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Permit to Work System Procedure
Document Revision and Approval
Revision Date Description
00 30 Nov 2011 First Issue
Proc. No: NC/PTW/SP-001
Proc Title: Permit to Work System Procedure
Developer Mohsin Abbas Awan GM (Quality) 22 Nov 2011
Reviewer I Haroon Tabani Manager (HSE) 23 Nov 2011
. ___.
VI
Reviewer II Kamal Sid coo 30 Nov 2011
Approver Julio Torre Gutierrez CEO 30Nov2011
Name Title Date Signature
Uncontrolled, if printed *Refer latest version in the server I SAP *If required, print both the si des•

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 2 of 59

Table of Contents

1. Purpose ...................................................................................................................................................... 3
2. Scope.......................................................................................................................................................... 3
3. Roles and Responsibilities ......................................................................................................................... 3
4. Equipment/Software ................................................................................................................................. 6
5. Terminology ............................................................................................................................................... 6
6. Procedure .................................................................................................................................................. 7
7. Records .................................................................................................................................................... 22
8. Legal Requirements and References ....................................................................................................... 23




Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 3 of 59
1. Purpose

To define NOMAC Permit to Work System (NPTW SYSTEM) which is a formal documented system and
recorded process used to control work in a safe manner.

2. Scope

All personnel and activities on operational facilities under NOMAC’s control including but not limited
to:
 Non-production work (maintenance, repair, inspection, testing, alteration, construction,
dismantling, adaptation, modification, cleaning etc).
 Non-routine operations.
 Works where two or more individuals or groups need to co-ordinate activities to complete the
job safely;
 Jobs where there is a transfer of work and responsibilities from one group to another.

3. Roles and Responsibilities

Roles Responsibilities
Plant
Manager
(PM/PGM)
 Accountable for ensuring the full implementation of the PTW system and ensuring
compliance. (Output: Certificate of PTWS Implementation, NC/PTW/SP-001/FM-026).
 Providing, or delegating authority to a senior manager to provide, resources and
training (technical and awareness) to effectively implement and maintain the PTW
system.(Output: Authority to train & resource PTWS, NC/PTW/SP-001/FM-027).
 Appointing, or delegating authority to a committee of senior managers to appoint, a
team of competent personnel to assure and authorize all necessary competent
personnel to manage and operate the PTW system. (Output: Formation of PTWS CAC,
NC/PTW/SP-001/FM-028).
 Monitoring or delegating authority to a senior manager to monitor, the functionality
and effectiveness of PTW system to deliver safe systems of work meeting industry
good practices. (Output: Compulsion to Monitor PTWS, NC/PTW/SP-001/FM-029).
 Quarterly Auditing the PTW system. (Output: PTWS Quarterly Audit Report,
NC/PTW/SP-001/RP-001).
 Setup a PTWS Office nearby CCR, with arrangements to manage LOTO kits, key safe,
documents etc. OM will be responsible to manage PTWS office.

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 4 of 59
Roles Responsibilities
PTWS
Competence
and
Authorizing
Committee
 To nominate competent employees to perform 9 roles of PTW System. The selection
should be based on competency only, keeping in view plant systems knowhow,
experience, PTWS training and proven technical & personal capabilities.
 To define SWS (Standard Work Statement) for routine tasks. (NC/PTW/SP-001/FM-
020)
 To define SWBS (Standard Work Breakdown Structure ) for SWS. (NC/PTW/SP-
001/FM-022)
 To define WC(Work Center) exhaustively. (NC/PTW/SP-001/FM-021)
 To nominate RA team & supervise RA activity.( NC/PTW/SP-001/FM-025)
 To edit Hazard and control sheet (NC/PTW/SP-001/FM-024) as per requirement.
 To define TBT (Tool Box Talk) for SWS. (NC/PTW/SP-001/FM-023)
 To define a relationship of one to many between PTWS Roles and Site Roles.
 To issue a list of Certified staffers for PTWS Roles.
(Output: Certified PTWS Roles, NC/PTW/SP-001/FM-030).

Permit
Authorizer
PA
 Ensures that PTW contains clear, simple, precise and complete descriptions and
limitations of works, details of location and start/end timing.
 Reviews and certifies the list of activities interacting with the PTW.
 Define control measures for the activities of PTW which are interacting or affecting
with other site activities being done with or without using PTW System.
 Certify that all other works that would create hazards if undertaken at the same time
are either suspended or made safe.
 Define pre-determined actions in the event of emergencies at site or plant.
 Identify competent persons engaged in preparation of permits.
 Identify the competent persons responsible for supervision.
Permit Issuer
PI
 Ensure that all hazards associated with job have been identified and suitably
addressed.
 Ensure that all steps necessary to ensure the safety have been taken.
 Ensure that all the required PTW system certificates and permits are identified,
prepared and attached to the PTW.
 Ensure that work activities that may interact or affect one another are clearly
identified and either conflict avoided or precaution included in PTW.
 Ensure that all precautions and isolations are withdrawn at the end of the job unless
they are cross referenced to other permit based activity.
Permit
Originator
PO
 Identify the work requiring PTW System’s activation.
 Clearly and completely describe the works and tasks, the location, the scheduled start
and end times
 Conduct preliminary RA.
 List of other ongoing activities under live permits or otherwise which may affect job
or may be affected by undertaking job.
 Define limitation on timings from PO perspective.
 Define precisely the boundaries of proposed work w.r.t Plant Functions and Plant
Technical Objects.

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 5 of 59
Roles Responsibilities
Isolation
Authority
IA
 Ensure that baseline isolation standard is determined and applied.
 All precautions and safety measures stated on permit are strictly followed.
 Ensure Isolation is fully implemented and documented.
 Issue Isolation Certificate.
 Conduct RA for Isolation and De-isolation scheme.
 Identify & maintain register for extended isolations.
 Identify & manage cross referenced isolations with other PTWs or activities.
 Prepare isolation and de-isolation sequence scheme.
Permit
Acceptor
PC
 Lead, supervise and monitor the team undertaking the works.
 Accept the permit on behalf of Permit User (PU) who carries out the work.
 Ensure the work being done comply with all PTW and safety requirements.
 Fully understands the PTW system and is fully competent to supervise/undertake the
proposed work.
Permit User
PU
 Undertake the works in full compliance with the PTWS and all HSE requirements.
 Be aware of and manage the works’ risks, scope, limits, nature and location related
issues.
 Be competent and trained to undertake the works and work within the PTW system.
 Stop work when in doubt and seek advice and support.
 Stop work if conditions change or become hazardous, make the area safe and
immediately seek advice or follow predetermined action list for such kind of
happenings.
Area
Authority
AA
 Custodian of the location of work.
 Ensure all hazards associated with the work are identified and risk controls are
applied.
 Monitor the works, location and permit user(s) to ensure that all precautions and safe
systems of work have been effectively implemented and are understood by the
permit user (undertaking the works).
 Ensure Interaction is controlled and known.
 Copies of PTW, Permits and Certificates applicable to job are available and displayed.
 Accept and acknowledge the return of plant or equipment into his full control on
completion of the works, reinstatement of good housekeeping practices and
cancellation of the PTW.
Site Checker
SK
 Have certified competency to check all site conditions associated with Plant functions
& processes.
 Competent to understand, implement and monitor compliance with the PTW system
 Only permit to start/continue works when/if necessary permits authorized, available
and understood
 Stop work when in doubt and seek advice and support.
 Responsible for checking the conditions at site before start of any activity.
 Remain conscious of possible degradation of site condition during the job &
document it.
 Let & verify AA and PU know about the limitations of site conditions.
 Stop work if conditions change or become hazardous, make the area safe and
immediately seek advice or follow predetermined action list for such kind of
happenings.

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 6 of 59
Roles Responsibilities
Supervision
Authority
SA
 Ensure understanding and competence of all employees using or complying with PTW
system.
 Ensure that the conditions and precautions specified in permits are fully understood,
implemented and effectively monitored.
 Ensure the arrangements that PA and PI will be timely informed when a job has been
completed, suspended, conditions altered, task need to alter and/or any emergency
exists.
Document
Controller,
DC
 PTWS data , copies of permits, or records of their issue, are kept for a specified period
to enable auditing or incident investigation.

4. Equipment/Software

SAP ERP, ECC 6.0 + systems including PM, PP, QA, PS Modules.
Share point file server.

5. Terminology:
Site Roles
PM/PGM : Plant Manager / Plant General Manager
OM : Operation Manager
MM : Maintenance Manager
TM : Technical Manager
SC : Shift In-charge
SS : Shift Supervisor
LO : Local Operator
CO : CCR Operator
ME : Maintenance Engineer
SB : Switch Board Operator
MS : Maintenance Supervisor
MT : Maintenance Technician
SL : Skilled Laborer
HO : HSE Officer
PE : Planning Engineer
PR : Process Engineer
PM : Performance Manager
LC : Lab Chemist
HS : HR Supervisor
DC : Document Controller
CS : Contractor’s Staff
CAC : Competence and Authorization Committee
COO : Chief Operations Officer
CEO : Chief Executive Officer.

PTWS Roles:
Supervision Authority (SA) Employee supervising the effectiveness of PTW
Permit Authorizer (PA) Highest Authority ordering issuance of permit
Permit Issuer (PI) Employee issuing the permit
Permit Originator (PO) Requestor of job

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 7 of 59
Isolation Authority (IA) Employee responsible for installing Isolations
Permit Acceptor (PC) Highest Authority (team leader) accepting the permit
Permit User (PU) Personnel complying with and working under the terms of Permits
Area Authority (AA) Employee in Control of location of work
Site Checker (SK) Employee carrying out site checks/tests

6. PTWS Procedure (Concept)

NOMAC PTW system is not designed to simply issue permission to carry out a dangerous job, It is a
process safety risk management system which determines how that job may be safely carried out
under predetermined conditions and communicates these requirements to those doing and
supervising the job. It should not be regarded as an easy way to eliminate hazard or reduce risk.

The issue of a permit does not, by itself, make a job safe, that can only be achieved by dedication &
competency of those preparing for the work, those supervising the work and those carrying out the
work.

The aim of the PTW system is to ensure that Authorized and competent people have thought about
foreseeable risks associated with the job. Associated risks are avoidable by using suitable precautions
and measures. Those carrying out the job will think about and understand what they are doing to
carry out their work safely, and take the necessary precautions for which they have been trained and
made responsible.

An initial appraisal and risk assessment will be carried out to identify the nature of a task and its
associated hazards before it is started. Precautions and controls to mitigate the risks will be defined
and the PTW system will be implemented to control the following types of tasks and situations:
 Non-production work (eg maintenance, repair, inspection, testing, alteration, construction,
dismantling, adaptation, modification, cleaning );
 Non-routine operations;
 Jobs where two or more individuals or groups need to co-ordinate activities to complete the job
safely;
 Jobs where there is a transfer of work and responsibilities from one group to another.

NOMAC’s PTW system consists of a set of procedures and forms. The PTW system clearly defines
roles, responsibilities, nature and extent of works to control all activities in a predetermined safe
manner. The system consists of:
 PTW System Procedure, to drive the entire system.
 PTWS sub-procedures with defined roles and processes which come in force at certain
predefined instant.
 PTW Permits and Certificates (mandatory to proceed with the job, as determined in RA).
 PTW Form, containing essential elements of PTW System.
 Standard lists of categorized Works, Work breakdown structures, Tool Box Talks, Work Centers
and Risks (with details of scope and limits).

The PTW System is an integral part of an overall safe system of work and is designed to properly
manage a wide range of routine and non-routine activities. This PTW System has taken into deep
consideration “The human factors” & its possible failure to understand the job, its extent, its limits
and nature. The failures may in turn be attributable to root causes such as a lack of training,
instruction, communication or understanding of either the purpose or practical application of PTWs.


Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 8 of 59
This PTWS Procedure should be subjected to test implementation in parallel with existing PTWS for
certain amount of time till understanding is developed & procedural documents are generated in a
proper sequence with requisite data quality.
Process flow:
1. SAP Maintenance Order will be raised in 3 cases by PO either through Malfunction (Operation)
Notification, Predictive Notification or Preventive Notification.
2. There are other possibility of EPC requirement which will be taken care by PO using Activity
Notification, Engg requirement taken care by Plant Modification Notification and other
requirements taken care by General Notification.
3. If a decision is made to conduct any of the aforesaid jobs in para 1 and 2, PO will raise permit
request by filling first part of the PTW form viz NC/PTW/SP-001/FM-001.
4. The category of job activity will be assessed by PO among A ( Access Required), B(Permit
required), C(permit with work pack required), D (New activity).
5. If activity falls in category A (based on RA), PO will fill first part of NC/PTW/SP-001/FM-001 ,
mentioning that it is now used as Access Permit & inform Operation about the activity, obtain
signatures of PI/PA and conduct work. When Job is completed it is the responsibility of PO to
inform PI/PA by closing the Access Permit. If activity falls in category B (based on RA), 4
documents are required to be raised, PTW form (NC/PTW/SP-001/FM-001), RA Form
(NC/PTW/SP-001/FM-025), Isolation Certificate(NC/PTW/SP-001/FM-010) and Tool Box
talk(NC/PTW/SP-001/FM-023). If activity falls in category C (based on RA), Work pack which
consists of all necessary documents including work instructions, drawings etc will also be
required. If it is a new activity for which there is no RA available, RA team already nominated by
Plant will conduct RA and ascertain the category of activity.
6. PM/PGM will nominate an RA team consisting of 6 competent and experienced professionals. At
least 2 members are required to conduct RA depending on complexity & severity of activity.

Supplementary Work Permits:

Hot Work Permit:
NC/PTW/SP-001/FM-002
1. PO will obtain Hot Work permit Form from PTWS Office. This should be done on every
occasion that Hot Work is required to be carried out. PO will fill the required sections of
the form and submit to SC.
2. PI will check the significance of any other permit to work going on in the vicinity which
may involve the use of flammable liquids or gases.
3. PI will only issue Hot Work Permit for a specific task undertaken in a clearly identified
area.
4. PI shall not issue Hot Work Permit for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. Hot Work Permit will be completed in duplicate with top copy for PC and second copy for
PI.
7. Completed form will remain with PI for record and future reference.

