Format No.

HSE-F-03
Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

Section - 1
WA Number Date 05.07.2016
GA / Office Rajkot
City / Town / Village Rajkot Job / Site Location Madhapar
Activity Start Date 05.07.2016 Activity Completion Date 06.07.2016
WA Validity
Start Time 16:30 Completion Time 18:30
Title of the Job Excavation of trial pit on charged PE

Scope/Description of the job Excavation of trial pit on charged PE

Name of the Contractor Bucon Infra

1. Safe System of Work 5 Confined Space entry

2. Excavation/Manual 6. Lifting Operations
Applicable Life Saver
3. Working at Height 7. Electrical Work
4. Gas Escape handling 8. Driving

Other jobs /plan having impact on this job? NO

Role and Responsibility Matrix

Description of Role Responsibility Name Designation Mobile Number
Risk Assessor Work In charge /HSE Rep NA NA NA
Technical Manager / CNG O&M In
Isolation Plan Approving Authority NA NA NA
charge
Isolation/De-Isolation Confirmation
Performing Authority (GGL) NA NA NA
Authority at Work Site
SIMOPS (Simultaneous
O&M In charge NA NA NA
Operations) Controller
Performing Authority (GGL) OS Engg Jignesh Vyas Site Engg 7574819989

Performiong Authority (Contractor) Supervisior Kuldip Supervisor 8401284963

Issuing Authority Sr Engineer Sandip Bhimani Sr.Engg 9099957607

Section - 2
WA Authorisation Requirement
Standard Work Instruction / Procedure Attached YES/NO YES
Standard Isolation plan /Overrrides & certificates Attached YES/NO NO
Site Specific Risk Register Attached YES/NO NO
Minimum PPES Attached YES/NO YES
Standard Emergency / Contigency arrangements Attached YES/NO YES

List of Work force involved in the task & Undergone the tool box Talk
Sr.
Name Responsibility Number Remarks
No.
1 Kuldip Supervisor 8401284963
2 Labor
3 Labor
4
5

List of critical Equipment / Tools / Instrument

Sr.
Item Qty Fit For Purpose Certificate Checked By (Work In charge) Verified By (HSE Rep)
No
1
2
Stake holder management
Affected Party Name Checked & Verified by

NA

Section - 3
Work Authorisation Requested By
Description of Role Name Of Person Sign Date

Performing Authority Jignesh Vyas

 Format No. HSE-F-03
Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

I am satisfied that the work can be carried out safety subject to life savers and other compliance and mentioned percautions of the WA . I authorise this WA
holder to complete with following conditions prior to commencing of the work.
1. Isolation / Inhibits / Overrides of safety critical equipment are authorised.
2. Tool box talk shall be held to ensure that all the people involved were explained and understands the task hazards, risk & controls and is clear about
individual responsibilities.
3. Communicate the message to the workforce that “Any person is expected to stop the work if they believe that conditions under which the Permit was issued
have changed, or that risk is not being controlled adequately”.
4. The performing authority and the persons carrying out the work shall ensure that all machine / equipment / instrument are suitably certified and fit for purpose
prior to commencing work..
5. Issued WA shall be displayed at relavent location and worksite.
6. Supplementary controls based on dynamic risk assessment shall be in place during the execution of work by performing authority and communicated back to
issuing authority..

7. WA is automatically cancelled when any emergency situation arise or emergency alarm is sounded and have to be reissued after normal conditions resume
8. Other condition if any :

Issue of Work Authorisation

Description of Role Name of Person Sign Date

WA Issuing Authority Sandip Bhimani

I/We have read and understood the requirement of the WA document and assure that the site would be kept safe at all times.

Acceptance of terms and Reciept of a Work Authorisation

Description of Role Name of Person Sign Date

Performing Authority ( GGL) Jignesh Vyas

Performing Authority ( Contractor) Kuldip

Suspension / Cancellation of work Authorisation

Joint Site inspection / Visit is done by performing and WA issuuing authority and site declared as ......................................
Task is suspended as incomplete Task is cancelled

Reasons/s ______________________________________________________________________________________________________________________

Suspension / Cancellation of WA Date Time Sign

Performing Authority

Permit Issuing Authority

Extention of Work Authorisation

Authorize extension / resumption of WA in consultation with SIMOP controller / Endorsing Authority.

Extension of work Authorisation

Extension /Resumption
Control Measures Sign of Performing Authority Sign of Issuing Authority
From (date /Time) To ( Date & Time)

Close out of work Authorisation

Close out of WA Date Time Sign

Declaration by Performing Authority
The site is returned to a safe, clear & tidy state, closures of inhibits / overriding of safety critical devices is confirmed and De-isolation is completed as per plan
with authorization from isolating authority and isolation confirmation certificate.
Declaration by Issuing Authority

It is ensured that site is restored to safe condition by performing authorities, PTW register or database is updated by Permit Coordinator and WA is now closed.

Performing Authority :

Permit Issuing Authority :

 Format No. HSE-F-03
Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

Section - 1
WA Number Date 05.07.2016
GA / Office Rajkot
City / Town / Village Rajkot Job / Site Location Madhapar Main Road
Activity Start Date 05.07.2016 Activity Completion Date 06.07.2016
WA Validity
Start Time 16:30 Completion Time 18:30
Title of the Job Excavation>1.5 mtr depth.

Scope/Description of the job Manual Boring

Name of the Contractor Bucon Infra

1. Safe System of Work 5 Confined Space entry

2. Excavation/Manual 6. Lifting Operations
Applicable Life Saver
3. Working at Height 7. Electrical Work
4. Gas Escape handling 8. Driving

Other jobs /plan having impact on this job? NO

Role and Responsibility Matrix

Description of Role Responsibility Name Designation Mobile Number
Risk Assessor Work In charge /HSE Rep NA NA NA
Technical Manager / CNG O&M In
Isolation Plan Approving Authority NA NA NA
charge
Isolation/De-Isolation Confirmation
Performing Authority (GGL) NA NA NA
Authority at Work Site
SIMOPS (Simultaneous
O&M In charge NA NA NA
Operations) Controller
Performing Authority (GGL) OS Engg Jignesh Vyas Site Engg 7574819989

Performiong Authority (Contractor) Supervisior Kuldip Supervisor 8401284963

Issuing Authority Sr Engineer Sandip Bhimani Sr.Engg 9099957607

Section - 2
WA Authorisation Requirement
Standard Work Instruction / Procedure Attached YES/NO YES
Standard Isolation plan /Overrrides & certificates Attached YES/NO NO
Site Specific Risk Register Attached YES/NO NO
Minimum PPES Attached YES/NO YES
Standard Emergency / Contigency arrangements Attached YES/NO YES

List of Work force involved in the task & Undergone the tool box Talk
Sr.
Name Responsibility Number Remarks
No.
1 Kuldip Supervisor 8401284963
2 Labor
3 Labor
4
5

List of critical Equipment / Tools / Instrument

Sr.
Item Qty Fit For Purpose Certificate Checked By (Work In charge) Verified By (HSE Rep)
No
1
2
Stake holder management
Affected Party Name Checked & Verified by

