HRO PERMIT TO WORK Permit

N°
A Permit to Work must be established before commencing a High-Risk Operations. The Permit must be available on the operation location and during the work.

A. Application
Requested by Requested Date:
(NAME & COMPANY)

Discipline  Electrical  Mechanical  M&D  Civil  Other :

Previsionnal End
Workers number estimation Start Date:
Date:

Works to be carried out

Work Location / Equipment

B. Applicable HRO
Attachments
 Scaffold  Lifeline  Manbasket  MEWP  Ladder  Height max:
Work at height
 with personal fall protection  Others:
/
S
Collective protection  Guardrail  Floor opening  Safety net  Scaffold element  Exposure Method Statement /
 removal  Others: Where/When: height: / Sequence of Event

 Grinding  Welding  Brazing  Oxy cutting  Gas cylinder use  Close S

 Hot works combustible / Task specific Risk
 Others:
Assessment
Complex Lifting
 Complex Lifting operation
plan 
Not intended continuous Drawing/Sketch
Confined space  Close or Confined  Large enough to enter  Limited opening  /
occupancy
 or Permit Space  Conditions above  Gas can be present or generated due to work #3 - CS 
 Excavation  Pre dig permit  Work in excavation #5 - Excavation Task Specific Rescue
Plan
 Lock-out Tag-out (LOTO) #2 - LOTO

 Radiography #4 - Radiography  Other:

#6 - Hazardous
 Hazardous substances  Asbestos  Lead  Others:
Susbstances
 Diving / subaquatic works PTW from subC.

 Other information to be considerated:

Permit resquester confirms:

 All intervenants have received required trainings to perform activity  Equipment have been controlled as required per local regulation & GE requirements
D
C. Permit Opening & Closure
EHS Review Permit Opening Permit Closure
Subcontractor EHS (if any) Permit Requester Permit Requester
Signature Signature Signature
Name: Name: Name:

Date & Time: Date & Time: Date & Time:

GE EHS (if any) GE Permit Issuer GE Permit Issuer

Signature Signature Signature
Name: Name: Name:

Date & Time: Date & Time: Date & Time:

D. Shift / Daily PTW Extension

Permit Requester and Permit issuer (or delegate) authorize the extension of the Permit to work based on documents review as per work preparation. In case of new HRO - the permit must be updated
SHIFT
Date and Time Permit Requester Permit Issuer
DAY