Working at height Permit:
NC/PTW/SP-001/FM-003
1. PO will obtain Permit Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 9 of 59
2. PI will check the significance of any other permit to work going on in the vicinity which
may interact.
3. PI will only issue the Permit for a specific task undertaken in a clearly identified area.
4. PI shall not issue Permit for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Permit will be completed in duplicate with top copy for PC and second copy for PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Confined Space Entry Permit:
NC/PTW/SP-001/FM-004
1. PO will obtain Permit Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other permit to work going on in the vicinity which
may interact.
3. PI will only issue the Permit for a specific task undertaken in a clearly identified area.
4. PI shall not issue Permit for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Permit will be completed in duplicate with top copy for PC and second copy for PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Confined Space Working Permit:
NC/PTW/SP-001/FM-005
1. PO will obtain Permit Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other permit to work going on in the vicinity which
may interact.
3. PI will only issue the Permit for a specific task undertaken in a clearly identified area.
4. PI shall not issue Permit for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Permit will be completed in duplicate with top copy for PC and second copy for PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Ground Disturbance Permit:
NC/PTW/SP-001/FM-006
1. PO will obtain Permit Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other permit to work going on in the vicinity which
may interact.
3. PI will only issue the Permit for a specific task undertaken in a clearly identified area.
4. PI shall not issue Permit for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 10 of 59
6. The Permit will be completed in duplicate with top copy for PC and second copy for PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Diving Permit:
NC/PTW/SP-001/FM-007
1. PO will obtain Permit Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other permit to work going on in the vicinity which
may interact.
3. PI will only issue the Permit for a specific task undertaken in a clearly identified area.
4. PI shall not issue Permit for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Permit will be completed in duplicate with top copy for PC and second copy for PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Disjoint Permit:
NC/PTW/SP-001/FM-008
1. PO will obtain Permit Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other permit to work going on in the vicinity which
may interact.
3. PI will only issue the Permit for a specific task undertaken in a clearly identified area.
4. PI shall not issue Permit for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Permit will be completed in duplicate with top copy for PC and second copy for PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Containment Break Permit:
NC/PTW/SP-001/FM-009
1. PO will obtain Permit Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other permit to work going on in the vicinity which
may interact.
3. PI will only issue the Permit for a specific task undertaken in a clearly identified area.
4. PI shall not issue Permit for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Permit will be completed in duplicate with top copy for PC and second copy for PI.
7. Completed form will be returned to PTWS Office for record and future reference.





Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 11 of 59
Certificates:

Isolation Certificate:
NC/PTW/SP-001/FM-010
1. PO will obtain Certificate Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other work going on in the vicinity which may
interact.
3. PI will only issue the Certificate for a specific task undertaken in a clearly identified area.
4. PI shall not issue Certificate for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Certificate will be completed in duplicate with top copy for PC and second copy for
PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Logic Isolation Certificate:
NC/PTW/SP-001/FM-011

1. PO will obtain Certificate Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other work going on in the vicinity which may
interact.
3. PI will only issue the Certificate for a specific task undertaken in a clearly identified area.
4. PI shall not issue Certificate for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Certificate will be completed in duplicate with top copy for PC and second copy for
PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Access Barrier Isolation Certificate:
NC/PTW/SP-001/FM-012
1. PO will obtain Certificate Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other work going on in the vicinity which may
interact.
3. PI will only issue the Certificate for a specific task undertaken in a clearly identified area.
4. PI shall not issue Certificate for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Certificate will be completed in duplicate with top copy for PC and second copy for
PI.
7. Completed form will be returned to PTWS Office for record and future reference.


Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 12 of 59
HV Environment Isolation Certificate:
NC/PTW/SP-001/FM-013
1. PO will obtain Certificate Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other work going on in the vicinity which may
interact.
3. PI will only issue the Certificate for a specific task undertaken in a clearly identified area.
4. PI shall not issue Certificate for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Certificate will be completed in duplicate with top copy for PC and second copy for
PI.
7. Completed form will be returned to PTWS Office for record and future reference.

PD Containment Isolation Certificate:
NC/PTW/SP-001/FM-014
1. PO will obtain Certificate Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other work going on in the vicinity which may
interact.
3. PI will only issue the Certificate for a specific task undertaken in a clearly identified area.
4. PI shall not issue Certificate for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Certificate will be completed in duplicate with top copy for PC and second copy for
PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Allowed to Test Certificate:
NC/PTW/SP-001/FM-015
1. PO will obtain Certificate Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other work going on in the vicinity which may
interact.
3. PI will only issue the Certificate for a specific task undertaken in a clearly identified area.
4. PI shall not issue Certificate for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Certificate will be completed in duplicate with top copy for PC and second copy for
PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Test Certificate:
NC/PTW/SP-001/FM-016

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 13 of 59
1. PO will obtain Certificate Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other work going on in the vicinity which may
interact.
3. PI will only issue the Certificate for a specific task undertaken in a clearly identified area.
4. PI shall not issue Certificate for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Certificate will be completed in duplicate with top copy for PC and second copy for
PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Interaction Certificate:
NC/PTW/SP-001/FM-017
1. PO will obtain Certificate Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other work going on in the vicinity which may
interact.
3. PI will only issue the Certificate for a specific task undertaken in a clearly identified area.
4. PI shall not issue Certificate for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Certificate will be completed in duplicate with top copy for PC and second copy for
PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Machinery Certificate:
NC/PTW/SP-001/FM-018
1. PO will obtain Certificate Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.
2. PI will check the significance of any other work going on in the vicinity which may
interact.
3. PI will only issue the Certificate for a specific task undertaken in a clearly identified area.
4. PI shall not issue Certificate for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Certificate will be completed in duplicate with top copy for PC and second copy for
PI.
7. Completed form will be returned to PTWS Office for record and future reference.

Radiation Certificate:
NC/PTW/SP-001/FM-019
1. PO will obtain Certificate Form from PTWS Office. This should be done on every occasion
that this type of job is required to be carried out. PO will fill the section 1-3 of the form
and submit to SC.

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 14 of 59
2. PI will check the significance of any other work going on in the vicinity which may
interact.
3. PI will only issue the Certificate for a specific task undertaken in a clearly identified area.
4. PI shall not issue Certificate for protracted periods.
5. If PI is not satisfied with the preparation as mentioned in check list and precautions
(section 2 and 3) PI may ask for more precautions which are to be entered in “Others”
box.
6. The Certificate will be completed in duplicate with top copy for PC and second copy for
PI.
7. Completed form will be returned to PTWS Office for record and future reference.











































Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 15 of 59
6.1 Process Map:
Operator
Notification Inspection
Planning
SAP Maint. Order
Preventive
Notification
Task List
Predictive
Notification
Work Request
Engineering
Construction
Validate Existing RA
Category A,
Only access
required
Identify Hazards
Conduct Risk Assessment
Design Process and Task Controls
Evaluate Residential Risks
Agreement to Proceed
Implement Controls & Prepare Draft PTWF
Isolation Certificates Prepared
PTW, RA, IC, TBT signed & accepted by
PA/PI & PO/PC
Undertake Task
in compliance with PTW requirements
PTW,RA,IC,TBT printed
Others
Define Parameters of Task and
required competencies
Implement Isolation
Prepare required Certificates, as per RA
PI authorizes and issues (signs) PTWF
Task completed
Hand-back procedure,
Job hand over procedure Opr. Shift Change over
Task suspended Job suspension Procedure
Job supervision Procedure
Permits Display Procedure
Define Isolation Standard
NOMAC PTW SYSTEM
N
N
Y
N
N
N
Y
CM
BD
Extended Isolation Required
Extended Isolations
Management Procedure
Y
N
Undertake Risk Assessment with
competent team
Y
Changes to scope
of works or risks
N
Standard RA
Y
Permits Interaction Procedure Permit/Task Interaction
N
N
LOTO Required LOTO Procedure
Y
Y
Y
Emergency/
Urgent Work
Emergency Tasks Procedure

STOP
STOP
Any Plant
Emergency
Scope change managable
Change Management
Procedure
Y
N
Routine work
Y
Standard WBS
Standard TBT
Finalize & Approve RA To PTWS Repository
PTW Form first part filled by PO
Standard IC
PTWS
Repository
To PTWS Repository
Managable
Y
N
Standard IC
available
Y
N


Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 16 of 59

Task Risk Analysis Isolation Certificte
S.Permits/
Certificates
PTW
Approved (PA)
Prepared (Any)
Schema Approved Approved (PA) Approved(PA)
Schema
Prepared (IA)
Awareness
Authorize
Surrundered
Withdrawn Long Term
De-Isolating
Proceed (IA)
Proceed (AA)
Available Issued
Raised (Any) Raised (Any) Raised (Any) Raised (Any)
Schema
Approved (IA)
Available
Prepare
Cancelled
Not Required Cancelled Not Required Not Issued
Cancelled
Cleared
Prepare
Available
Cancelled
TRA, Permits, Certificate and PTW document Cycle

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 17 of 59

6.2 Procedure Flow:

Issue Timing Description of activities
Responsible
(doing it)
Accountable (ensure
it is done)
Procedure/
SAP module
Outcome and
Records
Forms and
Templates
Competency
Assessment
Pre-planning Check availability of personal with required
competency for the scope of work
PO MM, PM 1. NC/HSE/SP-
001/FM-032.
2. NC/HSE/SP-
001/FM-033.
Confirmation of
availability of
personnel
SAP-PM-MO
Initial Risk
Assessment
Pre-planning Complete initial risk assessment and assemble
competent team to undertake full RA
PO MM,PM NC/HSE/SP-001 Initial risk
assessment
FM-0025
Initiate the
Maintenance
Order
Planning Complete planning part of Maintenance Order
by precisely dividing the maintenance
activities into autonomous tasks mentioning
duration, resources and material for each
task.
PO MM SAP-PM-MO SAP Maintenance
order
SAP-PM-MO
Work Request Planning Raise the work request by presenting
maintenance order & filling part 1 of PTW
Form
PO MM SAP-PM-MO.
1. NC/HSE/SP-
001/FM-001.

Work request Printed SAP-
PM-MO
Scope of works Planning Determine exactly what the task will involve,
The need for any special safety studies or
assessments. whether it is obvious that the
task cannot be carried out safely, and should
be immediately discarded or delayed until
other operations due to take place at the
same time have been completed. If the likely
hazards cannot be reconciled at this stage
through task or other risk assessment, then
the task should be rejected or redefined.
PO, PA OM,SC, ME, MM, SS SAP-PM-MO

NC/HSE/SP-001
Detailed description
of scope of works
and required safe
systems
Agreement to
proceed
SAP-PM-MO

NC/HSE/SP-
001/FM-001
Full Risk
Assessment
Planning A full RA is undertaken for tasks that do not
have a completed and available risk
assessment. PA with supporting HSE team and
PO will identify hazards associated with job
and conduct RA and suggest controls in a
predetermined formal way
PA, PO,PI HO, SC, ME NC/HSE/SP-001 RA, controls and safe
work requirement
NC/HSE/SP-
001/FM-001

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 18 of 59
Issue Timing Description of activities
Responsible
(doing it)
Accountable (ensure
it is done)
Procedure/
SAP module
Outcome and
Records
Forms and
Templates
Interaction with
other works
Planning Define the control required to manage new
planned works that could interact or impact
with ongoing and on existing works and
operations & vice versa.
PO, PA,PI,
AA,IA
SC, ME,SS,
LO,CO
PTW System Procedure.

Permits Interaction Proc
NC/PTW/SP-003
PI-Interaction jobs
list.

PO-Interaction Jobs
list.

Interaction
Certificate
NC/PTW/SP-
003/FM-001

NC/PTW/SP-
003/FM-002

NC/PTW/SP-
001/FM-003


Permits and
Certificates
Planning Define Residual risks associated with the
proposed job and determine the required
PTW System supplementary permits and
certificates.
PO, PA,SK,PI SS,HO,SC, ME NC/PTW/SP-001
NC/PTW/SP-002
NC/HSE/SP-001


Machinery
Certificate

NC/PTW/SP-
002/FM-001.

NC/PTW/SP-
001/FM-018..


Draft PTW Planning With all the information at hand the decision
to proceed with the job (or not) is taken. At
this point in time the PTW procedure will
come in force. and the draft PTW Form, with
all required RA controls, required Permits,
required Certificates is prepared
PO , PA, PI,
SK
ME, HO, SC PTW module NC/PTW/SP-
001
Draft PTW NC/PTW/SP-
001/FM-001
Define
isolations
Make safe Determine isolation and LOTO base line
standards for the proposed job. Prepare
Isolation scheme. Prepare Isolation De-
isolation sequence sheet. Determine common
Isolation scenarios. Determine extended
Isolation possibility.
PI,IA, AA SC,SS, LO Isolation Procedure
NC/PTW/SP-002
LOTO procedure
NC/PTW/SP-012
Isolation Scheme NC/PTW/SP-
002/FM-001.


Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 19 of 59
Issue Timing Description of activities
Responsible
(doing it)
Accountable (ensure
it is done)
Procedure/
SAP module
Outcome and
Records
Forms and
Templates
Effect Isolations Making Safe Implement the isolations and issue Isolation
Certificate(s) as relevant.

Verify Isolation Implementation.
IA, PI
SS,SC,LO Isolation Procedure
NC/PTW/SP-002.

PTW System Procedure
NC/PTW/SP-001.

Isolation Certificate.

Logic Isolation
Certificate.

HV Isolation
Certificate.

PD Containment
Isolation Certificate.

Access Barrier
Isolation Certificate.
NC/PTW/SP-
001/FM -010.

NC/PTW/SP-
001/FM -011.

NC/PTW/SP-
001/FM -013.

NC/PTW/SP-
001/FM -014.

NC/PTW/SP-
001/FM -012.



