Hazardous Work Permit

Date Form # XXX

The completion of the following work is authorized
DEPARTMENT: Time Started: Finished:

Exact Location: Description of Work:

Company: Representative

Precautions that must be observed

Type of Work: Mechanical Confined Space Electrical Welding/ Cutting Excavations Elevated Work

Hot Work (Cutting, Welding, Grinding, Sparks, Flames) Yes Work at Heights
Yes
Área free of combustible materials (35 feet). Cordon off work area. Personnel trained in working at heights
Required screen or fire blankets are in place. Área of work is marked.
Stop processes using flammable materials. Use of basic safety equipment as well as equipment specific for heights
Fire extinguisher available in the area. Fire watch in place during work and for 30 minutes
Safety harness use Lifelines 1 2
afterward.
Protect with barriers any flammable materials that can't be relocated lifeline is attached to harness at back

Machines, cables, tanks, clamps, hoses, gauges, regulators, flame arrestors in good Adequate ladder, in good condition. Ladders secured to work area and tools are secured. Do not use the last 2
condition. steps of ladder.

Área free of explosive atmosphere (Flammable/ Explosive Gases). Steps are clean and in good condition.

Use basic Personal protective equipment and equipment specific to hot work Platform/ basket is adequate and in good condition.

Check for leaks in pipes containing flammable materials Scaffold is adequate and in good condition:

Scaffold Assembly is secure Prohibited to use outdoors during rain

Confined Spaces Yes No material is moved above people. Each work level is 9 feet high

Cordon off work area. Platforms are 50 cm(20 inch) wide, minimum Scaffold is Level and vertical

Block lines/ valves if applicable. Wheels in good condition and locked Standard railing or using harness
Equipment for entry and exit is in good condition. Machinery Maintenance Yes

Use basic PPE and specific safety equipment as required / harness & life line Cordon off work area.

Lockout and tag out equipment following site specific procedure. Use additional PPE according to the activity
Take readings: Temperature Lockout/ Tagout (LOTO) equipment
Oxygen % LEL H2S CO Team to assist with equipment / guard removal if needed.
Safety Attendant is assigned, and rescue team is available Advise Affected Personnel
Equipment for emergency rescue is in good condition Activate Safety devices(Interlocks, Emergency Stop)
Air supply equipment in good condition Check that equipment is not energized.

Movement of Machinery / Lifting Heavy Materials Yes Work in Electrical Equipment

Yes
Cordon off work area. Cordon off work area.
Use additional PPE according to the activity Use basic PPE and specific safety equipment for electrical work

Review conditions and load capacity of equipment to lift material / machinery (Cranes,
Follow Lockout/ Tagout Procedure
Slings, Eyebolts, Chains, trolleys, etc.)
Review conditions and load capacity of equipment to move material / machinery (Rollers,
Appropriate Fire Extinguisher available at work area
cranes, hydraulic equipment, platforms, forklifts etc.)
Review space / dimensions (Width, Length, Height) For Work in Energized Electrical Panels
Analyze safety conditions on the route of movement Licensed Electrician Name:

Operators

Authorization
Authorized Worker: Supervisor of Area: Safety Representative:

A COPY MUST BE POSTED AT THE JOB SITE FOR THE DURATION OF THE WORK!
COMPLETED COPIES ARE MAINTAINED ON FILE FOR ONE YEAR
 Hazardous Work Permit Instructions

1. ORIGINATING THE PERMIT:

The supervisor of the employee(s) performing the work will complete the permit and obtain approvals from Area Supervisor and Safety Representative.
2. WHEN TO USE THE PERMIT (Check or circle THE TYPE OF WORK TO BE DONE)
The supervisor responsible for the equipment or personnel involved will make the decision as to whether or not a permit is required. A permit is mandatory when
the following activities are performed:

• Hot Work—using ignition sources in hazardous areas (e.g., open flames, heat, flame and/or sparks from cutting, welding, brazing, grinding, soldering, etc.).
• Disconnecting and/or cutting lines or opening lines or process equipment which have or could contain toxic, corrosive, flammable, hot, cold, or gaseous materials
under pressure.
• Electrical hot work.
• Working at heights, above production equipment, or using lifts that require fall protection (ie other than scissor lift with side rails).
• Working under and near electrical power lines with cranes, winch trucks, bucket trucks, etc.
• Manual excavations exceeding four feet in depth and all powered excavation work.
• Entering confined spaces that are posted: “DANGER—PERMIT-REQUIRED CONFINED SPACE, DO NOT ENTER” or other similar wording. Entry into a
non-life-supporting atmosphere by Minth employees is NOT permitted.

3. HOW TO USE THE PERMIT

• At a minimum, type of work and 1 other section must be completed. Appropriate sections must be completed for each type of work being performed.
• The Area supervisor and Safety Representative must sign in authorization section, along with the authorized employee/ Contractor.
• If the work involves confined space entry a pre-entry atmosphere check must be conducted prior to entry.
• The permit must be posted in a conspicuous place near the hazardous work area and shall remain there until the work is completed. The form is maintained on
file for a period of one year.
• A separate permit will be required each day when the work is continued from the previous day.

