R-0000003068Rev1 Pearl GTL Permit To Work Templates April2018

Qatar Shell GTL Ltd
RESTRICTED Page 1 of 37
Pearl GTL Permit To Work Templates
Nilay Taylor
AUTHOR :
Permit To Work Lead
APPROVED BY: Hussain Al-Hijji
(Business Process Owner) Pearl Site HSSE Manager
CONSULTED lmran Amir

Operations HSE Team Lead
CONSULTED Kieran Nelson
Chief Fire Officer
CONSULTED Mohammad lsmuddin MO\-\A\V\\V\A:D
I Site Scaff Services Coordinator I\
S.\V\\...l DD 1 ~
Metadata
Document ID R-0000003068
Revision 1
Document Hierarchy ABAM Document
Discipline HSSE General
Document Class Procedure
Document Criticality Critical Process
Originator Document ID NIA
Related I Asset Structure A081
EDMS Location (AIM/File Plan) AIM
Business Process Assure HSSE/SP
QBAM Code (plus Sub-Process - if applicable) 039.06 I PTW
Security Classification Restricted
Hard Copy Storage Required YES - Approved Offsite Storage Facility
Review Date (Event or Date Driven) 3 Years
Export Compliance Restriction N/A: NO US CONTENT
Number of Pages (Total incl Attachments) 37
Document Status Code APP - Approved
Required for DPSA No
Latest Detail of Revision Second issue with revised permit accompanying documents
tern late for ermit vision
**See Definitions and Table in AIM Sharepoint Site:

https ://eu001 -sp. shell. com/sites/ AAAAA2100/gynbhdpe/default.aspx
This document will be maintained in AIM. Copies or extracts of this document, which have been
downloaded from AIM, are uncontrolled copies and cannot be guaranteed to be the latest version.
Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

Revision: 1 Print Date: 24 April 201 8
Qatar Shell GTL Ltd
Content
1. Purpose ......................................................................................................................3
2. Perm it to work Templates ............................................................................................ 3
2.1. Gas Test Record Sheet ................................................................................................. 4
2.2. Confined space daily entry log ........ ............................................................... ............. 5
2.3. Rescue Plan .................................................................................................................. 7
2.4. Equipment Transfe r Certificate .................................................................................. 13
2.5. Excavation Certificate and Method Statement ......................................................... 14
2.6. Mobile Crane Planning & Risk Assessment .......................................................... ...... 20
2.7. Authorisation to take Photographs ............................................................ .......... ...... 22
2.8. Life Support System check list ............. .............................. ..................... .... .......... ...... 23
2.9. Mobile Air Supply System Equipment check list ........................................................ 25
2.10. Mobile Air Supply System Safety check list ....................... ........................................ 26
2.11 . Road Closure proced ure ............................................................................................. 28
2.12. Authorisation for Road Closure .................................................................................. 29
2.13 Ventilation plan .... .. .. .. .. ... .................. .......... .. ..... . .... .................................. 30
2.14 Rope Access activity execution check list. ............... .. . ...... ............. ........ ... ....... 31
2.15 HEAT STRESS CRITICAL ACTIVITY RI SK ASSESSMENT FOR PURPLE FLAG (CONFINED
SPACE AND ELAVATED WORK) AND BLACK FLAG ..... . ................ ......................... ... .... ... .. .. 36

Revision: 1 Print Date: 24 Apr 2018
Qatar Shell GTL Ltd
1. Purpose
This document shall have the controlled copies of below permit accompanying/enabling document templates used
within Pearl GTL Permit to work regulation.
2. Permit to work Templates:
Note: Permit Requestor or work party supervisor must have discussion with OMC during planning stage, ensure all
the required enabling documents are duly filled, authorised by respective SME’s and must be uploaded with
respective permits for verification in permit vision. Archiving the permit documents If archiving on paper, the permit is
attached and archived per normal document retention.
 Gas Test Record Sheet
 Confined Space Daily Entry Log
 Rescue Plan (Confined space / Working at Height / Rope access)
 Equipment Transfer Certificate
 Excavation Certificate, Method Statement and Excavation check list
 Mobile Crane Planning & Risk Assessment
 Authorisation to take photographs in Pearl GTL Production units
 Pearl GTL Life Support System (LSS) Check List
 Pearl GTL Mobile Air Supply System (MASS) Equipment Check List
 Pearl GTL Mobile Air Supply System (MASS)Safety Check List
 Pearl GTL Road Closure Procedure
 Pearl GTL Authorisation for Road Closure
 Pearl GTL Ventilation plan
 Rope access activity execution approval sheet
 HEAT STRESS CRITICAL ACTIVITY RISK ASSESSMENT FOR PURPLE FLAG
(CONFINED SPACE AND ELAVATED WORK) AND BLACK FLAG

Qatar Shell GTL Ltd
Note: To meet the prerequisite in issued permit, AGT can utilise the above template to
record all observations on gas testing . AGT must update issued permit before end of
the shift.

Qatar Shell GTL Ltd
Pearl GTL
CONFINED SPACE DAILY ENTRY LOG
Note: To be completed and attached to the Permit issued.
Pearl GTL Emergency Number: Area panel operator contact number:

4419 8000
Equipment Number to be work in:
Area /Location to be work in:

Confined Space Attendant (CSA) Name:
Authorisation card validity:
Authorised Confined Space Attendant Company:
Planned Confined Space Entry Work Start: Date: Time:
PTSW number:
Method of alerting confined space entry team in case of IS Phone/ Radio / Air Horn/ Klaxon/ Whistle/life line
Emergency: (select applicable options)
Field Operator Radio Channel:

Current ventilation plan attached: Yes (√) & Document number:
Current rescue plan attached: Yes (√) & Document number:
Confined Space Daily Entry Log to be completed by CSA

Company Badge/ID
Name Dept. Time In Time Out
No.