Making safe
Access Barrier Isolation Certificate


NC/PTW/SP-
001/FM -011.

NC/PTW/SP-
001/FM -013.

NC/PTW/SP-
001/FM -014.


High Voltage Environment Isolation Certificate
Logic Isolation
Certificate

Effect safe
technical
environment

PD containment Isolation Certificate AA
LO,SS NC/HSE/SP-001
Access Barrier
Isolation Cert


Allowed to Test Certificate PI
SB NC/PTW/SP-002
HV Isolation Cert
NC/PTW/SP-
001/FM -001.
Test Certificate PI,AA LO,SS NC/PTW/SP-002 PD Cont Isol Cert
Interaction Certificate PA,PI PI, NC/PTW/SP-001 Allow to Test Cert
Machinery Certificate SK, HO NC/PTW/SP-003 Test Certificate
PO,PI SC,SS NC/PTW/SP-002 Interaction Cert
PA,PO PI NC/PTW/SP-001 Machinery Cert
Radiation Certificate PO,SK HO NC/PTW/SP-001 Radiation Cert

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 20 of 59
Issue Timing Description of activities
Responsible
(doing it)
Accountable (ensure
it is done)
Procedure/
SAP module
Outcome and
Records
Forms and
Templates
Supplementary Make safe Issue supplementary permits after making
assessment of job and determining the
requirement of Permits and Certificates.
PA,PI,PO ME,SC,SS NC/PTW/SP-001
Working at
height Permit
NC/PTW/SP-
001/FM -003
permits Working at height Permit SK,PI HO,SC,SS Hot work Permit

Hot work Permit PA,PI
SC,SS
Confined Space
Entry Permit
NC/PTW/SP-
001/FM -004.

NC/PTW/SP-
001/FM -005.

NC/PTW/SP-
001/FM -006

Confined Space Entry Permit PA,SK,PI
HO,SC,SS Confined Space
Working Permit


Confined Space Working Permit PA,SK,PI
SC,SS,HO Ground
Disturbance
Permit

Ground Disturbance Permit PI,PA SC,SS Diving Permit
Diving Permit PI,PA SC,SS Disjoint Permit

Disjoint Permit PI,IA,PA
SC,SS,LO Containment
Break Permit

Containment Break Permit PI,PA SC,SS
PTW issued Made safe PTW Form issued with additional permits
and/or certificates prepared and issued
PI, PA, IA SS,SC,LO NC/PTW/SP-001 Signed PTW ,
Required Certificates
and Permits.
NC/PTW/SP-
001/FM-001
PTW
Acceptance
Accepted as
safe
Check and accept the PTW form and
supporting documents
PC, PU,PI, IA
behalf of PU
MT,MS,ME,SS,SC Permit to work NC/PTW/SP-
001
Signed and accepted
Permit to work
NC/PTW/SP-
001/FM-001
Undertake
works
Safe Works in
progress
Undertake job in compliance with all
precautions and instructions as per the PTW
documentation
PU, PC, AA,
PI,
MT,MS,ME,LO,SC,SS, Permits and Certificates
Display Procedure
NC/PTW/SP-013
PTW displayed at
work location,
Permits and
Certificates displayed
NC/PTW/SP-
001/FM-001
To
NC/PTW/SP-
001/FM-019.
Confined Space Safe Works in
progress
Ensure that additional personnel for confined
space entry are available
PO,SC,PC PC NC/PTW/SP-001 Confined space entry
permit.
Confined space
working permit
NC/PTW/SP-
001/FM-004.
NC/PTW/SP-
001/FM-005.
Supervision Ensure Safe
Works in
progress
The Job will be carried out under mandatory
supervision
SA HO,PO,PA Permit Supervision Proc
NC/PTW/SP-007
Records of
supervision
NC/PTW/SP-
007/FM-001

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 21 of 59
Issue Timing Description of activities
Responsible
(doing it)
Accountable (ensure
it is done)
Procedure/
SAP module
Outcome and
Records
Forms and
Templates
Change of scope Works change
management
During the job if any change in scope is
required PU will inform PC, PO, AA and PI
PU, PC, AA PU, MS,MT,ME Scope of Work Change
NC/PTW/SP-011
RA review, NC/PTW/SP-
011/FM-001
Unplanned
situation
Works in
progress
During the job if any unplanned situation
occurs the job will be stopped and a revised
RA may be undertaken and implemented
under Job suspension procedure.

PU,
PC,AA,IA,PI
PU, PC, PI, MT,
MS,SL,LO,SS, SC
Job suspension procedure
NC/PTW/SP-006
Reassessment,
Revalidation of
controls and permits
and certificates
NC/PTW/SP-
006/FM-001
Shift Change Works in
progress
If Operation Shift changed over during job, job
handover procedure will come in force.
If Maintenance team change over during the
job this procedure will become effective
PI,AA,PU,PC PI,
PC,LO,SC,SS,MT,MS,SL
Job Handover Procedure
NC/PTW/SP-004
SAP PM-MO-with
marking on the
operation list
showing current
status of job
NC/PTW/SP-
004/FM-004.
SAP-PM-MO
Extended
Isolations
Works in
progress
When extended isolations are required a
formal procedure will be followed leaving no
room for any mistaken activity.
IA, AA, PI,
PO
ME, LO, Extended Isolations Proc
NC/PTW/SP-014
Extended Isolation
Register.
Extended Isolation
List.

NC/PTW/SP-
014/PS-001.
NC/PTW/SP-
014/FM-001.
Monitoring Works in
progress
Continuous checking of controls in place
during the pendency of permit controlled job
AA, PI, IA, PA LO, SS,SC,MO,ME PTW Monitoring Proc
NC/PTW/SP-008
PTWS Monitoring
Report
NC/PTW/SP-
008/RP-001,
RP-002,
PTW
Compliance
Works in
progress
Periodic verification of compliance with PTW
system and procedures
PI, PA, PO OM,MM,PM,GMQ Permits Review Proc
NC/PTW/SP-010
PTWS compliance
Report
NC/PTW/SP-
010/RP-001
Suspension of
Works
Works in
progress
If task is suspended due to any reason then
compliance with suspension procedure is
required
PU,AA,PI, MS, MT,SL,LO,SS, SC Job suspension and
Re-start Procedure
NC/PTW/SP-006
Reassessment,
Revalidation of
permits, MO with
scope change
NC/PTW/SP-
006/FM-001
and RP-001
Completion of
Works
Works
completed
When task is completed as per plan then job
hand back procedure come into effect
PU,AA,IA,PI, LO,SC,SS, Job Hand-back Proc
NC/PTW/SP-005
List of Cancelled
permits, Cancelled
Certificates, General
Permit to work
NC/PTW/SP-
005/RP-001.
Compliance
Audit
After
completion
Periodic audits of compliance with the PTW
system should be undertaken






PA OM,MM,PM,GMQ PTWS Audit Proc
NC/PTW/SP-009
Audit Report NC/PTW/SP-
009/RP-001

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 22 of 59
7. Records:

Procedure Reference Document No.
Permit-to-Work System Procedure NC/PTW/SP-001
PTWS - Isolation Procedure NC/PTW/SP-002
PTWS - Permits Interaction Procedure NC/PTW/SP-003
PTWS - Job Handover Procedure NC/PTW/SP-004
PTWS - Hand-back Procedure NC/PTW/SP-005
PTWS - Job suspension and Re-start Procedure NC/PTW/SP-006
PTWS - Supervision Procedure NC/PTW/SP-007
PTWS - Monitoring Procedure NC/PTW/SP-008
PTWS - Audit Procedure NC/PTW/SP-009
PTWS - Permits Review Procedure NC/PTW/SP-010
PTWS - Scope of Work Change Procedure NC/PTW/SP-011
PTWS - Lock out Tag out procedure NC/PTW/SP-012
PTWS - Permits and Certificates Display Procedure NC/PTW/SP-013
PTWS - Extended Isolation Procedure NC/PTW/SP-014


Record Number Record Title Responsibility
Retention
Period
NC/PTW/SP-001/FM-001 Permit to Work PI 5 years
NC/PTW/SP-001/FM-002 Hot work Permit PI 5 years
NC/PTW/SP-001/FM-003 Working at height Permit PA 5 years
NC/PTW/SP-001/FM-004 Confined Space Entry Permit PA 5 years
NC/PTW/SP-001/FM-005 Confined Space Working Permit PA 5 years
NC/PTW/SP-001/FM-006 Ground Disturbance Permit PA 5 years
NC/PTW/SP-001/FM-007 Diving Permit PA 5 years
NC/PTW/SP-001/FM-008 Disjoint Permit PA 5 years
NC/PTW/SP-001/FM-009 Containment Break Permit PA 5 years
NC/PTW/SP-001/FM-010 Isolation Certificate IA, PI 5 years
NC/PTW/SP-001/FM-011 Logic Isolation Certificate IA, PI 5 years
NC/PTW/SP-001/FM-012 Access Barrier Isolation Certificate AA,PI 5 years
NC/PTW/SP-001/FM-013
High Voltage Environment Isolation
Certificate
PA, PI 5 years
NC/PTW/SP-001/FM-014 PD containment Isolation Certificate IA, PI 5 years
NC/PTW/SP-001/FM-015 Allowed to Test Certificate IA, PI 5 years
NC/PTW/SP-001/FM-016 Test Certificate SC, PI, PO 5 years

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 23 of 59
Record Number Record Title Responsibility
Retention
Period
NC/PTW/SP-001/FM-017 Interaction Certificate PI 5 years
NC/PTW/SP-001/FM-018 Machinery Certificate PI 5 years
NC/PTW/SP-001/FM-019 Radiation Certificate PI 5 years
NC/PTW/SP-001/FM-020 Standard Work Statement Sheet PM 20 years
NC/PTW/SP-001/FM-021 Standard Work Centers Sheet PM 20 years
NC/PTW/SP-001/FM-022
Standard Work Breakdown Structure
Sheet
PO 20 years
NC/PTW/SP-001/FM-023 Standard Tool Box Talk Sheet PO 20 years
NC/PTW/SP-001/FM-024 Standard Hazard Control Sheet PM 20 years
NC/PTW/SP-001/FM-025 Task Risk Analysis Form PO 20 years
NC/PTW/SP-001/FM-026 PTWS Implementation Certificate PM 5 years
NC/PTW/SP-001/FM-027 PTWS Resourcing PM 5 years
NC/PTW/SP-001/FM-028 Formation of CAC PM 5 years
NC/PTW/SP-001/FM-029 PTWS Monitoring PM 5 years
NC/PTW/SP-001/FM-030 PTW Supplementary activity Sheet PO 5 years

8. Legal Requirements and References:

8.1 HCIS
8.2 ACWA Power O&M Standards & Guidelines
8.3 ISO-9001-2008 Clause 7.5.1
8.4 ISO 14001-2004 Clause 4.4.6
8.5 OHSAS 18001-2007 Clause 4.4.6




Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 24 of 59

PERMIT TO WORK
PTW-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this permit. To Restart Contact PA
Activity Category: ( A:Access Controlled; B:Permit Controlled; C:Permit with Work Pack.; D New activity RA req.) PLANT
Activity Reference: RA Available RA No.: Date:
Valid From: RA Required RA No.: MO NO.
Valid To: Special Tools: Base Document Ref:
Maintenace Sections: Lead Sec. Work limitations:
Mechanical Functional Limits:
Electrical Object Limits:
I&C / Civil / / SWS ID: SWS:
1. WORK ACTIVITY F.L: Equipment:
Maintenance Order activities: CC by (ID) Duration(h) Work Center No. / ID RA Done/Ref

Supplimentary Work Activity Sheet Required Permit Originator (PO): Name & Signature & Date:
2. ADDITIONAL PERMITS / CERTIFICATES
Permits Permit No. YES NO Certifcates Certificate No. YES NO
. Hot Work Permit . Isolation Certificate.
. Confined Space Entry Permit . Logic Isolation Certificate.
.Confined Space Working Permit . Access Barrier Isolation Certificate.
. Working at Height Permit . HV Environment Isolation Certificate.
. Ground Disturbance Permit . PD Containment Isolation Certificate.
. Diving Permit . Allowed to test Certificate.
. Disjoint Permit. . Test Certificate.
. Containment Break Permit. . Interaction Certificate.
LOTO Key: Key: Key: . Machinery Certificate.
Key Safe No. Key: Key: Key: . Radiation Certificate.
3. APPROVAL & ACCEPTANCE:
. Permit Authorizer(PA): I certify that work is well defined with work limitations , RA done & controls mentioned therein are applied.
Name: Signature Date & Time:
. Area Authority(AA): I hereby certify that all the safety requirements of task are fulfilled and that the tasks as mentioned in para 1 can be performed safely.
Name: Signature Date & Time:
. Permit Acceptor(PC): I accept this permit & declare that I am aware of all requirements & all safety measures taken to make this job as mentioned in para 1, safe.
Name: Signature Date & Time:
. Permit Originator(PO): I accept this permit & declare that I am aware of all requirements & all safety measures taken to make this job as mentioned in para 1, safe.
Name: Signature Date & Time:
. Permit Issuer(PI): I hereby confirm that all the Permit requirements are identified, met, precautions taken and safety is not compromised.
Name: Signature Date & Time:
4. APPROVAL FOR HIGH HAZARD WORK:
. Permit Authorizer: I hereby further certify that all the safety requirements of this high hazard task are fulfilled and task can be performed safely.
Name: Signature Date Time:
5. PERMIT CONTROL:
Visit From date/time Role-Name-signature Observation
6. PERMIT USER/S CHANGE:
. Relieving Permit Accpeter / Permit User: I/We hereby certify that the status and all safety requirements of task are fully explained to incoming PC/PU.
Name: Signature Date Time:
Name: Signature Date Time:
. Incoming Permit Accpeter / Permit User: I/We hereby certify that we are made fully aware of the status and precautions of this job.
Name: Signature Date Time:
Name: Signature Date Time:
. Permit Issuer: I hereby certify that the plant will remain safe to be worked upon . NEW EXPIRY DATE & TIME:
Name: Signature Date Time:
7. OPERATION SHIFT CHANGE:
. Relieving Permit Issuer, Area Authority: We hereby certify that the status and all safety requirements of task are fully explained to incoming PI and AA.
Name: Signature Date Time: PI
Name: Signature Date Time: AA
. Incoming Permit Issuer / Area Authority: We hereby certify that we are made fully aware of the status and precautions of this job.
Name: Signature Date Time: PI
Name: Signature Date Time: AA
8. PERMIT CLOSURE & CANCELLATION
. Permit Acceptor: I hereby certify that all tasks as mentioned in para 1 are completed & work area is clear.
Name: Signature Date Time:
. Area Authority: I hereby certify that all the tasks as mentioned in para 1 has been checked & plant is ready for testing/recommissioning.
Name: Signature Date Time:
. Permit Authorizer: I hereby certify that tests have been completed and plant satisfactorily recommissioned. This permit stands cancelled.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-001
Y
B C D
N
A
Y N
Y N

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 25 of 59

HOT WORK PERMIT HWP-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this permit. To Restart Contact PA
This Hot Work Permit is issued subject to the following conditions
VALID FROM (Date/Time): VALID TO:
PLANT
REVISED VALIDITY , FROM(Date/Time): VALID TO:
PTW NO.
2nd REVISED VALIDITY , FROM (Date/Time): VALID TO:
MO NO.
1. HOT WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Brief work description:

. Permit Originator: Above Location has been examined & Check list in section 3 is completed to the best of my knowledge.
Name: Signature Date Time:
2. HOT WORK CHECK LIST (To be Checked by PO, PI)
YES NO YES NO
. Jobs performed by contractors or temporary workers . Within 35 m, foolrs are free of oil, grease, solvent
. Adjacent equipments and area safe . Within 35 m, any covering with fire materials required.
. Potential flammable / explosive atmosphere . Within 35 m, flammable materials removed
. Potential high temperature . Within 35 m, combustable surfaces are wetted down
. Ventilation is acceptable . Fire watch required. Name: Signature
. Welding & Cutting Equipments in safe condition . Suspended work, beneath area covered.
. Confined space work . Lead is present in the objects being cut oe welded.
. Bypassing or removing/altering safety devices and equipment . Fire / smoke alram / Sprinkler system needs isolation.
. Indoor, smoke detectors in service . Multi purpose Fire extinguishers required. / Available
. In sprinklered area, Spriklers in service . Walkways protected beneath hot work.
. Welding curtain / shield required . All Wall and floors openings covered within 35 m.
. Electrical troubleshooting or repair on live circuits . Combustibles required to be moved away from other side of wall / Moved.
. Others (state):
3. SAFETY PRECAUTIONS
YES NO YES NO YES NO
. Depressurising . Fresh air ventilation . Elevated work
. Physical Isolation . Atmosphere analysis : . Contractors trained
. Electrical Isolation . Oxygen . Eliminate ignition sources
. Safety tags and locks . Flammable . Fire hose
. Flushing with water/solvent . Toxic . Fire screen
. Steaming out . Other . Wet surrounding area
. Purging with inert gas/air . Area marked off . Audible/visible warnings
. Temperature normalisation . Warning notices . Clear area of combustibles
Others (state): . Fire extinguishers
Type :
Type :
4. PERSONNEL PROTECTION
YES NO YES NO YES NO YES NO Required Tools:
. Head . Ears Escape Set Harness 1
. Face . Hands SCBA Life Jacket 2
. Eyes . Feet Coverall Elsting Hood 3
. Body . Breathing Leather Apron Rubber Boots 4
State Special Requirements : 5
6
3. APPROVAL & ACCEPTANCE:
. Site Checker: This certifies that work area and all adjacent areas to which spark and heat might have spread have been inspected and found to be free of fire during and
following the completion of work. as detailed in Section 1.
Name: Signature Date Time:
. Permit Acceptor: I hereby accept this permit & declare that I am aware of all requirements & all safety measures taken to make this job as mentioned in para 1, safe.
Name: Signature Date Time:
. Permit Issuer: This Hot Work Permit Is issued subject to the conditioned as mentioned above.
Name : Signature : Date Time:
8. PERMIT CLOSURE & CANCELLATION
. Site Checker / Fire Watch: This certifies that work area and all adjacent areas to which spark and heat might have spread have been inspected and found to be
free of fire following the completion of work. as detailed in Section 1. (To be signed within 1 hour of completion of job)
Name: Signature Date Time:
. Area Authority: I hereby certify that all the tasks as mentioned in para 1 has been checked & plant is ready for testing/recommissioning.
Name: Signature Date Time:
. Permit Authorizer: I hereby certify that tests have been completed and plant satisfactorily recommissioned. This permit stands cancelled.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-002

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 26 of 59


WORKING AT HEIGHT PERMIT WHP-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this permit. To Restart Contact PA
ONLY TRAINED AND COMPETENT PERSONS SHALL WORK AT HEIGHT
VALID FROM (Date/Time): VALID TO:
PLANT
REVISED VALIDITY , FROM(Date/Time): VALID TO:
PTW NO.
2nd REVISED VALIDITY , FROM (Date/Time): VALID TO:
MO NO.
1. ELEVATED WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Description of work

. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. ELEVATED WORK CHECK LIST (To be Checked by PO, PI)
YES NO YES NO
. Jobs performed at Roof Surface: Roof pitch angle: . Method of access to Work Area
. Job is near exposed edge .Portable extension Ladder
. Work Area near open hole .Fixed Ladder
. On heavy plant and machinery .EWP
. Erecting Scafolding .SWP
. Job on steel structure .Man cage via crane
. On a Crane. .Climbing technique
. Others (state):
3. SAFETY PRECAUTIONS
YES NO YES NO YES NO
. Travel Restraint System . Full body harness .Cable fall-arrest device available
. Work positioning System . Using Retractable lanyard : . Adjustable lanyard available
. Fall arrest System . Seat belt type . Fallen worker retrieval plan
. Using Lanyard (adjustable length) . Cable type with winch . Pre-rigged retrieval kit available
. Using double Lanyard (twin-tail) . Cable type . ERT to be notified
. Using Lanyard (fixed length) . Other . Rescue plan annexed
. Purging with inert gas/air . Rope & rope grab/clamp . Standby persons available
. Person to foot ladder available . Warning notices .Name:
Others (state): .Name:
.Name:
.Name:
4. PERSONNEL PROTECTION Required Tools:
YES NO YES NO YES NO YES NO 1
. Head . Ears Escape Set Harness 2
. Face . Hands SCBA Life Jacket 3
. Eyes . Feet Coverall Elsting Hood 4
. Body . Breathing Leather Apron Rubber Boots 5
State Special Requirements : 5
6
3. APPROVAL & ACCEPTANCE:
. Permit User: I agreed to work within the conditions indicated on this permit and accept the responsibility. I declare that all the work at height will be acrried out in
following the completion of work. as detailed in Section 1.
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
. Permit Acceptor: I herby declare that the persons identified on this permit are competent and authorize to carry out the work at height subject to the terms and
conditions of this permit.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this work & allow to proceed.
PI Name: Signature Date Time:
8. PERMIT CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permithas been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Area Authority: I hereby certify that all the tasks as mentioned in para 1 has been checked & plant is ready for testing/recommissioning.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this permit.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-003

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 27 of 59

CONFINED SPACE ENTRY PERMIT CSP-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this permit. To Restart Contact PA
SAFETY STANDBY IS REQUIRED FOR ALL CONFINED SPACE WORK
VALID FROM (Date/Time): VALID TO:
PLANT
REVISED VALIDITY , FROM(Date/Time): VALID TO:
PTW NO.
2nd REVISED VALIDITY , FROM (Date/Time): VALID TO:
MO NO.
1. CONFINED SPACE ENTRY WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Work Description:
TYPE OF CREW Alternate Entry: Communication Type: Test Instrument Sr. No.
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. CONFINED SPACE WORK CHECK LIST (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. LOTO requirement completed: . Check after Isolation & Ventilation: Time - % Time-% Time-% Limit
. De-energization requirement completed .Oxygen 19.50%
. Rescue Plan ready .Explosive <10%
. Purge-Flush-Vent requirements completed .Toxic <10ppm
. Ventilation requirement completed .Combustible gas 10%
. Secure area (post and flag) .CO <25 ppm
. Lighting exlosive proof .Others
. Others (state):
3. SAFETY PRECAUTIONS NA: Not Applied
YES NO NA(Not Applied) YES NO YES NO NA
. Fire extingusher . Full body harness .Atmospheric testing during work
. Supplied air respirator . Using Retractable lanyard : . Ist
. Respirators (air purifiers) . Seat belt type . 2nd
. Protecting Clothing . Cable type with winch . 3rd
. Emergency scape retrieval equipment . Cable type . 4th
. Life lines . Other . 5th
. Purging with inert gas/air . Hoisting Equipment Stand by persons:
. Resuscitator Inhalator . Warning notices .Name:
Others (state): .Name:
.Name:
.Name:
4. PERSONNEL PROTECTION Required Tools:
YES NO YES NO YES NO YES NO 1
. Head . Ears Escape Set Harness 2
. Face . Hands SCBA Life Jacket 3
. Eyes . Feet Coverall Elsting Hood 4
. Body . Breathing Leather Apron Rubber Boots 5
State Special Requirements : 5
6
3. APPROVAL & ACCEPTANCE:
. Permit User: I agreed to work within the conditions indicated on this permit and accept the responsibility. I checked that the confined space entry is safe .
following the completion of work. as detailed in Section 1.
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
. Permit Acceptor: I herby declare that the persons identified on this permit are competent and authorize to enter the confined space & all safety measures are taken.
conditions of this permit.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this work & allow to proceed.
PI Name: Signature Date Time:
8. PERMIT CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permithas been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Area Authority: I hereby certify that all the tasks as mentioned in para 1 has been checked & plant is ready for testing/recommissioning.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this permit.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-004
Y N S P R V

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 28 of 59

CONFINED SPACE WORK PERMIT CWP-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this permit. To Restart Contact PA
SAFETY STANDBY IS REQUIRED FOR ALL CONFINED SPACE WORK
VALID FROM (Date/Time): VALID TO:
PLANT
REVISED VALIDITY , FROM(Date/Time): VALID TO:
PTW NO.
2nd REVISED VALIDITY , FROM (Date/Time): VALID TO:
MO NO.
1. CONFINED SPACE ENTRY WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Brief Job Description:
TYPE OF CREW Alternate Entry: Communication Type: Test Instrument Sr. No.
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. CONFINED SPACE WORK CHECK LIST (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. LOTO requirement completed: . Check after Isolation & Ventilation: Time - % Time-% Time-% Limit
. De-energization requirement completed .Oxygen 19.50%
. Rescue Plan ready .Explosive <10%
. Purge-Flush-Vent requirements completed .Toxic <10ppm
. Ventilation requirement completed .Combustible gas 10%
. Secure area (post and flag) .CO <25 ppm
. Lighting exlosive proof .Others
. Others (state):
3. SAFETY PRECAUTIONS NA: Not Applied
YES NO NA(Not Applied) YES NO YES NO NA
. Fire extingusher . Full body harness .Atmospheric testing during work
. Supplied air respirator . Using Retractable lanyard : . Ist
. Respirators (air purifiers) . Seat belt type . 2nd
. Protecting Clothing . Cable type with winch . 3rd
. Emergency scape retrieval equipment . Cable type . 4th
. Life lines . Other . 5th
. Purging with inert gas/air . Hoisting Equipment Stand by persons:
. Resuscitator Inhalator . Warning notices .Name:
Others (state): .Name:
.Name:
.Name:
4. PERSONNEL PROTECTION Required Tools:
YES NO YES NO YES NO YES NO 1
. Head . Ears Escape Set Harness 2
. Face . Hands SCBA Life Jacket 3
. Eyes . Feet Coverall Elsting Hood 4
. Body . Breathing Leather Apron Rubber Boots 5
State Special Requirements : 5
6
3. APPROVAL & ACCEPTANCE:
. Permit User: I agreed to work within the conditions indicated on this permit and accept the responsibility. I checked that the confined space entry is safe .
following the completion of work. as detailed in Section 1.
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
. Permit Acceptor: I herby declare that the persons identified on this permit are competent and authorize to enter the confined space & all safety measures are taken.
conditions of this permit.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this work & allow to proceed.
PI Name: Signature Date Time:
8. PERMIT CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permithas been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Area Authority: I hereby certify that all the tasks as mentioned in para 1 has been checked & plant is ready for testing/recommissioning.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this permit.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-005
Y N S P R V

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 29 of 59

GROUND DISTURBANCE PERMIT GDP-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this permit. To Restart Contact PA
ATTACH A SKETCH OR DRAWING WITH THIS PERMIT
VALID FROM (Date/Time): VALID TO:
PLANT
REVISED VALIDITY , FROM(Date/Time): VALID TO:
PTW NO.
2nd REVISED VALIDITY , FROM (Date/Time): VALID TO:
MO NO.
1. GROUND DISTURBANCE WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Location:
EXCAVATION WORK DETAILS: Start End Duration No. of Workers RA Done/Ref
EXCAVATION PURPOSE:

Sub Contractor: Estimated volume of Excavated material, m3:
MAX. DIMENSIONS: LENGTH: WIDTH: DEPTH:
. Protective System submitted: . AS-buit updare required
TYPE OF CREW Soil reuse for backfill . Excavation competent person
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. GROUND DISTURBANCE WORK CHECK LIST (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. Depth of excavation > 2 m: . Protective system is planned:
. Person entering .Slopping
. Sub contractor posses a valid permit .Benching
. Depth of excavation > 6 m .Shorting
. Protective system designed by professional Engr. . Soil Compaction testing required :
. Protected System submitted prior to excavation .Nuclear guage method
. Soil compaction required. .Sand cone test method
. Bore is near a housing . Excavation involve a well
. Others: . Excavation involve a soil boring

