Permit To Work Form

Author: SHEQ Manager Approver: General Manager Doc. No:

Review by: Operations Manager Permit to Work
Appendix to
Procedure

SITE PERMIT BOOK NO. PERMIT NO.

[A] GENERAL
[A1] ADMINISTRATIVE DATAS
[A1.1] Department of [A1.2] Name of Issuer [A1.3] Contact details of [A1.4] Company / Dpt. [A1.5] Name of Accepter [A1.6] Contact Details of [A1.7] Date and time [A1.8] Validity [A1.9] Location
issuer issuer of Accepter Accepter (Date and time)

[A2] PERMIT CARRY OVER

[A2.1] PREVIOUS PERMIT [Previous Permit Number: ]

I, the permit issuer of previous permit [ ] , confirms that all work aspects and safety precautions from previous permit were communicated and handed over to the permit issuer of this current permit.

Date & Signature:

[A3] DESCRIPTION OF THE WORK TO BE DONE

[B] RISK ASSESSMENT

[B1] HAZARD IDENTIFICATION

Other
[B2] PPE’s

Other
[B2] Permit(s) Required
Hot Work Pressurized System Electrical Civil Work Working at height Hazardous Material Confined Space Lifting, Rigging & Slinging
Other (specify) :

[C] SPECIFIC
[C1] HOT WORK
Sparks protection to be in place
All workers [D] trained on the use of fire & gassing
procedure
Equipments / Tools in good condition
Tools to be free from flammables, grime & dirt
Fire watchman / Buddy to be in place
All combustible to be cleaned & removed
Fire fighting equipment to be in place and on standby
Ensure Fire watch 15, 30 and 120 minutes after the
work is completed
[C4] PRESSURIZED SYSTEM
No combustible, flammable liquids or vapors to be Inspections to be done by competent person LOTO required
present
All covering / protection materials to be non combustible Inspection to be done by competent certified (AIA) Equipments / Tools in good condition
person
All floor surface to be protected [C5] HAZARDOUS MATERIAL
All floor openings to be covered All chemicals that will be used to be listed Workers [D] to be trained in HAZCHEM handling
LOTO required Buddy system to be in place Fire & gassing detection system to be in place
Ensure adequate ventilation Fire prevention equipment to be in place Spillage control equipments to be available
High Hygiene Authorization Form required (ALL Prod. Equipments / Tools in good condition LOTO Required
Areas)
Warning notice and physical barrier to prevent access in Workers [D] to be trained in spillages control /
place. containment

[C2] WORKING AT HEIGHT [C6] CHEMICAL LIST

Scaffolding to be leveled Fall arrester required Chemical name MSDS available
Scaffolding braces to be installed Scaffolding safety tag to be visible and filled in YES NO
Scaffolding to be inspected before use, weekly basis Scaffold erecter to be trained (proof of training to be YES NO
(if relevant) and after bad weather. given)
(certificate to be filed with SHEQ department)
All potential fall points to be identified Scaffold erecter to be appointed YES NO
Life line to be available and attached to secure anchor Fall prevention plan and Task Risk Assessment done YES NO
point. (as per CR 8(5))
Area below to be cordoned off to prevent injuries All workers [D] to be medically fit to work at height YES NO
Kick plates & handrails to be installed Carrying capacity to suit the job YES NO
Scaffolding footing to be on solid foundations / plates Trained scaffold inspector to inspect scaffolding YES NO
Equipments / Tools in good condition LOTO required [C7] ELECTRICAL
Do not work on roof during inclement weather All translucent roof sheets to be identified, if relevant. 1 worker [D] trained in electrical emergency Electrical Engineer to notify workforce
(rain, storm, wind)
Warning notice and physical barrier to prevent access Ladders for access to be secured and inspected by a Workers [D] trained & qualified LOTO required
to be in place. Competent person.
[C3] LIFTING, RIGGING & SLINGING Equipments / Tools in good condition
Trained & competent in using equipment All lifting equipment to be inspected & certified [C8] CIVIL WORK
Slings to be inspected and on register & certified LOTO required Area to be cordoned off to prevent injuries Equipments / Tools in good condition
Equipments / Tools in good condition High Hygiene Authorization Form required (ALL Prod. All floor openings to be covered High Hygiene Authorization Form required (ALL Prod.
Areas) Areas)
Trained scaffold inspector to inspect scaffolding Construct non combustible covering Suspended cover beneath work to collect falling objects Warning notice and physical barrier to prevent access to
to be in place be in place.
Ensure shoring on excavations deeper than 2m. Construct non combustible covering
[C9] CONFINED SPACE
[C9.1] HAZARDS / PREPARATION [C9.2] TESTING EQUIPMENTS
Site to be controlled LOTO Required Type Model Serial Number Manufacturer Cali. date Proof of calibration
Space to be ventilated before entry Pipes to be blanked, capped or disconnected
Space to be ventilated Equipments / Tools in good condition
Emergency communication equipment to be available Self Breathing Apparatus required for all workers [A] in
(Cell phone, radio, etc…) Space
Additional lighting required Buddy system to be in place [C9.3] ATMOSPHERIC TESTING
Rescue plan to be prepared and communicated to Atmosphere in space to be tested before entry Test Limit Pre-entry Test 2 Test 3 Test 4 Test 5 Test 6 Test 7
all workers [D] Test 1
Atmosphere in space to be tested during work Atmospheric testing equipment calibration proof to be O2 content 16 –
provided 23.5%
Fire prevention equipment to be in place Standby SCBA available for emergencies, if relevant % LEL <10%
Life line to be available and attached to secure anchor Winch / hoist to be available Toxic <PEL
point.
Warning notice and physical barrier to prevent access Ladders for access to be secured and inspected by a Acceptable
to be in place. competent person.
[D] WORKERS
Name First name Role(s) First Aider Buddy Signature Name First name Role(s) First Aider Buddy Signature

[E] PERMIT AUTHORIZATION

VERIFICATION & AUTHORIZATION UNDERSTANDING & ACCEPTANCE
I, the above mentioned issuer, certify that all above mentioned requirements were checked and proven to be sufficient for the work to be I, the above mentioned accepter, agree to follow all above mentioned points during the entire validity of this permit. I also certify that all above
commenced. All risks were considered while preparing this permit mentioned points and all identified risks were properly communicated & understood by all above mentioned workers.

Date & Signature: Date & Signature:

[F] POST JOB EVALUATION
Description YES NO Comments Issuer Signature Accepter Signature
Job completed
If Hot Work, fire watch after 15 min performed
If Hot Work, fire watch after 30 min performed
If Hot Work, fire watch after 120 min performed
Further work required (new permit required)
LOTO to be carried over (new permit required)
House keeping in good order
LOTO removed
Access restored
Warning signs removed