4. SAFETY ATTENDANT DUTIES FOR CONFINED SPACE ENTRY WORK

• Know the hazards that may be faced during entry, including signs or symptoms, and consequences of the exposure.
• Maintain an awareness of possible behavioral effects of hazard exposure in authorized entrants.
• Maintain an accurate count of authorized entrants in the permit space.
• Remain outside the permit space during entry operations until relieved by another attendant.
• Communicate with authorized entrants as necessary to monitor entrant status and to alert entrants of the need to evacuate the space.
• Take the necessary action to ensure that unauthorized personnel do not enter the permit space.
• Perform no duties that might interfere with the primary duty to monitor and protect the authorized entrant(s).
 FOLIO

PERMISO DE TRABAJO DE RIESGO 00001

MINTH MEXICO S.A. de C.V. FECHA MQP-641.05.1
Se autoriza la realización de los siguientes trabajos
DEPARTAMENTO: HORA DE COMIENZO: FINALIZA:

LUGAR EXACTO : DESCRIPCION DEL TRABAJO:

COMPAÑÍA: REPRESENTANTE

PRECAUCIONES QUE DEBEN OBSERVARSE

TIPO DE TRABAJO MECÁNICO ELÉCTRICO INSTRUMENTACIÓN CIVIL

TRABAJOS EN CALIENTE (CORTE, CHISPA, SOLDADURA, FLAMA) SI TRABAJO EN LAS ALTURAS.

SI
Área libre de materiales combustibles (a 10 mts). Personal entrenado en trabajo en alturas
Se requieren mantas o mamparas de protección. Área debajo al trabajo delimitada.
Detener procesos que utilizan materiales inflamables. Utilizar equipo de seguridad básico mas equipo específico para alturas
Extintor de incendio disponible en el área. Arnés tipo paracaidista Líneas de vida 1 2
Área libre de atmósfera explosiva (Gases Explosivos). Amarrarse a punto fijo ubicado sobre los hombros

Maquinas, cables, pinzas, tanque, mangueras, manómetros, reguladores, arresta flamas en

Escaleras adecuadas y en buen estado. Escaleras y herramientas amarradas. No usar los últimos dos peldaños.
buen estado.

Acordonar área de trabajo Peldaños en buen estado y limpios

Usar equipo de protección personal básico mas equipo especifico para trabajo en caliente Andamios adecuados y en buen estado:

Proteger con barreras anti flamas los materiales inflamables no relocalizables Armados con seguros propios Prohibidos en caso de lluvia

Verificar fugas en tuberías que contienen materiales inflamables No es movido con personas material arriba Venteados cada 3 metros

ESPACIOS CONFINADOS SI Plataformas de 50 cm de ancho Nivelados y verticales

Acordonar Área Ruedas en buen estado y bloqueadas Con barandal ó usando arnés

Bloquear líneas/ válvulas si aplica. Canastillas adecuadas y en buen estado.

Equipo para entrada y salida en buen estado. Plataformas adecuadas y en buen estado

Utilizar equipo de seguridad básico mas equipo especifico según requiera /línea de vida MANTENIMIENTOS MAYORES A MAQUINARIA SI

Bloquear y etiquetar según procedimiento Acordonar área de trabajo

Tomar lecturas de: Uso de EPP adicional acorde a la actividad
Temperatura Oxígeno Toxicidad CO Bloquear y Etiquetar (LOTO) / Método Alterno LOTO
Personal brigadista notificado Hombre Ayuda
Prevención de medidas de rescate Avisar Personal Afectado
Equipo de suministro de aire en buen estado Dispositivos de Seguridad Accionados (Interlocks, Paro de Emergencia)

MOVIMIENTO DE MAQUINARIA / IZAR MATERIALES PESADOS SI Sistema Redundante de Seguridad

Acordonar Área TRABAJOS EN TABLEROS ELECTRICOS SI

Uso de EPP adicional acorde a la actividad Acordonar área de trabajo
Revisar condiciones y capacidad de carga de equipo para izar materiales / maquinaria
Utilizar equipo de seguridad básico mas especifico para electricista
(Polipastos, Eslingas, Armellas, Cadenas, troles, grúas etc.)

Revisar condiciones y capacidad de carga de equipo para mover materiales / maquinaria

Seguir procedimiento de bloqueo y etiquetado
(Tortugas Neumáticas, tortugas rollers, grúas, equipo hidráulico, plataformas, etc.)

Revisar espacio / dimensiones (Ancho, Largo, Alto) Extintor operable a la mano

Analizar condiciones de seguridad en el trayecto a seguir PARA TRABAJO EN TABLERO ENERGIZADO
Electricista certificado: Nombre

Operadores

AUTORIZACIONES
TRABAJADOR AUTORIZADO: SUPERVISOR DEL ÁREA: SEGURIDAD E HIGIENE: