PROJECT

P1085
NO.
CLIENT: CRUDE OIL TERMINAL AND
ASSOCIATED FACILITIES AT MUNDRA,
PROJECT
GUJRAT (EPCC-11) FOR HPCL
TITLE
RAJASTHAN REFINERY LIMITED
(HRRL)

PMC:
LOCATION MUNDRA, GUJRAT

DOC TITLE.
EPC PTW PROCEDURE
CONTRACTOR:
DOC No:1085-020-S01-601-009
NO. OF
SHEETS:12

PERMIT TO WORK PROCEDURE

A 05/01/2022 Issued For Review/Approval GMK D M Tripathi SM

Rev Date Purpose of Issue Prepared By Checked By Approved By

 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

Contents
1. Purpose............................................................................................................3

2. Scope................................................................................................................3

3. Definitions........................................................................................................3

4. Reference Documents.....................................................................................4

5. Responsibilities................................................................................................5

6. Instructions....................................................................................................10

7. Appendix........................................................................................................13

Doc. Name: 1085-020-S01-601-009-A_PTW Procedure Page 2 of 13

 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

1. Purpose
The purpose of this procedure is to provide Permit to Work system requirements to be used
for construction and pre-commissioning activities where permits to work are necessary to
control work activities.

During commissioning activities, a separate Permit to Work System shall be

established.

2. Scope
This procedure applies to all potentially hazardous work carried out on the Project
work sites whilst they remain under the operational control of CONTRACTOR.

All areas designated as “operational” and under the control of OWNER shall work
to the OWNER Permit to Work System.

The CONTRACTOR Permit to Work system is applicable until the individual

systems, units, plants or geographical areas designated as under the control of
CONTRACTOR until they are handed over to OWNER by CONTRACTOR, at which
point the OWNER Permit to Work system shall be applicable.

3. Definitions
CONTRACTOR Chemie Tech DMCC
PMC/OWNER EIL/HRRL
AGREED Agreed between CONTRACTOR and
PMC/OWNER. SUBCONTRACTOR Appointed Contractors and lower-tier
contractors.
PI Authorised Issuer
(CONTRACTOR Authorized Permit to Work Issuer)
AGT Authorized Gas Tester
COM Commissioning Manager
PMC Project Management Consultant
MOC Management of Change
PTW Permit to Work
HSE Health, Safety and Environmental
PM Project Manager
PD Project Director
CM Construction Manager
SME Subject Matter Expert
PE Professional Engineer
RCM Resident Construction Manager

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 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

RA Receiving Authority
JSA Job Safety Analysis
HIRAC Hazard Identification & Risk Assessment & Control
AA Approving Authority
WL Work Leader
PA Permit Applicant
AAR Approving Authority Representative
RAR Receiving Authority Representative

4. Reference Documents
International Standards
 ISO 14001 (Environmental Management System)
 ISO 45001 (Occupational Health & Safety Management System)

National Standards
 The Factories Act and concerned Factory Rules
 The BOCW Act and rules
 The Petroleum Act and Petroleum Rules
 The Indian Explosives Act and Rules
 The Motor Vehicle Act and Central Motor Vehicle Rules
 The Workmen Compensation Act
 The Gas Cylinder Rules and the Static & Mobile Pressure Vessels Rules
 The Indian Electricity Act and Rules
 The Indian Boiler Act and Regulations
 The Water (Prevention & Control & Pollution Act)
 The Air (Prevention & Control of Pollution) Act
 The Atomic Energy Act
 The Radiation Protection Rules
 The Indian Forest Act
 The Wildlife (Protection) Act
 The Environment (Protection) Act and Rules
 The Hazardous Wastes (Management & Handling) Rules
 The Manufacturing, Storage & import of Hazardous Chemicals Rules
 The Public Liability Act
 Indian Standard Specification of Drinking Water

Doc. Name: 1085-020-S01-601-009-A_PTW Procedure Page 4 of 13

 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

 Standard Specification for Health & Environment

Management B224/B229-682-001 Rev-0

PMC/ OWNER Specification

 Tender Document Ref. No. DC/B224-020-EP-T-9890/3012, DC/B224-B229-6-
82-0001

Including Clarifications and Addendums

CONTRACTOR DOCUMENTS
 HSE PLAN
 TRAINING PROCEDURE
 EMERGENCY REPONSE PLAN
 PROJECT HIRAC
 TRAFFIC MANAGEMENT PLAN
 CHEMICAL MANAGEMENT PROCEDURE
 PERMIT TO WORK PROCEUDURE
 ENVIRONMENT MANAGEMENT PLAN
 LIFTING PROCEDURE
 WORK AT HEIGHT PROCEDURE
 HOT WORK PROCEDURE
 EXCAVATION PROCEDURE

5. Responsibilities
When an activity is defined for a certain position in this procedure, the
responsibility remains with that person although a designee may perform the
implementation of that activity. The appointment must be recorded, and the appointed
designee must report directly to the assigned individual.