3. SAFETY PRECAUTIONS
YES NO NA(Not Applied) YES NO YES NO NA
. Fire extingusher . Full body harness .Is the excavation within 7 lateral m
. Supplied air respirator . Excavation is within controlled area: of an under ground beam line housing.
. Respirators (air purifiers) . Contamination area . 2nd
. Protecting Clothing . Radiation area. . 3rd
. Environment Review:
. Waste classification of excavated material:
. Other requirements:
. Excavated Waste disposal arrangement:
. Utility Drawing review: Electrical Natural Gas Storm Drain Compressed air
Process Piping Telephone Control Cables Others
Groung water well Sewer Electrical Cable Water
4. PERSONNEL PROTECTION Required Tools:
YES NO YES NO YES NO YES NO 1
. Head . Ears Escape Set Harness 2
. Face . Hands SCBA Life Jacket 3
. Eyes . Feet Coverall Elsting Hood 4
. Body . Breathing Leather Apron Rubber Boots 5
State Special Requirements : 5
6
3. APPROVAL & ACCEPTANCE:
. HSE Engineer: I hereby reviewed this permit and work may proceed. the conditions indicated on this permit and accept the responsibility.
Name: Signature Date Time:
. Permit Users: we hereby declare that jwe are competent and authorize to excavate.
PU Name: Signature Date Time:
PU Name: Signature Date Time:
. Permit Acceptor: I herby declare that the persons identified on this permit are competent and authorize to excavate.
conditions of this permit.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this work & allow to proceed.
PI Name: Signature Date Time:
8. PERMIT CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permithas been returned in serviceable condition and the job
site is clear of any hazards associated with this work. .As-built drwaings updated:
Name: Signature Date Time:
. Site Checker: I hereby certify that all the tasks as mentioned in para 1 has been checked & plant is ready for testing/recommissioning.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this permit.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-006
Y
N Y N Y

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 30 of 59


DIVING PERMIT DVP-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this permit. To Restart Contact PA
SAFETY STANDBY IS REQUIRED FOR ALL DIVING WORK
VALID FROM (Date/Time): VALID TO:
PLANT
REVISED VALIDITY , FROM(Date/Time): VALID TO:
PTW NO.
1. DIVING WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Brief description of Diving activity: Start: End Duration Name of Divers RA Done/Ref

TYPE OF CREW Alternate Entry: Communication Type:
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. DIVING CHECK LIST (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. Divers medical Certificate produced . Insurance certificate produced
. Diver's log book produced .HSE Registration Certificate produced
. Rescue Plan ready .Diver's competence certificate produced
. Four Divers minimum per team . Diver's training certificate produced.
. Diving contractor's log book produced .Diver's medical fitness certificate produced
. First aid qualifications produced for atleast 2 divers . Emergency assisstance available
.Additional Isolation certificate required . Stated limit of place.
. Others (state): From:
To:
3. SAFETY PRECAUTIONS NA: Not Applied
YES NO NA(Not Applied) YES NO YES NO NA
. Fire extingusher . Full body harness .Stated limit of time
. Supplied air respirator . Using Retractable lanyard : From:
. Respirators (air purifiers) . Seat belt type To:
4. PERSONNEL PROTECTION Required Tools:
YES NO YES NO YES NO YES NO 1
. Head . Ears Escape Set Harness 2
. Face . Hands SCBA Life Jacket 3
. Eyes . Feet Coverall Elsting Hood 4
. Body . Breathing Leather Apron Rubber Boots 5
State Special Requirements : 5
6
5. TEMPORARY SUSPENSION:
. Permit Acceptor: I declare that all diving operations are ceased & diving team is clear of water.
PU Name: Signature Date Time:
. Permit Issuer: I hereby declare that diving permit is hereby suspended From: To:
PI Name: Signature Date Time:
. Permit Issuer: I hereby declare that diving permit is hereby resumed. From: To:
PI Name: Signature Date Time:
. Permit Acceptor: I declare that all diving operations are ceased & diving team is clear of water.
PU Name: Signature Date Time:
. Permit Issuer: I hereby declare that diving permit is hereby suspended From: To:
PI Name: Signature Date Time:
. Permit Issuer: I hereby declare that diving permit is hereby resumed. From: To:
PI Name: Signature Date Time:
3. APPROVAL & ACCEPTANCE:
. Permit User: I agreed to work within the conditions indicated on this permit and accept the responsibility. I checked that the & found safe .
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
8. PERMIT CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permithas been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Area Authority: I hereby certify that all the tasks as mentioned in para 1 has been checked & plant is ready for testing/recommissioning.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this permit.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-007
Y N S P R V

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 31 of 59

DISJOINTING PERMIT DJP-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this permit. To Restart Contact PA
SAFETY STANDBY IS REQUIRED FOR ALL DIVING WORK
VALID FROM (Date/Time): VALID TO:
PLANT
REVISED VALIDITY , FROM(Date/Time): VALID TO:
PTW NO.
1. DISJOINTING WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Work description: Start End Duration Name of Diver RA Done/Ref

TYPE OF CREW Alternate Entry: Communication Type: Test Instrument Sr. No.
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. DISJOINTING WORK CHECK LIST (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. LOTO requirement completed: . Check after Isolation & Ventilation: Time - % Time-% Time-% Limit
. De-energization requirement completed .Oxygen 19.50%
. Rescue Plan ready .Explosive <10%
. Purge-Flush-Vent requirements completed .Toxic <10ppm
. Ventilation requirement completed .Combustible gas 10%
. Secure area (post and flag) .CO <25 ppm
. Lighting exlosive proof .Others
. Others (state):
3. SAFETY PRECAUTIONS NA: Not Applied
YES NO NA(Not Applied) YES NO YES NO NA
. Fire extingusher . Full body harness .Atmospheric testing during work
. Supplied air respirator . Using Retractable lanyard : . Ist
. Respirators (air purifiers) . Seat belt type . 2nd
. Protecting Clothing . Cable type with winch . 3rd
. Emergency scape retrieval equipment . Cable type . 4th
. Life lines . Other . 5th
. Purging with inert gas/air . Hoisting Equipment Stand by persons:
. Resuscitator Inhalator . Warning notices .Name:
Others (state): .Name:
.Name:
.Name:
4. PERSONNEL PROTECTION Required Tools:
YES NO YES NO YES NO YES NO 1
. Head . Ears Escape Set Harness 2
. Face . Hands SCBA Life Jacket 3
. Eyes . Feet Coverall Elsting Hood 4
. Body . Breathing Leather Apron Rubber Boots 5
State Special Requirements : 5
6
3. APPROVAL & ACCEPTANCE:
. Permit User: I agreed to work within the conditions indicated on this permit and accept the responsibility. I checked that the disjointing is safe .
following the completion of work. as detailed in Section 1.
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
. Permit Acceptor: I herby declare that the persons identified on this permit are competent and authorize to do disjointing work & all safety measures are taken.
conditions of this permit.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this work & allow to proceed.
PI Name: Signature Date Time:
8. PERMIT CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permithas been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Area Authority: I hereby certify that all the tasks as mentioned in para 1 has been checked & plant is ready for testing/recommissioning.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this permit.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-008
Y N S P R V

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 32 of 59

CONTAINMENT BREAK PERMIT CBP-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this permit. To Restart Contact PA
SAFETY STANDBY IS REQUIRED FOR ALL CONTAINMENT BREAKING WORK
VALID FROM (Date/Time): VALID TO:
PLANT
REVISED VALIDITY , FROM(Date/Time): VALID TO:
PTW NO.
1. CONTAINMENT BREAKING WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Work brief description: Start End Duration Name of Diver RA Done/Ref

TYPE OF CREW Alternate Entry: Communication Type: Test Instrument Sr. No.
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. CONTAINMENT BREAKING WORK CHECK LIST (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. LOTO requirement completed: . Check after Isolation & Ventilation: Time - % Time-% Time-% Limit
. De-energization requirement completed .Oxygen 19.50%
. Rescue Plan ready .Explosive <10%
. Purge-Flush-Vent requirements completed .Toxic <10ppm
. Ventilation requirement completed .Combustible gas 10%
. Secure area (post and flag) .CO <25 ppm
. Lighting exlosive proof .Others
. Others (state):
3. SAFETY PRECAUTIONS NA: Not Applied
YES NO NA(Not Applied) YES NO YES NO NA
. Fire extingusher . Full body harness .Atmospheric testing during work
. Supplied air respirator . Using Retractable lanyard : . Ist
. Respirators (air purifiers) . Seat belt type . 2nd
. Protecting Clothing . Cable type with winch . 3rd
. Emergency scape retrieval equipment . Cable type . 4th
. Life lines . Other . 5th
. Purging with inert gas/air . Hoisting Equipment Stand by persons:
. Resuscitator Inhalator . Warning notices .Name:
Others (state): .Name:
.Name:
.Name:
4. PERSONNEL PROTECTION Required Tools:
YES NO YES NO YES NO YES NO 1
. Head . Ears Escape Set Harness 2
. Face . Hands SCBA Life Jacket 3
. Eyes . Feet Coverall Elsting Hood 4
. Body . Breathing Leather Apron Rubber Boots 5
State Special Requirements : 5
6
3. APPROVAL & ACCEPTANCE:
. Permit User: I agreed to work within the conditions indicated on this permit and accept the responsibility. I checked that the containment breaking is safe .
following the completion of work. as detailed in Section 1.
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
PU Name: Signature Date Time:
. Permit Acceptor: I herby declare that the persons identified on this permit are competent and authorize to do disjointing work & all safety measures are taken.
conditions of this permit.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this work & allow to proceed.
PI Name: Signature Date Time:
8. PERMIT CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permithas been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Area Authority: I hereby certify that all the tasks as mentioned in para 1 has been checked & plant is ready for testing/recommissioning.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this permit.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-009
Y N S P R V

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 33 of 59

ISOLATION CERTIFICATE ISC-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this Certificate. To Restart Contact PA.
SWS-ID: SWBS-ID: SRA-ID: SIC-ID:
VALID FROM (Date/Time): VALID TO: PLANT:/MO:
REVISED VALIDITY , FROM(Date/Time): VALID TO: PTW NO.
1. WORK PROPOSAL: ( To be Filled by PO)
SWS:
PURPOSE OF ISOLATION:
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2.ISOLATIONS CHECK LIST BEFORE JOB START (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. Separate Isolation Scheme Required. . Check requird by PI after Isolation & Ventilation:
. Separate Isolation scheme prepared. . More than one person impelenting isolations.
. Isolation scheme span to multiple responsibilities area. . Sequencing of isolation / de-isolation is critical.
. Testing requirements during job. . More than one Isolation certificates for this job.
. Control Loop diagram assessed & annexed .Work pack prepared & annexed.
. Check on overall plant integrity required. .RA done & annexed for Isolation De-isolation activities.
. All the effects of isolation scheme listed and annexed .Initial Isolation is required for final isolation.
. Others (state):
2. PRECAUTIONS NA: Not Applied
YES NO NA(Not Applied) . Loss of Isolation Contingency plan YES NO . Isolation point mistake assessed: YES NO NA
. Potential for human failure assessed . Containment planned .Identification
. Comptency of work centers assessed . Upstream isolation identified .Proving/monitoring
. Check list requird during job: . Safe escape planned .Securing / Maintaining
3. DETERMINATION OF BASE LINE ISOLATION STANDARD Level of Security: (Tag) T
1. Determine Substance Category: Tag+Lock T+L
.Category1 . Very Toxic (T+) . Toxic (T) .Carcinigenic .Mutagenic .Toxic for Reproduction .Sensitising Tag+Lock+Key T+L+K
.Category2 . Extremely flammable(F+) . Flammable(F) .Steam .Asphyxiants .Oxidising .Explosive .Flashing Fluids .Pressurized gas
.Category3 . Corrosive(C) . Harmful (Xn) .Irretant(Xi)
.Category4 . Flammable liquids stored below flash point (R10) . Below flash point following release (R10) Isolation Method Standard
.Category5 . Not Classified . Not Stored in harmful state Spade(S) POSITIVE
2. Determine Release Factor (RF): Line Size Pressure > 50 barg 10 to 50 < 10 barg Single Block Bleed Spade POSITIVE
.Factor H > 20 cm H H M Double Block Bleed Spade POSITIVE
.Factor M 5-20 cm H M L DBB, SB, SBB PROVED
.Factor L <5 cm M L L DB, SB Non-Proved
3. Determine Location Factor (LF):
.Factor H . Human at risk > 10 . Congested equipment .Potential for escalation .Large Fires .Multiple fatalities .Extensive damage
.Factor M . Human at risk 3-10 . Uncongested equipment .Storage area .Minor Fires .Damage
.Factor L . Human at risk 1-2 . Remot single equipment .Easily Contined .Contained minor Fires .Minor Damage
4. Determine Outcome Factor (OF): 5. Determine Base line Isolation Standard: ISOLATION STANDARDS:
.LF / RF H M L OF / Substance Category 1 2 3 4 5 R: Reduce Risk (Further)
H A B B A R R I II II I: Positive Isolation Standard
M B B C B I I II II III II: Proved Isolation Standard
L B C C C I II II II III III: Non-Proved Isolation Standard
4. ISOLATION SCHEME: (For more Isolation points use supplementary Isolation Points sheet)
Isolation Point Isolation Method Isolation. Seq Status 1 Time 1 T / L / K Deisol seq Status 2 Time 2

5. APPROVAL & ACCEPTANCE:
. Isolating Authority: I declare that my name is mentiomned in the competent person's register, authorized to effect Isloations. Isolations are iplemented as per scheme.
Isolations are secured, will be monitored and maintained through out the work.
IA Name: Signature Date Time:
. Permit Acceptor: I herby declare that all the isolation arrangements are adequate & all safety measures are taken.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this certificate & allow to proceed.
PI Name: Signature Date Time:
6. CERTIFICATE CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permit has been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Isolation Authority: I hereby certify that De-isolation has been implementd as per de-isolation plan.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this Certificate.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-010

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 34 of 59

LOGIC ISOLATION CERTIFICATE LIC-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this Certificate. To Restart Contact PA.
THIS CERTIFICATE CAN ONLY BE ISSUED WHEN THERE IS NO REASONABLE PRACTICAL ALTERNATIVE
VALID FROM (Date/Time): VALID TO:
PLANT:/MO:
REVISED VALIDITY , FROM(Date/Time): VALID TO: PTW NO.
1. WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Brief Description of logic requiring isolation Start End Duration Name of Worker RA Done/Ref
1

2

3

4

5

6

PURPOSE OF LOGIC ISOLATION:
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2.LOGIC ISOLATIONS CHECK LIST BEFORE JOB START (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. Isolation Scheme prepared. . Check requird by PI after Isolation & Ventilation:
. Isolation scheme cross checked by PI/PC/PA/PO. . More than one person impelenting isolations.
. Isolation scheme span to multiple responsibilities area. . Sequencing of isolation / de-isolation is critical.
. Testing requirements during job. . More than one Logic Isolation certificates for this job.
. Loop diagram annexed .Work pack prepared & annexed.
. Check on overall logic integrity required. .RA done & annexed for Isolation De-isolation activities.
. All the effects of isolation scheme listed and annexed .Initial logic Isolation is required for finallogic isolation.
. Others (state):
2.LOGIC ISOLATIONS CHECK LIST DURING JOB. (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. Controlling Changes. . Check requird by PI after logic Isolation
.Changes imposed by condition of plant . More than one person impelenting logic isolations.
.Changes imposed by changing scope of work . Sequencing of isolation / de-isolation is critical.
.Changes imposed due to incoplete job. <10ppm
3. PRECAUTIONS
YES NO NA(Not Applied) YES NO YES NO NA
. Potential for human failure assessed . Loss of Isolation Contingency plan . Isolation point mistake assessed:
. Containment planned .Identification
. Upstream isolation identified .Proving/monitoring
. Safe escape planned .Securing / Maintaining
4. ISOLATION POINT LIST: (For more Isolation points use supplementary Isolation Points sheet)
Isolation Point Isolation Method Isol /De seq. Time By T / L / K Status1 Status 2 (After job ) Time 2
1
2
3
4
5
6
7
8
9
10
11
12
3. APPROVAL & ACCEPTANCE:
. Isolating Authority: I declare that my name is mentiomned in the competent person's register, authorized to effect Isloations. Isolations are iplemented as per scheme.
Isolations are secured, will be monitored and maintained through out the work.
IA Name: Signature Date Time:
. Permit Acceptor: I herby declare that all the isolation arrangements are adequate & all safety measures are taken.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this certificate & allow to proceed.
PI Name: Signature Date Time:
8. CERTIFICATE CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permit has been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Isolation Authority: I hereby certify that De-isolation has been implementd as per de-isolation plan.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this Certificate.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-011

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 35 of 59

ACCESS BARRIER ISOLATION CERTIFICATE AIC-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this Certificate. To Restart Contact PA.
THIS CERTIFICATE CAN ONLY BE ISSUED WHEN THERE IS NO REASONABLE PRACTICAL ALTERNATIVE
VALID FROM (Date/Time): VALID TO:
PLANT:/MO:
REVISED VALIDITY , FROM(Date/Time): VALID TO: PTW NO.
1. WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Details of Access Barrier requirement & Job description Start End Duration WC RA Done/Ref
1

2

3

4

5

6

7

8

9

10

PURPOSE OF ACCESS BARRIER ISOLATION:
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. ACCESS BARRIER ISOLATION CHECK LIST (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. AB Isolation Scheme prepared. . Check requird by PI after AB Isolation :
. AB Isolation scheme cross checked by PI/PC/PA/PO. . More than one person impelenting AB isolations.
. AB Isolation scheme span to multiple responsibilities area. . Sequencing of AB isolation / de-isolation is critical.
. Others (state):
3. PRECAUTIONS
YES NO NA(Not Applied) YES NO YES NO NA
. Potential for human failure assessed . Loss of AB Isolation Contingency plan . AB Isolation point mistake assessed:
. Containment planned .Identification
4. ACCESS BARRIER ISOLATION POINT LIST: (For more Isolation points use supplementary Isolation Points sheet)
Access Barrier Isolation Point AB Isolation Method IA PA / PI Time T / L / K Status AB Isolation sequence Drawing Ref
1
2
3
4
5
6
7
8
9
10
11
12
5. APPROVAL & ACCEPTANCE:
. Isolating Authority: I declare that my name is mentiomned in the competent person's register, authorized to effect AB Isloations. AB Isolations are iplemented as scheme.
Isolations are secured, will be monitored and maintained through out the work.
IA Name: Signature Date Time:
. Permit Acceptor: I herby declare that all the isolation arrangements are adequate & all safety measures are taken.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this certificate & allow to proceed.
PI Name: Signature Date Time:
6. CERTIFICATE CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permit has been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Isolation Authority: I hereby certify that De-isolation has been implementd as per de-isolation plan.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this Certificate.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-012

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 36 of 59

HIGH VOLTAGE ENVIRONMENT ISOLATION CERTIFICATE HVC-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this Certificate. To Restart Contact PA.
THIS CERTIFICATE CAN ONLY BE ISSUED WHEN THERE IS NO REASONABLE PRACTICAL ALTERNATIVE
VALID FROM (Date/Time): VALID TO:
PLANT:/MO:
REVISED VALIDITY , FROM(Date/Time): VALID TO: PTW NO.
1. WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Brief Description of Work requiring HV environment isolation: Start End Duration Name of Worker RA Done/Ref
1

2

3

4

5

6

7

8

9

10

PURPOSE OF HV ISOLATION:
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. HV ENVIRONMENT ISOLATIONS CHECK LIST BEFORE JOB START (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. HV Isolation Scheme prepared. . Check requird by PI after HV Isolation :
. HV Isolation scheme cross checked by PI/PC/PA/PO. . More than one person impelenting HV isolations.
. HV Isolation scheme span to multiple responsibilities area. . Sequencing of HV isolation / de-isolation is critical.
. Testing requirements during job. . More than one HV Isolation certificates for this job.
. Loop diagram annexed .Work pack prepared & annexed.
. Check on overall Plant integrity required. .RA done & annexed for HV Isolation De-isolation activities.
. All the effects of HV isolation scheme listed and annexed .Initial HV Isolation is required for final HVisolation.
. Others (state):
3. PRECAUTIONS
YES NO NA(Not Applied) YES NO YES NO NA
. Potential for human failure assessed . Loss of HV Isolation Contingency plan . HV Isolation point mistake assessed:
. Containment planned .Identification
. Upstream isolation identified .Proving/monitoring
. Safe escape planned .Securing / Maintaining
4. HV ISOLATION POINT LIST: (For more Isolation points use supplementary Isolation Points sheet)
Isolation Point Isolation Method IA PA / PI Time T / L / K Status Isolation sequence Drawing Ref
1
2
3
4
5
6
7
8
9
10
11
12
3. APPROVAL & ACCEPTANCE:
. Isolating Authority: I declare that my name is mentiomned in the competent person's register, authorized to effect Isloations. Isolations are iplemented as per scheme.
Isolations are secured, will be monitored and maintained through out the work.
IA Name: Signature Date Time:
. Permit Acceptor: I herby declare that all the isolation arrangements are adequate & all safety measures are taken.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this certificate & allow to proceed.
PI Name: Signature Date Time:
8. CERTIFICATE CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permit has been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Isolation Authority: I hereby certify that De-isolation has been implementd as per de-isolation plan.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this Certificate.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-013

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 37 of 59

PD CONTAMINATION ISOLATION CERTIFICATE PDC-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this Certificate. To Restart Contact PA.
THIS CERTIFICATE CAN ONLY BE ISSUED WHEN THERE IS NO REASONABLE PRACTICAL ALTERNATIVE
VALID FROM (Date/Time): VALID TO:
PLANT:/MO:
REVISED VALIDITY , FROM(Date/Time): VALID TO: PTW NO.
1. WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Brief description of job requiring PD containment Start End Duration Name of Worker RA Done/Ref
1

2

3

4

5

6

7

8

9

10

PURPOSE OF PD CONTAMINATION ISOLATION:
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. PD CONTAMINATION ISOLATION CHECK LIST BEFORE JOB START (To be Checked by PO, PI)
YES NO NA(Not Applied) YES NO NA
. PD Isolation Scheme prepared. . Check requird by PI after HV Isolation :
. PD Isolation scheme cross checked by PI/PC/PA/PO. . More than one person impelenting HV isolations.
. PD Isolation scheme span to multiple responsibilities area. . Sequencing of HV isolation / de-isolation is critical.
. Others (state):
3. PRECAUTIONS
YES NO NA(Not Applied) YES NO YES NO NA
. Potential for human failure assessed . Loss of PD Isolation Contingency plan . PD Isolation point mistake assessed:
. Containment planned .Identification
4. PD CONTAMINATION ISOLATION POINT LIST: (For more Isolation points use supplementary Isolation Points sheet)
Isolation Point Isolation Method IA PA / PI Time T / L / K Status Isolation sequence Drawing Ref
1
2
3
4
5
6
7
8
9
10
11
12
3. APPROVAL & ACCEPTANCE:
. Isolating Authority: I declare that my name is mentiomned in the competent person's register, authorized to effect PD Isloations. PD Isolations are iplemented as scheme.
Isolations are secured, will be monitored and maintained through out the work.
IA Name: Signature Date Time:
. Permit Acceptor: I herby declare that all the isolation arrangements are adequate & all safety measures are taken.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this certificate & allow to proceed.
PI Name: Signature Date Time:
8. CERTIFICATE CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permit has been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Isolation Authority: I hereby certify that De-isolation has been implementd as per de-isolation plan.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this Certificate.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-014

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 38 of 59

ALLOWED TO TEST CERTIFICATE ATC-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this Certificate. To Restart Contact PA.
THIS CERTIFICATE CAN ONLY BE ISSUED WHEN THERE IS NO REASONABLE PRACTICAL ALTERNATIVE
VALID FROM (Date/Time): VALID TO:
PLANT:/MO:
REVISED VALIDITY , FROM(Date/Time): VALID TO: PTW NO.
1. WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Brief description of jobs requiring test Start End Duration Name of Worker RA Done/Ref
1

2

3

4

5

6

7

8

9

10

PURPOSE OF TEST:
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
SANCTION TO TEST Check list
YES NO NA(Not Applied) YES NO NA
. Test Scheme prepared. . Check requird by PI after Testing :
. Test scheme cross checked by PI/PC/PA/PO. . More than one person impelenting TEST scheme.
. Test scheme span to multiple responsibilities area. . Sequencing of TEST is critical.
. Others (state):
3. PRECAUTIONS
YES NO NA(Not Applied) YES NO YES NO NA
. Potential for human failure assessed .Contingency plan . TESTING point mistake assessed:
. Containment planned .Identification
4. TEST / TEST POINT LIST: (For more Isolation points use supplementary Isolation Points sheet)
Test / Test points Testing Method IA PA / PI Time T / L / K Status Testing sequence Drawing Ref
1
2
3
4
5
6
7
8
9
10
11
12
5. APPROVAL & ACCEPTANCE:
. Isolating Authority: I declare that my name is mentiomned in the competent person's register, authorized to sanction testings.
IA Name: Signature Date Time:
. Permit Acceptor: I herby declare that all the isolation arrangements are adequate & all safety measures are taken.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this certificate & allow to proceed.
PI Name: Signature Date Time:
6. CERTIFICATE CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permit has been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Isolation Authority: I hereby certify that De-isolation has been implementd as per de-isolation plan.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this Certificate.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-015

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 39 of 59

TEST CERTIFICATE TTC-0000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this Certificate. To Restart Contact PA.
THIS CERTIFICATE CAN ONLY BE ISSUED WHEN TEST DEVICES ARE APPROVED
VALID FROM (Date/Time): VALID TO:
PLANT:/MO:
REVISED VALIDITY , FROM(Date/Time): VALID TO: PTW NO.
1. WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Brief Description of Jobs requiring tests Start End Duration Name of Worker RA Done/Ref
1

2

3

4

5

6

7

8

9

10

PURPOSE OF TEST:
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
SANCTION TO TEST Check list
YES NO NA(Not Applied) YES NO NA
. Test Scheme prepared. . Check requird by PI after Testing :
. Test scheme cross checked by PI/PC/PA/PO. . More than one person impelenting TEST scheme.
. Test scheme span to multiple responsibilities area. . Sequencing of TEST is critical.
. Others (state):
3. PRECAUTIONS
YES NO NA(Not Applied) YES NO YES NO NA
. Potential for human failure assessed .Contingency plan . TESTING point mistake assessed:
. Containment planned .Identification
4. TEST / TEST POINT LIST: (For more Isolation points use supplementary Isolation Points sheet)
Test / Test points Testing Method IA PA / PI Time T / L / K Status Test Result Drawing Ref
1
2
3
4
5
6
7
8
9
10
11
12
5. APPROVAL & ACCEPTANCE:
. Isolating Authority: I declare that my name is mentiomned in the competent person's register, authorized to sanction testings.
IA Name: Signature Date Time:
. Permit Acceptor: I herby declare that all the isolation arrangements are adequate & all safety measures are taken.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this certificate & allow to proceed.
PI Name: Signature Date Time:
6. CERTIFICATE CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permit has been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Isolation Authority: I hereby certify that De-isolation has been implementd as per de-isolation plan.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this Certificate.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-016

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 40 of 59

Interaction Certificate:
PTW Ref: NC/PTW/SP-001/FM-001/
NC/PTW/SP-001/FM-017 Ref.No: NC/PTW/SP-001/FM-017/ PI-Name: Date:
Sr. Interacting Jobs
Nature
(PTWS/Opr
/Other)
LOTO Reqd. Start Time End Time Ref. PO
Permits
/Crtificates
Common
Isolation
(Y/N)
Responsible Controlling Scheme
1
2
3
4
5
I hereby Certi fy that al l I nteracti on acti vi ti es are known, veri fi ed, control scheme prepared & appl i ed.
PI-Signature:
NC/PTW/SP-003/FM-001, Ref:
NC/PTW/SP-003/FM-002, Ref:

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 41 of 59

MACHINERY CERTIFICATE MCC-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this Certificate. To Restart Contact PA.
THIS CERTIFICATE CAN ONLY BE ISSUED TO WORK ON A LARGE & COMPLEX ITEMS OF MACHINERY
VALID FROM (Date/Time): VALID TO:
PLANT:/MO:
REVISED VALIDITY , FROM(Date/Time): VALID TO: PTW NO.
1. WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Brief Description of Jobs requiring workon Heavy Machinery Start End Duration Name of Worker RA Done/Ref
1

2

3

4

5

6

7

8

9

10

PURPOSE OF WORK:
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. MACHINERY CERTIFICATE Check list
YES NO NA(Not Applied) YES NO NA
. Isolation Scheme prepared. . Check requird by PI after IsolationsTesting :
. Isolation scheme cross checked by PI/PC/PA/PO. . More than one person impelenting Isolation scheme.
. Isolation scheme span to multiple responsibilities area. . Sequencing of Isolation / De-Isolation is critical.
. Others (state):
3. PRECAUTIONS
YES NO NA(Not Applied) YES NO YES NO NA
. Potential for human failure assessed .Contingency plan . Isolation point mistake assessed:
. Containment planned .Identification
4. MACHINERY ISOLATION POINT LIST: (For more Isolation points use supplementary Isolation Points sheet)
Machinery Isolation points Isolation Method IA PA / PI Time T / L / K Status Isolation sequence Drawing Ref
1
2
3
4
5
6
7
8
9
10
11
12
5. APPROVAL & ACCEPTANCE:
. Isolating Authority: I declare that my name is mentiomned in the competent person's register, authorized to Implement Isolation / De-Isolation of very larg MAchinery.
IA Name: Signature Date Time:
. Permit Acceptor: I herby declare that all the isolation arrangements are adequate & all safety measures are taken.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this certificate & allow to proceed.
PI Name: Signature Date Time:
6. CERTIFICATE CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permit has been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Isolation Authority: I hereby certify that De-isolation has been implementd as per de-isolation plan.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this Certificate.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-018

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 42 of 59

RADIATION CERTIFICATE RDC-000000
Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this Certificate. To Restart Contact PA.
THIS CERTIFICATE CAN ONLY BE ISSUED TO AVOID EXPOSURE TO RAIDIATION
VALID FROM (Date/Time): VALID TO:
PLANT:/MO:
REVISED VALIDITY , FROM(Date/Time): VALID TO: PTW NO.
1. WORK PROPOSAL: ( To be Filled by PO)
Plant / Unit : Functional Location: Equipment:
Brief desription of job being planned in the radiation area Start End Duration Name of Worker RA Done/Ref
1

2

3

4

5

6

7

8

9

10

PURPOSE OF WORK:
. Permit Originator: Above Location and task has been examined & Check list in section 2 & precautions in section 3 are completed to the best of my knowledge.
Name: Signature Date Time:
2. RADIATION CERTIFICATE Check list
YES NO NA(Not Applied) YES NO NA
. Site Inspection done. . Check requird by PI after IsolationsTesting :
. Isolation scheme cross checked by PI/PC/PA/PO. . More than one person impelenting Isolation scheme.
. Isolation scheme span to multiple responsibilities area. . Sequencing of Isolation / De-Isolation is critical.
. Others (state):
3. PRECAUTIONS
YES NO NA(Not Applied) YES NO YES NO NA
. Potential for human failure assessed .Contingency plan . Isolation point mistake assessed:
. Containment planned .Identification
4. RADIATION POINT LIST: (For more Isolation points use supplementary Isolation Points sheet)
Radiation points Isolation Method IA PA / PI Time T / L / K Status Remarks Drawing Ref
1
2
3
4
5
6
7
8
9
10
11
12
5. APPROVAL & ACCEPTANCE:
. Isolating Authority: I declare that my name is mentiomned in the competent person's register, authorized to Issue Radiation Certificate.
IA Name: Signature Date Time:
. Permit Acceptor: I herby declare that all the isolation arrangements are adequate & all safety measures are taken.
PC Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with all the arrangements of this certificate & allow to proceed.
PI Name: Signature Date Time:
6. CERTIFICATE CLOSURE & CANCELLATION
. Permit Acceptor: All work associated with this permit is completed . All equipments associated with this permit has been returned in serviceable condition and the job
site is clear of any hazards associated with this work.
Name: Signature Date Time:
. Isolation Authority: I hereby certify that De-isolation has been implementd as per de-isolation plan.
Name: Signature Date Time:
. Permit Issuer: I hereby declare that I am satisfied with completion requirements & cancel this Certificate.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-019

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 43 of 59

PTW SYSTEM; STANDARD WORK STATEMENT
NC/PTW/SP-001/FM-020
VALIDITY: 12 months Or Plant modification date (Whichever happens first) PLANT:
1. PTWS FOUNDATION CHECK LIST: ( To be Filled by PGM)
Sr. Authority Designation Ref. Abbreviations:
1 Responsibility to develop SWS (Standard Work Statement). OM FM-028 WBS-ID: Work Break down Strucrure ID Q: SQIWPP A: Access
2 Responsibility to develop WBS (Work Breakdown Structure) for SWS. MM FM-029 SRA-ID: Standrad Risk Analysis ID E: SIWEP B: Permit
3 Responsibility to develop Standard IC(Isolation Certificate) for SWS. OM FM-010 SIC-ID: Standard Isolation Certificate ID S: SIWPP C: Permit+WP
4 Responsibility to Conduct RA for SWS. MM-HO FM-010 SIC-ID: Standard Isolation Certificate ID B: BARGES D: Unknown
5 Responsibility to develop Standard Tool Box Talk for SWS. MM-HO FM-032 SWP-ID: Standard Work Pack ID R: IPPR
. PM/PGM: I hereby certify that above mentioned senior managers are competent & authrized to develop Master data for PTWS. AC: Activity Category. (A; B; C; D)-P:Preventive, N:Non-prev.
Name: Signature Date Maint Section: Lead Section to be placed first.
2. SWS ( Standard Work Statement):
ID. SWS (Standard Work Statement) WBS ID Maint.
Section
SRA ID SIC ID STB ID AC SWP ID
MM-EM-IC
NOMAC PTW System NC/PTW/SP-001/FM-020

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 44 of 59

PTW SYSTEM; WORK CENTERS
NC/PTW/SP-001/FM-021
VALIDITY: 12 months Or Change management date (Whichever happens first) PLANT:
1. PTWS FOUNDATION CHECK LIST: ( To be Filled by PGM)
Authority Designation Ref. Abbreviations:
Responsibility to develop SWS (Standard Work Statement). OM FM-021 WBS-ID: Work Break down Strucrure ID P:Preventive,
Responsibility to develop WBS (Work Breakdown Structure) for SWS. MM FM-028 SRA-ID: Standrad Risk Analysis ID N:Non-prev.
Responsibility to develop Standard IC(Isolation Certificate) for SWS. OM FM-010 SIC-ID: Standard Isolation Certificate ID CC:Completion-
Responsibility to Conduct RA for SWS. MM-HO FM-027 SWP-ID: Standard Work Pack ID Conf irmation
. PM/PGM: I hereby certify that above mentioned senior managers are competent & authrized to develop Master data for PTWS. AC: Activity Category. (A; B; C; D)-P:Preventive
Name: Signature Date Maint Section: Lead Section to be placed first.
2. SWBS ( Standard Work Break Down Structure):
WC-ID
Plant
Section
Sub-
Section
WC Description
Week
hrs
Daily
Hrs
WC-Type EMP-ID
Compet
ency/McI
d
Expert
ise/K
H
Rate/
hr
OT/
hr
Reports to

KnowHow Rating: E: Expert P: Prof essional N: Novice T: Trainee
Experience Category: H: Highly Experienced E: Experienced >5Y L: Little Experience <5 Y
Competency Level:
C-1: Welding Certif icate C-7: Working Safely Certificate C-13: Internal Audit Certificate C-19: Graduate Engineer
C-2: FF Certif icate C-8: Managing Safely Certificate C-14: Lead Auditor Certificate C-20: Diploma of Associate Engineer
C-3: Heavy Driving Certif icate C-9: BLS Certificate C-15: Corrosion Certificate C-21: Working Safely Certificate
C-4: Fork lif t driving certif icate C-10: H&S Certificate C-16: Working Safely Certificate C-22: Working Safely Certificate
C-5: Crane operator Certif icate C-11: SAP Certificate C-17: Working Safely Certificate C-23: Working Safely Certificate
C-6: Vibration Analysis Certif icate C-12: Defensive Driving Certificate C-18: Working Safely Certificate C-24: Working Safely Certificate
NOMAC PTW System NC/PTW/SP-001/FM-021 WC Types: Man; Group; Machine

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 45 of 59


PTW SYSTEM; STANDARD WBS
NC/PTW/SP-001/FM-022
VALIDITY: 12 months Or Plant modification date (Whichever happens first) PLANT:
1. PTWS FOUNDATION CHECK LIST: ( To be Filled by PGM)
Authority Designation Ref. Abbreviations:
Responsibility to assign WC. MM FM-021 WBS-ID: Work Break down Strucrure ID
Responsibility to develop WBS (Work Breakdown Structure) for SWS. MM FM-020 SWS-ID: Standrad Work Statement ID
Responsibility to develop Standard IC(Isolation Certificate) for SWS. OM FM-010 WC: Work Centers , Man,Machine,Group CC:Completion-
Responsibility to Conduct RA for SWS. MM-HO FM-025 Conf irmation
. PM/PGM: I hereby certify that above mentioned senior managers are competent & authrized to develop Master data for PTWS.
Name: Signature Date Maint Section: Lead Section to be placed first.
2. SWBS ( Standard Work Break Down Structure):
SWS ID. WBS-ID
WBS-
Element-ID
WBS Element Description WC WC WC. WC
Maint.
Section
Dur.
hrs
Lead WC WC CC WC
MM-EM-IC
NOMAC PTW System NC/PTW/SP-001/FM-022

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 46 of 59

PTW SYSTEM; STANDARD TOOL BOX TALK
NC/PTW/SP-001/FM-023
VALIDITY: 12 months Or Plant modification date (Whichever happens first) PLANT:
1. PTWS FOUNDATION CHECK LIST: ( To be Filled by PGM)
Authority Designation Ref.
Responsibility to deveolp TBT for each Standard permit controlled Operation Job . OM SWS-ID:
Responsibility to deveolp TBT for each Standard permit controlled Maint. Job . MM SRA-ID:
Responsibility to deveolp TBT for each Standard permit controlled other Job . OM SIC-ID:
Responsibility to Conduct RA for SWS. MM-HO SWBS-ID:
. PM/PGM: I hereby certify that above mentioned senior managers are competent & authrized to develop Master data for PTWS.
Name: Signature Date
2. Tool Box Talk Mandatory Topics:
Sr. Topic Discussion
NOMAC PTW System NC/PTW/SP-001/FM-023

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 47 of 59

PTWS HAZARD CONTROL SHEET
NC/PTW/SP-001/FM-024
HG-
ID
Harzard
Group
Hazard_ID Hazard Control ID Control
1
Work Area
Related
Hazards
10 Potential oxygen deficiency
61
62
63
64
11 Potential flammable, exposive atmosphre
65
66
67
12 Potential high temperature / Pressure
68
69
70
13 Confined space entry
71
72
73
14 Elevated work
74
75
76
15
Area or line or equipment containing hazardous
conditions
77
78
79
31 Exposure to traffic
125
126
127
32 Exposure to moving / rotating machinery
128
129
130
33 Lack of fimiliarity with location
131
132
34 Slips or trips
21 Make arrangements to periodically clean floor
22 Trip hazard to be removed physically
23 Trip hazard to be marked or bridged
24 Good house keeping all the time
133
134
135
35 Poor lighting
10
Temporary lighting to ne provided at work
place
11
Temporary lighting to ne provided at escape
route
136
137
138
36 Adjacent operation
139
140
141
37 Hot or cold surface
142
143
144
38 Dropped objects
145
146
147

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 48 of 59
39 Obstackle at work site
148
149
150
40 Poor communication
151
152
153
41 Lone working
154
155
156
42 Extreme working conditions
157
158
159
43 Radiations
160
161
162
47 Long Working
172
173
174
56 Poor access
12 Ensure good house keeping
13 Clear access and scape routes
14 Erect barriers , signs & screens
199
200
201
65 Laser
226
227
228
78 High noise level
265
266
267
85 Negative biouncy
287
288
289
102 Electrocution
15
Make insulation material available for workers
to stand upon
16 Related Equipments to be isolated and earthed
17
All non certified electrical tools and equipments
to be tagged
18 Make portable fire extinusher available
338
339
340
2
Equipment
being
worked on,
related
Hazards
1 Lack of Equipment fimiliarity
25
26
27
28
2 Pressurized System
29
30
31
32
3 Presence of Static Charge
33
34
35
36

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 49 of 59
4 Presence of PD
37
38
39
40
5 Electrical hazard
41
42
43
44
6 Moving Machinery
1 Mechanically Isolate Equipment
2 Electrically Isolate Equipment
3 Apply Earthing to Equipment
4 Isolate System
5 Depressurize System
6 Erect Barriers
7 Place Sign
8 To be viewed when started
9 To be Isolated when unattended
45
46
47
48
7 Hot surface
49
50
51
52
8 Cold surface
53
54
55
56
9 Stored Energy
57
58
59
60
57 Inadvertant motion
202
203
204
58 Impact
205
206
207
59 Fragments
208
209
210
61 Mechanical
214
215
216
63 Vibration
220
221
222
66 Laser
229
230
231
87 Container rupture
293
294
295
94 Inadequate design
314
315
316
95 Sharp edges
317