NA

Section - 3
Work Authorisation Requested By
Description of Role Name Of Person Sign Date

Performing Authority Jignesh Vyas

 Format No. HSE-F-03
Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

I am satisfied that the work can be carried out safety subject to life savers and other compliance and mentioned percautions of the WA . I authorise this WA
holder to complete with following conditions prior to commencing of the work.
1. Isolation / Inhibits / Overrides of safety critical equipment are authorised.
2. Tool box talk shall be held to ensure that all the people involved were explained and understands the task hazards, risk & controls and is clear about
individual responsibilities.
3. Communicate the message to the workforce that “Any person is expected to stop the work if they believe that conditions under which the Permit was issued
have changed, or that risk is not being controlled adequately”.
4. The performing authority and the persons carrying out the work shall ensure that all machine / equipment / instrument are suitably certified and fit for purpose
prior to commencing work..
5. Issued WA shall be displayed at relavent location and worksite.
6. Supplementary controls based on dynamic risk assessment shall be in place during the execution of work by performing authority and communicated back to
issuing authority..

7. WA is automatically cancelled when any emergency situation arise or emergency alarm is sounded and have to be reissued after normal conditions resume
8. Other condition if any :

Issue of Work Authorisation

Description of Role Name of Person Sign Date

WA Issuing Authority Sandip Bhimani

I/We have read and understood the requirement of the WA document and assure that the site would be kept safe at all times.

Acceptance of terms and Reciept of a Work Authorisation

Description of Role Name of Person Sign Date

Performing Authority ( GGL) Jignesh Vyas

Performing Authority ( Contractor) Kuldip

Suspension / Cancellation of work Authorisation

Joint Site inspection / Visit is done by performing and WA issuuing authority and site declared as ......................................
Task is suspended as incomplete Task is cancelled

Reasons/s ______________________________________________________________________________________________________________________

Suspension / Cancellation of WA Date Time Sign

Performing Authority

Permit Issuing Authority

Extention of Work Authorisation

Authorize extension / resumption of WA in consultation with SIMOP controller / Endorsing Authority.

Extension of work Authorisation

Extension /Resumption
Control Measures Sign of Performing Authority Sign of Issuing Authority
From (date /Time) To ( Date & Time)

Close out of work Authorisation

Close out of WA Date Time Sign

Declaration by Performing Authority
The site is returned to a safe, clear & tidy state, closures of inhibits / overriding of safety critical devices is confirmed and De-isolation is completed as per plan
with authorization from isolating authority and isolation confirmation certificate.
Declaration by Issuing Authority

It is ensured that site is restored to safe condition by performing authorities, PTW register or database is updated by Permit Coordinator and WA is now closed.

Performing Authority :

Permit Issuing Authority :

 Format No. HSE-F-03
Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

Section - 1
WA Number Date 30.06.2016
GA / Office Rajkot
City / Town / Village Rajkot Job / Site Location Madhapar Main Road
Activity Start Date 30.06.2016 Activity Completion Date 30.06.2016
WA Validity
Start Time 10:30 Completion Time 18:30
Title of the Job Manual Boring

Scope/Description of the job Manual Boring

Name of the Contractor Bucon Infra

1. Safe System of Work 5 Confined Space entry

2. Excavation/Manual 6. Lifting Operations
Applicable Life Saver
3. Working at Height 7. Electrical Work
4. Gas Escape handling 8. Driving

Other jobs /plan having impact on this job? NO

Role and Responsibility Matrix

Description of Role Responsibility Name Designation Mobile Number
Risk Assessor Work In charge /HSE Rep NA NA NA
Technical Manager / CNG O&M In
Isolation Plan Approving Authority NA NA NA
charge
Isolation/De-Isolation Confirmation
Performing Authority (GGL) NA NA NA
Authority at Work Site
SIMOPS (Simultaneous
O&M In charge NA NA NA
Operations) Controller
Performing Authority (GGL) OS Engg Jignesh Vyas Site Engg

Performiong Authority (Contractor) Supervisior Kuldip Supervisor

Issuing Authority Tech Mngr Chirag Bhanvadia Deputy Mngr 9099953936

Section - 2
WA Authorisation Requirement
Standard Work Instruction / Procedure Attached YES/NO YES
Standard Isolation plan /Overrrides & certificates Attached YES/NO NO
Site Specific Risk Register Attached YES/NO NO
Minimum PPES Attached YES/NO YES
Standard Emergency / Contigency arrangements Attached YES/NO YES

List of Work force involved in the task & Undergone the tool box Talk
Sr.
Name Responsibility Number Remarks
No.
1 Kuldip Supervisor 0
2 Labor
3 Labor
4
5

List of critical Equipment / Tools / Instrument

Sr.
Item Qty Fit For Purpose Certificate Checked By (Work In charge) Verified By (HSE Rep)
No
1 33 KV Hand Gloves 1 Yes Jignesh Vyas
2 Boring Tool 1 Yes Jignesh Vyas
Stake holder management
Affected Party Name Checked & Verified by

NA

Section - 3
Work Authorisation Requested By
Description of Role Name Of Person Sign Date

Performing Authority Jignesh Vyas

 Format No. HSE-F-03
Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

I am satisfied that the work can be carried out safety subject to life savers and other compliance and mentioned percautions of the WA . I authorise this WA
holder to complete with following conditions prior to commencing of the work.
1. Isolation / Inhibits / Overrides of safety critical equipment are authorised.
2. Tool box talk shall be held to ensure that all the people involved were explained and understands the task hazards, risk & controls and is clear about
individual responsibilities.
3. Communicate the message to the workforce that “Any person is expected to stop the work if they believe that conditions under which the Permit was issued
have changed, or that risk is not being controlled adequately”.
4. The performing authority and the persons carrying out the work shall ensure that all machine / equipment / instrument are suitably certified and fit for purpose
prior to commencing work..
5. Issued WA shall be displayed at relavent location and worksite.
6. Supplementary controls based on dynamic risk assessment shall be in place during the execution of work by performing authority and communicated back to
issuing authority..

7. WA is automatically cancelled when any emergency situation arise or emergency alarm is sounded and have to be reissued after normal conditions resume
8. Other condition if any :

Issue of Work Authorisation

Description of Role Name of Person Sign Date

WA Issuing Authority Chirag Bhanvadia

I/We have read and understood the requirement of the WA document and assure that the site would be kept safe at all times.

Acceptance of terms and Reciept of a Work Authorisation

Description of Role Name of Person Sign Date

Performing Authority ( GGL) Jignesh Vyas

Performing Authority ( Contractor) Kuldip

Suspension / Cancellation of work Authorisation

Joint Site inspection / Visit is done by performing and WA issuuing authority and site declared as ......................................
Task is suspended as incomplete Task is cancelled

Reasons/s ______________________________________________________________________________________________________________________

Suspension / Cancellation of WA Date Time Sign

Performing Authority

Permit Issuing Authority

Extention of Work Authorisation

Authorize extension / resumption of WA in consultation with SIMOP controller / Endorsing Authority.

