Project Name : Project No.

:
Document No. :
ISOLATION PERMIT

ISOLATION PERMIT No:

This Permit is for Isolation to :

Issued To : Work location : Type of Work:

Permit Holder :
Print Name Signature Date

AUTHORIZATION
Validity Period from : a.m./p.m. / / to: a.m./p.m. / /

Verified By :
Print Name Signature Date

Authorized by :
Print Name Signature Date

ASSESSMENT OF POTENTIAL HAZARDS

ENVIRONMENT & ISOLATION ASSESSMENT
What is involved? Yes No N/A What is involved? Yes No N/A

1) Pipelines (water, steam, gas)    2) Vessel pressurization   

3) Sludges/storm water (inrush)    4) Electricity   

5) Fall of ground (excavation)    6) Fire   

7) Chemicals    8) Harmful materials   

CONTROLS REQUIRED

9) Main power source isolation    10) Local area power isolation   

11) Circuit breaker isolation    12) Emergency stop   

13) On-off switches    14) Removable fuses   

15) Moveable parts blocked    16) Suspended parts lowered   

17) Compressed fluids/gases 18) Spring tension
     
drained released/blocked
19) All valves closed & locked    20) All lines blinded & tagged   
22) Extreme heat/cold
21) Double block & bleed      
dissipated
23) Atmospheric testing    24) Continuous monitoring   

25) Monitoring every ____ hrs    26) Ventilation forced/natural   

27) Red Locks and tags    28) Yellow Locks and tags   

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Isolation Permit

29) Lockout Hasps    30) Plug lock out device   

CONTROLS REQUIRED Yes No N/A CONTROLS REQUIRED Yes No N/A

31) Circuit breaker lockout devices    32) Cable lockout devices   

33) Valve lockout devices    34) Pneumatic lockout devices   

35) Barricades    36) Signage   

37) Ground support system stable    38) Batters & benches stable   

39) Access for personnel    40) Emergency rescue access   

PERSONAL REQUIREMENTS
42) JSEA
41) Risk management completed      
training/communicated.
43) Head protection    44) Eye protection   

45) Face protection    46) Fume/dust protection   

47) Hand protection    48) Hearing protection   

49) Foot protection    50) Clothing protection   

51) Fall protection    52) Other body protection   

53) Additional PPE training    54) Sentry   

55) Hot work permit 56) Emergency equipment

58) Other requirements
57) Notification - other departments      
(continuing)

EMERGENCY EQUIPMENT
List any emergency equipment required:

OTHER REQUIREMENTS and ASSOCIATED DOCUMENTATION

List any relevant documentation/work-specific method statements/drawings or manufacturer’s
instructions:

SHUT DOWN PROCESS

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Isolation Permit
Operating Plant & Equipment shall be shut down using the following steps :

For Isolation and De-Isolation Processes, refer to the following page.

START UP PROCESS
After Plant & Equipment has been de-isolated and energized, it shall be started up using the following
steps :

CLEARANCE FOR ISOLATION Refer form I0216-SAF-FM-009C, Isolation Entry/Exit Log

All persons are clear of the area that was isolated by this Permit. Further work requires a new Isolation Permit.

Permit Holder :
Print Name Signature Date

COMPLETION OF WORK
Work covered by this Permit is Completed / Suspended. Further work requires a new Isolation Permit.(select
one)

Permit Holder :
Print Name Signature Date

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Isolation Permit

ISOLATION TYPE CODES Isolation Permit No.:

LVI Low Voltage Isolation (< 1,000V) HVI High Voltage Isolation ( 1,000V) DCR De-Contactor Removed GI Gravitational Isolation
VLC Valve Locked Closed VLO Valve Locked Open SR Spool Removed (blank fitted) BI Blank Inserted
RI Radiation Isolation HI Hydraulic Isolation MI Mechanical Isolation BE Barrier

ISOLATION AND DE-ISOLATION PROCESSES

Isolati Isolation by Cross Checked by Special Precautions De-Isolation
No. Isolation Point on (Verification & Monitoring
Type Print Name Initials Print Name Initials Req’ts.) Print Name Initials

Where isolation extends beyond one shift, the New Permit Holder shall complete one of the sections below to indicate he has received adequate handover of this Isolation Permit

Time: …… ..…am/pm Time: ….…am/pm

New Permit New Permit
Holder Holder
Print Name Signature Date: ……./……./…… Print Name Signature Date: ….../……/…

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