HEALTH and SAFETY

DIGGING or EXCAVATIONPERMIT Form

ALL RIGHTS RESERVED FOR ALL COUNTRIES
DGT JOB NUMBER
SIZE DATE DRAWN UP CHECKED APPROVED

A4
B-000874

COMPANY FORMAT TYPE ZONE NUMBER REV. VERSION DOCUMENT STATUS COMMENTS STATUS

JVT W Q S 000 033 B FV

B


r.v Date Aim of revision Drawn up by Checked by Approved by

 1 DOCUMENT PRESENTATION

1.1 PURPOSE

This form is to be used to ensure, through technical and organizational measures, the control of
risks of accidents and occupational illnesses, according to the Work Permit Procedure.

1.2 SCOPE

This document applies to all activities under the responsibility of Degrémont Marubeni JV Doha
West Extension 5 Project. The list of required activities were a Digging and/or Excavation Permit in
addition of the general Work Permit is mandatory is detailed in the Work Permit Procedure.

1.3 TO BE CARRIED OUT BY:

Title Main role

Permit Issuer Issues the permit
Controls the respect of the permit on site
Analyzes the risks
HSE Officer Inspect compliance on site
Permit Holder Carries out the intervention as per the Work Permit instructions
Permit requester Requests for the work permit
Participate to the risk analysis
Ensure compliance with work permit content
O&M Head of Checks that no underground services will be damaged by inadvertence
Operation Validates the Work Permit

1.4 REFERENCES

JVT-W-QS-000-830 Work Permit Procedure

JVT-W-QS-000-831 Work Permit Form

1.5 DEFINITIONS

Work permit Safe work permit is a written record that authorizes an employee
with a specific work, at a specific location, for a specific period of
time
Permit requester Person requesting for a Work Permit
Permit holder Person carrying out the intervention
Permit issuer Person issuing the permit and therefore authorizing the start of
the intervention
2 CONTENT
See next page

The 3 first pages of this document must be removed before using the document.

Degrémont Marubeni JV Copyright - No reproduction without permission

 Document to be completed in addition to Work Permit if Digging / Excavation activities are
DiggingPermit no.:
identified.
The measures set out in this permit are applicable in addition to those specified in the
Associated Work Permit no.:
HSE Plan and/or Work Permit

DESCRIPTION OF WORK (if any points differ from work permit)

Name of contractor: Requester Name: Date of request:
Area: Building: Equipment Tag:
Duration of work: Date and starting hour: Date and ending hour (forecast):
Nature of the work:

Number of intervener workers: Permit Holder Name:

IDENTIFICATION OF RISKS ASSOCIATED WITH WORK(to be checked by O&M Head of Operation)

Existence or suspicion of underground electrical cables Proximity to hazardous areas (roadway, equipment operating area, etc.)
Existence or suspicion of buried conduits Miscellaneous obstacles (trees, etc.)
Permeation of subsoil (soil pollution by hazardous products) Other:

MEANS REQUIRED TO UNDERTAKE WORK

Hand tool: Shovel Pick Hammer pick
Machinery: Mechanical digger Coring rig Other:………………………………………

PREVENTIVE MEASURES
Shielding (mandatory if trench depth exceeds 1.30 m) Manual work within 50 cm of a cable or pipe before using machinery to
Slope less than 45° in absence of shielding and depending on type of soil finish filling
Use of helmet with chinstrap Ongoing presence of at least one stand-by worker (or several
depending on scope of excavation)
Marking of work area
Taking into account excess loads created by vehicular traffic and
Redirecting immediate traffic
construction equipment and by fill or other materials dumped near
Digging manually before switching to machinery excavation sites
Definition of means of trench access Establishment of a minimum safe distance from edge of hole to be
maintained by machinery: ………….

INFORMATION ON PERSONS PERFORMING WORK

Name of worker Company Training: machinery operation Validity period

TO BE VERIFIED BEFORE STARTING WORK

Plans available: Use of mechanical digger:
Electrical networks Copy of last inspection report
Fluid networks (e.g. gas, water, air) Presence of maintenance logbook
Geological profile Proof of driver training (or equivalent in accordance with regulations)

If no plans available:
Boring mandatory

APPROVAL OF DIGGING / EXCAVATION WORK PERMIT

Permit Requester Permit Holder Project Manager O&M Head of Operation HSE Officer
Date: Hour: Date: Hour: Date: Hour: Date: Hour: Date: Hour:
Name: Name: Name: Name: Name:
Company: Company: Company: Company: Company:
Signature: Signature: Signature: Signature: Signature:

I understand these work I have checked the above

I ensured that the safety I will use the safety precautions hazards and ensured that I ensured that the STP conditions and consider it safe
precautions are sufficient. listed in this document. operatives know them operation will not be disturbed. for this work.

DURATION OF PERMIT
Start date: hour: Finish date: hour:

White copy:Permit Issuer Green: HSE Office Yellow: Permit Requester Pink:Permit Holder

Degrémont Marubeni JV Copyright - No reproduction without permission