A List of Permit to work Authorised Persons will be prepared and maintained,

detailing persons Authorised to Apply, check, Issue, and Receive Permits to Work.
CONTRACTOR shall carry out an assessment and issue appointment letter to all
authorized persons.

Health, Safety & Environment (HSE) Manager

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 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

CONTRACTOR HSE Manager shall be responsible for the continuous monitoring

of the implementation of this procedure, in conjunction with the CONTRACTOR
Construction or Commissioning Manager, and will:

 Function as an adjudicator on any issues from the implementation of this

procedure
 Audit Contractors to ensure the requirements of this procedure are
implemented and provide feedback to CONTRACTOR. Assist
CONTRACTOR to plan and coordinate the work to effectively
implement the requirements of the procedure
 Ensure the required HSE records are generated and available for review
by OWNER, CONTRACTOR Management and Legal Authorities as
appropriate.
 In conjunction with CONTRACTOR Resident Construction or
Commissioning Manager, and /or their designees will conduct periodical
audit and review the effectiveness of this procedure.

CONTRACTOR HSE Manager will provide feedback to the PD/PM on the

performance monitoring and shall assist CONTRACTOR Supervision to plan and
coordinate the work to effectively implement the requirements of the procedure.

Commissioning Manager (COM)

CONTRACTOR Commissioning Manager in coordination with Construction and
the HSE Manager will:

 Evaluate work activities and determine the schedule from when these Permit to
Work procedure/requirements shall come into force for commissioning activities

 In consultation with the Resident Construction manager Schedule the transfer of

construction led activities to commissioning control.

Note: The date Transfer of Control from construction to commissioning will

typically be two weeks prior to the Introduction of hazardous / flammable materials or the
pressurization and energization of equipment.

Permit Issuer (PM/RCM/CM/Designate) (Approving Authority)

The CONTRACTOR PM has the overall responsibility for implementation of this
procedure and for ensuring compliance.

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 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

Those who shall be listed as Permit Issuer and shall Issue permit for the area
specified, should be;

 Experienced and familiar with the work activities for which the permit is to
be issued
 Capable of evaluation of work activities and scheduling the introduction of
the Permit to Work and various checklists.
 Able to coordinate with the Area Construction Manager the development of
Work Instructions (WI) to cover the transition and interface
communications in advance of the transfer from construction led to
commissioning led activities in the field.
 Clearly identifies the positions within CONTRACTOR and SUB-
CONTRACTOR organization and the roles and responsibilities in
implementing this procedure as indicated below:
 Responsible for ensuring the effective implementation, dissemination and
education of the requirements throughout the CONTRACTOR and SUB-
CONTRACTOR organizations.
 Able to ensure retention of all permits for a period of Project completion.
 Trained and certified to issue Permit to Work,
 Familiar with hazards associated with the work activities in their area.
 Able to review all relevant Permits to Work and documentation.
 Able to discuss scope of work with the Area Construction Manager.
 Able to ensure a physical check of the area along with the HSE,
Permit Approver, assigned by them, prior to the issuing of a PTW to a
Task Supervisor,
 Able to coach the Permit Applicant on the use PTW system

Permit Approver (CM/SITE ENGINEER) (Approving Authority

Representative) should.
 Be experienced and familiar with the work activities for which the permit
is to be issued
 Be trained and certified to approve Permit to Work
 Ensure the PTW is effectively implemented and applied
 Sign on the permit and acknowledge that the permit seekers are aware
of the work to be performed.
 Assess the area prior to, during and after the work
 Ensure a physical check on site and endorse the PTW

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 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

 Review all relevant documentation Including Method statements and

Risk Assessment.
 Be familiar with hazards associated with the work activities in their area.
 Discuss scope of work with the applicant
 Carry out physical safety precaution check of the area, prior to the issuing
of a PTW to a Task Supervisor.

Permit Coordinator should.

 Be trained and certified to check & coordinate Permit to Work
 Be responsible for liaising with SIMOPS
 Ensure the Method Statement and JSA/Risk Assessment are well known
to the permit applicants.
 Be responsible for coordinating all the permits in designated area.
 Ensure drawing and attachments are relevant to the activity described in the
permit.
 Conduct Permit coordination meeting as per the timely requirement.
 Ensure the permit is maintained and kept updated.

Permit Applicant (Receiving Authority) should.

 Be responsible for managing the permitted work and those staff
and/or Contractors who are going to carry out the Job.
 Be responsible for communicating the work requirements to the Task
Supervisors (Work Leaders).
 Ensure proper supervision for the work and that the PTW is understood
by workers prior to commencement of the work.
 Be responsible and accountable for identifying and assessing the
hazards/threat while performing the work activity including compliance
to Project policy and procedures, and Regulatory requirements for the
work activity.
 Only apply up to a maximum of 12 permits including other certificates
for one shift.

HSE Supervisor (Receiving Authority Representative) should.

 Be trained and certified competent for HSE supervision of Permit to Work.

