Work Permit
Work Permit
Work Permit
Valid only when signed by an authorized issuer, delegated by management. This permit must be issued before specified work is started; it must be
canceled immediately after completion of the work or at the end of the shift as agreed by parties identified on this permit. File canceled permits in
chronological order in a file, which will be stored in unit.
ISSUED TO:
NAME COMPANY/CONTRACTOR DESIGNATION
This certifies that I HAVE personally completed a safety inspection of the area where this work is to be done, as well as the surrounding area, with
specific attention to the type of work checked below. I HAVE reviewed the minimum precautions and have indicated on the reverse side of this
permit all necessary precautions taken to protect the personnel engaged in this work from accident and injury. I HAVE made sure that the assigned
personnel know the applicable safety rules and that they know what to do in an EMERGENCY.
Engineer: Date:
Supervisor: Date:
1. Potential Exposure to Hazardous Atmospheres ( Confined Space) 5. Crane Lifts & Critical Rigging. Contractor procedure in place: YES NO
(Oxygen deficiency or enrichment, dust, toxic gas, and vapors) Precautions Taken
Contractor procedure in place: YES NO Crane / Slings inspected before use
PERMIT REQUIRED SPACE: YES NO , If Yes STOP Operator qualified by the contractor
Precautions Taken Electrical power line clearance (12ft) checked
All valves and equipment locked and tagged Ground condition inspected
Safety Observer Assigned
Blinds Block and Bleed Piping Separation Path cleared for material movement
Guy rope, rigger available
Process lines purged Ventilation provided Mechanical Specific Requirements:
Natural Draft
Atmosphere tested (O2, H2, CH4, etc.) See Table Below. 6. Radiation (X-rays) Contractor procedure in place: YES NO
Attendant / Rescuer Precautions Taken
Equipment Provided Source control & duration on site part of work sequence planning
Work schedules considered the minimum potential exposures to site personnel
Respirator SCBA Neg. Pressure Supplied Air Competent qualified personnel assigned for tasks
Lifeline Two-way communication device Barricades and warning signs are in place and obvious
Emergency Alarm Special Clothing Specific Requirements:
Hood Dust Goggles
Other (explain) 7. Suspended work basket / Platform Contractor procedure in place: YES NO
Precautions Taken
Approved by competent personnel
2. Hot Work (Welding, Grinding, Cutting) (For any hot work , monitor Lifelines and harnesses approved type with separate anchorage
for flammable and oxygen enriched atmosphere and record above) Two-way communication established
Contractor procedure in place: YES NO Specific Requirements:
Precautions Taken
Flammables / Combustibles (paper, rags, wood, etc.) protected or 8. Working Around Pressurized or Energized Systems / Pneumatic Testing
removed Contractor procedure in place: YES NO
Fire Watch Established Precautions Taken
Welding & Cutting equipment Safe to use and positioned properly Is work to be performed planned: YES NO , If No - STOP
Leads up and do not pose a tripping hazard Access/egress, Hot work, Other on-going work considered in plan
Area hazards covered Specific hazards in the work area identified
Specific Area cleared of non-test personnel and barricaded
Requirements: Discharge of safety relief valves directed away from personnel area
Formal discussions with personnel performing work or affected by this work held
Specific Requirements:
Fire Protection
Precautions Taken 9. Electrical Work Contractor procedure in place: YES NO
Area wet down Precautions Taken
Spark shields installed LIVE ELECTRICAL WORK PERFORMED BY QUALIFIED ELECRTRICIAN ONLY
Spark resistant tools LOTO done
Area and its adjacent cleared off and barricaded Circuit checked for zero voltage
Work spot has proper access Portable cords and electric tools inspected
Specific Safety back-up man appointed
Requirements: Area and its cleared off and area barricaded
Equipment Provided Equipment Provided
PPE Approved rubber and leather gloves Insulating mat Fuse puller
recommended: Disconnect pole or safety rope Non-conductive hard hat
Fire bucket Earth Leakage Circuit Breaker ( ELCB ) Flash protective clothing
Fire extinguishers Specific Requirements:
Type: CO2 Dry Powder Other
10. Lockout / Tag out ( LOTO) Contractor procedure in place: YES NO
3. Excavations Exceeding 1.2 m ( 4 ft ) Contractor procedure in
Precautions Taken: Type of power supply Hydraulic Pneumatic Steam
place: YES NO
Mechanical Electrical Other
Precautions Taken
Contractor has a competent person assigned to inspect & control All valves locked and tagged
condition of excavation on site Blinds installed
Block and bleed valves positioned
Underground utilities identified
Barricades, flashers, pennants (area warning) placed Piping separated
Means of egress (ladder or steps) in place Pressure bled from lines and equipment
Area and its adjacent cleared off and barricaded Instrument gas disconnected
Material or soil removed from excavation edge Attempt to start the equipment
Specific Mechanical energy blocked
Maintenance lock / contractor lock required
Requirements:
4. Elevated / Height Work Contractor procedure in place: YES
NO 11. Commissioning Activities
Precautions Taken All commissioning work is scheduled, approved and coordinated through Unit Manager.
Ladder(s) inspected prior to use and is secured. Work Plan includes available
Scaffolds/platforms inspected for good repair Work area laid out
Work area roped off and warning signs in place LOTO done
Proper access available from near by areas Specified hazards identified
Area cleared below and adjacent areas prior to starting work Other on-going work cleared off the area
Area barricaded Required Personal Protective Equipment available with workers
Equipment Provided Identification of energized or pressurized systems
Full Body Safety Harness and Lanyard anchored to independent rigid Fire protection equipment, location and accessibility
object
Lifeline with rope grab shock absorber 12. Others:
Safety Net
Specific
Requirements: