SHURA ISLAND HE3&HE4

ENERGIZED AREA WORK PERMIT FORM

APPLICATION DATE: SHIFT DAY NIGHT Permit No:

Isolation Required YES NO TYPE OF LOCKOUT: ELECTRICAL MECHANICAL PTW Linked No:

PR: Sign: Company:

ACTIVITY DETAILS
Project Contract Area Zone

Details of CO Complete Section/ Isolation required

Activity Task and Equipment Shutdown By
description
Device Isolated By

Lockout Verified By
Work Activity

Work away from energized or LOTO systems Work near energized or LOTO systems Work on Live Systems(T&C Only) LOTO Isolated systems

Safety Requirement

Additional PPE Fire Extinguisher Voltage related tools Caution/Danger sign LOTO warden Others

Documents

START Attendence Sheet Procedure No Test Equipment Certificate LOTO Tagging Form

ENERGIZED AREA WORK CHECK LIST

GENERAL YES NO N/A
All personnel are LOTO trained
Tool box talk has been provided and all personnel are aware of the risk involved in performing the activity in live area
Supervison available(Charge Hand/Leadman/Foreman/Supervisor//Engineer
Suitable Lighting required and available
All Personnel not working on live or LOTO isolated equipment MUST NOT WORK OR OPERATE those equipment
WORKING ON LIVE SYSTEM YES NO N/A
System equipment to be tested have been identified
Each personnel are aware of their duties and responsibilities in performing the activity
Additional PPE are required, available and personnel are knowledgeable on the use of such PPE
Equipment to be used are in proper working order and calibrated(if required)
Ensure that warning signages, barricades and contact details of relevant personnel are in place
WORKING ON ISOLATED SYSTEM YES NO N/A
Ensure that isolated system have proper Lock Out and Tag Out devices installed
Ensure systems that are isolated from the power source are de-energized /de-pressurized and proven dead
Equipment to be used are in proper working order and calibrated(if required)
Ensure that warning signages, barricades and contact details of relevant personnel are in place
After completion of task, ensure that no personnel are working on the equipment and it is safe to re-energize/re-pressurized
Authorized Workers/Affected Employee
NAME Signature NAME Signature

PERMIT APPROVAL
Responsible Person(RP) CONTROLLING ORGANIZATION (CO-ELEGANCIA) CONTROLLING ORGANIZATION (CO-RSG)

Name: Name: Name:

Company: Company: Company:

Signature: Signature: Signature:

Date: Date: Date:

On Job Completion and Prior to Closing the Permit YES NO N/A
Have all themen working on the equipment/apparatus been withdrawn?
Have all the tools and other materials used for the job been removed?
Has the area been properly cleaned and the barrier/warning boards/tags been removed?
PERMIT CLOSURE CANCELLATION
Performing Authority/Permit User(PU) CONTROLLING ORGANIZATION (CO-ELEGANCIA) CONTROLLING ORGANIZATION (CO-RSG)

Name: Name: Name:

Company: Company: Company:

Signature: Signature: Signature:

Date: Date: Date:

Remarks:

Attachments: 1.Approved Risk Assessment 2.Relevant Drawing 3.Competency Certs

 SYSTEM/COMPONENT SAFETY TAGGING PERMIT ENTRY INSTRUCTIONS

The Permit Requestor fills up the following information:

_Application Date,Isolation requirement, activity Date, shift, PR Name, Signature, Company, Project Contract and detailed activity desription
Non-Energized Works
_Additional Safety requirement is not required and to be filled out as N/A. attach documents except Calibration Certificate and LOTO Tagging
form. For filling up Energized Area Work Check list , ensure to fill out General section. Other section will be filled as N/A
Work on Live system
_Only T&C personnel are allowed to perform this section. Fill out the Safety Requirement and ensure documentation is complete. If
equipment to be live tested have LOTO device installed, fill out the LOTO Request form, Complete the details and attach the LOTO tagging
form along with this permit. For filling up LOTO Controlled Area Check List section, ensure to fill out General and Working on Live System
Sections. The other section will be filled out as N/A
Work On LOTO Isolated system
_Fill out the Safety Requirement and ensure documentation is complete. Fill out the LOTO Request, Complete the details and attach
the LOTO request form along with this permit. For filling up LOTO Controlled Area Check List section, ensure to fill out General and Working
on LOTO Isolated System . Work on Live System section to be filled out as N/A
Permit approval
On the Permit Approval Section, Permit Requester to bring to permit to Responsible Person. Once reviewed and signed, PR to submit the
permit to Tagging Authority Office for verification and approval. The permit needs to be submitted to the DH office a day prior to activity
in order to have enough time for review if there will be no conflict in the permits and to have a smooth flow of work at site.
Tagging Authority (Elegancia)
Review the permit if it would require isolation or would be in conflict T&C Energization activity. If there are no work conflict, Elegancia
Tagging Authority will release the permit to RSG Tagging authority
Tagging Authority (RSG)
Reviews the permit and release for approval
Permit Closure:
Performing Authority/Permit User(PU)
_After the end of the shift, Performing Authority/Permit User(PU) to sign the permit closure section and submit to the Tagging Authority
office for closure and record keeping