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 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

 Provide advice on improvement to Method Statement and JSA/Risk

Assessment.
 Assure that the ground conditions are safe to work to precede as per PTW.
 Ensure a physical check on safety requirements applicable to the site work.
 Make sure the work activities in PTW were approved.

Task Supervisor (Work Leader)

CONTRACTOR and SUBCONTRACTOR Task Supervisors shall be thoroughly
familiar with this procedure and its implementation and enforcement. They shall: -

 Ensure that all relevant information and Documentation is provided to the

CONTRACTOR Authorised Issuer and that the Permit to Work and
relevant documentation is continuously available at the work location
throughout the work activity.
 Ensure that only competent persons are assigned work tasks. This includes
ensuring that the worker has the skills, knowledge, and physical ability to
safely execute the work task.
 Communicate the Method Statement and JSA/Risk Assessment and
Permit to Work requirement to the personnel working under the Permit to
Work and any other relevant information.
 Stop all work activities if there is change in conditions or activities that
invalidates the Permit to Work authorisation or if Permit to Work is
withdrawn.
 Remain at the work location throughout the Permit to Work activities.
 Transfer responsibilities only to an approved alternate Task Supervisor
if unable to remain in attendance at site.
 Be responsible for removing and closing invalid/expired Permit to Work’s.
 Responsible for ensuring that a valid Permit to Work is available in
the work area before commencing work and during the period of
work.
 Responsible to ensure that the MS and JSA/RA are known to the crew
performing the task listed in the permit and that only the task listed in the
permit is executed at the work site.

Authorized Gas Tester (AGT)

 The AGT shall be trained and certified by CONTRACTOR to conduct
the Atmospheric testing of the construction work areas.
 They shall be approved in writing by CONTRACTOR PD/PM/RCM.

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 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

 Shall be trained and tested for competency in the skills required to

conduct atmospheric test in the areas for which they have been assigned.
 Shall conduct such test as may be required to fulfil the criteria of this
Permit to Work procedure.
 Identify unsafe conditions related to hazardous atmosphere.
 Responsible for carry out gas testing (oxygen Level, toxicity and
Flammability).
 Keeping Record of atmosphere test.

Sub-Contractors
 Sub-contractors shall understand and comply with the Health, Safety and
Environmental requirements of this procedure applicable to the work
they perform.
 Sub-contractors must report to their supervisor any equipment
malfunction or event that may affect the safe operation of the equipment.
They are empowered to stop work at any time.
 Sub-contractors must advise their immediate Supervisor whenever
unsure of the instructions for a task or where concerned about the safety
status of any task.
 Sub-contractors to ensure valid PTW available prior to work start.

6. Instructions

6.1 Use of the Permit to Work (PTW)

The Permit to Work is to ensure that proper consideration is given to the hazards
of a particular job. The Permit to Work authorizes the carrying out of specific work, at a
certain time, and sets out the preparations, isolations and precautions necessary to
complete the work safely. All works shall require the production of a detailed written
Method Statement & JSA/Risk Assessment, TBT, which will be appended to the Permit to
Work. The application and strict adherence to this Permit to Work procedure is
compulsory and any non-compliance or deviations shall be reported and investigated as
per violation requirements.

Examples of activities that require a Permit to Work are all activities except:

 Site-wise Housekeeping.
 Emergency Rescue Works.

Doc. Name: 1085-020-S01-601-009-A_PTW Procedure Page 10 of

 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

6.2 Training Requirement

All Permit Applicants, Approvers, Coordinators, Issuers, shall be trained in the
PTW system implemented at COT Project. The competency requirements are listed
below:

Permit Applicants – Be able to read and speak basic English and carry out
JSA/risk assessment for tasks that will be performed by him.

Permit Approvers – Be able to read and speak basic English and carry out and
approve the risk assessment for tasks that will be performed by him.

Permit Coordinator - Be able to read and speak basic English and carry out,
approve and ensure adequacy of risk assessment for tasks that will be performed by him.

AGT - Shall have successfully completed Confined space training course.

6.2 Permit to Work Issue and Control

The timing of the Introduction of the General Permit to Work and associated
Checklists is the overall responsibility of Resident Construction or Commissioning
Managers in conjunction with the PM and HSE Manager.

Permit to be used:
 General Permit to Work: This permit will be used to perform works
exceeding one day at COT with a maximum validity period of 7 days. The
works envisaged are other than high risk and these permits are endorsed
by all the signatories, i.e., Authorised persons mentioned on the permit
form.
 Confined space Permit to Work: All works in confined space shall be
performed by competent persons only, using the confined space permit.
This permit will be used to perform works exceeding one day at COT
with a maximum validity period of 7 days provided atmosphere test
conducted by AGT in a frequent interval.
6.3 Clearance Certificates
When there is a need to perform high risk work under the General permit to work,
clearance certificates as described below will come into force. The certificate shall have to
be obtained for the high-risk work that will be executed during the currency of the
General permit to work and will be valid for 7 days. It is mandatory to cross reference the
general permit to work number in the clearance certificate. The different types of
clearance certificates are listed below.

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 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

 Hot work certificate: Required when Hot work is to be performed, e.g., welding,
grinding operations.
 Lockout Tag out certificate: Required during energy isolation tasks.
 Work at height certificate: When work is being performed in such a manner that
exposes workers to fall through a distance greater than 2 m, this clearance
certificate shall be used.
 Excavation clearance certificate: Required for any excavation at the work site.
 Lifting Certificate: Required whenever lifting activity has to be performed.
 Radiation Certificate: Required when carrying out activity involving exposure of
workers to ionization / radiation, e.g., NDT of weld work. This permit will be
used to perform NDT works for one day at COT.

All additional Checklists must be attached to a General Permit to Work and shall
form part of the Permit to Work.

The completed General Permit to Work is the final but to acquire authorization to
proceed, all relevant checklists, drawings and documentation must be attached to the
Permit to Work prior to authorisation to proceed being given.

6.4 Close Out

The Permit to Work shall be closed out by Permit Issuer, Permit Coordinator,
Permit Applicant when any of the following occurs:

 Work task is complete.

 Permit to Work has expired or has been revoked.

6.5 Termination
 Requirements set forth in the Permit to Work are not effective (Permit to
Work withdrawn).
 Working conditions change.
 Scope of work is changed.
 Unsafe or emergency conditions occur in the work area.

Doc. Name: 1085-020-S01-601-009-A_PTW Procedure Page 12 of

 Crude Oil Terminal (COT) and associated
facilities at Mundra, Gujarat (EPCC-11) for
HPCL Rajasthan Refinery Limited (HRRL)

Project No. 1085

PERMIT TO WORK PROCEDURE

Upon termination of the work activity, the Permit to Work and all other certificates
shall be returned by the Task Supervisor to the Issuer. The Permits to Work shall be
retained and archived by the Permit Issuer for Project completion period and produced for
verification when required by OWNER / CONTRACTOR. It is a legal document and
must be produced during any investigation of incident, if any.

6.6 Permit Duration and Renewal

Permit to Work’s shall be valid for the period not exceeding one 12-hour shift and
extension granted up to 2200hrs subjected to review & approval by Permit Approver.

Application of night work PTW from 1900hrs to 0700hrs.

Any permit that lapses 02 consecutive days will be automatically revoked and a
new application will be required.

If work is stopped for any continuous period exceeding 1-day, new permit need to
be applied.

Revalidation is required by AGT for Confined Space activity.

If work is stopped due to non-conformance with Permit to Work requirements, the

Permit to Work will be cancelled and shall not recommence until a new Permit to Work
application has been submitted and work is approved.

7. Appendix
 General Permit to Work Form
 Confined space entry Permit
 Hotwork certificate.
 Lockout Tagout certificate.
 Work at height certificate
 Excavation clearance certificate
 Lifting Certificate
 Radiation Certificate

Doc. Name: 1085-020-S01-601-009-A_PTW Procedure Page 13 of

 Date / Time Issued: Additional precautions for the work (in addition to those overleaf, and stated in associated certificates):
Day Serial No. Specify additional precautions :
COT Project Permit to Work
Date / Time Till:
(General) B/Fwd from Permit No:
Night

Description of Work: Attachments - Clearance CertificateYesNo

Hot Work
Excavation
Radiation Reference made to attached method of statement: YES NO
Safeguard Override
Isolation LOTO I certify that I have fully considered the implications of the work in line with the responsibilities detailed in the permit to work procedure and that the
Work at Height above precautions are adequate for the work to be carried out provided that the precautions are established and maintained.
Lifting
Permit Applicant Name/ Signature: Date/ Time:

Permit Acknowledge and Authorized By:

LOCATION: (Attach drawing/sketch as necessary) ADDITIONAL PPE REQUIRED Safety Assessor
YESNO Permit Approver Permit Issuer
Exact location of work: (HSE
Face Shield Chemical Suits N95 Respirator (Superintendent/Designate) (Project Director / CM/Designate)
ZONE 1 Supervisor) Permission is given for the work to proceed Permission is given for the work stated in this
Cartridge Respirators Leather Gloves Neoprene Gloves Rubber Boots Eye Protection
ZONE 2 I have checked on the HSSE subject to conditions above daily permit to proceed subject to conditions above
Ear Protection Breathing protection (SCBA) Others (specify):
ZONE 3 requirements applicable to the site work
ZONE 4 area daily
ZONE 5 Any additional PPE required shall be included in the MS & RA.
Valid
Until: Valid From: Until: Valid From: Until:
From:
Equipments to be used: Name: Name: Name:
Signature: Signature: Signature:
Date Time: Date Time: Date: Time:

Specialised / Rescue Equipments(if any): Permit validity (where work is going to last more than the duration of a day)
Permit Coordinator & Permit Applicant confirm by signing that the precautions required to work safely have been complied with prior to starting work each
day / work period and confirms that the work areas have been left in a safe condition and all staff has left the site.

Contractor List – Permit Applicant & Task supervisor to ensure their staff on site have made themselves familiar with the permit conditions, the work area
and the hazards of the work.
PERMIT APPLICANT Task Supervisor (Contractor)Permit Applicant Daily Close Out
Checklist Name : Company : Job Title : Date / Time Permit Applicant HSE Supervisor
Underground utilities Overhead power lines Rescue equipments Access and Egress Flammable materials
Task Supervisor:
Cutting
Nitrogen pressure test / DrillingFlow
Pressurised Housekeeping Adjacent
Lines Scaffold works
required Hydrostatic test
Noise Overhead works Grinding / Welding
Barricade/ Warning Signs
Hot Surface Hydro Jetting
Fire extinguishers
Grit blasting Banks man / Warden Lifting / Crane activities
OTHERS:
Lighting
Electrical activities
INSTRUCTIONS FOR APPLICANT

Work SHALL be performed according to PTW Procedure

(1085-020-S01-601-009)

Extended working hours are works to be carried out between 1900hrs – 2200hrs only.
SIMULTANEOUS OPERATIONS Extended Working Hours Date / Time Task Supervisor (Contractor)
Adjacent Issuing Authority (Zone) Permit Applicant HSE Supervisor Permit Approver
Commissioning Working Along Boundaries
Permit No:
I/C Name: Signature:
Permit No: I/C Name: Signature: Permit No: I/C Name: Signature:
Date Date:

DateTime: Time: Time:

LOTO MEASURES (if any) Permit Coordinator (HSE)

MECHANICAL ELECTRICALINSTRUMENTATION <24V (Review)
Equipment: Equipment / Electrical MotorInstrument: (Specify)
I have verified that the necessary drawings, attachments, approved copy of MS & RA arePermit
attached Close Out:
and in order.

ID / Tag Number: ID / Tag Number: ID / Tag Number: I hereby declare that all works for which this permit was issued has been Completed / Cancelled / Renewed, all personnel under my control have been
withdrawn and the work area and any associated equipments has been left in a safe condition.
YESNO YESNO YESNO
Permit Applicant Permit Coordinator Permit Issuer
Pressure free Locked off Isolated Locked off Isolated Disconnected
Name: Signature:
anked off Locked off Flushed See Isolation certificate: Bypass
Date: Name: Name: Name:
Ventilated, specify: No. of Isolation Certificate/s:

Time: Signature: Signature: Signature:

No. of Isolation Certificate/s:
Date: Date: Date:

Time: Time: Time:

WHITE: WORK LOCATION & PERMIT APPLICANT COPY BLUE: PTW COORDINATOR COPY
 Date / Time Issued:
Day Serial No.
COT Project Confined Space Permit
Date / Time Expires:
B/Fwd from Permit No:
Night

Communications Requirements:

The Attendant must be able to communicate with the worker(s) inside the confined space at all times. Check (√) means of communication to be used:
RadioVoiceVisualOther (Specify):

Should the Attendant be unable to establish communications after several attempts, activate the Rescue Plan
Description of Work: Attachments - Clearance CertificateYesNo
Hot Work
Excavation
Radiation We have reviewed the work authorized by this permit and the information contained here, written instructions and safety procedures have
Safeguard Override been received and are understood.
Isolation LOTO
Work at Height
Permit Applicant (Site Engineer/Task Supervisor)
Permit Coordinator Permit ApproverPermit Issuer
Name: (HSE) (Superintendent/Designate)(Project Director / CM/Designate)
Lifting
Name: Name:Name:

LOCATION: (Attach drawing/sketch as necessary) ADDITIONAL PPE REQUIRED Signature: Signature: Signature: Signature:
Exact location of work: YESNO
Face Shield Chemical Suits N95 Respirator Date: Date: Date: Date:
Area
Cartridge Respirators Leather Gloves Neoprene Gloves Rubber Boots Eye Protection
Ear Protection Breathing protection (SCBA) Others (specify):
Time: Time: Time: Time:
Any additional PPE required shall be included in the MS & RA.
Permit validity

Equipments to be used: Permit Applicant confirm by signing that the precautions required to work safely in confined space have been complied with prior to
starting work each day / work period and confirms that the work areas have been left in a safe condition and all staff have left the site.
Contractor List – Task supervisor to ensure their staff on site are familiar with this permit to work conditions, the work area and the
hazards of the work.

Specialised / Rescue Equipments(if any): Gas Tests Performed by AGT: Name: Date/Time:

Task Supervisor (Contractor) Permit Applicant Daily Close Out

Date / Time Permit Applicant AGT

Potential Hazards Yes NoN/A Potential Hazards Yes NoN/A

H2S (Hydrogen Sulphide) Oxygen Deficiency (e.g. Nitrogen) Flammable/Explosive
Environmental Conditions
/Toxic Gas Engulfment by liquids or solids
Flammable, Liquids/Solids Temperature
Ignition Sources Pumps or lines been blinded, disconnected,
or blocked
Other (Specify):
Other (Specify):

Electrical
Ionizing Radiation (X-Ray) Below Ground Level (Cave In)

Test 1 Test 2 Test 3 Test 4

Date / Time O2LELCOH2SO2LELCOH2SO2LELCOH2SO2LELCOH2S

PERMIT APPLICANT
Checklist YesNo Checklist Yes No
Gas Test required at Entrance and all Exhaust Locations Fire extinguisher(s) required
Communication Between Work Crew and Watch Person Lifeline and harness required
Emergency Services Notified of Work Location and Duration Rescue tripod required
Watch Person Clearly Identified (Vest) Trained on Duties Airline equipment required
Continuous/Periodic Gas Monitoring Required (Go to 11) Low Voltage lighting required
Entry and gas logs attached Low Voltage equipment required
SDS protective measures reviewed for implementation Warning signs posted at all entrances
Electrical / Instrumentation/ Mechanical Isolation required Ventilation Fan/Blowers required
Flammable material to be Used in Confined Space Safe Condition of all equipment has been assessed prior to use (Intrinsically safe)
Ventilation measured at outlet
(minimum flow rate 1.5Meter Cubic/ Person)
Remove ignition sources
(e.g. Hand phones matches lighters)
Confined Space work requires continuous supplied air
Close Out:
I hereby declare that all works for which this permit was issued has been Completed / Cancelled / Renewed, all personnel under my
If Yes, Specify Allowable Material and Required Safety Measures control have been withdrawn and the work area and any associated equipments has been left in a safe condition

Permit Applicant Permit Coordinator Permit Issuer

Name: Name: Name:

11. Gas
WHITE: Monitoring
WORK Required.
LOCATION CO/O2/LEL
& PERMIT Levels measured
APPLICANT COPY and recorded on section 3 of this permit prior to personnel entering Confined Space.
BLUE: PTWPreCOORDINATOR
entry after / BreaksContinuousEvery
COPY HourEvery 2 Hours
Signature: Signature: Signature:
 Tim

ReferenceSerial No. Permit to Work No.

COT PROJECT
A HOT WORK CERTIFICATE
Emergency Contact Info:
Specify location of work:

HOT WORK CHECKLIST

Communication link has been established with Site Control Room and Emergency Response Team Calibrated gas testing equipment to be used by
Lines/equipment’s drained, flushed and purged Adequate Fire extinguishers

Type:
(Additional other than those installed in the plant/work area),
The working area is defined with barriers or signs to prevent un-authorized entry/encroachment
Suitable spark containment, ARC shields/screens and Fire Blankets provided
Name:
Designated fire watch is assigned and understands their role.
Fire watcher remains on site for 15-30 minutes observation after work has been completed
Area within 15 meters of ignition sources are free of flammable materials or such materials are covered with fire retardant material Sewer m

HOT WORK IGNITION SOURCES (mark the applicable sources for the work being performed)
WeldingBlazingGas CuttingGrindingOther

Gas Tests Performed by: AGT Print Name and Signature:

INITIAL LEL READING by AGT: Hot Work not to commence unless LEL reading is 0%
Date and Time:Initial LEL % reading:

LEL Testing Results during the Hot Work: Work to be halted if LEL readings are MORE than 1% LEL If non continuous testing is done sp
Time of reading:LEL readingTime of readingLEL readingTime of reading

LEL reading

Other Atmospheric Testing results if required: enter any potentially toxic gases to be monitored below in blank Reading
Time of reading:O2 ReadingTime of reading: ReadingTime of reading: Reading

VALIDITY OF THE HOT WORK PERMIT: I certify that I have reviewed the proposed work and I am satisfied that the workers understand th

Hot work as described in the Permit to Work is allowed between: From: To:
Name
Signature Date/time
Permit Applicant: Permit Approver
Task Supervisor

HSE Supervisor

Hot Work Certificate is Withdrawn

Permit Applicant Initials
Date/Time Reason
 Reference Serial No.
COT PROJECT
E
Permit To Work No.
ISOLATION LOCKOUT/TAGOUT CERTIFICATE

Emergency Contact Info:

Specify location of work:

IDENTIFICATION OF EQUIPMENT BEING WORKED ON AND THE EQUIPMENT THAT IS LOCKED/TAGGED:

(specific Valves, Pumps, Motors, switchgear etc.)
Equipment Being worked on and verified to be at a zero energy state prior to work starting (describe or attach drawings if any):

TYPE OF LOCK OUT / TAG OUT (LO TO) USED:

Each Authorized Individual will apply LO / TO to each isolation device Use of Group LO / TO Using Lock Box

Energy Type Isolated: Mark below (√) the type of energy to be isolated:
Electrical Steam Hydraulic Mechanical Pneumatic Other
Method of Isolation: Mark below (√) isolation being used
Other
Lock & Tag Tag Only Blinds Double Block & Bleed
_
1) Prepare for shutdown, 2) Equipment shut down, 3) Identify all equipment isolation points, 4) Apply L/O-T/O
Sequence of Lockout: device(s), 5) Release stored energy, 6) Verify equipment will not start, 7) Perform work, 8) Clear tools,
inspect equipment, 9) Clear personnel from area, 10) Remove lock out/tag out devices, 11) Restart
equipment

AUTHORIZED INDIVIDUALS (Individuals doing the Lock out/Tag out including verification of zero energy state– If more signatures are require

Printed Name Signature Company Date

Validity of this Isolation Lock Out Tag Out Certificate

I certify that I have reviewed the proposed work and I am satisfied that the workers understand the hazards and that preventive measures are in place
with adequate supervision to proceed. The Isolation Work is allowed between:

From date/time: Until date/time:

Name Signature Date/time

Permit Applicant:

Permit Approver
Adjacent Issuing Authority: :

RECONNECTION

I have verified that the equipment under Lockout/Tagout is no longer locked or tagged, has been re-connected and is in safe working condition.
Name Signature Date/time
Permit Applicant: Permit Approver: HSE Supervisor:
Task Supervisor:
Isolation points must be recorded. This is to assist in identifying and recording any lock out or tag out points used. This record is useful prior to beginning
work and at completion of maintenance work (prior to return to normal operation) by creating a useful check to assure all locks and tagged devices have
been returned to their safe operating state (inclusive of vents and drains) prior to restart. Check (x) “Blind Installed” column only for isolation points using a
blind.

ISOLATION POINT IDENTIFICATION

 if Normal
Isolation  if Tag Blind Date Date
Isolation Point Identification Lock Operating Initials Initials
Point Installed Installed installed Removed
Installed position

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
COMMENTS
 Reference Serial No.
COT PROJECT
D WORK AT HEIGHT CERTIFICATE
Permit To Work No.

Location of work:
Description of work: Date / Time:

Emergency Contact No:

FIELD CHECKS (To be carried out before any Work at Height activities) (Tick where applicable)
YES NO COMMENTS
1 Can Engineering controls be applied, secure platform,
scaffolding, Mobile Elevated Work Platforms (MEWP)?
2 Are persons working exposed to unprotected edge?
3 Are hard barriers and warning signs required and displayed?
4 Are alternative walkways and emergency egress/exit routes identified?
5 Is there any barrier/ scaffold that require modifying or
removing? Is there a potential for objects to fall from height?
 Tools fitted with lanyards / Contained?
6  Debris nets
 Screened scaffolding?
Can objects be prevented from striking people below?
7  NO GO ZONES
 Overhead protection
8 Standby person be required below work location?
9 Proper means of transferring tools and materials to working platform
at height been considered?
Have fall restraint and fall arrest differences been properly identified and
10 suitable equipment selected?
11 Equipment in good condition, inspected and tagged?
12 Are suitable anchor points identified? Inspected and serviceable?
13 Are rescue equipment’s readily available around work areas?
14 Are you using a ladder within the ladder length of a handrail or moving
equipment?
15 Is the ground level stable & ladder secure from falling over?
17 Are personnel trained in work at height and safe use of equipment?
18 Any of the person carrying out the work suffer from any condition that
may impede his/her ability to work at height E.g.( Vertigo, Epilepsy )
19 Communication link has been established with Site Control Room and
Emergency Response Team
20 Are rescue equipment’s readily available around work
areas? Additional Checks / Comments Required:

VALIDITY OF THE WORK AT HEIGHT CLEARANCE: I certify that I have reviewed the proposed work and I am satisfied that the workers u
Work at heights as described in the Permit to Work is
From: To:
allowed between:
Name Signature Date/time
Permit Applicant: Permit Approver: HSE Supervisor:
Task Supervisor:

Work at Height Certificate is Withdrawn

Permit Applicant Initials
Date/Time Reason
 Reference Serial No.
COT PROJECT EXCAVATION CERTIFICATE
B Permit To Work No.

Location of excavation and estimated depth:

Excavation instructions applicable to the Permit Holder who is responsible for assuring compliance.
 When sloping is utilized as a protective measure for excavations, an acceptable sloping is 35 to 45 degrees’
horizontal. Steeper slopes may be allowed where pre-defined tables or charts exist based on soil classification or
where recognized soil engineering expertise personnel are involved in defining acceptable steeper slopes.
 Identify Overhead electrical lines (or other overhead infrastructure) and assure provisions are in place to prevent
contact (or encroachment beyond established safe distances when high voltage power lines exist) by equipment.
 Underground cabling and piping must be clearly marked /identified prior to excavation. Services drawings shall be
attached.
 Within 0.5 meter around piping and cabling, only manual method and digging shall be used.
 Exposed underground piping and cabling shall be supported in a safe manner.
 Soil removed from excavation must be a minimum of 1.5 meters’ setback from the edge of the excavation.
 Excavations 3 meters or deeper require proper benching and shoring plan with risk assessment report.
 Contaminated soil requires the use of appropriate PPE as well as specific Hazardous waste handling/disposal
plans.
 Hard barriers and warning signs must be displayed to prevent unauthorized entry, and visual warning systems in
place for vehicles
 A designate authorized person(s) must be identified below for daily inspections (may be Permit Applicant)

Controls Used: Sloping Shoring Shielding

a) Document below additional controls not otherwise included in this PTW to address job specific threats including: 1.
measures to minimize weather impacts on cave-ins, 2. provisions for safe access and exit for personnel who enter
the excavation, 3. additional rescue and emergency response provisions, 4 other threats specific to the job

Designated Task Supervisor for excavation (Name):

Additional necessary info not otherwise included elsewhere:

Additional space to communicate via sketch information about hazards/threats and controls:

Emergency Contact Info:

Validity of the Excavation Permit: I certify that I have reviewed the proposed work and I am satisfied that the workers understand th
Excavation Permit is allowed between:From:To:
NameSignatureDate/time
Permit Applicant: Permit Approver: HSE Supervisor:
Task Supervisor:

Excavation Certificate is Withdrawn

Permit Applicant Initials
Date/TimeReason
 Reference Serial No.
COT PROJECT LIFTING CERTIFICATE
F Permit To Work No.

PRE – LIFTING CHECKS ( tick where applicable)

Description of Lift

Classification of Lift Scoring: ROUTIN HEAVY LIFT

Exact Location of Lift
(provide sketch if necessary)

Type of Crane CRAWLER MOBILE CRANE LORRY CRANE OTHERS

Model Crane Make MAX. Capacity Total weight of load
TONS

Description of Load
(including hook, rigging, etc.) TONS
MAX. Working Radius
Boom Length SWL (load chart)
metres metres TONS
RemarksCrane Capacity
(if any)Used %

Lifting Supervisor Particulars / /

Name of Lifting/ Rigging Supervisor Signature Date

FIELD CHECKS (To be carried out on site before the actual lifting) (tick where applicable)

YES NO COMMENTS
Are lifting accessories (such as shackles, hooks slings) certified and free from visual signs of damage or deterioration?
Are the JSA/Risk Assessment and Lifting plan available and approved?
Are the involved equipment and accessories (i.e. slings, spacers, etc.) as indicated in the approved Lifting Plan?
Are the involved equipment (cranes, trailers with load, etc.) positioned according to approved Lifting Plan?
Is the daily crane checklist filled by the crane operator & the defects, if any, are reported & corrected?
Have the lifting crew been briefed on the safe lifting procedures?
Are the outriggers fully extended & approved pads provided?
Has the work area been barricaded with warning signs or other means of controlling pedestrian, vehicle or vessel traffic?
Has all environmental and SIMOPS hazards been identified? (including weather, visibility/lighting, traffic/human movement and other work act
Are all key personnel involved in the lifting identified and fit to work?

VALIDITY OF THE LIFTING PERMIT:

I certify that I have reviewed the proposed work and I am satisfied that the workers understand the hazards and that preventive measure
Lifting works as described in the Permit to Work is allowed
From: To:
between:
NameSignatureDate/time
Permit Applicant: Permit Approver: HSE Supervisor:
Task Supervisor:

Lifting Certificate is Withdrawn

Permit Applicants Initials
Date/Time Reason
 Reference Serial No.
COT PROJECT RADIATION CERTIFICATE
Permit To Work No.

C
Emergency Contact Info:

Section 1 To be completed by the NDT contractor's level II radiographer

Contractor Requesting:
NDT Contractor:
Date:
Time:
Location of radiography:

Names of Technicians Dosimeter (0-200mR/h)

NDT Level Badge No. Start Finish

Name of level ll Radiographer: Signature:

Section 2 To be completed by Radiography Coordinator

Equipment Checklist
YES NO Comments

Survey meter
Reading: mR, Calibration till:
Collimator
Audible warning devices
Emergency tool kit available
Tongs
Blinking warning lights available?
Area is defined with barriers and signs to prevent
un-authorized entry/encroachment
Are radiation workers wearing their film badge?

Extra shielding needed?

Communication link has been established with Site
Control Room and Emergency Response Team
Communication with other discipline contractors
established and informed?
Tool box meeting conducted before start of work
Lighting sufficient for RT crew
Other permits required are complied
Type of Isotope
Source Strength: Curies/KVA
Camera manufacturer:
Serial No:

Prior to use all equipment is to be inspected and after each exposure both the camera and guide tube are to be surveyed
ensuring the source is in the shielded position. The radioactive source shall not be left unattended

Measures to prevent and mitigate exposure:

Additional controls required:

The information stated overleaf has been reviewed by:

 Designation Radiography Supervisor Radiography
Name Coordinator Signature Date Time
Radiography In charge

Radiography will not commence until all safety requirements have been confirmed and all irregularities during work must
be reported immediately to Permit Issuer.

Validity of the Radiation Permit

Permit Applicant Permit Approver
I certify that I have reviewed the proposed work and I am satisfied that it is certificate
Work adequately described on to
and Permit theWork
Permitare
to Work documents
withdrawn and that
I certify that Ithe
amprecautions
aware of thedetailed
plannedinwork
this certificate
and that thear
From: Until:
Name:
Signature: Date/Time:

Date/Time: Reason:
Signature:

Date: Name:
Signature: Date/ Time: