PROJECT: Tolling, Operation, Maintenance & Transfer of Palanpur- Radhanpur –

Samkhiyali section of NH-27 from KM 589+500 to KM 536+000 in the State of

Gujarat (TOT Bundle 5A1)

TRUPTI INFRASTRUCTURE PRIVATE LIMITED

Document No TIPL/HSE/14 Health Safety Environment
P
Annexure – 1A

adani INTEGRATED WORK PERMIT FOR PROJECT

(Valid in Project/Construction Area Only)
Sl. No………. PERMIT TO WORK FOR INDIVIDUAL WORKING AGENCY Date:……………..
(TO BE FILLED IN TRIPLICATE BY PARTY – ORIGINAL YELLOW & OTHERS WHITE; VALID FOR ONE SHIFT AND MAY BE RENEWED TWICE ONLY)
Location Site…………………………………………………………..…Area #.........................................................................Section:………………………
Original Permit Valid From:…………………………AM/PM Dt………………………..to…………………AM/PM Dt………………………..
1st Renewal Valid From:……………………………...AM/PM Dt………………………..to…………………AM/PM Dt………………………..
2nd Renewal Valid From:……………………………...AM/PM Dt………………………..to…………………AM/PM Dt……………………….. OHS-12F-01A-Work Permit for
SHUT DOWN TAKEN: YES NO NA Project. Effective Date: May 01, 2019
(IF YES), SHUT DOWN planned From:…………………………..AM/PM Dt……………………to………….……..AM/PM Dt…………………………….
Details of job to be undertaken
(1) Area/ Tank/ Vessel/ Equipment/ Pipeline Exact Location: Equipment #
(2) Work to be done : Working Agency: No. of Men:
Engineer/Supervisor:
Work Order / Service Order #
(3) Safety Precautions
(a) Breathing Apparatus / Gas sets (as applicable) :
(b) Protective Equipments to be worn (Ring items which apply):
Helmet, Eye Wear, Face Shield, Self-contained Breathing Apparatus, Supplied air mask, Ear Muffs, Fire Retardant
Cloths, Hand Gloves, Shoes, Gumboots, High Visibility Jacket, Any others:
(c) Other Precautions / Special Instruction:

(4) State of Isolation No. of Depressurized Positive Tagged Off Valve Initials as Not
(Electrical, Solid, Gas, Vapor, lines & Drained Isolation Only applicable Isolated
Fuel, Solid, Air, Nitrogen)

(a) All Motive Power has been isolated & YES , Lock # Tag # NO N/A
any logic control interrupted(LOCK/TAG)
(c) Electrical fuses have been withdrawn & all circuits are dead, Sign ………(Electrician) Date……………Time…….
(d) Electric circuits are on line for trouble shooting only: Sign…………..(Electrician/ Inst) Date………….Time….......
(5) (a) CONFINED SPACE ENTRY (Cancelled if not required)
O2%......................; System Isolated :……………. (Y/N/NA) ; Rescue System………………..(Y/N/NA)
CS Attendant ……(Y/N/NA) Name………………….. Register for entry & exists……………..(Y/N/NA)
Any other gas…………..ppm and is therefore safe to enter from……….Hrs to…..….Hrs on Dt………………….
Sign……………………………………………………(Approved Signatory)
(b) HOT WORK / OTHER HAZARDOUS WORK (Working at height, Pneumatic, Hydraulic System, Material
Lifting, and Excavation): Inspected the site as per requirement overleaf, job specific SWP /SOP exists (Doc# ………)
6. I understand the hazard involved and have taken all necessary precaution/controls as mentioned above.
Permit Original Permit Renewal First Permit Renewal Second
Requested by Issued by Taken by Issued by Taken by Issued by Taken by
Name/G/EPN.
Design. / Dept.
Signature
Date & Time
7. Return of Permit:- After completion of job, removal of all materials / men from site has done by Working Agency.
Now Equipment & Area is safe for operation. The above Equipment / Facility can be restored.
Permit Return by Return Permit Received by Central Return Permit Received by
Agency / Maint. Group Department Issuing Agency
Name/G/EPN. Original 1st Renewal 2nd Renewal Original 1st Renewal 2nd Renewal Original 1st Renewal 2nd Renewal
Design. / Dept.
Signature
Date & Time
Note: This PTW shall deemed to be cancelled if there is any change in work condition, climate (rain, storm) & team working.
Page 1 of 2

adani Annexure – 1A OHS-12F-01A-Work Permit for

Project. Effective Date: May 01, 2019
Checklist to Ensure Safety (Multiple categories may apply to any given job):- Check items completed prior to start.
1. Permit to be signed by people not less than Site Engineer (from Adani Business Location/Contractor’s).
2. Permit requester may be party who raised work order to frontline working agency, issuer may be party owing site and receiver may be
the working agency or agency who had awarded work order for the specific job.
3. This work permit cannot be raised unless SWP/SOP is available and site induction / tool box talk is given based on the same.