Qatar Shell GTL Ltd
Badge/ID
Name Company Dept. Time In Time Out
No.
Confined Space Attendant:

1. Certifies that the confined space entry log sheet is completed
2. Confined space entrance is suitably closed off during all unoccupied periods.
Confined Space Attendant Name Company / Date Time Sign
Department
Area Field Operator Name Pearl GTL Date Time Sign

Qatar Shell GTL Ltd
Pearl GTL
RESCUE PLAN
CONFINED SPACE/WORKING AT HEIGHT/ROPE ACCESS
Tick an appropriate box;

Confined Space / Rope access inside confined space: ☐
Working at Height / Rope access activity.: ☐
Below documents must be submitted with this Rescue plan:

1. Method Statement approved by the Permit Verifier
2. The appropriate marked up Area/Vessel drawing
NOTE:
 In the event of any incident involving Confined Space, Working at Height stop the work.
 Permit Holder/Work party supervisor shall immediately alert 44198000 and Pearl GTL Shift Manager.
 Shift Manager shall inform all operational areas to suspend all activities involving rescue plan.
Permit Requestor (PR) to complete sections below before submission to the Pearl GTL FIT.
The Permit Requestor must co-ordinate with the Permit Verifier, Permit Authoriser and QSGTL FIT to complete the
required RESCUE PLAN
Rescue plan Number:
(” Rescue plan NOT VALID without the number provided by FIT”)

Area Unit Equipment Number
Work Party Involved
Location:
Grid Reference:
Work to start Date: Time:
Work completion expected Date: Time:
Permit Requestor (PR) Name: Signature:
Position: Tel: Date: Time:

Qatar Shell GTL Ltd
Site Survey Required by Pearl GTL FIT

Yes ☐
Site Survey Completed by Pearl GTL FIT, Permit verifier/Permit authoriser Date: Time:
Communications: Methods to be employed between the worker party and rescue team
☐ Direct voice communication ☐ Mobile phone
☐ Whistle
Other:
Confined space activity / Rope access inside confined space

Type of Confined Space

(Vessel, Tank, Trench)
Horizontal / Vertical (Designate H or V)
Description of Confined Space Area:
(Elevated, Congested)
Space Dimensions:
Shape & Size of Openings
Description of work been undertaken
(Hot Works, Painting, Mechanical Repair, NDT, Cleaning,
Scaffold erecting, refractory repairing etc.)
Location & Number of Openings

Number of Entrants expecting to enter in Confined Space: Top: Middle: Bottom:
Maximum Entrants at a time allowed to enter Confined Space
during work period (QSGTL FIT):
Provisions made for retrieval by entrants (Lines, Tripods and Ladders etc.) Yes / No
Is Breathing Apparatus (BA) required to complete task Yes / No
Type of BA to be used if required (SCBA, Rig-Walker, Airline sets):

Ventilation Plan required (FIT to consider implications to Rescue plan if required) Yes / No
Ventilation Plan completed and available (Do not sign form if not available) Yes / No
Provisions in place for firefighting by entrants (Extinguishers) Yes / No

Qatar Shell GTL Ltd
Note: if No to any of the above questions then ensure valid remarks with suitable &
sufficient alternate arrangements are made before work starts.
Additional Information:
Working at Height(WAH) / Rope Access Activity.

Note: All personnel working on rope must be able to self-rescue or be rescued by the other rope access work
party members or by rescue team(FIT).
Type of Process equipment:
 Vessel, Tank, column, pipe rack etc.
Description of WAH/ Rope Access area:

(Open area, Congested, Nearby HOT Surface etc.)
Others: specify
Description of work been undertaken
(Painting, Maintenance job, Cleaning, etc)
Others: specify
Additional Information: e.g. Hot Work, live equipment.

Qatar Shell GTL Ltd
RESCUE PLAN APPROVAL

CONFINED SPACE/WORKING AT HEIGHT/ROPE ACCESS
Note: If not the Permit Requestor then all responsibilities are accepted by Permit Holder.
Name: Position: RLIC No:
Sign: Date: Time
In evaluating the request and the supporting documentation the Permit Requestor, Permit verifier, Permit authoriser
and QSGTL FIT will jointly decide if this Rescue Plan is sufficient or whether FIT standby is required.
PLAN SUFFICIENT Yes / No
Pearl GTL FIT STANDBY REQUIRED Yes / No
Pearl GTL FIT to complete below section if FIT stand by required.
Pearl GTL FIT:

Name: Position:
Sign: Date: Time
Rescue Team Requirements

Rescue Equipment  Rescue ladder system
Requirements:  Main Lines for Vertical or Horizontal access
[Indicate quantity needed]  Safety Lines
 Hauling Systems
 Tripods
 Retractable Cables
 Harness
 Fall Arrest lanyards
 Karabiners
 Pulleys
 Ascenders / Descenders
 Anchor straps
 Rescue Poles
 Rescue Rope
 Scaffold
 Suspended access equipment
 Crane man basket
 MEWP
 Pneupac Resuscitator

Qatar Shell GTL Ltd
 Toxic shock strap

 Aerial equipment from ground
 RPD
 Life Ring
 Breathing Apparatus/SCBA
 Breathing Apparatus/Airline
 Breathing Apparatus Control Board
 Communication Equipment
 Gas Detectors
 Emergency Lighting
 Mechanical Ventilation.
 Firefighting Hose & Nozzles/Monitors/Hydro shield
 Spinal Immobilization Device
 Stretchers
 C-Collar
 Medical Kit
 Specialist Equipment/tools
 Other Equipment or specialist advisors required
 Other Please specify
Brief description of Rescue Plan

Qatar Shell GTL Ltd
Sketch of Rescue Method (suitable anchors and equipment to be utilised)
Contingency
Does RLIC Need to be informed Yes / No
If yes, FIT to be included in TBT/LMRA.
FIT Commander
Name: Position:
Sign: Date: Time
Original document is to be kept in the FIT office and a photocopy is to be attached to the issued permit and made
available at the work site.
On completion of work this rescue plan should be retained for 12 months

Qatar Shell GTL Ltd
Pearl GTL No. :
EQUIPMENT TRANSFER CERTIFICATE

Section A To be completed by Engineering/Maintenance Personal responsible for removing and
transferring equipment
Department / Unit Equipment No./Description
Where to be transfer to (Location) :

Description of Work required:
Equipment Removed By:

Name: _______________________Dept./Company: _____________ Contact Number : ________
Section B To be completed by AGT / Permit Authoriser (Operation Team Members)
Tick Yes/No as appropriate Yes No

1. Equipment has contained or has been in contact with hazardous material
A. If NO, straight AGT sign below, and release this transfer certificate
B. If YES, State what material in equipment
2. Equipment has been made free from flammable gas and Gas test result = Less than 1%
LEL
3. Equipment is free from hazardous material
safe to transfer/ handle and carry out work with below precautions
Additional PPE as indicated below must be worn
Hand Gloves Leather/PVC Goggles Face shield Respirator Dust Mask
Additional Precautions
AGT Name/ID Sign Date & Time
Permit Name/ID Sign Date & Time

Authoriser
Permit authoriser must approve and sign if equipment cannot be confirmed free from process hazardous material or to be
transferred out side Pearl GTL site.
Emergency Contact no. 44198000 Panel Operator no.

Qatar Shell GTL Ltd
Pearl GTL
EXCAVATION CERTIFICATE AND METHOD STATEMENT
This is NOT a Permit to Start Work
Risk Assessment of Excavation activity done within this Excavation Certificate and Method Statement
must be attached to the relevant Permit to Start Work.
SECTION 1:
(Area/ Number/Year) To be issued by Area Permit issuer
Work Description
Permit requestor Name Signature Contact Number
Company Position Date & Time
Detail of Excavation Work : -
_________________________________________________________________ ________________________________
______________________________________________________________________________________
______________________________________________________________
A record search for underground services has been Yes / No / Not required * (*Strike out which is not
carried out applicable)
Search carried out by Name Signature Contact Number
Company Position Date & Time
Details of underground services are shown on the attached drawing number(s):

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Qatar Shell GTL Ltd
Services unlikely to interfere with the excavation (tick if applicable):
Control & Telecom cables Road Lighting Cables Drains/Sewers Process Line
Proposed method of excavation (i.e. Hand Dig / Machine etc., also if inserting spikes/pins into ground):
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________
SECTION 2 : METHOD STATEMENT APPROVAL (Permit verifier) for excavation depth up to 1.2 meters. If excavation
depth is greater than 1.2 meter additional approval is required within section 3 of this document.
The check list over leaf has been completed and this Excavation Certificate and Method Statement approved to carry out
excavation work up to 1.2 meter depth with following precautions and control measures :
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
________________________________________________________________
Permit verifier Name Signature Contact Number Date & Time
SECTION 2a : METHOD STATEMENT APPROVAL (QSGTL Telecoms)
NOTE: This section must be signed by QSGTL Telecoms for excavations on Cable Trenches.
Following precautions and control measures required carry out when telecom cable are exposed/effected while carrying out
excavation activity :
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
________________________________________________________________
Telecom Authorized Signature Contact Number Date & Time

Person Name/SME

Qatar Shell GTL Ltd
SECTION 2b : METHOD STATEMENT APPROVAL (QSGTL Instruments)
NOTE: This section must be signed by QSGTL Instruments for excavations on Instrument Cable Trenches.
Following precautions and control measures required carry out when instruments cable are exposed/effected while carrying
out excavation activity :
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
________________________________________________________________
Instrument Reliability Signature Contact Number Date & Time

Authorized
Person/SME Name
SECTION 2c : MACHINE AND ELECTRICAL CABLE EXPOSURE EXCAVATION APPROVAL

(QSGTL Electrical) – Permit verifier/SME
NOTE: This section must be signed by QSGTL SME for machine and electrical cable exposure excavation.
Following precautions and control measures required carry out when machine and electrical cable are exposed/effected while
carrying out excavation activity:
Trail Holes / pits where required have to be made available for inspection and machine excavator approval.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
________________________________________________________________
This section must be jointly signed by Permit verifier and SME for electrical
Electrical SME Name Signature Contact Number Date & Time

Qatar Shell GTL Ltd
SECTION 3 : METHOD STATEMENT ADDITIONL APPROVAL

(Excavation /SME)
For excavation depth, greater than 1.2 meters
Design Drawings / Sketches submitted by Contractor for shoring or benching for trench stability or slope protection up to 3
metres deep is approved by Excavation/SME. Shoring materials are available onsite and inspected.
Professional Engineer designed Shoring or Benching Drawings and calculations for depth greater than 3 metres submitted by
Contractor is approved by Excavation/SME
The check list over leaf has been completed and the Method Statement is approved.
Permit verifier for underground pipes (Process, Utility or Drainage)

Electrical /SME for underground cables
Electrical SME Name Signature Contact Number Date & Time

Civil SME – for final approval on shoring and slope stability
Civil SME Name Signature Contact Number Date & Time

Qatar Shell GTL Ltd
Pearl GTL
Excavation Check List
(To be completed by Permit VERIFIER/Civil SME)
Yes No N/A Comments