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 50 of 59
318
319
3
Exposure to
surface or
material
related
Hazards
16
Area or line or equipment containing hazardous
conditions
80
81
82
17 Potential flammable, exposive atmosphre
83
84
85
18
Area or line or equipment containing hazardous
chemicals (toxic, reactive )
86
87
88
19
Area or line or equipment containing hazardous
substances
89
90
91
60 Fragments
211
212
213
67 Using Flammable substance
232
233
234
103 Using hazardous substance
19 Not be used within 1m of hot surface
20 Substance to be stored seperately
341
342
343
4
Tools or
Equipments
being used,
related
Hazards
20 Use of mobile cranes
92
93
94
21 Use of fork lifts
95
96
97
22 Use of adopters
98
99
100
62 Mechanical
217
218
219
64 Vibration
223
224
225
68 Non certified electrical tools
235
236
237
91 Compressed air tools
305
306
307

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 51 of 59
5
Task
specific
Hazards
23 Job performed by contractor / temporary staff
101
102
103
24 By passing or removing or altering safety devices
104
105
106
25
Introduction of ignition source where not permanently
allowed
107
108
109
26 Repair on live circuit
110
111
112
27 Electrical trouble shooting
113
114
115
28 Manual or powered excavation
116
117
118
29 Insulation handling
119
120
121
30 Catalyst handling
122
123
124
55 Product conversion in vessel
196
197
198
69 Little know how
238
239
240
6
Personnel
related
hazard
44 Lack of familiarity
163
164
165
45 Lack of extpertise
166
167
168
46 Lone Working
169
170
171
48 Long working
175
176
177
49 Competency
178
179
180
50 Fear
181
182
183
70 Lack of fitness
241

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 52 of 59
242
243
7
Control
documents
deficiency
related
hazards
51 Lack of drawings
184
185
186
52 Lack of work instructions
187
188
189
53 Lack of procedures
190
191
192
54 Permits
193
194
195
71 Lack of technical data
244
245
246
8
Loss or
impairement
of safety
system
related
hazards
72 Loss of FF system
247
248
249
9 Others
73 Involve transfer of work
250
251
252
74 Contamination
253
254
255
75 Lubricity
256
257
258
76 Violent odor
259
260
261
77 Structural failure
262
263
264
79 High intensity visible light
268
269
270
80 Infrared radiation
271
272
273
274
81 Microwave radiation
275
276
277
82 Laser
278

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 53 of 59
279
280
83 Corrosive
281
282
283
84 Negative pressure effect
284
285
286
86 Pressure differential
290
291
292
88 Hydraulic hammer
296
297
298
89 Blown objects
299
300
301
90 Accidental release
302
303
304
92 Stored energy (Spring, weight, flywheel etc)
308
309
310
93 Weight to be lifted
311
312
313
96 Thermal stress
320
321
322
97 Thermal limits unknown
323
324
325
98 Source of non electrical heat
326
327
328
99 Presence of fuel (any kind)
329
330
331
100 Electrical storage (capcitors, coils, magnets etc)
332
333
334
101 Batteries
335
336
337
10
Weather
related
hazards









Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 54 of 59


TASK RISK ANALYSIS TRA000000
SWS-ID: SWBS-ID: SRA-ID:
RA Team: 1 3 5
(Name with WC No.) 2 4 6
Activity Reference: Previous RA Available RA No.: Date:
Valid From: MO NO.
Valid To: Base Document Ref:
1. WORK ACTIVITY F.L: Equipment:
Maintenance Order activities: Duration(h) Work Center No. / ID RA Done/Ref

Supplimentary Work Activity Sheet Required Permit Originator (PO): Name & Signature & Date:
2. ADDITIONAL PERMITS / CERTIFICATES
Permits Permit No. YES NO Certifcates Certificate No. YES NO
. Hot Work Permit . Isolation Certificate.
. Confined Space Entry Permit . Logic Isolation Certificate.
.Confined Space Working Permit . Access Barrier Isolation Certificate.
. Working at Height Permit . HV Environment Isolation Certificate.
. Ground Disturbance Permit . PD Containment Isolation Certificate.
. Diving Permit . Allowed to test Certificate.
. Disjoint Permit. . Test Certificate.
. Containment Break Permit. . Interaction Certificate.
. LOTO Required:. . Machinery Certificate.
. Radiation Certificate.
2. POTENTIAL HAZARDS & HAZARDOUS JOBS
YES NO YES NO
. Jobs performed by contractors or temporary workers . Maintenance or repairs in areas, or to equipment or lines,
. Potential oxygen deficiency or enrichment containing or supposed to contain hazardous materials or conditions
. Potential flammable / explosive atmosphere . Manual or powered excavations
. Potential high temperature / pressure . Use of mobile cranes
. Potential exposure to hazardous chemicals (toxic, reactive, . Insulation or catalyst handling
acid, caustic….) . Use of adapters
. Confined space entry . Product conversion of stationary or mobile or portable vessels
. Bypassing or removing/altering safety devices and equipment and containers
. Elevated work . Temporary or permanent changes, alterations, modifications of
. Introduction of ignition sources where not permanently equipment or processes
allowed (fire permit) . Exposure to traffic (road, mail)
. Electrical troubleshooting or repair on live circuits . Exposure to moving / rotating machinery
. Others (state):
3. SAFETY PRECAUTIONS
YES NO YES NO YES NO
. Draining . Remove hazardous materials . Standby man
. Depressurising . Fresh air ventilation . Elevated work
. Physical Isolation . Atmosphere analysis : . Contractors trained
. Electrical Isolation . Oxygen . Eliminate ignition sources
. Safety tags and locks . Flammable . Fire hose
. Flushing with water/solvent . Toxic . Fire screen
. Steaming out . Other . Wet surrounding area
. Purging with inert gas/air . Area marked off . Audible/visible warnings
. Temperature normalisation . Warning notices . Clear area of combustibles
Others (state): . Fire extinguishers
Type :
Type :
4. PERSONNEL PROTECTION Required Tools:
YES NO YES NO YES NO YES NO 1
. Head . Ears Escape Set Harness 2
. Face . Hands SCBA Life Jacket 3
. Eyes . Feet Coverall Elsting Hood 4
. Body . Breathing Leather Apron Rubber Boots 5
State Special Requirements : 6
7
5. CONTROL MEASURES ( Use Standard Hazards and Controls Sheet NC/PTW/SP-001/FM-024)
HazardGroup-Hazard-Control HazardGroup-Hazard-Control HazardGroup-Hazard-Control Evaluated Initial Risk before applying controls:
Severity/LiklyhoodA B C D E
1
2
3
4
5
Evaluated Final Risk after applying controls:
Severity/LiklyhoodA B C D E
1
2
3
4
Initial Risk (L/M/H): Final Risk (L/M/H): 5
RA Team: This certifies that we have consulted all relevant departments/personnel, discussed the scope of work, inspected the preparatory work,
,the work area covered by this RA, listed all possible hazards and suggested controls to reduce the risk ALARP. we therefore confirm that the work,
as detailed in Section 1, can be carried out provided all the control measures as mentioned in section 5 are taken & verified.
Name : Signature : Name : Signature :
Name : Signature : Name : Signature :
Name : Signature : Name: Signature :
Activity Category Declared as: A:Access Controlled; B:Permit Controlled; C:Permit with Work Pack.
NOMAC PTW System NC/PTW/SP-001/FM-025
Y N
Y N
B C A

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 55 of 59

PTW SYSTEM IMPLEMENTATION CERTIFICATE
NC/PTW/SP-001/FM-026
VALID FROM (Date/Time): VALID TO:
PLANT:
1. PTWS FOUNDATION CHECK LIST: ( To be Filled by PGM)
Sr. Task Site Role Date Name of Resource Done
1 Responsibility to train PTWS Users given.
2 CAC (Competence and Authorizing Committee) formed
3 Authority to arrange resources given
4 Responsibility to Monitor PTWS given
5 PTW Roles assigned & certificates issued
2. PTWS PROCEDURES Check list:
Sr. Procedure Ref. Date Name of Resource Done
1 PTW System Procedure

2 Isolation Procedure

3 Permits Interaction Procedure

4 Job hand over procedure

5 Job hand back procedure

6 Job suspension and restart procedure

7 Supervision procedure

8 Audit procedure

9 Review Procedure

10 Scope of work change procedure

11 LOTO procedure

12 PTW display procedure

13 Extended Isolations procedure

3. PTWS PERMITS AND CERTIFICATES IMPLEMENTATION CHECK LIST:
Sr. Permits / Certificates Ref. Date Name of Resource Done
1 PTW
2 Working at height Permit
3 Hot work permit
4 Confined Space entry permit
5 Confined space working permit
6 Ground Disturbance permit
7 Diving Permit
8 Disjoint permit
9 Containment Break permit
10 Isolation Certificate
11 Logic Isolation Certificate
12 Access Barrier Isolation Certificate
13 HV environment isolation certificate
14 PD containment Isolation Certificate
15 Allowed to test certificate
16 Test Certificate
17 Interaction Certificate
18 Machinery Certificate
19 Radiation Certificate
4. CERTIFICATE
. PM/PGM: All work associated PTWS is completed . I hereby certify that PTWS is implemented.
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-026

Permit to Work System Procedure

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 56 of 59

PTW SYSTEM; RESOURCING
NC/PTW/SP-001/FM-027
VALID FROM (Date/Time): VALID TO:
PLANT:
1. PTWS FOUNDATION CHECK LIST: ( To be Filled by PGM)
Sr. Authority Designation Ref. Date Name of Resource Done
1 Responsibility to train PTWS Users given. OM
2 Responsibility to Resource PTWS Users given. OM
3 Responsibility to Resource PTWS Users given. MM
. PM/PGM: I hereby certify that above mentioned senior managers are authrized to resouce PTWS.
Name: Signature Date Time:
2. PTWS AUTHRIZED USERS:
Sr. Role Site Role Name Desig. Emp. No. Emp. Sig. Authority Sig. Remarks
1 PO (Permit Originator)








2 PA (Permit Authorizer)




3 PI (Permit Issuer)







4 IA (Isolation Authority)


















5 AA (Area Authority)



6 PC (Permit Acceptor)




7 PU (Permit User)



8 SK (Site Checker)









9 SA (Supervising Authority)




4. CERTIFICATE
. PM/PGM: All PTWS Roles are assigned to competent site staff & certificates issued
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-027

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 57 of 59


PTW SYSTEM; FORMATION OF CAC
NC/PTW/SP-001/FM-028
VALID FROM (Date/Time): VALID TO:
PLANT:
1. PTWS FOUNDATION CHECK LIST: ( To be Filled by PGM)
Sr. Authority Designation Ref. Date Name of Resource Done
1 Responsibility to train PTWS Users given. OM
2 Responsibility to Resource PTWS Users given. OM
3 Responsibility to Resource PTWS Users given. MM
. PM/PGM: I hereby certify that above mentioned senior managers are authrized to resouce PTWS.
Name: Signature Date Time:
2. PTWS CAC Members
Sr. Role Site Role Name Desig. Emp. No. Emp. Sig. Authority Sig. Remarks
CAC Members








4. CERTIFICATE
. PM/PGM: CAC members are appointed on the basis of competnecy and proven track record
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-028

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Proc. No: NC/PTW/SP-001 Rev: 00 Page 58 of 59


PTWS: CHECK LIST TO MONITOR PTW SYSTEM NC/PTW/SP-001/FM-029
Date: Time: Active: Complete:
Permit Type: Name of Monitor: Position:
Permit No.
Annexed Certificates:
Sr. Monitor check list OK Not OK
1 Is the scope of work clearly specified
2 Are the necessary Risk assessment avaiable to review
3 Are the Identified hazards listed on RA/PTW
4 Are the appropriate precautions listed on the PTW
5 Are Isolations clearly specified
6 Is the operational time limit of permit is clearly mentioned
7 Are extensions properly authorized
8 Are the certificates properly completed
9 Are the certificates appended to the PTW
10 Are othe area activities cross referenced correctly
11 Are the system activities cross referenced correctly
12 Are the copies of permit, certificates & attachments ligible
13 Are the signatures and initials traceable & legible
14 Are the copies of certificates & permits posted at correct locations
15 Is the record of live permit & suspended permits maintained at the point of issue
16 Are the attachments , drawings kept at correct positions
17 Are the permit users briefed as tool box talk
18 Do the permits clearly specifies whome they are issued to
19 Do the permits clearly specifies the equipment or plant area the job is limited to
20 Are the recipients actually read and understood the hazards of job
21 Are the Permit users have the understanding of requirements
22 Are the staff using PTW system is specifically trained for
23 Do the permit users know what to do in emergency
24 Are the isolations appropriate & clearly specified & correctly implemented
25 Are common isolations cross referenced
26 Are the right people aware of isolated equipments
27 Is the area Authority aware of the work
28 Is the work being carried out on the terms of permit
29 Does the permit contains the clear rules to be folloewed in case of emergency.
30 Are all the precautions mentioned on permit taken
31 Is there any provision of contingency plan within PTW if required
32 Are the control measures as mentioned in PTW taken
33 Are the tools & equipment suitable
34 Are the tools in good condition
35 Are the house keeping standard satisfactory
Auditor
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-029

Permit to Work System Procedure

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
Proc. No: NC/PTW/SP-001 Rev: 00 Page 59 of 59

PTW: Supplimentary Work Activity Sheet PTW-000000
1. WORK ACTIVITY S. Work Activity Sheet No.
F.L.: Equip.: MO No;
Maintenance Order activities: CC by (ID) Dur. Hr Work Center No. / ID RA Done/Ref

Permit Originator (PO): Name & Signature & Date:
Name: Signature Date Time:
NOMAC PTW System NC/PTW/SP-001/FM-030

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