed person must carry out the necessary isolations to ensure that work can proceed without danger, ensuring that the correct plant
is being isolated, using safety locks and prohibitory signs according to the requirements of the Plant Safety Regulations, applying general
good safety practice, and adhering to any local procedure which may be in force regarding the isolation of that particular plant.
Clean Hands Approach must be followed when extracting fuses .
The responsible person must ensure that the correct plant has been isolated, that the work details are correct, that the stated isolations have
been effected, and that these are adequate for the prescribed work to be carried out without danger.
The responsible person must sign the permit to work, having taken cognisance of any special conditions, requests or dangers endorsed
thereon. The permit to work will be deemed to be in force after the responsible person has signed acceptance.

Supervise/Supervision - means to oversee the actions of a person(s) to such an extent as to prevent any dangerous act, as far as reasonably
practicable.
Danger/dangerous - means a condition/substance that constitutes a risk of personal injury, impairment of health, or death.
Any special precautions, conditions or dangers must be stipulated on the permit to work.

PERMIT TO WORK SUSPENSION

SUSPENSION - means a mutual agreement on the permit to work form between the responsible person and the appointed person, which
stipulates that the work detailed on the permit to work has been suspended for the purpose specified on the permit to work.
The responsible person must inform the workers involved in the work that it is no longer safe to do any further work on that plant, and the
workers register must be withdrawn. The appointed person must ensure that it is safe to operate the plant . The appointed person must sign
the permit suspension on the original and the copy of the permit to work, thus suspending the permit to work. The date and time of suspension
must be entered and must coincide with the date and time of the sanction for test.

SUSPENSION REVOCATION - means a written declaration on the permit to work form, signed by both the appointed person and the
responsible person, stating that the suspension has been revoked, the isolations as detailed on the permit to work reapplied, and that work
may be safely resumed. A new workers register must be completed.
CLEARANCE - means a declaration on the permit to work form, signed and issued by the responsible person in charge of the work, stating that
all personnel, tools and debris have been withdrawn and that the plant is in a serviceable condition.
REVOCATION - means a declaration on the permit to work form, signed by the appointed person, formally withdrawing the authority to work
previously given on the permit to work, and stating the date and time of the withdrawal.

1ST REQUEST FOR PERMIT SUSPENSION AS AGREED IN SANCTION FOR TEST No

TIME: DATE: TIME: DATE:
RESPONSIBLE PERSON SIGNATURE: APPOINTED PERSON SIGNATURE:

1ST PERMIT SUSPENSION REVOCATION

TIME: DATE: TIME: DATE:
RESPONSIBLE PERSON SIGNATURE: APPOINTED PERSON SIGNATURE:

2ND REQUEST FOR PERMIT SUSPENSION AS AGREED IN SANCTION FOR TEST No

TIME: DATE: TIME: DATE:
RESPONSIBLE PERSON SIGNATURE: APPOINTED PERSON SIGNATURE:

2ND PERMIT SUSPENSION REVOCATION

TIME: DATE: TIME: DATE:
RESPONSIBLE PERSON SIGNATURE: APPOINTED PERSON SIGNATURE:

CHANGE OF THE RESPONSIBLE PERSON FOR PERMIT TO WORK

TIME: DATE: TIME: DATE:

FIRST NEW RESPONSIBLE PERSON SECOND NEW RESPONSIBLE PERSON

NAME SIGNATURE: NAME SIGNATURE:

ABBREVIATIONS THAT MUST BE USED TO INDICATE ISOLATION STATUS

Abbreviation Description Component Abbreviation Description Component

L/O : locked open valve R/O+L : racked out and locked breaker/contactor
L/S : locked shut valve F/W+L : fuses withdrawn, barrier / cabinet locked fuse holder
O : open valve T+L : tripped and locked UP, MCB
S : shut valve TEST : in test position Breaker
T/S : tagged/taped shut valve CaE+L : cable earthed and locked Breaker
T/O : tagged/taped open valve TEMP : temporary supplied breaker/contactor
T/AVL : tagged/taped available valve CLSD : closed for temporary supply breaker/contactor
AVAIL : available valve L/O+CF : locked open and control fuses withdrawn Breaker