SAFE WORK PERMIT
E – Permit
Sections 1-5, 8, 12, 13, 16 are required for all jobs
(1) BOUNDARY OF WORK
(MAINTENANCE/CONTRACTOR)
Start Date
Start Time
Expiration Time (Max = End of worker’s shift)
Building
Floor
Area/Room/Equipment
Operating Unit # (Where work is completed)
Maintenance Unit/Contractor (Who will perform the work)
Phone or Radio # of Maintenance Unit/Contractor
(2) HAZARDS OF WORK
(MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Noise
Potential To Be Struck By An Object
Heat or Cold
Slip or Trip
Asbestos
Other Hazardous Work/Permits In Area
Lead
Other:
(3) PPE/HAZARD CONTROLS REQUIRED
(MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Safety Glasses
Hard Hat
Harness/Retrieval Line (Confined Space)
Protective Clothing Type:
Goggles(Line Entry)
Hearing Protection
X-Ray Boundary
Chemical Boots
Respiratory Protection Type:
Face Shield
Fall Protection
Barricade Area
Glove Type:
Other Type:
(4) WORK DESCRIPTION
(MAINTENANCE/CONTRACTOR)
Description of Work (How work will be completed - including safety precautions)
See Attached
None Identified
Chemical
Flammable or Combustible
Product Residue
Oxygen Deficiency
Dust/Mist/Fumes
High Pressure
Electrical
Elevated Work (>4 feet)
Restricted Egress
Excavation
Mechanical or Pinch
Chemicals, Paints, or Solvents Used During JobMSDS’s Must Be Available For All Chemicals
NA
Specialty Equipment/Tools Used:
NA
(5) TYPE OF WORK
(MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Complete Required Sections (1-5, 8, 12, 13, 16) for all jobs. In addition, complete the designated sections for the following types of work:
None Of These (Complete Required Sections)
Heights>4 ft/Roof/Trestle (Complete Section 6)
X-Ray
(Complete Section 7)
Hot Work
(Complete Sections 7, 10)
Other Energy Isolation
(Complete Section 9)
Confined Space Entry (Complete Sections 9-11)
Line Entry/Line Break
(Complete Sections 9, 15)
Demo/Excavation/Crane (Complete KCA Checklists)
(6) FALL PROTECTION
(MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Complete for all Work At Heights Greater Than 4 Feet, Unguarded Roof Work, and Trestle Work
Y
N
Fall Protection equipment/provision required? (“Y” for work on unguarded surfaces >4 ft above adjacent floor OR work outside confines of ladder)
Anchor points used? If yes, anchor point is:
Engineered Anchor Point
I-Beam
Structural Steel
(7) HOT WORK or X-RAY WORK
Complete for all Hot Work or X-Ray Work
Other:
(MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Type I Hot Work - Welding, grinding, burning & open flame cutting
Type II Hot Work - Non-rated electrical equipment
X-Ray Work
Electrical Adapter ID:
Inspected prior to use: _______________________
Electrical Adapter ID:
Inspected prior to use: _______________________
(Initials)
(Initials)
Y NA
Y NA
Y NA
Equipment is clean
Hot Work signage/X-Ray barrier at work perimeter
Area cleared of combustibles (min 35 ft for Type I work)
Spark protection/blankets
Nearest alarm, phone OR radio identified
Fire Extinguisher available at job site (Bring 10 lb. for Type I)
Fire or X-Ray Watch assigned (Required for Type I Hot Work OR X-Ray Work only. Must remain at site for 30 min [4 hrs in B-41 truss area] after Hot Work stops)
FIRE or X-RAY WATCH INFO
Name (Print)
Signature
Time In
Time Out
1st Fire or X-Ray Watch
2nd Fire or X-Ray Watch
3rd Fire or X-Ray Watch
4th Fire or X-Ray Watch
(8) PERSONNEL WORKING UNDER PERMIT
(MAINTENANCE/CONTRACTOR)
I have read this permit and will ensure that its requirements are adhered to. If working conditions change, I will cease work and contact the issuer immediately. I am
familiar with emergency procedures for the area where I will be working. I know the location of the closest phone, safety shower, eyewash, and fire extinguisher.
Worker Names
Organization
Contact Info (Phone/Radio#)*
I agree with the statements
above (initial below)
* Contact info required for minimum of one team member
Form#: GM00037-E Revised: Jan 09 2009
EMERGENCY PHONE #: 1-2-3 (Cell Phone: 833-4799)
SPILL EMERGENCY PHONE #: 3-3800 (833-3800)
(9) ENERGY ISOLATION
Complete for all Line Entry, Confined Space Entry and Other Energy Isolation
(MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Y NA
Equipment has been properly shut down per appropriate procedure, cleaned, and prepped for energy isolation activities?
Existing equipment specific LOTO procedure followed? Procedure #
(Energy Isolation Form not required if LOTO procedure is followed)
Safe Work Permit Energy Isolation Form followed? Form #
(Form not required when isolating single energy sources)
All energy sources were verified by each worker that they are isolated properly prior to their work on the system? Includes walking down valves/pumps/etc.
Equipment energy isolation has been verified by attempting to start the equipment while in the energy-isolated state.
Personal lock applied to Lock Box for group LOTO? (See Section 11 for Confined Space Entry LOTO scenarios).
(10) ATMOSPHERIC MONITORING – INITIAL and PERIODIC
(MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Complete for all Hot Work, or Confined Space Entry
All Work:
1. Atmospheric testing personnel (minimum of 2) must be trained in the use of
4. Conduct tests of work area as close as possible to work times.
appropriate meters and allow all workers the opportunity to observe tests.
5. Conduct tests in nearby trenches/drains/etc.
2. Both parties must conduct separate BUMP tests, but may use the same meter.
6. When testing work area for flammables, confirm <2.0 % of LEL.
3. Acceptable BUMP ranges are noted in the table below.
7. Re-test required if re-entering space or work area is vacated.
Confined Space Entry:
1. Continuous monitoring of Oxygen(O2),Carbon Monoxide(CO),Hydrogen Sulfide(H2S) & Flammables required for sewer entry.
2. Continuous monitoring required if Oxygen levels could be depleted.
3. When testing work area for Oxygen, confirm 19.5% - 23.5% Oxygen in the area.
4. BUMP test and monitor for toxic vapors if potentially toxic atmospheres will be entered.*
BUMP Tests
Test
Results must be within range
Operating Unit Maint/Contr.
Oxygen
Oxygen
18.5% -19.2%
Flammable
18.5% -19.2%
Flammable
27% - 33% LEL
Toxic
27% - 33% LEL
Toxic
If Applicable*
If Applicable*
Initial Tests Of Work Area
Test 1
Test 2
AREA MONITORING
Re-Test 1
Re-Test 2
Re-Test 3
Re-Test 4
Re-Test 5
Time:________ Time:________ Time:________ Time:________ Time:_______
Oxygen-Top
CS
CS
CS
CS
CS
CS
CS
Oxygen-Bottom
CS
CS
CS
CS
CS
CS
CS
Flammable-Top
CS
CS
CS
CS
CS
CS
CS
HW / CS
HW / CS
HW / CS
HW / CS
HW / CS
HW / CS
HW / CS
*Toxic-Top
CS
CS
CS
CS
CS
CS
CS
*Toxic-Bottom
CS
CS
CS
CS
CS
CS
CS
Operating
Unit
Maintenance
or Contractor
Flammable-Bottom
Meter ID
Name or Initials
Unit/Organization
* If toxic vapor BUMP test or monitoring is required, list toxic material: _____________ and allowable limit: ____________. Consult EHS for toxic vapor questions.
(11) CONFINED SPACE ENTRY
(MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Complete for all Confined Space Entry
ENTRY SUPERVISOR(S)
ATTENDANT(S)
ENTRANT(S)
Name (Print)
Name (Print)
Name (Print)
1. __________________________________
1. _____________________________________
1. __________________________________
Initial to indicate approval to enter: _______
2. _____________________________________
2. __________________________________
3. _____________________________________
3. __________________________________
4. _____________________________________
4. __________________________________
5. _____________________________________
5. __________________________________
3. __________________________________
6. _____________________________________
6. __________________________________
Initial to indicate approval to enter: _______
7. _____________________________________
7. __________________________________
2. __________________________________
Initial to indicate approval to enter: _______
Personal Locks
(NA if using Energy
Isolation Form)
Applied
Communication between attendant and entrants via:
Radio
Voice
Other:___________ Falcon Horn was tested for functionality: ______(Attendant initials)
Radio communication w/Fire Station established & maintained during entry______(Attendant init.) Is forced ventilation required during entry?
Yes
No
(12) ADDITIONAL PRECAUTIONS/INSTRUCTIONS
(OPERATING UNIT)
Complete if there is a need to describe any Specific Hazards, waste disposal info, and/or other requirements for the work
(13) PERMIT APPROVAL
(OPERATING UNIT)
Y NA
Joint walkthrough with operating unit and worker rep required after job
Notified other areas of work (Required for Hot Work and X-Ray Work)
Unit Representative Name
Radio #: _________________
Signature
Date/Time
(14) UNIT REPRESENTATIVE CHANGE
(OPERATING UNIT)
If applicable, the outgoing unit representative has communicated the details of
this permit/job to an incoming unit representative
Incoming Unit Representative
Signature
Date/Time
Radio #: _________________
(MAINTENANCE/CONTRACTOR & OPERATING UNIT)
(15) LINE INTEGRITY CHECKLIST
NA Complete for all process and service piping after Line Entry is complete and system is being restored
Y N
Is system returned to a condition allowing pressure testing?
If Yes, Maintenance/Contractor may move on to Section 16, and the operating unit will complete the remainder of section 15. If No, finish Section 15 together.
Y N NA
Y NA
Y NA
Pressure check will be performed
New gaskets used
Operating unit positioned valves properly
Pressure check not possible-use following precautions
Flanges/connections are tight
Established and maintained flow/pressure
Spill kit is on hand & available
Drain/bleed valves are closed
Confirmed integrity of system (no leaks)
Fugitive Emissions requirements: Operations called 3-6444 for OVA monitoring on tagged equipment. Pressure tests completed on Pressure Test Trains
(16) PERMIT COMPLETION
(MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Maintenance/Contractor To Address The Following Items Prior To Sign-Off
Final Sign-off To Close Out This Safe Work Permit
Y NA
All work relating to this job is completed.(NA = Work will resume later)
_________
_
Equipment removed from area (Adapters, Barriers, X-Ray Sources,etc.) Maintenance/Contractor Signature
Date
Time
Notification made to effected workers that work is complete (Required
_
____
after X-Ray work. Must notify Fire Station after Confined Space Entry)
Unit Representative Signature
Date
Time
All personal locks are removed from the equipment and/or lock box.
Send completed permit to Kalamazoo EHS at PORT-41-16
Form#: GM00037-E Revised: Jan 09 2009
EMERGENCY PHONE #: 1-2-3 (Cell Phone: 833-4799)
SPILL EMERGENCY PHONE #: 3-3800 (833-3800)