1. Hot Work (Welding, Grinding, Cutting, Brazing, Hot Rapping) 5. Crane Lifts & Critical Ragging.

Precautions Taken Precautions Taken

Flammables/Combustibles (charged gas line, cylinder, paper, rags, wood, etc.) protected. Safety devices (limit switch, boom angle etc.) of the appliances are inspected before use.
Fire Watch Established. Operator qualified & medically fit including eye sight examined by authority.
Welding & Cutting equipment integrity checked & positioned properly. Lifting appliances are certified by competent authority and labeled properly.
Cables / Hoses routed over the ground and do not pose a tripping hazard. Hoist chain or hoist rope free of kinks or twists and wrapped around the load.
Area hazards reviewed. Lifting hook has a Safety Hook Latch that will prevent the rope from slipping out.
Electrical Connections through ELCB of 30 mA sensitivity. Lifting gears operator been instructed not to leave the load suspended.
Electrical equipments are free from damage and earthed properly. Electrical power line clearance (12ft) checked. Signal man identified.
Performers are competent and equipped with appropriate PPE’s i.e. including face shield with Outriggers supported, Crane leveled Load chart available in the crane.
Adequate shade number/welding goggles/cotton/fire retardant apron etc. Barrier Installed Riggers are competent.
No tampering / manipulation attempted in safety device of the equipments. Slings are inspected for free from cut marks, pressing, denting, bird caging, twist, kinks or core
Only industrial type electrical appliances are in use. Protrusion prior to use.
Cables/fuses are of adequate size & capacity fit with the requirement. Sling mechanically spliced (Hand spliced may not be allowed).
Hoses are free from damage & connected with jubilee clamp. D / Bow shackles are free from any crack, dent, distortion or weld mark, wear / tear.
No cable joint within 1 m from the holder/grinding machine and completely insulated Job hazards explained to all concern through tool box talk meeting.
within M/C body Special lift as per erection / lift plan (Life plan mandatory for all life >5 tons).
Gas cylinders used: Oxygen/Industrial LPG/Dissolved Acetylene. Guide rope is provided while shifting / lifting. Maintenance record of crane available.
Gas cutting torch of reputed make, ISI marked, installed with NRV / 3 way torch and / or
Flash back arrestors are in use. 6. Electrical Work.
Regulator pressure gauges in working condition, visible & not damaged.
Welding cable & earthing cable are crimped with proper size lugs. Precautions Taken
LIVE ELECTRICAL WORK CAN BE PERFORMD BY LIENCED ELECTRICIAN ONLY.
Fire Protection Power supply locked & tagged. Circuit Checked for Zero voltage.
Precautions Taken Portable cords and electric tools inspected. Safety back-up man appointed.
Combustible gas or liquid containers removed Physical isolation is ensured If yes, State the method _________________________
Area wet down In case of lock applied, ensure the safe custody of the key by putting it in group lock.
Spark / Spatters shields / Ceramic Cloth installed / used. If physical isolation is not possible state the alternative method of precaution/isolation.
Others (explain)__________________________________________________________ Stored energy discharged through discharge rod.
3 way power tester is available for testing live system.
Equipment Provided Electrical shutdown to follow LOTO. Recheck to be sure about correct panel for work.
Fire Extinguishers Equipment Provided
Type: Co2 Dry Chemical Powder Other___________________ Approved rubber & leather gloves Insulating mat Fuse puller
Size______________________ Quantity ____________________ Disconnect pole or safety rope Non-conductive hard hat.
Earth Leakage Circuit Breaker (ELCB) Cool Coat/Electrical Flush Suit, suitable power resistant
2. Excavations Exceeding 1 m (3 ft) Shoes, gloves.
Precautions Taken
Contractor has a competent person assigned to inspect & control condition of excavation. 7. Scaffolding Erection & Dismantling.
Underground utilities identified Power equipment grounded. Precautions Taken
Electrical or mechanical overhead clearances checked. Presence of competent person assigned to ensure safe erection, maintenance, or modification of
Protective / indicative Barricading, beyond 1 m from edge) done, area warning placed. Scaffolds.
Means of access (ladder or steps) placed Side walls shored or laid back. Scaffolds inspected for proper access, egress by competent persons. Green Tag visible.