Extension of work Authorisation

Extension /Resumption
Control Measures Sign of Performing Authority Sign of Issuing Authority
From (date /Time) To ( Date & Time)

Close out of work Authorisation

Close out of WA Date Time Sign

Declaration by Performing Authority
The site is returned to a safe, clear & tidy state, closures of inhibits / overriding of safety critical devices is confirmed and De-isolation is completed as per plan
with authorization from isolating authority and isolation confirmation certificate.
Declaration by Issuing Authority

It is ensured that site is restored to safe condition by performing authorities, PTW register or database is updated by Permit Coordinator and WA is now closed.

Performing Authority :

Permit Issuing Authority :

 Format No. HSE-F-03
Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

Section - 1
WA Number Date 08.07.2016
GA / Office Rajkot
City / Town / Village Rajkot Job / Site Location Dhoridhar Feeder
Activity Start Date 11.07.2016 Activity Completion Date 13.07.2016
WA Validity
Start Time 10:00 Completion Time 18:30
Title of the Job Flushing & Testing

Scope/Description of the job Flushing & Testing work at Dhoridhar Feeder (Dia90-2600mtr)

Name of the Contractor B J Patel

1. Safe System of Work 5 Confined Space entry

2. Excavation/Manual 6. Lifting Operations
Applicable Life Saver
3. Working at Height 7. Electrical Work
4. Gas Escape handling 8. Driving

Other jobs /plan having impact on this job? NO

Role and Responsibility Matrix

Description of Role Responsibility Name Designation Mobile Number
Risk Assessor Work In charge /HSE Rep NA NA NA
Technical Manager / CNG O&M In
Isolation Plan Approving Authority NA NA NA
charge
Isolation/De-Isolation Confirmation
Performing Authority (GGL) NA NA NA
Authority at Work Site
SIMOPS (Simultaneous
O&M In charge NA NA NA
Operations) Controller
Performing Authority (GGL) OS Engg Indravijay Zala Site Engg

Performiong Authority (Contractor) Supervisior Anil Supervisor

Issuing Authority Sr Engg Sandip Bhimani Sr Engg 9099957607

Section - 2
WA Authorisation Requirement
Standard Work Instruction / Procedure Attached YES/NO YES
Standard Isolation plan /Overrrides & certificates Attached YES/NO NO
Site Specific Risk Register Attached YES/NO NO
Minimum PPES Attached YES/NO YES
Standard Emergency / Contigency arrangements Attached YES/NO YES

List of Work force involved in the task & Undergone the tool box Talk
Sr.
Name Responsibility Number Remarks
No.
1 Anil Supervisior 0
2 Bhogilal Welder
3
4
5

List of critical Equipment / Tools / Instrument

Sr.
Item Qty Fit For Purpose Certificate Checked By (Work In charge) Verified By (HSE Rep)
No
1 EF Machine 1 S.12.B.61.04.020 Indravijay Kunal Pathak
2 05.01.2017
Stake holder management
Affected Party Name Checked & Verified by

NA

Section - 3
Work Authorisation Requested By
Description of Role Name Of Person Sign Date

Performing Authority Indravijay Zala

 Format No. HSE-F-03
Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

I am satisfied that the work can be carried out safety subject to life savers and other compliance and mentioned percautions of the WA . I authorise this WA
holder to complete with following conditions prior to commencing of the work.
1. Isolation / Inhibits / Overrides of safety critical equipment are authorised.
2. Tool box talk shall be held to ensure that all the people involved were explained and understands the task hazards, risk & controls and is clear about
individual responsibilities.
3. Communicate the message to the workforce that “Any person is expected to stop the work if they believe that conditions under which the Permit was issued
have changed, or that risk is not being controlled adequately”.
4. The performing authority and the persons carrying out the work shall ensure that all machine / equipment / instrument are suitably certified and fit for purpose
prior to commencing work..
5. Issued WA shall be displayed at relavent location and worksite.
6. Supplementary controls based on dynamic risk assessment shall be in place during the execution of work by performing authority and communicated back to
issuing authority..

7. WA is automatically cancelled when any emergency situation arise or emergency alarm is sounded and have to be reissued after normal conditions resume
8. Other condition if any :

Issue of Work Authorisation

Description of Role Name of Person Sign Date

WA Issuing Authority Sandip Bhimani

I/We have read and understood the requirement of the WA document and assure that the site would be kept safe at all times.

Acceptance of terms and Reciept of a Work Authorisation

Description of Role Name of Person Sign Date

Performing Authority ( GGL) Indravijay Zala

Performing Authority ( Contractor) Anil

Suspension / Cancellation of work Authorisation

Joint Site inspection / Visit is done by performing and WA issuuing authority and site declared as ......................................
Task is suspended as incomplete Task is cancelled

Reasons/s ______________________________________________________________________________________________________________________

Suspension / Cancellation of WA Date Time Sign

Performing Authority

Permit Issuing Authority

Extention of Work Authorisation

Authorize extension / resumption of WA in consultation with SIMOP controller / Endorsing Authority.

Extension of work Authorisation

Extension /Resumption
Control Measures Sign of Performing Authority Sign of Issuing Authority
From (date /Time) To ( Date & Time)

Close out of work Authorisation

Close out of WA Date Time Sign

Declaration by Performing Authority
The site is returned to a safe, clear & tidy state, closures of inhibits / overriding of safety critical devices is confirmed and De-isolation is completed as per plan
with authorization from isolating authority and isolation confirmation certificate.
Declaration by Issuing Authority

It is ensured that site is restored to safe condition by performing authorities, PTW register or database is updated by Permit Coordinator and WA is now closed.

Performing Authority :

Permit Issuing Authority :

 Format No. HSE-F-03
Hot / Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

Section - 1
WA Number Date 28.06.2016
GA / Office
Yash Regency&Rajhans
City / Town / Village Job / Site Location Appartment
Activity Start Date 28.06.2016 Activity Completion Date 28.06.2016
WA Validity
Start Time 11:00 Completion Time 18:30
Title of the Job On line Tapping
Scope/Description of the job Online Tapping at Yash Regency and Rajhans Appartment

Name of the Contractor B J Patel

1. Safe System of Work 5 Confined Space entry

2. Excavation/Manual 6. Lifting Operations
Applicable Life Saver
3. Working at Height 7. Electrical Work
4. Gas Escape handling 8. Driving

Other jobs /plan having impact on this job? Yes / No

Role and Responsibility Matrix

Description of Role Responsibility Name Designation Mobile Number
Risk Assessor Project Incharge
Technical Manager / CNG O&M In
Isolation Plan Approving Authority Chirag Bhanvadia Deputy Mngr 9099953936
charge
Isolation/De-Isolation Confirmation
Performing Authority (GGL) NA NA NA
Authority at Work Site
SIMOPS (Simultaneous
O&M In charge NA NA NA
Operations) Controller
Performing Authority (GGL) OS Engg Vijay Site Engg

Performiong Authority (Contractor) Supervisior Mahesh Supervisor

Technical Manager / CNG O&M In
Issuing Authority Sr.Engg
charge Sandip Bhimani

Section - 2
WA Authorisation Requirement
Standard Work Instruction / Procedure Attached YES/NO Yes
Standard Isolation plan /Overrrides & certificates Attached YES/NO Yes
Site Specific Risk Register Attached YES/NO Yes
Minimum PPES Attached YES/NO Yes
Standard Emergency / Contigency arrangements Attached YES/NO Yes

List of Work force involved in the task & Undergone the tool box Talk
Sr.
Name Responsibility Number Remarks
No.
1 Ravi Plumber
2 Mahesh
3
4
5

List of critical Equipment / Tools / Instrument

Sr.
Item Qty Fit For Purpose Certificate Checked By (Work In charge) Verified By (HSE Rep)
No
1 Safety Belt 1 Vijay Zala Kunal Pathak
2
Stake holder management
Affected Party Name Checked & Verified by

NA

Section - 3
Work Authorisation Requested By
Description of Role Name Of Person Sign Date

Performing Authority Vijay

 Format No. HSE-F-03
Hot / Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

I am satisfied that the work can be carried out safety subject to life savers and other compliance and mentioned percautions of the WA . I authorise this WA
holder to complete with following conditions prior to commencing of the work.
1. Isolation / Inhibits / Overrides of safety critical equipment are authorised.
2. Tool box talk shall be held to ensure that all the people involved were explained and understands the task hazards, risk & controls and is clear about individual
responsibilities.
3. Communicate the message to the workforce that “Any person is expected to stop the work if they believe that conditions under which the Permit was issued
have changed, or that risk is not being controlled adequately”.
4. The performing authority and the persons carrying out the work shall ensure that all machine / equipment / instrument are suitably certified and fit for purpose
prior to commencing work..
5. Issued WA shall be displayed at relavent location and worksite.
6. Supplementary controls based on dynamic risk assessment shall be in place during the execution of work by performing authority and communicated back to
issuing authority..

7. WA is automatically cancelled when any emergency situation arise or emergency alarm is sounded and have to be reissued after normal conditions resume
8. Other condition if any :

Issue of Work Authorisation

Description of Role Name of Person Sign Date

WA Issuing Authority Sandip Bhimani

I/We have read and understood the requirement of the WA document and assure that the site would be kept safe at all times.

Acceptance of terms and Reciept of a Work Authorisation

Description of Role Name of Person Sign Date

Performing Authority ( GGL) Vijay

Performing Authority ( Contractor) Mahesh

Suspension / Cancellation of work Authorisation

Joint Site inspection / Visit is done by performing and WA issuuing authority and site declared as ......................................
Task is suspended as incomplete Task is cancelled

Reasons/s _______________________________________________________________________________________________________________________

Suspension / Cancellation of WA Date Time Sign

Performing Authority

Permit Issuing Authority

Extention of Work Authorisation

Authorize extension / resumption of WA in consultation with SIMOP controller / Endorsing Authority.

Extension of work Authorisation

Extension /Resumption
Control Measures Sign of Performing Authority Sign of Issuing Authority
From (date /Time) To ( Date & Time)

Close out of work Authorisation

Close out of WA Date Time Sign

Declaration by Performing Authority
The site is returned to a safe, clear & tidy state, closures of inhibits / overriding of safety critical devices is confirmed and De-isolation is completed as per plan
with authorization from isolating authority and isolation confirmation certificate.
Declaration by Issuing Authority

It is ensured that site is restored to safe condition by performing authorities, PTW register or database is updated by Permit Coordinator and WA is now closed.

Performing Authority :

Permit Issuing Authority :

 Format No. HSE-F-03
Hot / Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

Section - 1
WA Number Date 13.07.2016
GA / Office
Chaitanya Villa,Bapa
City / Town / Village
Job / Site Location Sitaram Chowk
Activity Start Date 13.07.2016 Activity Completion Date 13.07.2016
WA Validity
Start Time 10:30 Completion Time 18:30
Title of the Job Header Installation-1''-H+7

Scope/Description of the job Header Installation

Name of the Contractor B J Patel

1. Safe System of Work 5 Confined Space entry

2. Excavation/Manual 6. Lifting Operations
Applicable Life Saver
3. Working at Height 7. Electrical Work
4. Gas Escape handling 8. Driving

Other jobs /plan having impact on this job? Yes / No

Role and Responsibility Matrix

Description of Role Responsibility Name Designation Mobile Number
Risk Assessor Project Incharge
Technical Manager / CNG O&M In
Isolation Plan Approving Authority NA NA NA
charge
Isolation/De-Isolation Confirmation
Performing Authority (GGL) NA NA NA
Authority at Work Site
SIMOPS (Simultaneous
O&M In charge NA NA NA
Operations) Controller
Performing Authority (GGL) OS Engg/ Sr Engg Vijay Site Engg 9099957578

Performiong Authority (Contractor) Supervisior Rohit Supervisor 9825480068

Issuing Authority Tech Mngr Chirag Bhanvadia Deputy Mngr 9099953936

Section - 2
WA Authorisation Requirement
Standard Work Instruction / Procedure Attached YES/NO Yes
Standard Isolation plan /Overrrides & certificates Attached YES/NO NO
Site Specific Risk Register Attached YES/NO Yes
Minimum PPES Attached YES/NO Yes
Standard Emergency / Contigency arrangements Attached YES/NO Yes

List of Work force involved in the task & Undergone the tool box Talk
Sr.
Name Responsibility Number Remarks
No.
1 Rohit Supervisor 9825480068
2 Ravi Plumber
3
4
5

List of critical Equipment / Tools / Instrument

Sr.
Item Qty Fit For Purpose Certificate Checked By (Work In charge) Verified By (HSE Rep)
No
1 Harness 1 151871G2268 Vijay Zala Kunal Pathak

2 Rope 1 151871G2208 Vijay Zala Kunal Pathak

3 ID 1 15090SB7101 Vijay Zala Kunal Pathak

4 Fall Arrester 1 14344FM5878 Vijay Zala Kunal Pathak

Stake holder management
Affected Party Name Checked & Verified by

NA

Section - 3
Work Authorisation Requested By
Description of Role Name Of Person Sign Date

Performing Authority Vijay

 Format No. HSE-F-03
Hot / Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

I am satisfied that the work can be carried out safety subject to life savers and other compliance and mentioned percautions of the WA . I authorise this WA
holder to complete with following conditions prior to commencing of the work.
1. Isolation / Inhibits / Overrides of safety critical equipment are authorised.
2. Tool box talk shall be held to ensure that all the people involved were explained and understands the task hazards, risk & controls and is clear about
individual responsibilities.
3. Communicate the message to the workforce that “Any person is expected to stop the work if they believe that conditions under which the Permit was issued
have changed, or that risk is not being controlled adequately”.
4. The performing authority and the persons carrying out the work shall ensure that all machine / equipment / instrument are suitably certified and fit for purpose
prior to commencing work..
5. Issued WA shall be displayed at relavent location and worksite.
6. Supplementary controls based on dynamic risk assessment shall be in place during the execution of work by performing authority and communicated back to
issuing authority..

7. WA is automatically cancelled when any emergency situation arise or emergency alarm is sounded and have to be reissued after normal conditions resume
8. Other condition if any :

Issue of Work Authorisation

Description of Role Name of Person Sign Date

WA Issuing Authority Chirag Bhanvadia

I/We have read and understood the requirement of the WA document and assure that the site would be kept safe at all times.

Acceptance of terms and Reciept of a Work Authorisation

Description of Role Name of Person Sign Date

Performing Authority ( GGL) Vijay

Performing Authority ( Contractor) Rohit

Suspension / Cancellation of work Authorisation

Joint Site inspection / Visit is done by performing and WA issuuing authority and site declared as ......................................
Task is suspended as incomplete Task is cancelled

Reasons/s ______________________________________________________________________________________________________________________

Suspension / Cancellation of WA Date Time Sign

Performing Authority

Permit Issuing Authority

Extention of Work Authorisation

Authorize extension / resumption of WA in consultation with SIMOP controller / Endorsing Authority.

Extension of work Authorisation

Extension /Resumption
Control Measures Sign of Performing Authority Sign of Issuing Authority
From (date /Time) To ( Date & Time)

Close out of work Authorisation

Close out of WA Date Time Sign

Declaration by Performing Authority
The site is returned to a safe, clear & tidy state, closures of inhibits / overriding of safety critical devices is confirmed and De-isolation is completed as per plan
with authorization from isolating authority and isolation confirmation certificate.
Declaration by Issuing Authority

It is ensured that site is restored to safe condition by performing authorities, PTW register or database is updated by Permit Coordinator and WA is now closed.

Performing Authority :

Permit Issuing Authority :

 Format No. HSE-F-03
Hot / Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

Section - 1
WA Number Date 02.07.2016
GA / Office Rajkot
Copper Green City,Rail
City / Town / Village
Rajkot Job / Site Location Nagar
Activity Start Date 02.07.2016 Activity Completion Date 02.07.2016
`yy
Start Time 10:00 Completion Time 18:30
Title of the Job LP Commissioning

Scope/Description of the job LP commissioning at Copper Green City Rail Nagar

Name of the Contractor B.J.Patel

1. Safe System of Work 5 Confined Space entry

2. Excavation/Manual 6. Lifting Operations
Applicable Life Saver
3. Working at Height 7. Electrical Work
4. Gas Escape handling 8. Driving

Other jobs /plan having impact on this job? Yes / No

Role and Responsibility Matrix

Description of Role Responsibility Name Designation Mobile Number
Risk Assessor Project Incharge NA NA NA
Technical Manager / CNG O&M In
Isolation Plan Approving Authority NA NA NA
charge
Isolation/De-Isolation Confirmation
Performing Authority (GGL) NA NA NA
Authority at Work Site
SIMOPS (Simultaneous
O&M In charge NA NA NA
Operations) Controller
Performing Authority (GGL) OS Engg Vijay Site Engg

Performiong Authority (Contractor) Supervisior Gopal Bhai In charge

Issuing Authority Sr.Engineer Sandip Bhimani Sr Engg 9099957607

Section - 2
WA Authorisation Requirement
Standard Work Instruction / Procedure Attached YES/NO NO
Standard Isolation plan /Overrrides & certificates Attached YES/NO Yes
Site Specific Risk Register Attached YES/NO NO
Minimum PPES Attached YES/NO Yes
Standard Emergency / Contigency arrangements Attached YES/NO Yes

List of Work force involved in the task & Undergone the tool box Talk
Sr.
Name Responsibility Number Remarks
No.
1 Rohit In charge
2 Bhogilal Welder
3
4
5

List of critical Equipment / Tools / Instrument

Sr.
Item Qty Fit For Purpose Certificate Checked By (Work In charge) Verified By (HSE Rep)
No
1 EF Machine 1 S128B.61.04.02 Vijay
2 03.01.2017
Stake holder management
Affected Party Name Checked & Verified by

NA

Section - 3
Work Authorisation Requested By
Description of Role Name Of Person Sign Date

Performing Authority Vijay

 Format No. HSE-F-03
Hot / Cold
Work Authorisation Rev. No. 00
Effective Date 11/3/2015

I am satisfied that the work can be carried out safety subject to life savers and other compliance and mentioned percautions of the WA . I authorise this WA
holder to complete with following conditions prior to commencing of the work.
1. Isolation / Inhibits / Overrides of safety critical equipment are authorised.
2. Tool box talk shall be held to ensure that all the people involved were explained and understands the task hazards, risk & controls and is clear about
individual responsibilities.
3. Communicate the message to the workforce that “Any person is expected to stop the work if they believe that conditions under which the Permit was issued
have changed, or that risk is not being controlled adequately”.
4. The performing authority and the persons carrying out the work shall ensure that all machine / equipment / instrument are suitably certified and fit for purpose
prior to commencing work..
5. Issued WA shall be displayed at relavent location and worksite.
6. Supplementary controls based on dynamic risk assessment shall be in place during the execution of work by performing authority and communicated back to
issuing authority..

7. WA is automatically cancelled when any emergency situation arise or emergency alarm is sounded and have to be reissued after normal conditions resume
8. Other condition if any :

Issue of Work Authorisation

Description of Role Name of Person Sign Date

WA Issuing Authority Sandip Bhimani

I/We have read and understood the requirement of the WA document and assure that the site would be kept safe at all times.

Acceptance of terms and Reciept of a Work Authorisation

Description of Role Name of Person Sign Date

Performing Authority ( GGL) Vijay

Performing Authority ( Contractor) Gopal Bhai

Suspension / Cancellation of work Authorisation

Joint Site inspection / Visit is done by performing and WA issuuing authority and site declared as ......................................
Task is suspended as incomplete Task is cancelled

Reasons/s ______________________________________________________________________________________________________________________

Suspension / Cancellation of WA Date Time Sign

Performing Authority

Permit Issuing Authority

Extention of Work Authorisation

Authorize extension / resumption of WA in consultation with SIMOP controller / Endorsing Authority.

Extension of work Authorisation

Extension /Resumption
Control Measures Sign of Performing Authority Sign of Issuing Authority
From (date /Time) To ( Date & Time)

Close out of work Authorisation

Close out of WA Date Time Sign

Declaration by Performing Authority
The site is returned to a safe, clear & tidy state, closures of inhibits / overriding of safety critical devices is confirmed and De-isolation is completed as per plan
with authorization from isolating authority and isolation confirmation certificate.
Declaration by Issuing Authority

It is ensured that site is restored to safe condition by performing authorities, PTW register or database is updated by Permit Coordinator and WA is now closed.

Performing Authority :

Permit Issuing Authority :

 Manual Boring Safety
Sr. No Work Instructions
1 Criticality of the manual boring to be assessed prior to issue of Permit by GSPC Gas concerned site in charge if required a
visit may be instructed for executive or engineer/HSE Officer.
2 As per PtW Matrix, Permit to be obtained
3 Proper supervision as per PtW matrix for execution & safety to be ensured
4 GSPC GAS Life Saver to be performed
5 Tool Box talk to be performed prior to start job
6 All Hazards to be identified through site specific risk assessment
7 Prefer open cut whenever possible and avoid boring
8 Barricades, warning signs to be put in place. Use of PPE`s ensured.
9 All underground utilities to be identified and marked and informed to all persons working on the job.
10 Rescue arrangements to be in place for any emergency situation if critical boring is envisaged
11 Proper pit to be excavated suitable for person to enter properly and do the job safely.
12 Contractors’ responsible person to be on site for the activity and with his knowledge and under his supervision work to be
started.
13 Use of Electrical approved hand gloves and mandatory PPEs to be ensured.
14 Route of manual boring to be such that it must be possible to have observation pits at every 5 meter length for ensuring
proper trajectory of the tool.
15 Teflon Coated tools to be used for the manual boring.
16 Undercutting in pit shall not be allowed

5.4 Flushing & Pneumatic Testing by Air/Nitrogen

Sr. No Work Instructions
1 As per PtW Matrix, Permit to be obtained.
2 Proper supervision as per PtW matrix for execution & safety to be ensured.
3 GSPC GAS Life Saver to be performed.
4 Tool Box talk to be performed prior to start job.
5 All hazards to be identified through Site Specific Risk Assessments.
6 Barricades, warning signs to be put in place. Use of PPE`s ensured. Hard barricading in case of heavy traffic, main road.
7 Rescue arrangements to be ensured in case of an emergency.
8 Project Engineer should ensure proper tools & tackles & as laid drawing clearly marking pressurizing, venting and flushing
points .

9 Ensure calibrated pressure gauges are used having a range 1.5 times of test pressure or least count of 0.1 kg/cm2.
10 Ensure hoses are properly clamped .
11 GSPC GAS approved procedure for “PE Testing/cleaning & Commissioning” checklist should be complied.
12 Pneumatic testing of PE line shall not be done by keeping the PE line out of trench. PE line must be buried and ends to be
kept exposed outside of trench for nitrogen inserting and venting.
No flushing testing by pneumatic/nitrogen or natural gas on public place or crowded places. This test if required on
13 crowded places must be done during night hours/lean hours when public is not near the site. Still all safety arrangements
and precautions to be ensured e.g. barricades and warning signs.

14 As far as possible flushing by natural gas to be avoided. If unavoidable then proper procedures to be prepared and get it
approved by City Manager & Zone Head, or attach it for their review during authorizing of PtW.

15 All the equipment and materials used for flushing, testing to be of proper pressure class and tested and certified for the
use intended. Test certificates must be obtained and verified wherever required.
16 Fittings on flushing-testing assembly must be properly secured.
17 Flushing by air can be done up to 7 bars; above this pressure nitrogen must be used.
If flushing is of new line then it must be ensured that the surrounding area is checked for hazards, injury to working
18 persons nearby or bothering of nearby population due to high noise.
19 The air pressure shall never exceed the working pressure of the system.
20 Avoid burning of shrubs and plants for cleaning the pipeline laying area as the fire becomes uncontrollable.
 Movement of labor should not be allowed in the testing area only skilled personnel who are involved in testing should be
21 present and carry out the activity with utmost care.
22 Auto stopped compressor used for compressed air.
23 Testing of pipes with N2 /Air at 7 bar should not be done above ground.

6.6 Online Tapping From Charged GI Line

Sr. No Work Instructions
1 As per PtW Matrix, Permit to be obtained
2 Proper supervision as per PtW matrix for execution & safety to be ensured
3 GSPC GAS Life Saver to be performed
4 Tool Box talk to be performed prior to start job
5 All hazards to be identified through Site Specific Risk Assessments.
6 Barricades, warning signs to be put in place. Use of PPE`s ensured.
7 Ensure closing of main isolation valve of GI line and remove the handle and same to be communicated to affected
customers.
8 Provide danger tag on the main isolation valve showing ‘Do not open’.
9 Keep one helper near isolation valve
10 Vent the gas available in the downstream of isolation valve
11 After complete removal of gas, carry out plumbing work.
12 After completion of the activities, inform all customers about opening of isolation valve.
13 Remove the Danger tag and open the valve
14 Ensure customers are being informed timely before starting the work & after completion
15 Ensure adequate fire-extinguisher are available at site
16 Any spark produced material shall be kept at least 15 meters distance.

6.1 GI Riser Installation

Sr. No Work Instructions
1 As per PtW Matrix, Permit to be obtained
2 Proper supervision as per PtW matrix for execution & safety to be ensured
3 GSPC GAS Life Saver to be performed
4 Tool Box talk to be performed prior to start job
5 All hazards to be identified through Site Specific Risk Assessments.
6 Barricades, warning signs to be put in place. Use of PPE`s ensured.
7 Rescue arrangements in case of an emergency to be ensured.
8 Are rescue arrangements ensured in case of an emergency?
9 GI pipe end shall be cut at right angle by proper pipe cutters
10 Ensure only BSP taper thread die is used for threading GI pipe
Ensure that charged risers and risers under construction are marked and known to all on site, if workforce is to change in
11 between proper handover of work to be ensured. Open ends of piping under construction or not to be commissioned to
be plugged properly.
12 Permission of the housing society taken for the job.
13 Working at height as per Safety Code i.e. provision of safety belts, Scaffolding, Provision of PETZL WAH system to be
ensured.

14 Ensure that no overhead electrical cables are passing closer to the building where riser to be installed. If possible other
route to be explored.
15 Material staked properly in the premises.
16 Trained plumbers are doing the job and they carry the tool bags so that material does not fall on persons working under
construction area.

17 Plumber should be physically fit to perform the work and plumber’s medical test certificate to be taken before starting the
work (for vertigo, BP, sugar etc).
18 Plumber should not start the work with empty stomach.
If ladder is to be used, Length of ladder and spacing between the rungs confirm to safety code and inspected and
19
approved for use by HSE.
 Ladders to be secured at and at bottom & one person to be available for help. Every ladder shall be securely fixed. No
20 portable single ladder shall be over 9 metres in length. The width between the side rails in run ladder shall in no case be
less than 30 cms .for ladder up to and including 3 metres in length; for longer ladders this width should be increased at
least 15 mm for each additional metre of length. Uniform step spacing shall not exceed 30 cms.

21 All precautions ensured for suspended type of scaffolding or erected scaffolding those are inspected and ensured to be
safe for use by HSE Person or Execution engineer.
All working platforms, gangways, stairways more than 4 meters above ground level, closely boarded & have adequate
22 width.

23 All openings in floors of buildings or working platforms are provided with fencing or railing with minimum height of 1
meter.

