Permit to Work Plan Your Company Name Version 1.0 November 5, 2018 1|Page This Page left blank intentionally. Version 1.0 November 5, 2018 2|Page Contents ACRONYM LIST ........................................................................................................................................... 5 1. SCOPE................................................................................................................................................... 6 2. OBJECTIVES ........................................................................................................................................ 6 3. DEFINITIONS, TERMS, AND ABBREVIATIONS .............................................................................. 6 4. RESPONSIBILITIES ............................................................................................................................ 7 5. 6. 4.1 YOUR COMPANY NAME Site Manager .................................................................................... 7 4.2 YOUR COMPANY NAME Construction Manager.................................................................... 7 4.3 YOUR COMPANY NAME Field HSE Coordinator (FHSEC) on site ....................................... 8 4.4 YOUR COMPANY NAME PTW Coordinator ............................................................................ 8 4.5 Subcontractor Construction Manager ................................................................................... 8 4.6 Subcontractor HSE Manager ................................................................................................... 8 4.7 Employees .................................................................................................................................. 9 PERMIT TO WORK SYSTEM WORKFLOW ..................................................................................... 9 5.1 Workflow Description .............................................................................................................. 9 5.2 Subcontractor Receiving Authority (Originator) .............................................................. 11 5.3 YOUR COMPANY NAME Permit to Work Coordination Meeting ..................................... 11 5.4 Contractor Issuing Authority (Validator) ........................................................................... 11 5.5 Contractor Permit Coordinator ............................................................................................ 12 5.6 Contractor Operating Authority (Operator) .................................................................... 12 5.7 Subcontractor Performing Authority (Performer) ......................................................... 13 5.8 Minimum Acceptance for Permit Signatories .................................................................... 13 TYPES OF PERMIT ........................................................................................................................... 14 6.1 General ...................................................................................................................................... 14 6.2 Activities Requiring a Permit to Work ................................................................................ 15 6.3 General Work Permit (cold).................................................................................................. 15 6.4 Hot Work Permit ..................................................................................................................... 15 6.5 Radiography Work Permit .................................................................................................... 15 6.6 Other Permits and Certificates ............................................................................................. 16 6.6.1 Confined Space Certificate ................................................................................................. 16 6.6.2 Electrical Work Certificate ................................................................................................ 16 Version 1.0 November 5, 2018 3|Page 6.6.3 Lock out-tag out ................................................................................................................... 16 6.6.4 Execution of Energization, Removal of Tags, Padlock and Restoration of Power .. 18 6.6.5 Excavation Work Certificate ............................................................................................. 19 6.6.6 Accompanying Certification for Permit to Work........................................................... 19 6.7 Permit issuance and duration............................................................................................... 19 6.8 Permit closure ......................................................................................................................... 21 6.9 Layout and Color of Permits .................................................................................................. 21 6.10 Permit and Certificate validity and endorsement periods .......................................... 21 6.11 Permit to Work Procedure Auditing and Review.......................................................... 22 6.12 Emergency Response .......................................................................................................... 22 Attachment 1. Your Company Name Work Permit Forms .................................................................. 23 Attachment 2. Your Company Name Hot Work Permit Form............................................................. 24 Attachment 3. Your Company Name Confined Space Work Permit Form .......................................... 25 Attachment 4. Your Company Name Confined Space Work Permit .................................................... 26 Attachment 5. Your Company Name Daily Permit to Work Review ................................................... 27 Attachment 6. Your Company Name Excavation Work Permit ........................................................... 28 Attachment 7. Your Company Name Authorization Signatures.......................................................... 29 Attachment 8. Your Company Name Radiography Work Permit ....................................................... 30 Attachment 9. Your Company Name Electrical Work Permit ............................................................. 31 Version 1.0 November 5, 2018 4|Page ACRONYM LIST DFW…………………………….Definable Features of Work FHSEC........................... Field HSE Coordinator HSE............................... Health, Safety, and Environment HSE............................... Health, Safety, and Environment PTW…........................... Permit to Work Version 1.0 November 5, 2018 5|Page 1. SCOPE Under this contract, YOUR COMPANY NAME will be responsible for the construction of (Project Name) which will include the construction of (Description of Project) for YOUR COMPANY NAME. 2. OBJECTIVES The Work Site Safety Plan is designed to give direction and guidance in term of Health/Safety/Environmental (HSE) requirements to YOUR COMPANY NAME and subcontractor personnel during the construction activities. This document combined with the HSE Plan for Construction complete the HSE control and management of industrial and occupational HSE risks during Construction phases. In order to seamlessly adhere to the scope of a project; plans, policies and procedures shall be modified as required prior to commencement of said definable feature of work. The purpose of this document is to enhance management control over the various work activities carried out by the Contractor and subcontractors, which may be potentially hazardous, within the designated areas known as Construction Areas. All activities shall also be controlled by a Method Statement. Work shall be performed in compliance with: Federal Regulations MSHA National Electric Code (NEC) National Fire Protection Association (NFPA) OSHA 1910 OSHA 1926 State Regulations This procedure defines the administration arrangements of the Permit to Work System only for the Construction activities phase and must not be used for the Commissioning activities phase, because a different and specific Permit to Work System will be applied. This work permit procedure will be applied during the Construction for the work activities carried out in the areas under the direct responsibility and control of the Contractor. 3. DEFINITIONS, TERMS, AND ABBREVIATIONS Please refer to the Acronym List after the Table of Contents. Permit to Work (PTW): Written permission given to carry out work together with any supporting Permits or Certificate. Issuing Authority (Validator): The person appointed and authorized by the Contractor and trained to carry out the task as required by the Permit to Work Procedure, who is responsible for reviewing the submitted Permit, confirming that the worksite has been examined and all precautions specified to be taken before work commences have in fact been taken, confirming than no conflict exists with other Permits. Certificates: Additional form to be issued together with the Permit to Work for the following specific definable features of work: Confined pace Electrical work Excavation work HVAC Version 1.0 November 5, 2018 6|Page Plumbing Roofing Sheet Metal Receiving Authority (Originator): The person appointed and authorized by the Subcontractor and trained to carry out the task as required by the Permit to Work Procedure, who applies for a Permit and completes the Permit for approval by the appropriate Authority, accepting the Permit and agreeing with the Issuing Authority. Permit Coordinator: Person(s) authorized by the Contractor Construction Manager to issue Permits and trained to carry out the task as required by the Permit to Work Procedure. This person(s) should coordinate issue of all Permits to identify potentially conflicting work tasks, both on a geographical and time basis. User: Person(s)/subcontractor working under an authorized permit. Employees: All Contractor, subcontractor, vendor and client employees who are included in the organization list (permanent organization). Hot Work: Any job within the Contractor area of work, wherein the heat generated is of sufficient magnitude and intensity to cause ignition of any flammable liquids, gases or any other material. Common sources of ignition are internal combustion engines, gas cutting torches, welding machines, non-flame proof electrical equipment, grinders, annealing blankets, jack hammers, etc. Cold Work: Work which will not involve the use of naked flames nor produce any source of ignition. Confined Space: Any area that has limited access or egress, or which is sufficiently confined to permit the accumulation of flammable or toxic gases or vapors, or where an oxygen deficiency or enrichment could occur. Electrical Work: A job on any electrical equipment or system. Excavation and Civil Work: All the excavation jobs. Radiography Work: A work involving use of radioactive source. 4. RESPONSIBILITIES 4.1 YOUR COMPANY NAME Site Manager The Site Manager is responsible for all site activities. Appointed personnel will manage most of the aspect of site activities, including the Permit to Work system and performance. The Site Manager will delegate the duty of the correct application of YOUR COMPANY NAME Permit to Work Procedure to Construction Manager. 4.2 YOUR COMPANY NAME Construction Manager The Construction Manager will be responsible for ensuring the effective administration of this procedure within Construction site activities and shall ensure that this procedure is properly implemented at site. The Construction Manager shall ensure that all work is carried out under the controls of the Permit to Work System. Further to this, the Construction Manager shall: Provide a safe and healthful environment for all personnel working on the project. Ensure that sufficient funds and recourses are made available to ensure the continuity of this procedure for the duration of the works. Version 1.0 November 5, 2018 7|Page 4.3 Nominate a Permit Coordinator to ensure that the coordination of permits is administered correctly. Ensure the proper coordination of construction activities between YOUR COMPANY NAME and subcontractors. Verify that the subcontractor is providing the correct information and equipment for the scope of work. Ensure training is given to all persons requiring how to use a Permit to Work. Nominate personnel and authorize them to perform the duties of permit to Work Signatories. Approve the personnel nominated by the by subcontractors as signatories of the Permit to Work. YOUR COMPANY NAME Field HSE Coordinator (FHSEC) on site The FHSEC will: Perform duties of the position in order to provide a safe and healthful working environment to all personnel working on the project. Ensure that all necessary support, advice and guidance is made available to enable this procedure to be properly implemented. Ensure adequate training to all personnel involved in this procedure. Ensure that suitable and sufficient inspections and audits are carried out. Evaluate the effectiveness of this procedure and change/amend as is required or becomes necessary to achieve its purpose. Advise the Contractor Management of any irregularities or areas of concern in order to investigate and to implement corrective actions. Maintain a current list of Permit signatories and inform all parties and remove any permit signatory from the list, found to be in breach of the required duty and responsibility. 4.4 YOUR COMPANY NAME PTW Coordinator 4.5 Assure that all work permit signature flow is in place. Verify that the correct work permit is going to be issued for each activity. Check that all documentation required as job safety analysis is attached to the work permit. Assist FHSEC in all improving activities. Stop some work permit if required by FHSEC. Subcontractor Construction Manager Subcontractors Construction Managers will: Ensure that sufficient and qualified resources are made available to enable the safe implementation of this procedure. Ensure that all concerned personnel have read and understood this procedure. Ensure that adequate facilities and means are in place for the implementation of this procedure. Identify and communicate in writing the personnel authorized to sign the work permit such as: o Receiving Authority and Performing Authority. 4.6 Subcontractor HSE Manager Subcontractor HSE Manager will: Ensure that proper instruction, training and supervision is provided at all times. Ensure that suitable and sufficient inspections are carried out by competent personnel, and that proper records are maintained. Ensure that work is carried out in accordance with this procedure. Ensure that the conditions are satisfactory for the work to proceed. Ensure that each item on the permit is accurately filled out and covered. Version 1.0 November 5, 2018 8|Page 4.7 Ensure that personnel understand the requirements on the permit and any unusual conditions connected with the job. Ensure the continue monitoring of the work area conditions and to stop, the environment and/or equipment to convey pertinent information about the work to the relievers. Advise the Contractor Field HSE Coordinator of any irregularities or areas of concern in order to identify any necessary corrective action. Sign the relevant part of the Permit to Work when applicable. Employees All employees shall comply with the requirements of the Permit to Work Procedure. Any person found to be in breach of the procedure or deviates from any written instruction shall be subject to disciplinary action, which may lead to dismissal and action being taken against the individual under the current local Legislation. 5. PERMIT TO WORK SYSTEM WORKFLOW 5.1 Workflow Description Each permit shall be completed according to the workflow shown in Figure 1, namely by the following steps: 1. The Originator (Subcontractor Receiving Authority) fill in YOUR COMPANY NAME’s PTW proper form(s), including details showing the equipment, description, location and date and estimated duration of work; 2. During YOUR COMPANY NAME’s PTW Coordination Meeting, the involved actors analyze the general permit status, including new permits issue and identify any potential conflicting activities; 3. The authorized Validator (YOUR COMPANY NAME Issuing Authority) check the new permits, specifying the safety equipment that shall be used and defines any special applicable instruction; 4. The authorized Validator (YOUR COMPANY NAME Issuing Authority) check for existing permits for revalidation and supervision. If none, issue new PTW. 5. YOUR COMPANY NAME Permit Coordinator distribute copies of new permit to works to the involved parties; 6. Operator (YOUR COMPANY NAME Operating Authority) carrying out all preliminary checks required by the Validator and will sign the PTW to verify that all requirements have been met and that the work area is in a safe condition for the work to commence. 7. Performer (Subcontractor Performing Authority) carries out and supervises the works in compliance with the relevant permit prescription; once completed such activities notify to Validator the permit closure. Version 1.0 November 5, 2018 9|Page Figure 1. Permit to Work System Flowchart Originator Subcontractor Receiving Authority compiles YOUR COMPANY NAME PTW Performer Subcontractor Performing Authority Version 1.0 November 5, 2018 YOUR COMPANY NAME PTW Coordination Meeting Operator YOUR COMPANY NAME Operating Authority Validator YOUR COMPANY NAME Issuing Authority (control, validation, and approval) YOUR COMPANY NAME Permit Coordinator (Permits Control Office - HSE Dept.) Distribution copies to all departments 10 | P a g e In the following paragraphs each step is described in detail. 5.2 Subcontractor Receiving Authority (Originator) The position of Receiving Authority is the responsibility of the Subcontractor Discipline Engineer who is in charge of the scope of work to be executed. The Subcontractor Discipline Engineer shall complete the description of the work to be carried out supplying all relevant information inclusive of drawings method statements and risk assessments in support of the permit application. The Subcontractor Receiving Authority of the Work Permit has the following responsibilities: To instruct the subcontractor Performing Authority (Performer) of the permit requirements and satisfy herself/himself that the subcontractors Performing Authority has enough information and resource to perform the work safely. Ensures that the subcontractors Performing Authority understands what, where, and how the work is to be performed. To ensure compliance with the conditions stipulated on the permit. To ensure that the Subcontractor Performing Authority supervises the work group and is satisfied that the persons carrying out the work use the proper tools and equipment for the job. That the Subcontractor Performing Authority informs the work group of the safe working practices. To inform YOUR COMPANY NAME’s Issuing Authority of any changes in the condition of the job or the surrounding area, or of any delay in starting the work, so as not to infringe upon any safety factors. Notify YOUR COMPANY NAME’s Issuing Authority upon completion of the work. 5.3 YOUR COMPANY NAME Permit to Work Coordination Meeting The objectives of this coordination meeting are to: Provide the overview of all ongoing and planned work under the control of the Permit to Work System. Identify any potential conflicting activities, both geographically (i.e. across other work) or on a time basis (activities which may start later). Agree on requirements of new permits. Ensure re-validation of existing permits. The date, time and place (schedule) of this coordination meeting will be defined at Site by YOUR COMPANY NAME’s Construction Manager. As minimum the meeting will be attended by YOUR COMPANY NAME’s Permit Coordinator and appointed YOUR COMPANY NAME and subcontractors Discipline Superintendent or deputy. Further attendees, for example technical support, YOUR COMPANY NAME and subcontractors Construction Manager and/or YOUR COMPANY NAME Field HSE Coordinator, Subcontractor HSE Manager will be present if requested. 5.4 Contractor Issuing Authority (Validator) YOUR COMPANY NAME’s Construction Manager shall ensure that there are sufficient signatory’s onsite to fulfill the role of approving the Permit to Work. This role shall be held by a YOUR COMPANY NAME employee with the minimum management level of Superintendent and shall sign the Permit to Work as Issuing Authority. He/She will be the responsibility of the Issuing Authority. No work can commence without the approving authorities signature. Version 1.0 November 5, 2018 11 | P a g e The Contractor Construction Manager may designate persons other than herself/himself to approve Permits to Work. This designation will be made in writing and informed to the Contractor Field HSE Coordinator, Contractor Permit Coordinator and all relevant permit signatories. The Validator of the Permit to Work has the following responsibilities: Check the completeness and reliability of the submitted forms. Specify the required worksite precautions and controls. Detail required safety equipment. Identify any worksite preparation requirements, if deemed necessary. Ensure that Certificates (attached to Permits as required) for Confined Space work, excavation and electrical works are duly signed off by authorized engineers. Ensure that permits are authorized on the day of use. Ensure that permits are closed on the day of use. No work can commence without the approving authorities signature. In this context YOUR COMPANY NAME’s Construction Manager or her/his designee has the responsibility of approving the work to commence and shall sign the Permit to Work as Approving Authority. 5.5 Contractor Permit Coordinator The Permit Coordinator nominated by YOUR COMPANY NAME’s Construction Manager has the responsibility of ensuring that all permits to work are entered into the system in the correct manner. Additionally the Permit Coordinator shall: Ensure that all Permits to Work are submitted onetime for entry into the system; Ensure that Permit to Work is completed correctly and that all relevant controls and signatures are added; Permit to Work is properly distributed to the interested parties as indicated; understand the scope and the details of execution of the work; Ensure the necessary checks have been satisfactorily executed before signing the permit to work; Suspend the Permit to Work at any time if the Permit to Work conditions are not complied with; Approve the effective closure of the work and sign for acceptance upon satisfactory completion of the works. 5.6 Contractor Operating Authority (Operator) The Operating Authority is responsible for carrying out all preliminary checks required by YOUR COMPANY NAME’s Issuing Authority and will sign the Permit to Work to verify that all requirements have been met and that the work area is in a safe condition for the work to commence. The Operating Authority is nominated by YOUR COMPANY NAME’s Construction Manager. Additionally the Operating Authority shall: Ensure that all signatories have signed the Permit to Work. Ensure that all instructions training has been given to the work party prior to the work commencing. Inform YOUR COMPANY NAME’s Issuing Authority that he work is about to commence in order that this can be notified and recorded as a live permit. Inspect the worksite periodically to ensure there is no change in condition. Suspend the work immediately if there is any breach of this procedure or change in conditions and to notify YOUR COMPANY NAME’s Issuing Authority for the reason. Ensure a good standard of housekeeping is maintained throughout the work and that all equipment is removed upon completion. Notify YOUR COMPANY NAME’s Issuing Authority upon the completion of work; inform YOUR Version 1.0 November 5, 2018 12 | P a g e COMPANY NAME’s Issuing Authority of any change in the working conditions of the surrounding areas in the vicinity of the working area. Note: it is foreseen that there will be more than one area operator, because as the works progress and as the work activities increase, then YOUR COMPANY NAME’s Construction Manager may decide to nominate Operating Authorities by discipline, for example Electrical Operating Authority, Piping Operating Authority, Mechanical Operating Authority. It may also be possible to divide the site into different areas as the works again progress so the numbers of controlled areas increase. In this case Operating Authorities will be nominated for each additional area. 5.7 Subcontractor Performing Authority (Performer) The Subcontractor Performing Authority is the person responsible for supervising the work group carrying out the job and shall hold as a minimum the supervisory grade of Foreman. The Subcontractor Performing Authority is not entitled to start any job without previous approval of the Permit to Work by both YOUR COMPANY NAME Issuing Authority and Operating Authority. The Subcontractor Performing Authority is responsible to: Ensure the work group carrying out the work is fully briefed usually by means of dedicated tool box talk. Ensure that they have clearly understood instructions given, including the scope of their activity and the relevant risks. Remain at the worksite until the completion of the task. After signing the Permit to Work the Subcontractor Performing Authority shall ensure that all copies of the Permit to Work are correctly distributed and that a copy is retained and posted at the work site. In addition the Subcontractor Performing Authority shall: Inform the subcontractor Receiving Authority or Contractor Operating Authority of any change in the working conditions of the job, or a delay in starting the work. Using proper tools and equipment for the safe execution of the job. Ensure the worksite is left in a safe and tidy condition. 5.8 Minimum Acceptance for Permit Signatories The key steps of validating, issuing, accepting and endorsing of Permits is done by person who has been assessed as competent. Permit signatories are those who have had sufficient training and experience and have been duly authorized as those Permit signatories by YOUR COMPANY NAME’s Construction Manager for the Permit Coordinator, Issuing Authority and Operating Authority and by the Subcontractors Construction Manager for the Receiving Authority and Performing Authority. Version 1.0 November 5, 2018 13 | P a g e It is essential for example that a signatory fully understands the requirement. Figure 2 illustrates the minimum acceptable level for permit to work signatories. Figure 2. Matrix of Permit to Work Authorization and Receipt for Permits to be Used. Issuing (Approving) Authority Minimum level for Operating Authority Issuing (Approving) Authorities shall be designated by YOUR COMPANY NAME’s Construction Manager YOUR COMPANY NAME Subcontractor Discipline Superintendent Supervisor 6. TYPES OF PERMIT 6.1 General Minimum level for Receiving Authority Minimum level for Performing Authority Subcontractors Foreman Validity Validity of the permit to work will be marked upon the permit and is unconditional A written permit to work system provides formal written procedure and formal actions to ensure that potentially hazardous activities are carried out as safely as possible. The work permit is a written document which authorizes persons to carry out the work concerned warns of possible dangers and clearly states the precautions to be taken for the job to be carried out safely. The permit ensures that full consideration is given to the hazards and risks, and that these are properly dealt with, prior to commencement of the work. The permit to work has to be filled by the subcontractors for what concerns its activities and references. Contractor will give the necessary support as required. The permit to work shall clearly specify the particular equipment and the construction area involved, the extent of work allowed, the conditions to be observed and the duration of the permit. Should any doubt exist as to the requirements for specific types of Permits, YOUR COMPANY NAME’s Field HSE Coordinator and/or YOUR COMPANY NAME’s Permit Coordinator should be consulted for advice. The instructions in the procedure are the minimum requirement and are mandatory. Personnel must at all times comply with them and are not permitted to make arbitrary changes. The present procedure considers the following permits and certificates: General Work Permit (cold) Hot Work Permit Radiography Work Permit Confined Space Certificate Electrical Work Certificate Excavation Work Certificate Note: Confined Space, Electrical and Excavation Work Certificate, signed by authorized engineers, must always be combined with General Work Permit (cold) or Hot Work Permit. Version 1.0 November 5, 2018 14 | P a g e 6.2 Activities Requiring a Permit to Work A Permit to Work will be required for the following activities: Any activity on live electrical equipment. Areas electrically classified. Closure of site roads to enable excavation and similar activities to be carried out. Confined space work (i.e. any work inside a vessel). Confined space work. Connection to the electrical supply. Connection to the water supply. Crane Lifts; lifting operations over living lines / equipment. Disconnecting or opening of any closed pipeline or vessel containing flammable or other hazardous material. Erection of site huts and lay down areas. Excavation and trenching. Facilities for the storage of cylinder gases, highly flammable liquids, paint or similar hazardous materials. Hot work of any type, where heat is used or generated. Hot work. Installation of pits for the storage of sealed radioactive sources. Isolation/lock-out/tag-out. Radiography (i.e. any work involving use of radioactive source, including the installation of pits for the storage of sealed radioactive sources). Working in hazardous zoned areas. 6.3 6.4 General Work Permit (cold) The general Work Permit shall be utilized for all activities requiring a Permit to Work, other than those capable of generating or using sources of ignition. The general Work Permit will facilitate all activities from scaffold erection to those controlling activities such as pressure testing. The general Work Permit has the facility to be validated for a period of 28 consecutive days. Revalidation of any Permit to Work shall remain at the discretion of YOUR COMPANY NAME’s Construction Manager and only if all Permit Signatories are in agreement, that there is no significant change in condition, changes in work schedule or there is no significant changes in personnel. Permits to Work shall clearly specify the particular equipment and the construction area involved the extent of work allowed, the conditions to be observed and the duration of the permit. Hot Work Permit The Hot Work Permit shall be utilized for all activities requiring a Permit to Work, capable of generating or using sources of ignition. 6.5 Radiography Work Permit The Radiography Work Permit is to control all site radiography and the use of ionizing Radiation. It is imperative that the controls remain in compliance with government legislation regulating the movement and uses of radioactive sources. The Permit should be used in conjunction and in agreement made between YOUR COMPANY NAME’s Field HSE Coordinator, YOUR COMPANY NAME’s Permit Coordinator and the Subcontractor RPS Version 1.0 15 | P a g e November 5, 2018 (Radiation Protection Supervisor) to ensure provision is made for the inclusion of local rules requirements to be submitted with the permit to work. The subcontractor should stipulate the type of source to be used, the ID number of the source, and the records and timings of source movement from storage facility to the work area. Prior to the signing of the Permit to Work the subcontractor shall demonstrate that the area is completely fenced by means of warning tapes and signoff and that there is no risk to personnel from the use of radioactive substances. An RPS nominated by the subcontractor shall be present at site during site radiography to oversee all activities and to sign relevant documentation. The RPS shall remain at the worksite for the duration of radiography work. 6.6 Other Permits and Certificates Should additional and/or other permits be required, they shall be created prior to commencement of work on definable features of work. The following Certificates shall be issued with the Work Permit (both general and hot) and they give details of the existing situation of the area. 6.6.1 Confined Space Certificate The Confined Space Certificate, shall be used in conjunction with the Permit to Work (both general and hot), and is required for any entry into a confined space as defined in this section. The Confined Space Certificate, once in place, only controls the entry of persons into a confined space. The actual task shall be controlled by the general Permit to Work. The Permit numbers shall be cross referenced to each other. Entry into confined spaces is subject to special requirements being put into place prior to the commencement of work. This will include but not be limited to: o Condition monitoring o Presence of a Safety Watch Person o PPE/RPE o Emergency Escape Plan 6.6.2 Electrical Work Certificate This Certificate shall be used in conjunction with the Permit to Work (both general and hot), for any activity to be carried out on live electrical equipment or plant. The Electrical Competent Person should complete this form and demonstrate that all necessary isolations have been made and that the system or plant is safe to be worked on. The electrical work certificate shall be utilized when an energization or de-energization operation should be carried out. 6.6.3 Lock out-tag out De-energization (Isolation) may be required prior to installation, inspection, repair, cleaning or dismantling. Where a job involves isolation of equipment, there shall be a work permit for the job and a lockout and tag-out procedure shall be followed. A lockout generally involves: Stopping all energy flows (for example, by tuning off switches or valves on supply lines). Version 1.0 November 5, 2018 16 | P a g e Locking switches and valves. Securing the machine, device or power transmission line in de-energizer state. Electrical isolation may be required to immobilize machinery or to protect personnel working in electrical equipment. Situations involving electrical isolation including rotating machinery and machinery with moving parts and entry into vessel which contain stirrers or agitators. Electrical isolation should be performed only by a competent electrical engineer. Energization may be required for executing pre-commissioning electrical test. Where a job involves temporary energization, there should always be a work permit for the job and a power on and power off procedure should be followed. The padlock has to be provided with a tag reporting: ID number as recorded in the isolation log book. Date and time of lock out. Name and signature of the individual who installed the padlock and the reason of the installation. Warning tags has to be properly secured with wire to the isolation points to ensure the same does not fall off. An example of a Warning Tag and Tag-out and lock-out are shown in Figure 3. Figure 3. Example Warning Tag and Tag-out/Lock-out tags. TAG No. DO NOT OPERATE CAUTION REMARKS : DATE : SIGNED BY : COMMISSIONING TEAM If the equipment is provided with an electrical isolation facility available on the field (e.g. start/stop button or other switchgear) then the Competent Electrical Engineer should attempt electrical start test in the field. This is to ensure that the equipment is no longer live and to verify that the electrical isolation is effective. The Competent Electrical Engineer then, shall fit a second numbered padlock, together with a “Danger: Do Not Operate” tag, to the local electrical isolation point. In situation where it is not possible to lockout or chain off an isolating device, isolation may be accomplished by removal of fuses, disconnection of electrical cables or physical removal of a component of the system supplying energy to the equipment. The point of physical interruption shall be identified with a dedicated tag. Version 1.0 November 5, 2018 17 | P a g e If other organizations or individuals working on equipment shall also install their locks and tags at locations have to be fit. In that case multiply lockout clips (Hasps) shall be used if necessary. When all padlocks will be removed energization will be possible. An example of Hasps is shown in Figure 4. Figure 4. Example HASP The Competent Electrical Engineer shall report all actions on the substation logbook for record purpose. As a general rule other discipline engineers cannot interfere with any electrical isolation work to be executed inside the substation for safety reasons and nobody (with the only exception of the Competent Electrical Engineer) can take or keep the padlock keys for their scopes. Field HSE Coordinator should hold spare keys for all Lock Outs. This ensures no keys will go missing, if they are controlled by the Permit to Work Coordinator. 6.6.4 Execution of Energization, Removal of Tags, Padlock and Restoration of Power After receiving the Electrical Certification in which the ENERGIZATION is required the Competent Electrical Engineer shall proceed to energize the equipment. The following procedure covers the energization for safe execution of the pre-commissioning electrical tests. If a padlock and a tag are installed (to show that the switchgear is isolated) the Competent Electrical o Engineer shall remove both of them. The Competent Electrical Engineer will give power to the equipment. As soon as the equipment is energized the Component Electrical Engineer shall hung a tag “IN SERVICE” close to the switchgear, as shown in Figure 5. The Competent Electrical Engineer shall report all actions on the substation logbook for record purpose. Version 1.0 November 5, 2018 18 | P a g e Figure 5. Example of “In Service” tag. 6.6.5 Excavation Work Certificate This Certificate shall be used in conjunction with the Permit to Work, for Excavation activities. This Certificate should be submitted with the Permit to Work together with any supporting documentation such as sketches drawings and method statements. In this shall be reported all the underground services present in the area. 6.6.6 Accompanying Certification for Permit to Work The more information there is to support a permit to work, the more safety factors can be considered or put in place to make the job safer. Therefore it is important to submit supporting documents in the form of site layout drawings, equipment drawings, etc. with the certificate. This is especially important when trying to locate underground services and etc. Failure to provide these documents may result in an application being rejected. 6.7 Permit issuance and duration The Permit to Work will involve the following steps shown below: 1. Conduct a thorough risk assessment and determine who is at risk, what control measures are necessary to eliminate the hazards, and the level of residual risk. 2. Prepare a written system of work identifying the following: The level of competence of all operatives and any specialist skills List Isolation / Pre-work precautions List prohibited activities (communicate to others as necessary) List Plant and Equipment required List Personnel Protective Equipment to be used List sequence of events as planned with identified hazards/residual risks and controls clearly defined Emergency procedures for all foreseeable risks (ensure that procedures are conveyed to competent persons and fully understood) 3. Brief those who will be required to operate under the Permit to Work on the hazards and controls necessary to avoid them being realized (for example during Tool Box Talks). 4. Ensure that those conducting the task know that the safe system must be followed in full and that no other methods or sequence of work are allowed (i.e., work must stop, all persons withdrawn, and the Version 1.0 November 5, 2018 19 | P a g e safe system reviewed by the Authorized Person). If the safe system is found to be flawed, then the Permit must be cancelled, the system of work reassessed, a new Permit raised, and those conducting the task re-briefed. 5. Display the Permit at the work site/isolation point to ensure all that those who need to know, do so. 6. Ensure that the work area is clean, tidy, and that all safety devices have been replaced and are functioning correctly, prior to inspection by the Authorized Person. Please note the Authorized Person must not sign the “hand back” section of the form until the area is in fact clean and safe. Any person requiring permit to work must submit their request to Contractor Permit Coordinator at least one working day prior to the commencement of the work. Prior to issuing the permit, the Contractor Permit Coordinator should satisfy himself that the safety conditions described in the permit are correctly applied. If any conditions required by the work permit cannot be met, the permit is to be withdrawn by the Contractor Construction Manager or the Area Superintendent and the work must not be allowed, until remedial actions have been taken. If the work extends beyond the stated validity period, then the permit is to be returned to the Contractor Construction Manager or the Area Superintendent and the work suspended until the extension has been authorized. The requirement for a Permit to Work inside the Contractor controlled area will remain at the discretion of the Contractor Construction Manager. However certain activities may be necessitated without the need for a Permit. More specifically, these works may include: Maintenance and repair, of subcontractor’s plant. Inspection activities, excluding Vessel Entry. Testing of plant & equipment, excluding pressure test and weight test. Alteration, refueling and oiling activities. Storage of materials. Clean-up operations (excluding the use of Hazardous Substances). Work required to create a safe condition. The Permit to Work can be invalidated under any of the following conditions: Two hours or more pass between the preliminary tests and the start of the work (the maximum acceptable delay shall be anyway evaluated based on the specific conditions). For gas testing in confined spaces, the maximum time between the gas test and the entry / work commencement exceeds 30 minutes (the maximum acceptable delay shall be anyway evaluated based on the specific conditions). The conditions on the permit are not complied with. Area or unit conditions change, e.g. venting or spillages of hazardous materials occurred, etc. Plant fire & gas/emergency alarm is released. Work is carried over to the next shift; in this case the Permit to Work can be renewed; the renewal shall be done before the next shift is starting its activity. The validity of the Permit to Work will be evaluated according to the activity and operative patterns, shall be evaluated at Site by YOUR COMPANY NAME’s Construction Manager (refer to Figure 6). Version 1.0 November 5, 2018 20 | P a g e Figure 6 Permit Validity Period DOCUMENT VALIDITY PERIODS ENDORSEMENT PERIODS Work Permit (cold) 28 consecutive (calendar) days 7 Days Hot Work Permit 14 consecutive (calendar) days 12 hours Confined Space Certificate * 28 consecutive (calendar) days 12 hours Excavation Work Certificate * 28 consecutive (calendar) days 12 hours Radiography Work Permit Maximum 12 hours N/A Electrical Work Certificate * No validity period N/A * Supporting documentation has to be required at the same time of the Work Permit (general and/or hot) for identifying particular hazards introduced by the work, which require further than formal controls. Where such risks are identified, supporting Certificates are enclosed in the Work Permit. 6.8 Permit closure The Permit to Work will be considered to be closed when YOUR COMPANY NAME’s Issuing Authority signs the completion section of the Permit to Work (after receiving the subcontractor confirmation on the Permit to Work that the work is complete). Acceptance of this signature is conditioned to: Completion of the work according to the instructions; Cleanliness of work area, including the removal of all the work equipment; Re-installation of all safety conditions. 6.9 Layout and Color of Permits The Permits to Work are in A4 format and for visibility purposes, to aid identification of documents, different colors are used on the border of Permits as per Figure 7. Figure 7. Permit and Certificate Identification Color Codes DOCUMENT BORDER COLOUR REFERENCE Black Attachment 1 Red Attachment 2 Confined Space Certificate Dark Green Attachment 3 Excavation Work Certificate Brown Attachment 4 Radiography Work Permit Bright-Orange Attachment 5 Electrical Work Certificate Blue Attachment 6 Work Permit (cold) Hot Work Permit 6.10 Permit and Certificate validity and endorsement periods To ensure that precautions required for tasks of a long duration are reviewed regularly, limits are set on the validity periods that Contractor Permit Coordinators may set for Permits, please refer to Figure 6. Version 1.0 November 5, 2018 21 | P a g e 6.11 Permit to Work Procedure Auditing and Review The objective is the periodically review and monitor the effectiveness and the application of this procedure. The site will prepare an annual program of monthly compliance checks. The program will: Identify those who will participate as lead auditors and audit team members; Have a minimum of one audit each month; Include all types of supporting Permits and Certificates; Include all areas of the site where the Permit to Work Procedure applies; Check that Permits are being displayed correctly in the Contractor Permit Coordinator Office; Confirm that the Permit to Work authorization register is up to date; Check that the Permits archiving is being done; Check by reviewing previous incident report statistics, that any incidents involving Permits have been reviewed for potential impact on the Permit to Work Procedure. A standard audit summary form will be provided and YOUR COMPANY NAME’s Construction Manager, through YOUR COMPANY NAME’s FHSEC, is responsible for producing the action plan resulting from the audit. 6.12 Emergency Response Should any situation on site arise where there is a risk to personnel then the work shall cease immediately and the response taken shall be in accordance with YOUR COMPANY NAME’s Emergency Response Plan. Version 1.0 November 5, 2018 22 | P a g e Attachment 1. Your Company Name Work Permit Forms Work Order No.: Location: _________________ _________________ WORK PERMIT SUBCONTRACTOR ____________________________________AREA OF W ORK TO BE FILLED BY SUBCONTRACTOR WORK STARTING DATE Work Permit No.: Issue Date: ____________________________ ____________________________ ______________________________________ _______________ TIME __________ WORK ENDING DATE _____________ TIME ________________ DESCRIPTION OF THE W ORK _______________________________________________________________________________ ___________________________________________________________________________________________________________ WORK EQUIPMENT _________________________________________________________________________________________ ___________________________________________________________________________________________________________ Subcontractor receiving Authority _ _ _ Date Time _ _ Subcontractor performing Authority ______________________________________________ Date ________ Time __________ TO BE FILLED BY CONTRACTOR The above signing person is responsible to ensure the work is performed under all the mentioned and required safety precautions. Failure on this will be subject to disciplinary actions. INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN X): □ Helmet □ Hear Protectors □ Gas Mask □ W elder’s Helmet □ Emergency Respirator □ Safety Shoes □ W elder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W work Clothes □ Safety Belts □ Dielectric Boots □ Dust Mask □ □ □ Safety Gloves □ Safety Glasses □ H2S Mask □ Double Safety Harness □ __________ COMMON PROTECTION EQUIPMENT _________________________________________________________________________ __________________________________________________________________________________________________________ OTHER SAFETY MEASURES _________________________________________________________________________ __________________________________________________________________________________________________________ Contractor Issuing Authority ___________________________________________________Date ________ Time _________ Is Electrical PTW required YES ___ NO ___ PTW Number Is Confined Space PTW required YES ___ NO ___ PTW Number Site Preparation completed and work can commence. Contractor Operating Authority SANCTION AUTHORIZATION SIGNATURES DATE TIME CLOSURE □ Dielectric Gloves □ Rubber Safety Boots □ W elders Breeches □ Safety Harness □ In case Electrical or Confined Space PTW is required? YES ___ NO ___ If yes, attach a Copy. I understand the precaution to be taken as described above. Sub-Contractor Operating Authority The Work is completed and working area cleared The Site has been checked and working Area accepted _____________________________________ Subcontractor performing Authority ________________________________________ Contractor Operating Authority Version 1.0 November 5, 2018 23 | P a g e TO BE FILLED BY CONTRACTOR TO BE FILLED BY SUBCONTRACTOR Attachment 2. Your Company Name Hot Work Permit Form W work Order No.: W work Permit HOT WORK PERMIT _________________ Location: No.:_______________________ Issue Date __________________ _ _ SUBCONTRACTOR _______________________________ AREA OF W ORK ______________________________________ WORK STARTING DATE ____________ TIME __________ WORK ENDING DATE ___________ TIME __________________ DESCRIPTION OF THE W ORK_____________________________________________________________________________ SOURCE OF IGNITION _____________________________________________________________________________________ DRAW ING ATTACHED ______________________________________________________________________________________ WORK EQUIPMENT ____________________________________________________________________________________ Subcontractor receiving Authority Date Time Subcontractor performing Authority Date Time The above signing person is responsible to ensure the work is performed under all the mentioned/required safety precautions. Failure will be subject to disciplinary actions. Has the equipment to be: YES NO CHK OTHER: YES NO CHK Depressurized Are sewer, drain properly secured Drained Is Site clear from combustible Isolated by spading Is Fire Protection required Water flushed Is Fire Watch required Ventilated by natural/mechanical Is Gas Tester required Purged with inert gas/steam Specify how often gas tester is required Other special precautions to be taken: INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN X): □ Helmet □ Hear Protectors □ Gas Mask □ Dielectric Gloves □ Safety Gloves □ Welder’s Helmet □ Emergency Respirator □ Safety Shoes □ Rubber Safety Boots □ Safety Glasses □ Welder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W elders Breeches □ H2S Mask □ Work Clothes □ Safety Belts □ Dielectric Boots □ Safety Harness □ Double Safety Harness □ Dust Mask □ □ □ □ __________ COMMON PROTECTION EQUIPMENT _______________________________________________________________________ OTHER SAFETY MEASURES ______________________________________________________________________________ Contractor Issuing Authority ___________________________________________________Date ________ Time _________ GAS ANALYSYS TEST COMBUSTIBLE TOXIC H2S O2 OTHERS DATE TIME DATE TIME DATE TIME DATE TIME Signature Authority Gas Tester: CLOSURE Site Preparation completed and work can commence ________________________________________________ Contractor Operating Authority The Work is completed and working area cleared _____________________________________ Subcontractor performing Authority Version 1.0 November 5, 2018 I understand the precaution to be taken as described above _________________________________________________ Contractor Performing Authority The Site has been checked and working Area accepted ________________________________________ Contractor Operating Authority 24 | P a g e Attachment 3. Your Company Name Confined Space Work Permit Form Version 1.0 November 5, 2018 25 | P a g e Attachment 4. Your Company Name Confined Space Work Permit CONFINED SPACE WORK PERMIT TO BE FILLED BY CONTRACTOR TO BE FILLED BY SUBCONTRACTOR Work Order No: ________________ Location: _ _ Confined Space Permit No:___________ Issue Date _______________________ SUBCONTRACTOR ______________________________ AREA OF W ORK _________________________________________ WORK STARTING DATE _____________ TIME ________ W ORK ENDING DATE ___________ TIME ___________________ DESCRIPTION OF THE W ORK _____________________________________________________________________________ _________________________________________________________________________________________________________ WORK EQUIPMENT _______________________________________________________________________________________ Stand-by W watchman Name Fire W watchman Name _ Stand-by W watchman Name shall record in/out of personnel; No one is allowed to enter without the presence of the Stand-by W watchman Subcontractor receiving Authority Date Time Subcontractor performing Authority Date Time Has the equipment to be: YES NO CHK OTHER: YES NO CHK Depressurized Are sewer, drain properly secured Drained Is Site clear from combustible Isolated by spading Is Fire Protection required Water flushed Is Fire Watch required Ventilated by natural/mechanical Is Gas Tester required Purged with inert gas/steam Specify how often gas tester is required Is power cable to be disconnected Is control cable to be disconnected Is wind direction to be considered Are warning notice/area restriction required Other special precautions to be taken: INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN X): □ Helmet □ Hear Protectors □ Gas Mask □ Dielectric Gloves □ Safety Gloves □ W elder’s Helmet □ Emergency Respirator □ Safety Shoes □ Rubber Safety Boots □ Safety Glasses □ W elder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W elders Breeches □ H2S Mask □ W work Clothes □ Safety Belts □ Dielectric Boots □ Safety Harness □ Double Safety Harness □ Dust Mask □ □ □ □ __________ COMMON PROTECTION EQUIPMENT ________________________________________________________________________ OTHER SAFETY MEASURES ________________________________________________________________________________ Contractor Issuing Authority Date Time GAS ANALYSYS TEST COMBUSTIBLE TOXIC H2S O2 OTHERS DATE TIME DATE TIME DATE TIME DATE TIME CLOSURE Signature Authority Gas Tester: Site Preparation completed and work can commence I understand the precaution to be taken as described above Contractor Operating Authority Subcontractor Performing Authority The W work is completed and working area cleared ______________________________________ Subcontractor performing Authority The Site has been checked and working Area accepted ________________________________________ Contractor Operating Authority Version 1.0 November 5, 2018 26 | P a g e Attachment 5. Your Company Name Daily Permit to Work Review Version 1.0 November 5, 2018 27 | P a g e Attachment 6. Your Company Name Excavation Work Permit APPROVAL TO BE FILLED BY CONTRACTOR TO BE FILLED BY SUBCONTRACTOR Work Order No: ________________ Location: _ _ EXCAVATION WORK Permit Excavation Work Permit No: ___ Issue Date ___________________ SUBCONTRACTOR ______________________________ AREA OF W ORK ____________________________________ WORK STARTING DATE TIME W ORK ENDING DATE TIME DESCRIPTION OF THE W ORK _________________________________________________________________________ Excavation by: HAND ____________________ EQUIPMENT ___________________ OTHER ______________ WORK EQUIPMENT _ YES NO CHK YES NO CHK Has the equipment to be: OTHER: Is the excavation more than 1.2m depth Is shoring, benching or sloping required Are access ladders needed Is road closure required Is a Confined Space PTW required Are nearby structures (buildings, equip.) that would affect the excavation Other special precautions to be taken: Subcontractor shall provide along with the Excavation PTW also all necessary above and underground drawings Subcontractor receiving Authority Date Time Subcontractor performing Authority Date Time ________ SAFETY PRECAUTIONS □ Watchman □ Flagman □ Safety Signs □ Warning Tape □ Permanent barricade □ Spoil clearance □ PPE □ Others FACILITY In case of presence of underground facilities, hand excavation must be done to expose them and after a Site Survey shall be done by Subcontractor and Contractor to ensure all necessary precautions are taken and eventually allow mechanical excavation. Are the underground pipes, cables, etc. in the area exposed? □ YES □ NO Are the underground pipes, cables, etc. within 15 m of existing facilities? □ YES □ NO Are there any suspected facilities not identified in the drawings? □ YES □ NO SITE SURVEY PERFORMED ON (date) _______________________ (time) ____________________ BY: CONTRACTOR______________________________ SUBCONTRACTOR ________________________________ Civil Department Signature ___________________________ Date _________ Mechanical Department Signature __________________________ Date _________ Electrical Department Signature __________________________ Date _________ Instrument Department Signature ___________________________ Date _________ EHS Department Signature __________________________ Date _________ Others Signature ___________________________ Date _________ Is the Banksman required full time during excavation? Are hard barricades required to protect excavation? Is warning tape required to highlight excavation location Is the spoil to be immediately removed from the working area? Excavation by hand only? Is the Area to be screened by cable detector before the work? □ YES □ YES □ YES □ YES □ YES □ YES □ NO _____________ □ NO □ NO ____________________________ □ NO ____________________________ □ NO ____________________________ □ NO _____________________________ The Site has been checked and working Area accepted The Site has been checked and working Area accepted __________________________ SUPERINTENDENT ______________________________________ CONSTRUCTION MANAGER OR DELEGATE Version 1.0 November 5, 2018 28 | P a g e Attachment 7. Your Company Name Authorization Signatures Version 1.0 November 5, 2018 29 | P a g e Attachment 8. Your Company Name Radiography Work Permit TO BE FILLED BY SUBCONTRACTOR Work Order No: ______________ Location: RADIOGRAPHY WORK PERMIT Work Permit No: Issue Date SUBCONTRACTOR _______________________________ AREA OF W ORK ________________________________________ WORK STARTING DATE TIME __________ W ORK ENDING DATE ___________ TIME __________________ DESCRIPTION OF THE WORK _____________________________________________________________________________ OTHER PTW REQUIRED: Confined Space No. H o t W work No. ____________ C o l d W work No. ___________ Subcontractor receiving Authority Date Time Characteristics of Radiation Equipment: NUCLIDE SOURCE ACTIVITY Amount adsorbed in the air one meter from the active source X-Rays KV 1 GBq GBq (1Ci) (Ci) GBq (Ci) mA 0,114 mGy/h mGy/h (420 mrad/h) (mrad/h) IRIDIUM 192 Directional COBALT 60 0,311 mGy/h mGy/h (1150 mrad/h) (mrad/h) Panoramic CAESIUM 137 0,078 mGy/h mGy/h (290 mrad/h) (mrad/h) Intensity of Amount in the Air Per 1 m/A : mGy/h: (mrad/h): Per m/A : mGy/h: (mrad/h): Is Storage of the equipment foreseen in the Site Area? YES NO SAFETY MEASURES 1) Exposure Time envisaged for the examination shown in Point A: min Total amount envisaged, outside the enclosure, for the examinations shown in point A: microGy/h (__ mrad/h) 2) From the ratio between the maximum amount of 20 microSv/week and the total envisaged exposure time of hours/week, it is established the intensity of outside the bounded area for unexposed workers, at m, must be less than ________ microGy/h mrad/h) 3) Safety measures and signaling system: □ W work Clothes □ Safety Harness □ Dust Mask □ Helmet □ Hear Protectors □ Safety Gloves □ Stand by person □ Shields □ Climator □ Safety Shoes □ Safety Glasses □ Enclosure signs □ W warning lights □ Protective Goggles □ Flashing lights □ H2S Mask □ □ __________ To be filled by Subcontractor’s qualified expert Summary of the amount in the air and Exposure of this Intensity of the amount in Intensity of the amount in the air at exposure times permit the air at the Area limit Area limit (time(1)+Intensity (2) = micro Gy Exposure Over 8 Date From hrs. To hrs. Minutes microGy/h mrad/h microGy/h mrad/h time hrs. TO BE FILLED BY CONTRACTO R Subcontractor Qualified Expert Date Time Subcontractor NDT Representative ____ Date ________ Time __________ Signatures above certify all Safety precautions/measures are on place and the work can commence AUTHORIZATION FOR START THE W ORK Contractor Issuing Authority ______________________________________________________ Date ________ Time __________ Special Safety precautions: __________________________________________________________________________________ YOUR COMPANY NAME Construction Manager YOUR COMPANY NAME Area Superintendent YOUR COMPANY NAME HSE Department _________________________________ __________________________________ _ WORK COMPLETED The work as above described in the mentioned Area has been completed and the Area is safe for normal working condition Subcontractor Qualified Expert Date Time Subcontractor NDT Representative Date ________ Time ______ Contractor Operating Authority Date Time Version 1.0 November 5, 2018 30 | P a g e Attachment 9. Your Company Name Electrical Work Permit ELECTRICAL WORK PERMIT TO BE FILLED BY OWNER CONTRACTOR TO BE FILLED BY SUBCONTRACTOR TO BE FILLED BY CONTRACTOR TO BE FILLED BY SUBCONTRACTOR W work Order No: Location: _________________ W work Permit No: _______________________ Issue Date _________________________ SUBCONTRACTOR _______________________________ AREA OF W ORK_____________________________________ WORK STARTING DATE TIME WORK ENDING DATE TIME DESCRIPTION OF THE W ORK __________________________________________________________________________ YES NO CHK YES NO CHK Live work required Connected to ground/earth Remote control isolated Lock Out/Tag Out in place W warning signs & barriers erected Suitable access/regress provided/available PPE required Other hazards WORK EQUIPMENT _______________________________________________________________________________________ Associated W work permit: HOT No.: COLD No.: CONFINED SPACE No.: Subcontractor receiving Authority Date Time Subcontractor performing Authority Date Time INDIVIDUAL PROTECTION EQUIPMENT (CROSS W ITH AN X): □ Helmet □ Hear Protectors □ Gas Mask □ W elder’s Helmet □ Emergency Respirator □ Safety Shoes □ W elder’s Apron □ Protective Goggles □ Anti-Dust Overalls □ W work Clothes □ Safety Belts □ Dielectric Boots □ Dust Mask □ □ Is the prime mover to be isolated from mechanical motive power? Is the prime mover to be isolated from the other power source? Is the power cable to be disconnected? Is control cable to be disconnected? □ Dielectric Gloves □ Rubber Safety Boots □ W elders Breeches □ Safety Harness □ □ YES □ YES □ YES □ YES □ NO □ NO □ NO □ NO □ Safety Gloves □ Safety Glasses □ H2S Mask □ Double Safety Harness □ __________ Tag & Log Out No.: Tag & Log Out No.: Tag & Log Out No.: Tag & Log Out No.: Additional Safety Precautions: ____________________________________________________________________________ Special Instructions to be followed in case of associated work permits (Hot, Cold, Confined Space): The Equipment and/or location where the work is to be done has been inspected and the work is safe to do? □ YES □ NO Competent Electrical person _________________________________________________ Date Time Contractor Issuing Authority ___________________________________________________Date ________ Time ________ CLEARANCE I hereby declare that the work is completed, all workers under my control have been withdraw and warned that is no longer safe to work on the apparatus specified in this Permit of W work and that tools, temporary earthling connections have been removed and the Site restored to safe conditions. Subcontractor Performing Authority Date Time I accept that the work is completed/suspended and the Site is restricted to a Safe conditions and the Apparatus is ready for restart Operating Authority _____________________________________________________________ Date ________ Time ______ Competent Electrical person _____________________________________________________ Date ________ Time _______ Version 1.0 November 5, 2018 31 | P a g e