A. GENERAL
This work method is generally acceptable.
Drawings/sketches of the proposed work are attached.
Area has been swept with a cable detector.
All possible services have been considered in work method.
All civil aspects of the excavation have been considered including any
concrete demolition and reinstatement works.
Where excavation depth is less than 1.2 m, slope and trench wall stability
have been assessed and considered where required shoring or slope
benching has been specified.
Method statement includes a plan for reinstatement.
Adequate steps have been specified in method statement to guard the work
area (vehicle bump stops, spoil storage, barriers etc.)
The use of any power/air tools have been clearly defined in work method.
Where HV cables have been identified, has the Electrical SME/ Duty Holder
been informed
Are spikes or pins to be driven into the ground during work i.e. foundation
shoring?
Where excavation depth is greater than 1.2 m, Civil SME for Excavation has
been informed for additional approval
Where excavation depth is greater than 1.2 m but less than 3 m, an approved
shoring or benching design is available for protection against ground
instability
Confined space procedure is considered and ventilation provided.
Where excavation depth is greater than 3 m, an approved shoring design

from Professional Engineer is available
Where excavation is at road crossing, ER Team has been informed for
approval
Where shoring protection is specified, the required materials are available
onsite before work begin
Proper access for ingress and egress into the excavated area is provided for
work and emergency response.
Any risks for undermining any concrete paving, cable trench wall and
foundation and vibration in the excavation area which can cause instability
or collapsed has been identified and considered.
Location for Storing Excavated Soil is known and approved to avoid silting up
underground drainage and overloading trenches.
Where ground water is to be encountered, dewatering plan with approved
water pump is available
Has joint site visit been conducted with contractor

Qatar Shell GTL Ltd
Yes No N/A Comments

B. MACHINE EXCAVATION
Method statement must state machinery and proposed use.
Extent of machine excavation (where required) has been marked on ground
and keep away a minimum of 0.6 meter all around from every services
Has a Competent Banksman been appointed?
Have trial holes been completed and identified/eliminated all services?
C. SERVICE DETECTION
Satisfactory evidence is provided with regard to record search for buried
services
Area has been swept using an approved cable detector.
Hand excavation to trial holes has been specified.
Underground services are clearly identified and marked and where exposed
are protected and supported
D. SUPERVISION
Adequate level of supervision with excavation competency has been
arranged and is specified in method statement
Inspection checklist for trench condition assessment, after weather
inclement and before first entry is specified in the method statement which
will form part of contractor safety assurance record.
Note: If an item on checklist has been ticked “NO”, then the comment should be made in order for the contractor to amend
the method statement prior to acceptance.

Qatar Shell GTL Ltd
Pearl GTL
Mobile Crane Planning & Risk Assessment Sheet
MCPRA Document No. : ___________________________
Name of Person in Charge of the lift Company Date & Time Contact Number
Details to be completed for the maximum lift for a single crane set up and attached to the Permit with an authorised
plot plan indicating the crane entry route map with crane set up position at the lifting location.
Permit verifier /SME will sign the Plot Plan.
Work Description:
Description of Ground Crane to be Set-Up On:
List Lifting Equipment:
Height of Lift: Boom Length Required: Max. Radius of Lift:
Max. Weight of Load: Weight of Hook Block: Total Load Including 15%:
Crane Required:
LIFT CATEGORIZATION
If the answer to the following question is 'Yes' then the category of lift is elevated to 2a YES/NO
COMPLEX
1. Is the weight of the load to be lifted more than 10 tonnes?
If the answer to any of the following questions is 'Yes' then the category of lift is elevated to 2b YES/NO
COMPLEX and high risk permit must be raised.
1. Will the lift go over live process lines or equipment?
2. Will more than one crane be used for the lift (tandem lift)?
3. Is the lift area on weak ground or uneven ground?
4. Will the lifting operation require a suspended load transfer?
5. Will the lift involve lifting of personnel?
6. Will the crane outriggers be positioned next to an excavation, trench or canal?
7. Are there any underground services under outrigger locations?
8. For crane capacity up to 55 tonnes, will outrigger mats be less than 1000mm x 1000mm?
9. For crane capacity of 60-90 tonnes will outrigger mats be less than 1200mm x 1200mm?
10. Is the load to be lifted within sight of the crane operator (Blind Lift)?

Qatar Shell GTL Ltd
11. Is the centre of gravity of the load above the slinging attachment points?
12. Does the eccentricity of the centre of gravity of the load present rigging difficulties?
13. Does the irregularity of the shape of the load present rigging or lifting difficulties?
14. Are there any lifting points that are attached to the load that are damaged or are in poor
condition that might have to be considered for MPI / DPI?
If the answer to any of the following questions is 'Yes' then the category of lift is elevated to YES/NO
HEAVY COMPLEX 3 and high risk permit must be raised.
1. Is the weight of the load to be lifted more than 30 tonnes
2. Does the proposed crane have a rating of greater than 200 tonnes?
Category of Lift: Standard 1 Complex 2a Complex 2b Heavy Complex 3
I confirm that the risks associated with this lift are as low as reasonably practicable
Date & Time:
Person In Charge of Lift Name: Signature
Date & Time :
Appointed person Name: Signature
ATTACHMENTS (As required)

Authorized Plot Plan
Rigging Study
Berthing Study
Method Statement
Others
ADDITIONAL CONTROLS AND SPECIAL REQUIREMENTS
HANDOVER (In case of change of PERSON IN CHARGE)

Name:
Person In Charge of Lift Signature Date:
Name:
Person In Charge of Lift Signature Date:
Closing of this Mobile Crane Risk Assessment plan
I confirm lifting activity under this Mobile crane Risk Assessment Plan is complete and Permit closed.

Qatar Shell GTL Ltd
Authorisation to take Photographs

in Pearl GTL Production Units
IS Camera Non IS Camera (Tick as applicable)
Here with Mr. / Mrs.: _______________________ Designation : ____________________ of
_____________________ Discipline is authorised to take Photographs of
Area: __________________________________ Section: _______________________________
Unit: ___________________________________ Equipment: _________________________________
For the purpose of :
_________________________________________________________________________
Date of Photography from ___________________ to __________________________
Authorised by Production Unit Manager or his / her delegate:
Name _____________________________________ Sign. _______________________
Date & Time ___________
Note: photographs must not be shown or given to any other organisation or person without the specific approval of
Pearl GTL Asset Manager.

Qatar Shell GTL Ltd
Pearl GTL Life Support System Check list

Reference: Pearl GTL Breathing Apparatus procedure (R-0000002987)
LIFE SUPPORT SYSYEM (LSS) CHECK LIST Revision September 2017

Area : Activity description: Date:
Train: Assigned Subject Matter Expert: Time:
Contractor: LSS identification no:
Job/ reactor:
Complying
Sr No Check Remarks
Yes/No/NA
Ensure the checklist for the procured breathing air cylinders from supplier, is signed off by authorized
1
person (Supervisor/ QHSE Officer)
Air Quality Test certificate is available and valid:
i- AQT certificate is valid for maximum 3 months after sampling
ii- O2 content must be 21% (+/- 1 %).
iii- CO content must be </= 10 ppm.
vi- CO2 content must be </= 1000 ppm.
2
v- Condensed hydrocarbon must be </=5 mg/m3.
vi- Dew point (maximum) at atmospheric pressure, at least 5 °C (10 °F) below the ambient temp.
Residual water vapour might be on the AQT sheet and not dew point. In that case it must be
maximum 25 mg/m3.
vii- The air must be free of bad taste or odour
3 Air inlet/ outlet on umbilical line correctly matched and connected
4 Air bottles are connected (collector line)
5 Umbilical line setup is correctly positioned and fastened
6 Air bottle outlet valves' operation checked and ready for OPEN
7 Scaffold pranks shade provided to protect the breathing air cyclinders from direct sunlight
8 All the hoses have correct colour code
9 All the hose connections complete have a whip-lock

Check if the weight of the hoses is properly managed by the use of S-hooks and securing the hoses
10
on separate levels
11 All airline couplings are secured
12 LSS certificate is valid, overall LSS is in good condition and ready for use,
13 LSS alarm system is healthy and in good working condition
14 Oxygen & LEL analyser certificate is valid, continuous gas analyzer is in good working condition
15 Audio and video is in good working condition
16 Ensure that dedicated power supply is provided to LSS cabin
17 Ensure earthing connections in place
18 All instruments functional test is available on display

Ensure LSS certificate is valid and LSS operator is holding valid LSS training. LSS operator must also
19
have a valid CSA training
20 Setup of emergency escape system/ escape line at access point
21 Functional test of low pressure alarm available
22 Functional test of primary Air/ secondary Air and LSS Helmet available
23 The primary, secondary and evacuate cylinder are tested and in good condition
24 The "A" Frame or Tripod is installed and secured on top, setup is in good condition and ready for use

Qatar Shell GTL Ltd
Pearl GTL Life Support System Check list(cont.)
IF "NO" or NA - State the finding (Reasons) for "Not Complying" and Action Item
Send this assurance check list to OPS HSE Team Lead by email within 48 hours after inspection
Name Date
Authorized SME:
Checked /Approved by (SIGN):

Qatar Shell GTL Ltd
Pearl GTL Mobile Air Supply System (MASS) Check List

Reference: Pearl GTL Breathing Apparatus procedure (R-0000002987)
MOBILE AIR SUPPLY SYSYEM (MASS) CHECK LIST Revision September 2017
Area : Activity description: Date:
Train: Assigned Subject Matter Expert: Time:
Contractor: MASS identification no:
Job/ reactor:
Complying
Sr No Check Yes/No/NA
Remarks
1 Equipment inspection reports are available for the equpiment to be used on site and are valid
Air Quality Test certificate is available and valid:
i- AQT certificate is valid for maximum 3 months after sampling
ii- O2 content must be 21% (+/- 1 %).
iii- CO content must be </= 10 ppm.
vi- CO2 content must be </= 1000 ppm.
2
v- Condensed hydrocarbon must be </=5 mg/m3.
vi- Dew point (maximum) at atmospheric pressure, at least 5 °C (10 °F) below the ambient temp.
Residual water vapour might be on the AQT sheet and not dew point. In that case it must be
maximum 25 mg/m3.
vii- The air must be free of bad taste or odour
Schematic diagram/ simple drawing is available showing; components parts, capacities, flow rates,
3
line sizes, etc. SME to check if line up at location is in lien with the provided diagram/ drawing.
4 Maintenance and test schedule, including filter changes
Verification by functional test of the mass balance or air supply by the system against the air intake
5 by the end users. The number of people used in the functional test will be the maximum number of
personnel allowed to use the MASS at the same time.
Method statement, supplied by the supplier, must state; equipment operating parameters, operator
6 instructions, operator instructions in case of component failure (air pressure low, warnign device
activation), cleaning instructions (to ensure equipment hygiene/ poor air quality), etc
Air intake is positioned in such a way that minimises the risk of contamination of the air intake (e.g.
7
exhaust of diesel generator, etc)
Hoses to be used for Breathing Air must be labelled "breathing air". There should be no possible
8
connection between the BA hoses and other systems (e.g. tool air, N2, etc)
9 Access, egress and emergency routes for the end-users of the BA (and others) are not blocked
The person assigned as the MASS observer/ controller has a clear understanding of the roles &
10 responsibilities; stand by at all time, what to do in case of an plant alarm, what to do in case of a
MASS system alarm, etc
11 Exclusion zone is set up with barricades in place of at least 15 meters (360 degrees)
IF "NO" or NA - State the finding (Reasons) for "Not Complying" and Action Item
1
Send this assurance check list to OPS HSE Team Lead by email within 48 hours after inspection
Authorized
Checked & Approved by (SIGN): Date
SME:

Qatar Shell GTL Ltd
Pearl GTL Mobile Air Supply System Safety Check List
PTSW No: ………………………………………… Date:
Work party:……………………………….
Work Party team members:
1. ……………………………………… 2. …………………………………………
2. ………………………………….…… 4. …………………………………………
5. ……………………………………… 6. ………………………………………….
Permit Holder: ......................................
Mobile Contact number: …
Permit VERIFIER to complete check list:

Sr. Check list
No. Yes/ No/
NA
1 The work is covered by a valid Permit, JHA/ Risk Assessment and a method statement
2 The work party are competent for the duties they will carry out, are aware of the rescue
plan, know what actions to take in an emergency and they are aware of their
responsibilities.
3 The FIT / rescue team shall be notified prior to starting the work.
4 TBT held with work party to discuss the job and the associated hazards.
5 A Rescue Plan is available and is suitable for recovery of an unconscious person

wearing BA equipment by the recovery method approved (Confined Space / WAH ).
6 A Safety Observer able to observe in a position not exposed to danger, has been
nominated. The safety Observer will not take part in any other work activities and must
always be in a position where he can hear or see any warning devices.
7 The safety observer will establish radio contact with the Central Control Room (CCR)
and the FIT before work commences and recheck radio contact at frequent intervals of
not less that every two hours.
8 The CCR is on VHF radio Channel State here >
9 The FIT is on radio channel State here >
10 The Safety Observer shall keep an up to date log of personnel using MASS

Qatar Shell GTL Ltd
11 All personnel using MASS shall wear a full body harnesses to enable a rescue line to be
quickly attached ( Confined Space / WAH ).
12 A tool Box Talk shall be held with the work party regarding risks involved in performing
the work and what actions to take in an emergency.
13 Confirm a SME inspected MASS equipment and approved the check list (good condition
and functioning correctly)
14 Adequate barriers and signs have been erected to prevent the entry of unauthorised
personnel within the operating area?
15 Radio to be checked a minimum of hourly intervals. In case radio communications

failure, all work must cease and personnel return to a nominated assembly point.
I verify that there is a Rescue Plan (Confined Space /WAH activity) and rescue equipment is available in case of an
emergency.
Officer of the First Intervention Team Name:
Signed: Date:
I verify that all controls are in place, the equipment is inspected and safe for use, the personnel are competent to
carry out the work.
Permit Verifier Name:
Signed: Date:
All the above requirements must be in place before work can commence. Any change to the agreed work above, the
work must stop, change risk assessed and mitigations put in place before work is recommenced.

Qatar Shell GTL Ltd
Pearl GTL ROAD CLOSURE PROCEDURE

By Requestor
Road Closure Planned
By Reques tor
No Road Closure Application

Road Closure Not Required
>50%?
Yes
By Reques tor
Road Closure Application
By Permi t i s s uer (PI)
Reviewed by PTSW Signatory
By Reques tor
Reviewed by Area Safety District
Owner
By Reques tor
Reviewed by Affected Area Safety
District Owner(s)
By Reques tor
Approved/Closed by Shift
Manager
By PI By PIScanned copy sent to FIT, By Reques tor

Res tricted Road? Yes Medevac and affected Area Work Finished
(for di stribution
PTSW Road Re-opened
l i st)
No
By PI By Reques tor
Sca nned copy s ent to FIT,
Medeva c, Securi ty, Tra ns port, WORK EXECUTION
Logi s ti cs a nd a ffected Area PTSW

Qatar Shell GTL Ltd
Authorisation for Road Closure -Pearl GTL

Road Closure
Permi t Reques tor Na me: Compa ny/Dept: Phone:
Permit Requestor
Des cri pti on of work to be ca rri ed out:
Na me/Loca ti on of Roa d Cl os ure: Area Sa fety Di s tri ct Affected Al terna ti ve Roa d Ava i l a bl e?
(Yes /No)-Dra wi ng a tta ched
Pl a nned Cl os ure Da te & Ti me: Pl a nned Re-open Da te & Ti me

Permit Issuer
PTW Offi ce Comments :
Na me (Pri nt): Si gna ture: Da te:

SDO/Nominee
Comments a nd Approva l from Sa fety Di s ctri ct Owner /Nomi nee Identi fi ed

Area
Comments a nd Approva l from Sa fety Di s ctri ct Owner /Nomi nee Affected

Area SDO
Affected
Comments a nd Approva l from Shi ft Ma na ger

Manager
Shift

Approved document to be s ent to Area PTSW Si gna tory for di s tri buti on.
Road Reopened
Rea s on of Roa d Reopened
Requestor
/Holder
Permit
Na me (Pri nt): Si gna ture: Da te/Ti me:
Acknowl edge by Shi ft Ma na ger

Manager
Shift
Acknowl edge by PTSW Si gna tory

Permit
Issuer
1. Ori gi na l a t the work l oca ti on, photocopy kept i n PTW offi ce a nd a rea a ffected PTW offi ce. Sca nned copy to be di s tri buted
by a rea PTSW Si gna tory to:
a . Res tri cted roa d cl os ure: FIT, Medeva c a nd Affected Area PTSW s i gna tory
b. Non Res tri cted roa d cl os ure: FIT, Medeva c, Securi ty, Tra ns port, Logi s ti cs a nd Affected Area PTSW Si gna tory
i . Securi ty QSGTL-Securi ty-Shfi t-Supervi s ors @s hel l .com i v. Ta ns port Secti on GXQSGTLPea rl Tra ns port@s hel l .com
i i . FIT QSGTL-UIQ/S/CQSGTL-FIT-Comma nd-Tea m@s hel l .com v. Logi s ti cs QSGTL-Logi s ti cs @s hel l .com
i i i . Medeva c tea m qa ta rs hel l .emtp@i nterna ti ona l s os .com
2. When the roa d reopened, the Area PTSW Si gna tory s ha l l i nform the a ffected pa rty a s a bove. One l egi bl e copy to be
reta i ned for mi ni mum of 3 months .

Qatar Shell GTL Ltd
Pearl GTL
Ventilation Plan for CSE Details
Job Description:
Work Order No CLEAR SHEET

Unit:
Location:
Location/ Area: Elevation:
Equipment:
Task:
Equipment Number:
Vessel volume Internal Hot Work

(cu ft): Required (Yes/No):
Approximate Refresh Rate Standard Air Hose Length

#DIV/0!
(Vol/hr): (m):
Minimun Refresh Rate

Total No. of Air Hoses
(Total Volumes Replaced
Required:
per Hour):
Ventilation Point 1: Ventilation Point 2: Ventilation Point 3: Ventilation Point 4:
Location
Description:
Type of Ventilation Point:
Ventilation Size:
Elevation (Meters):
0 0 0 0
Ventilation Unit Type:
Air Movement Method:
Ventilation Rate
0 0 0
(cu ft/min):
Ventilation Unit Size:
Ventilation Unit Drive:
Reviewed & Approved By

Prepared By:
Shell Authorised Person:
Name:
Signature:
Date:
Assumptions:
- Flow rate of a larger diameter ventilation unit on a smaller diameter nozzle is proportionally reduced to suit the smaller nozzle size.
- Ventilation units with the same air movement direction are summed separately and the larger sum only is used to calculate the overall replacement rate.
- Additional efficiency factor of 75% applied to overall volume refresh rate as a safety factor.

Qatar Shell GTL Ltd
Pearl GTL Rope Access Activity Execution Check List

Permit Requestor:
Name: Company: Phone:
Equipment/site to be worked on/in:
Description of work to be carried out:
Approval Signatures
A. To be signed by the Shell Civil Integrity Engineer or Cranes & Heavy Lifting Coordinator: I certify that the
attachment & rigging points have been verified with the Level 3 Operative and are safe to use.
Civil Integrity Engineer
Remarks:
Civil Integrity Engineer Name Phone Date Time

signature
Cranes & Heavy Lifting

Coordinator Remarks:
Cranes & Heavy Lifting Name Phone Date Time

Coordinator signature
B. To be signed by the Permit Verifier: I certify that the equipment to be worked on is in a safe mechanical
condition for the proposed work.
PV Remarks:
PV signature Name Phone Date Time
C. To be signed by the Permit Authoriser (High Risk) : I certify that I have inspected the area and the
equipment specified to be worked on and it is in a safe process condition for the proposed work, providing
the specified controls are followed.
Valid Date Date
From: To:
Time Time
PA Comments:
PA Signature Name Phone Date Time

Qatar Shell GTL Ltd
Checklist for Descending/Climbing Gear: The following checklist needs to be duly filled by all competent
personnel.
CHECKLIST
DESCENDING/CLIMBING GEAR
Execution with Rope Access in only permitted if all the below questions can be answered with a ''Yes'' or with
valid remarks from competent person in case of ''No''
Subject/Activity Competent Person Yes No Name Initials
Preparatory Phase before requesting work permit
Is the executing contractor IRATA QSGTL SME-Rope

certified and are valid? Access
Are all Rope Access accessories
inspected and found in good condition Cranes & Heavy
with valid third-party inspection Lifting Coordinator
certificate?
Is the scope of the work clearly
Permit Verifier
described?
Is the team executing the Rope

Access activity is consist of IRATA Permit Requestor
Level-3 and QSGTL SME.
Where applicable
Carry out temperature check for
Permit Authorizer to
proposed rope access route using
nominate Operations
temperature gun.
person
During execution of the rope access
activity, can it be guaranteed that
there are no hot parts that could Permit Authorizer
cause burns or injury to the executing
parties?
activity, can it be guaranteed that
there are no corrosive parts that could Civil Integrity
damage the climbing gear (such as
the lines)?
activity, can it be guaranteed that no
climbing gear (such as the lines) can Permit Verifier
be damaged, putting the executing
parties in dangerous circumstances.
activity, can it be guaranteed that no
Permit Authorizer
silencers and/or safety devices can
be opened, jeopardizing the work?
Are there enough sufficiently strong QSGTL SME-Rope

anchor points? Access

Qatar Shell GTL Ltd
Formulating Temporary Rope Access
Is IRATA Level-3 supervisor who

Permit Verifier
carries out the field check present?
Have cordons been discussed during

formulation of the Temporary Rope Permit Verifier
Access?
Has an emergency Rescue plan been
Permit Verifier
approved by the QSGTL FIT?
Has the possible risk of falling
Permit Verifier
materials and tools been discussed?
Is all rope access equipment certified
Permit Verifier
and fit to use?
No moving equipment or machineries
in the Rope’s line below, that can Permit Verifier
cause risk of ropes entanglement.
Has the necessity for stable process
operation during the execution of the
Permit Authorizer
rope access activity is required to be
discussed in shift team meeting?
Before Execution
Has the emergency rescue plan and
Rope Access procedure been Permit Holder / IRATA
completed in full and communicated Level-3
to the executing party?
Have all anchor lines (ropes) been
routed away from edges where
QSGTL SME-Rope
possible Or protection sleeves have
Access
been provided to protect the lines
from sharp edges?
Are anchor lines rigged to separate
anchor wires and are those anchors
SME-Integrity
secured to an anchor point of
unquestionable strength?
Are all tools and equipment fitted with
Permit Holder /
lanyards and/or independently
IRATA Level-3
suspended?
To follow work and rest cycle, any
competent person from operations
assigned to monitor and report heat
Permit Authorizer
index / wind speed at regular intervals
to IRATA Level-3 Supervisor at
location?
Does the team consist of a minimum
of two people, of which at least one is Permit Verifier
IRATA Level-3?
Has it been agreed to maintain
continual supervision by IRATA Level- Permit Verifier
3 during the work?

Qatar Shell GTL Ltd
Are all working crew members in Permit Holder / IRATA

good physical health? Level-3
Check each line to ensure it reaches
the ground or suitable transition point
and a stopper knot is tied in the end Permit Holder /
to prevent accidentally abseiling out IRATA-3
of the system. (action party- IRATA-3)

Qatar Shell GTL Ltd
HEAT STRESS CRITICAL ACTIVITY RISK ASSESSMENT FOR PURPLE FLAG (CONFINED SPACE AND ELAVATED WORK) AND BLACK FLAG
Section 1 - Application Details (Permit Requester is responsible for completion of this section. If activity is not approved as critical, no further sections need to be completed.)
Permit Requester (AAPA) signature and date: Mobile: Activity location:
Company/Department: Risk assessment to be valid from: Risk assessment to be valid until:
Activity description:
Purple flag work? Yes No Black flag work? Yes No Day shift work? Yes No Night shift work? Yes No
Criticality reviewed with Permit Requester (AAPA) and approved by the OMC/HOMPTA? Criticality justification (completed by the OMC/HOMPTA):
Yes No Emergency:
Critical path activity:
Safety critical:
OMC/HOMPTA signature and date: Production critical:
Other (specify):
Section 2 - Risk Assessment and Mitigations (Permit Requester is responsible for completion of this section. If not approved by Permit Verifier, no further sections need to be completed.)
Work location (select all that apply) Work load (select all that apply): Clothing (select all that apply): Respiratory protection (select all that apply):
Inside a confined space: Very heavy work: Standard site PPE: Breathing apparatus:
Radiant heat source: Heavy work: Disposable coverall: Full face mask:
Elevated location: Moderate work: Chemical coverall: Half face mask:
Non-shaded area: Light work: Insulated clothing: Disposable mask:
Shaded area: Other (specify): Other (specify):
Can work be rescheduled to a cooler period of the day or night? Yes No Describe local Heat Describe access to air- Describe drinking water
Work party has an agreed communication protocol with the panel/permit issuer? Yes No Index monitoring plan conditioned shelter: availability:
(who, where and how often):
Describe the work organisation (e.g. manning/number of workers, scheduling and execution
strategy):

Qatar Shell GTL Ltd
Section 2 - Risk Assessment and Mitigations (Continued)

Mandatory mitigations: Engineering mitigations (select all that Procedural mitigations (select all that apply): Other mitigations (specify all):
- Minimise layering of clothing apply) Communication protocol Describe for all selected
- Buddy system (no lone working) Habitat: Describe for all Worker rotation:
- Experienced and trained workers, fully acclimatised selected Modified work/rest period:
- Continuous supervision and visual monitoring of the workers Portable shading: Training:
- Means of communication (e.g. radio, Ex-phone) Ventilation: Other (specify):
- Heat Index monitoring every 30 minutes by work party using Kestrel Air-conditioning:
- Rest taken in an air-conditioned shelter, cool drinking water available Other (specify):
- Rest cycle and water consumption as per the Flag colour
- Recording of the working and rest periods
- If work duration is more than half a shift, rotate workers
- Tool Box Talk on Heat Stress and mitigations
Permit Requester (AAPA) signature and date: Permit Verifier (AE/MFE) and date:
Section 3 – SDO Approval (Permit Requester is responsible for completion of this section, Sections 1 and 2 must be completed beforehand.)
HSSE signature and date (if requested by the SDO): Comments or additional requirements imposed by the SDO:
Yes
No
Safety District Owner* (or delegate) signature and date:
Section 4 – Readiness for Execution (the undersigned are jointly aware of the work to be carried out, the handover condition of the euipment and the precautions to be
taken – as specified above)
Permit Holder signature and date: Valid for permit numbers (completed by the Permit Issuer):
Permit Issuer signature and date:
* Approval for critical emergency work outside of core office hours is to be done by the on-duty Shift Manager/OIM

Qatar Shell GTL Ltd


R-0000003068Rev1 Pearl GTL Permit To Work Templates April2018

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

R-0000003068Rev1 Pearl GTL Permit To Work Templates April2018

Uploaded by

Copyright:

Available Formats

Qatar Shell GTL Ltd

Pearl GTL Permit To Work Templates

CONSULTED lmran Amir

**See Definitions and Table in AIM Sharepoint Site:

Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

2. Permit to work Templates:

 Gas Test Record Sheet

 Confined Space Daily Entry Log

 Rescue Plan (Confined space / Working at Height / Rope access)

 Equipment Transfer Certificate

 Excavation Certificate, Method Statement and Excavation check list

 Mobile Crane Planning & Risk Assessment

 Authorisation to take photographs in Pearl GTL Production units

 Pearl GTL Life Support System (LSS) Check List

 Pearl GTL Mobile Air Supply System (MASS)Safety Check List

 Pearl GTL Road Closure Procedure

 Pearl GTL Authorisation for Road Closure

 Pearl GTL Ventilation plan

 Rope access activity execution approval sheet

 HEAT STRESS CRITICAL ACTIVITY RISK ASSESSMENT FOR PURPLE FLAG

(CONFINED SPACE AND ELAVATED WORK) AND BLACK FLAG

Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

Note: To be completed and attached to the Permit issued.

Pearl GTL Emergency Number: Area panel operator contact number:

Area /Location to be work in:

Field Operator Radio Channel:

Confined Space Daily Entry Log to be completed by CSA

Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

Confined Space Attendant:

Area Field Operator Name Pearl GTL Date Time Sign

Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

Tick an appropriate box;

Below documents must be submitted with this Rescue plan:

Rescue plan Number:

(” Rescue plan NOT VALID without the number provided by FIT”)

Work Party Involved

Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

Site Survey Required by Pearl GTL FIT

Confined space activity / Rope access inside confined space

Type of Confined Space

Location & Number of Openings

Is Breathing Apparatus (BA) required to complete task Yes / No

Type of BA to be used if required (SCBA, Rig-Walker, Airline sets):

Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

Working at Height(WAH) / Rope Access Activity.

Description of WAH/ Rope Access area:

Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

RESCUE PLAN APPROVAL

Name: Position: RLIC No:

Sign: Date: Time

Pearl GTL FIT STANDBY REQUIRED Yes / No

Pearl GTL FIT to complete below section if FIT stand by required.

Pearl GTL FIT:

Sign: Date: Time

Rescue Team Requirements

Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

 Toxic shock strap

Brief description of Rescue Plan

Document ID: R-0000003068 ALL PAPER COPIES ARE UNCONTROLLED

Sketch of Rescue Method (suitable anchors and equipment to be utilised)

Here with Mr. / Mrs.: ___ Designation : of

Area: ____ Section: _

Unit: ___ Equipment: _

Date of Photography from _ to ________

Name _______________ Sign. _