24 While demolition all precautions like cordoning, warning, traffic diversion ensured? All electrical cables, wiring, installation
securely isolated
All safety precautions ensured for work in Confined spaces if risers are to be erected in such areas, with availability of
25
qualified stand by person
26 Arrangements ensured to safe guard the fall of a suspended load
27 Ensure concrete guard provided for risers
28 Ensure all open ends plugged properly
29 Ensure Teflon tapes are overlapped minimum three times on threaded portions
30 Ensure GI clamps are installed at not more than 1 mtr of distance from each other
31 Pipe provided with proper protection while it enters the kitchen through a wall?
32 Ensure all precautions ensured that no falling of objects on employees working below, fall of objects from the working
heights
33 Ensure touch up of powder coating wherever peeled off
34 For idle/future point, only hollow hex plug is to be used
 Contingency Action Plan for Flushing & Testing
SN Scenario Sequence of Actions Responsibility
Affected person to be taken away from work area
1 Electric shock and first aid to be given and to be taken to nearest
hospital

Affected person to be taken away from work area

Injury to working and first aid to be given, if required person to be
2
person taken to nearest hospital
Gokul Hospital-0281 246 4125

PPE Requirement
Sr No Activities Minimum Required PPEs
1 Flushing & Testing Hard hat, safety shoes, Reflecting jacket, Hand gloves, Ear plug, Boiler suit

5.4 Flushing & Pneumatic Testing by Air/Nitrogen

Sr. No Work Instructions
1 As per PtW Matrix, Permit to be obtained.
2 Proper supervision as per PtW matrix for execution & safety to be ensured.
3 GSPC GAS Life Saver to be performed.
4 Tool Box talk to be performed prior to start job.
5 All hazards to be identified through Site Specific Risk Assessments.
6 Barricades, warning signs to be put in place. Use of PPE`s ensured. Hard barricading in case of heavy traffic, main road.
7 Rescue arrangements to be ensured in case of an emergency.
8 Project Engineer should ensure proper tools & tackles & as laid drawing clearly marking pressurizing, venting and flushing points .
9 Ensure calibrated pressure gauges are used having a range 1.5 times of test pressure or least count of 0.1 kg/cm2.
10 Ensure hoses are properly clamped .
11 GSPC GAS approved procedure for “PE Testing/cleaning & Commissioning” checklist should be complied.

12 Pneumatic testing of PE line shall not be done by keeping the PE line out of trench. PE line must be buried and ends to be kept exposed outside of trench for
nitrogen inserting and venting.

13 No flushing testing by pneumatic/nitrogen or natural gas on public place or crowded places. This test if required on crowded places must be done during night
hours/lean hours when public is not near the site. Still all safety arrangements and precautions to be ensured e.g. barricades and warning signs.
As far as possible flushing by natural gas to be avoided. If unavoidable then proper procedures to be prepared and get it approved by City Manager & Zone Head,
14 or attach it for their review during authorizing of PtW.

15 All the equipment and materials used for flushing, testing to be of proper pressure class and tested and certified for the use intended. Test certificates must be
obtained and verified wherever required.
16 Fittings on flushing-testing assembly must be properly secured.
17 Flushing by air can be done up to 7 bars; above this pressure nitrogen must be used.
If flushing is of new line then it must be ensured that the surrounding area is checked for hazards, injury to working persons nearby or bothering of nearby
18 population due to high noise.
19 The air pressure shall never exceed the working pressure of the system.
20 Avoid burning of shrubs and plants for cleaning the pipeline laying area as the fire becomes uncontrollable.
Movement of labor should not be allowed in the testing area only skilled personnel who are involved in testing should be present and carry out the activity with
21 utmost care.
22 Auto stopped compressor used for compressed air.
23 Testing of pipes with N2 /Air at 7 bar should not be done above ground.
 Excavation >1.5 mtr safety
Sr. No Criticality of the manual boring to be assessed priorWork Instructions
to issue of Permit by GSPC Gas concerned site in charge if required a
1 visit may be instructed for executive or engineer/HSE Officer.
2 As per PtW Matrix, Permit to be obtained
3 Proper supervision as per PtW matrix for execution & safety to be ensured
4 Proper supervision as per PtW matrix for execution & safety to be ensured
5 Tool Box talk to be performed prior to start job
6 All Hazards to be identified through site specific risk assessment
8 Barricades, warning signs to be put in place. Use of PPE`s ensured.
9 All underground utilities to be identified and marked and informed to all persons working on the job.
11 Properperson
Contractors’ responsible pit to be
toexcavated
be on site suitable for person
for the activity and to enter
with his properly
knowledgeandand
do under
the jobhis
safely.
supervision work to be
12 started.
13 step cutting to be done for trench depth more than 1.5 mtr.
16 Undercutting in pit shall not be allowed

Contingency Action Plan for Manual boring

SN Scenario Sequence of Actions Responsibility

Affected person to be taken

away from work area and first
aid to be given, if required
person to be taken to nearest
2 Injury to person hospital

PPE Requirement
Sr No Activities Minimum Required PPEs
Hard hat, safety shoes, Reflecting
Excavatio
n >1.5
1 mtr. jacket.
 Manual Boring Safety
Sr. No Criticality of the manual boring to be assessed priorWork Instructions
to issue of Permit by GSPC Gas concerned site in charge if required a
1 visit may be instructed for executive or engineer/HSE Officer.
2 As per PtW Matrix, Permit to be obtained
3 Proper supervision as per PtW matrix for execution & safety to be ensured
4 Proper supervision as per PtW matrix for execution & safety to be ensured
5 Tool Box talk to be performed prior to start job
6 All Hazards to be identified through site specific risk assessment
7 Prefer open cut whenever possible and avoid boring
8 Barricades, warning signs to be put in place. Use of PPE`s ensured.
9 All underground utilities to be identified and marked and informed to all persons working on the job.
10 Rescue arrangements to be in place for any emergency situation if critical boring is envisaged
11 Properperson
Contractors’ responsible pit to be
toexcavated
be on site suitable for person
for the activity and to enter
with his properly
knowledgeandanddounder
the jobhis
safely.
supervision work to be
12 started.
13 Route of manual boringUse of Electrical
to be such thatapproved
it must behand gloves
possible to and
havemandatory PPEs
observation pitstoatbe ensured.
every 5 meter length for ensuring
14 proper trajectory of the tool.
15 Teflon Coated tools to be used for the manual boring.
16 Undercutting in pit shall not be allowed

Contingency Action Plan for Manual boring

SN Scenario Sequence of Actions Responsibility
Affected person to be taken
away from work area and first
aid to be given and to be taken
1 Electric shock to nearest hospital

Affected person to be taken

away from work area and first
aid to be given, if required
person to be taken to nearest
2 Injury to person hospital

PPE Requirement
Sr No Activities Minimum Required PPEs
Manual Hard hat, safety shoes, Reflecting
1 Boring jacket, 33 KV Hand gloves, Boring tool
 Contingency Action Plan for MP commissioning
SN Scenario Sequence of Actions Responsibility

Affected person to be taken away from work area and first aid to be given, if
Injury to working person
required person to be taken to nearest hospital
2

• All persons to be immediately removed from site,

• Identified sectionalize valves will be closed,
• Try to extinguishing fire with help of fire Extinguisher,
3 Fire due to gas leakage
• Victim to be taken to nearest hospital in case of any with providing first aid,
• Evacuation of unwanted person from site and restrict entry of others with proper
barricading,