Area adequately lighted Material or soil removed from excavated edge. All pipes, clamps, H-frames, couplers, boards checked assembly.
Excavator is fit for job. Banks Man provided to guide the operator. Standard guardrail (900-1050mm top rail, 500 mm mid-rail, and 90-150 mm toe board) been used
Method of dewatering is established and ensured the stoppage of water return. Whenever possible.
Excavated pit edges free from heavy over-burden, stack of materials. Platforms, walkways on scaffolds are wide of minimum of 600 mm wherever possible.
People are prevented from working inside pits if heavy vehicle movement in the vicinity due to which Overhead protection provided where there is exposure.
Soil collapse may take place. No opening / Gap in the platform / walkway.
All component of the scaffold more than 12’ away from any exposed power lines.
3. Height Work (More Than 1.8 M High) Contractor Procedure in place: Y/N
Precautions Taken 8. Hydro / Pneumatic Testing.
Only medically fit personnel engaged in work and list is available. Precautions Taken
Ladder(s)/ Approach way inspected prior to use Safe access & egress ensured. Is work to be performed planned: YES NO, If No – STOP.
Ladder properly supported and leveled : Tied Top Tied Bottom. Access/egress, Hot work, Other on-going work considered in plan.
Distance between the ladder support and the ladder base is at least ¼ the total length of the ladder. Specific hazard in the work area identified.
Ladder been provided with skid resistance feet. Proper Housekeeping is done. Area cleared from non-test personnel and barricaded.
Scaffolds/Platforms inspected for good repair & proper construction (secured flooring & guardrails). Discharge of safety relief valves directed away from personnel area.
Floor openings covered/guarded. Work area roped off and warning signs in place. Compressor is certified by the competent authority.
Personnel assigned warned of floor opening & other hazardous exposure/opening covered. Safety release valves and NRVs of system are in working condition.
Tools & other equipment stored in safe manner. Pressure gauges are calibrated and identified for the job.
Area cleaned below prior to starting work People at height are secured. Formal discussions with personnel performing work or affected by this.
Equipment Provided Roof Top: Crawler Board / Securing arrangement checked. Workmen instruction for not attempt the tightening / loosening of bolts and hammering while the line
Full body safety harness with double lanyard and anchored to independent rigid object. is under process.
Lifelines with rope grab shock absorber/fall arrestor.
Safety net is provided but not less than 5 M from the work area / NA. 9. Confined Space (CS).
Precautions Taken
4. Suspended man basket / Platform The written confined space entry program is firmly implemented and being enforced.
Precautions Taken Whether permit issued after verification of LOTO system for all upstream and downstream equipments
Use strictly controlled. Certified by competent authority. As applicable with respect to Process Flow Diagram (PFDP).
Lifeline and harnesses approved type with separate anchorage. Whether CS numbered, warning displayed, PFD available with required isolation for job.
Communications established. Basket properly labeled with load capacity. Is there a qualified stand-by man deputed?
Lifting appliance is certified by third party competent authority. Does he/she maintain a list of personnel entries with sign and date/time of entry?
Guardrails are provided. Workmen are competent and medically fit. Gas / Oxygen deficiency/ presence of toxic – flammable vapor test done and found ok.
Proper means of access is provided to the work platform. Are only 24V hand lamps used inside the vessel?
Lifting appliances operator never left the site while man bucket is in use. Proper means of exit provided.
Kept at secured mode while not in use. Proper ventilation & lighting provided.

10. Working area has a display board, communication board on Contract Job indicating site In-
charge, Safety In-charge, their mobile number, space for displaying permit sheet.
11. Others:_________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

12. List of person engaged in the job may be maintained in separate register.

Sign. Of Permit Receiver (Original) Sign. Of Permit Receiver (1st renewal) Sign. Of Permit Receiver
(2nd renewal)
 With name (Working Agency) With name (Working Agency) With name (Working
Agency)