Applicable Isolations (For performing the job)

Type Applicable – YES / NO Isolation Details Performed by Confirmed by
Mechanical

PPE Requirement
Sr No Activities Minimum Required PPEs
Excavation on Charged
1 Peline Hard hat, safety shoes, hand gloves, goggles

`
 Contingency Action Plan for 20mm Tee
SN Scenario Sequence of Actions Responsibility

Affected person to be taken away from work area and first aid to be given and to
1 Electric shock
be taken to nearest hospital

Affected person to be taken away from work area and first aid to be given, if
Injury to working person
required person to be taken to nearest hospital
2

• All persons to be immediately removed from site,

3 Fire due to gas leakage
• Identified sectionalize valves will be closed,
• Try to extinguishing fire with help of fire tender,
• Victim to be taken to nearest hospital in case of any with providing first aid,
• Evacuation of unwanted person from site and restrict entry of others with proper
barricading,
Civil Hospital - 0281 2471118

Applicable Isolations (For performing the job)

Type Applicable – YES / NO Isolation Details Performed by Confirmed by
Mechanical Yes 20mm Service line squzing Samir

PPE Requirement
Sr No Activities Minimum Required PPEs
1 20mm Tee Hard hat, safety shoes, hand gloves, goggles, Boiler suit

Nearest Hospital- Civil Hospital-0281 2471118

`
 Contingency Action Plan for Online Tapping
SN Scenario Sequence of Actions Responsibility

Affected person to be taken away from work area and first aid to be given and to
1 Electric shock
be taken to nearest hospital

Injury to working Affected person to be taken away from work area and first aid to be given, if
person required person to be taken to nearest hospital
2

• All persons to be immediately removed from site,

• Identified sectionalize valves will be closed,
Fire due to gas • Try to extinguishing fire with help of fire tender,
3
leakage • Victim to be taken to nearest hospital in case of any with providing first aid,
• Evacuation of unwanted person from site and restrict entry of others with proper
barricading,

Applicable Isolations (For performing the job)

Applicable – YES /
Type Isolation Details Performed by Confirmed by
NO

Mechanical Yes Riser Valve Samir J

PPE Requirement
Sr No Activities Minimum Required PPEs
1 Online Tapping Hard hat, safety shoes, hand gloves, goggles, Boiler suit

6.6 Online Tapping From Charged GI Line

Sr. No Work Instructions

1 As per PtW Matrix, Permit to be obtained

2 Proper supervision as per PtW matrix for execution & safety to be ensured
3 GSPC GAS Life Saver to be performed
4 Tool Box talk to be performed prior to start job
5 All hazards to be identified through Site Specific Risk Assessments.
6 Barricades, warning signs to be put in place. Use of PPE`s ensured.
7 Ensure closing of main isolation valve of GI line and remove the handle and same to be communicated to affected customers.
8 Provide danger tag on the main isolation valve showing ‘Do not open’.
9 Keep one helper near isolation valve
10 Vent the gas available in the downstream of isolation valve
11 After complete removal of gas, carry out plumbing work.
12 After completion of the activities, inform all customers about opening of isolation valve.
13 Remove the Danger tag and open the valve
14 Ensure customers are being informed timely before starting the work & after completion
15 Ensure adequate fire-extinguisher are available at site
16 Any spark produced material shall be kept at least 15 meters distance.
 Contingency Action Plan for Riser installation
SN Scenario Sequence of Actions Responsibility
Affected person to be taken away from work area and first aid to be given
1 Electric shock
and to be taken to nearest hospital

Falling/Hit of
Affected person to be taken away from work area and first aid to be given,
object on head or
if required person to be taken to nearest hospital
body
2

Affected person to be taken away from work area and first aid to be given
3 Fall from Height
and to be taken to nearest hospital

PPE Requirement
Sr No Activities Minimum Required PPEs
1 Riser Installation Hard hat, safety shoes, hand gloves, goggles, PETZL set

GI Riser Installation
Sr. No Work Instructions

1 As per PtW Matrix, Permit to be obtained

2 Proper supervision as per PtW matrix for execution & safety to be ensured
3 GSPC GAS Life Saver to be performed
4 Tool Box talk to be performed prior to start job
5 All hazards to be identified through Site Specific Risk Assessments.
6 Barricades, warning signs to be put in place. Use of PPE`s ensured.
7 Rescue arrangements in case of an emergency to be ensured.
8 Are rescue arrangements ensured in case of an emergency?
9 GI pipe end shall be cut at right angle by proper pipe cutters
10 Ensure only BSP taper thread die is used for threading GI pipe
11 Ensure that charged risers and risers under construction are marked and known to all on site, if workforce is to change in between proper handover of work to be ensured. Open
ends of piping under construction or not to be commissioned to be plugged properly.
12 Permission of the housing society taken for the job.
13 Working at height as per Safety Code i.e. provision of safety belts, Scaffolding, Provision of PETZL WAH system to be ensured.
14 Ensure that no overhead electrical cables are passing closer to the building where riser to be installed. If possible other route to be explored.
15 Material staked properly in the premises.
16 Trained plumbers are doing the job and they carry the tool bags so that material does not fall on persons working under construction area.

17 Plumber should be physically fit to perform the work and plumber’s medical test certificate to be taken before starting the work (for vertigo, BP, sugar etc).

18 Plumber should not start the work with empty stomach.

19 Ladders to be securedIf ladder
at andisattobottom
be used,
& Length of ladder
one person to beand spacing
available forbetween the ladder
help. Every rungs confirm
shall beto safety code
securely fixed.and
No inspected and approved
portable single for be
ladder shall useover
by HSE.
9 metres in length. The
20 width between the side rails in run ladder shall in no case be less than 30 cms .for ladder up to and including 3 metres in length; for longer ladders this width should be increased at
21 All precautions ensured for suspended least 15ofmm
type for each or
scaffolding additional metre of length.
erected scaffolding thoseUniform step spacing
are inspected shall not
and ensured exceed
to be 30 use
safe for cms.by HSE Person or Execution engineer.
22 All working platforms, gangways, stairways more than 4 meters above ground level, closely boarded & have adequate width.
23 All openings in floors of buildings or working platforms are provided with fencing or railing with minimum height of 1 meter.
24 While demolition all precautions like cordoning, warning, traffic diversion ensured? All electrical cables, wiring, installation securely isolated
25 All safety precautions ensured for work in Confined spaces if risers are to be erected in such areas, with availability of qualified stand by person
26 Arrangements ensured to safe guard the fall of a suspended load
27 Ensure concrete guard provided for risers
28 Ensure all open ends plugged properly
29 Ensure Teflon tapes are overlapped minimum three times on threaded portions
30 Ensure GI clamps are installed at not more than 1 mtr of distance from each other
31 Pipe provided with proper protection while it enters the kitchen through a wall?
32 Ensure all precautions ensured that no falling of objects on employees working below, fall of objects from the working heights
33 Ensure touch up of powder coating wherever peeled off
34 For idle/future point, only hollow hex plug is to be used