Classification: Internal Use #

EWP # XXXXXX ELECTRICAL WORK PERMIT

Fire Watch Details: Yes NA (Limited cases when power is isolated and LOTO is applied)
Details of work activity:

(Receiver)
SECTION-7
Sr. # Name Authorization # Department Signature Time
Equipment details Work execution details 1
Dept./Plant Unit Name / No. Equipment Name/Tag No. Department / Contractor SMP IF #. 2
3
Description of work: No of Workers: Gas Test: Yes NA If Yes Frequency ______hr Continuous Initial Gas Test Only
SECTION-1
(Receiver)

Time Oxygen LEL CO CO2 Benzene H2S Others Name Auth. No. Signature
20.80% 0% 25 PPM 5000 PPM 0.5 PPM 1.0 PPM PPM

SEC-8 (Issuer)
Type of Work:
Isolation/Restoration Repair Troubleshooting
<480V De-Enerize Live Fire protection: YES N/A
480V - 4.16 kv <50V 50 - 480 V DC AC CO2 Fire extinguisher Barricade / barrier Warning signs
< or equal to 480 Volts
>4.16 - 34.5 kv >480 V - 4.16kv >4.16 - 34.5 kv <50V Other ____________
>34.5 kv >34.5 kv <125V
Review & Approval: To be reviewed and approved as per SHEM-08.05 Authorization Matrix
Applicable LOTO Certificate: Yes NA If Yes, LOTO Certificate # ________________

(Authorized
Electrician)
(Review &
Approval)
Special PPE required : YES

SEC-09
1. Single line diagrams & Schematic diagrams Yes
SECTION-2

Review
(Issuer )

Insulated Rubber gloves Ear protection Goggles ARC Flash Jacket 2. Confirm that no other critical loads will be affected at the downstream of switchgear Yes
ARC Hood ARC Flash Face shield Chemical suit Dust mask 3. Confirm no interlock signal will be activated as result work execution Yes
High voltage gloves Di-Electrical Foot wear Full body harness Rescue Stick Name: ________________________ Authorization # __________________ Date: ______________ Signature: ___________________________
Rubber foot mats Leather Gloves Other ___________ Other ___________
Authorization (After Joint site visit)
Equipment & Tools to be used: Yes (Ensure that all tools & equipment should be inspected.)
SECTION-3
(Receiver)

Electric tools Insulated Hand tools Soldering tool Fork lift Permit Issuer Permit Receiver
Hydraulic tools Voltage Detector Non-classified electrical tool Crane Date: _________________________
Pneumatic tools Generator/compressor Other __________ Time: From ___________hrs. To ___________hrs. I hereby accept the stated conditions & precautions for the
Preparation check list, mention any abnormality or additional precaution to be add in Hazard Identification: work to be done safely.
I have checked and certify that the conditions & precautions required are as stated & work
Description YES N/A can be carried out safely.
SECTION-4
(Receiver)

SECTION-10 (Issuer & Receiver)

1. Equipment de-energized tagged, LOTO done? Name ________________________________ Name ________________________________
2. Proper grounding in place to avoid static electricity? ID : ________________________________ ID : ________________________________
3. Incoming supply isolated : Equipment no: Signature ________________________________ Signature ________________________________
4. Alternative standby /Parallel supply isolated Permit Extension
Extended by Permit Issuer Acknowledeged by Permit Receiver
ELECTRICAL SAFETY PPE & TOOLS REQUIREMENT Duration
Name ID. No. Signature Name ID # Signature
From To
FIRE RESISTANCE UNIFORM

SWITCH BOARD MATTING

INSULATED HAND TOOLS

EAR MUFF OR EAR PLUG

DIELECTRIC FOOT WEAR

ARC FLASH FACE SHIELD

ELECTRICAL ARC HOOD

INSULATING GLOVES

VOLTAGE DETECTOR
ARC FLASH JACKET
RUBBER BLANKET
SAFETY GOGGLES

HAND GLOLVES

Description of

AUDIO VISUAL
SAFETY SHOE

RESCU STICK
Hazard
HELMET

Isolation Operation for LOTO activities

Risk Endorsement
unit power / control isolation/ Category (In case Permit Issuer or Receiver left the shift due to any reason during valid work permit, new issuer or receiver has to make endorsement))
RACK IN-RACKOUT Name ID. No Endorsement as Signature Time
SECTION-5
(Issuer)

# 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
POWER - SWITCH OFF / ON - DOOR 0 √ √ √ √ √ √
Less than CLOSED Permit close-out
1 kV CONTROL SUPPLY - SWITCH OFF / ON 0 √ √ √ √ √ √ √ √ √ Permit Receiver :
4 √ √ √ √ √ √ √ √ √ √ √

RECEIVER
SEC-11 (Issuer & Receiver)

RACKING - OUT & RACKING - IN Work is completed Yes No

POWER - SWITCH OFF / ON - DOOR 0 √ √ √ √ √ √ √ √ Housekeeping completed Yes NA (Job is not completed)
4.16kV CLOSED

MCC CONTROL SUPPLY - SWITCH OFF / ON 0 √ √ √ √ √ √ √ √

RACKING - OUT & RACKING - IN 4 √ √ √ √ √ √ √ √ √ √ √ √ Name: __________________ID #: ____________Signature: ______________ Date: ___________ Time: ________
4.16 KV POWER - SWITCH OFF / ON - DOOR Acceptance by Permit Issuer:
2 √ √ √ √ √ √ √ √ √
Switchgear CLOSED Confirm Work & housekeeping is completed; notify effected area in section 6: YES N/A
CONTROL SUPPLY - SWITCH OFF / ON 2 √ √ √ √ √ √ √ √ √ √ √
ISSUER

& Confirm all Associated Certificates are closed in section 2: Yes No NA

Above RACKING - OUT & RACKING - IN 4 √ √ √ √ √ √ √ √ √ √ √ √ If No (State Reason)_________________________________________________________________________________
Affected Area Counter Sign by Supervisor or above : YES N/A
Name: __________________ID #: ____________Signature: ______________ Date: ___________ Time: ________
Confirmation with comments:
SECTION-6
(Issuer)

1) Tick ( √ ) for applicable boxes in the permit

Plant _____________ Name ____________________ Signature __________________ Date _________ Time __________
2) Perform TAKE TWO before starting the job
Note

Plant _____________ Name ____________________ Signature __________________ Date _________ Time __________ 3) 2nd copy to be displayed at worksite until close-out and then exchange the copy with permit issuer
Classification: Internal Use
Hazard Identification
#

1. What can go wrong? 2. What can cause it to go wrong?

Slips / Trips / Fall Flying Objects Sharp Edges Activity Inside confined space

Dust / Fumes / Mist Exposure to Noise Manual Handling Contact with Hot Surface

Fall from height Exposure to Vibration Contact with electric current Start/Stop Machinery

Poor Visibility Exposure to Pressure Working at height Awkward Positions / Static Postures

Blind Spot / Shadows Exposure to heat / Hot surface Poor Lighting Hazardous substance

O2 Deficiency / Enrichment Exposure to chemical Lifting activity. Dealing with high pressure

Flammable Material Exposure to cryogenic material Mobile Equipment Source of Ignition

Heat Stress / Cold stress Exposure to Radiation Contact with Machinery Surrounding Area

Falling Objects Electrical Shock / Static electricity/ Arc flash Radiant heat source Radiation source

Cut / Pinching Movement / Hit by / Caught in between Vehicle Entry Tools / Equipment involved

Wrong Posture Damage to EHSS critical assets. Environmental conditions Excavation

Fire / Explosion Engulfment Release of energy Congested area

Strain Bypass of EHSS critical devices Nitrogen handling

SECTION 11 4 What's Methods

Others (Specify);________________________________________________________________________________________________ (Others Specify);_________________________________________________________________________________

_______________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________
_________________________________________________ _______________________________________________________________________

Control Measures
3. What can be done to prevent it? 4. If it does go wrong what can be done to minimize the negative consequences?

Avoid Hand lifting Provide Machine guards. Develop a Rescue Plan TLD to radiographers in case of dealing with radiation sources.

Use of Tested & Certified Tools Avoid obstructions/spillage on Walkways. Provide Fire Extinguisher / Fire hose. Determine the safe distance from radioactive source

Physical Guard Rails / Fall Arrest Remove all combustibles / flammable materials. Location of Safety Shower / Eyewash Conduct Survey for monitoring the area radiation.

Provide sufficient lights. Provide continuous ventilation to worksite. Stand by ERT Install of retrieval device

Provide certified lights / flashlights. Grounding / bonding to avoid static electricity. Tool Box Talk with Crewmembers Provide warning signage

Use of Competent User Continuous Gas & O2 testing (Area / Personal) Provide Work instructions Report to Clinic

Blinds Installation Maintain Proper Housekeeping Use of Air horn Use Appropriate PPEs (Specify below)

Check equipment in close proximity Provide soundproof barriers to avoid high level Noise. Use of Flagman ________________________________________________

Lock out / Tag out (energy isolation) Maintain a wet area. Rotation of workers ________________________________________________

Provide GFCI. Area Barricade / Fencing Provide Special communication tools ________________________________________________

Provide fire Blanket / curtains _______________________________________________ Location of MCP ________________________________________________

Others (Specify);____________________________________________________________________________________________________ Others (Specify);________________________________________________________________________________

_______________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________
_____________________________ _______________________________________________________________________
Permit Issuer Name: ____________________________________ Signature: ______________________ Permit Receiver Name: _____________________________________ Signature_______________

* Tick [√] mark for Top applicable Hazard Recognition & Hazard Control points.

** Concerned department Owner / Executer shall add or elaborate on additional control of measures in Others (Specify) if necessarily.

***Formal JSA is required for Critical activities such as but not limited to activities inside confined space, critical lifting, hydro jetting, Man-lift with cage, Freezing, Diving, Repair on lifeline, and activities does not have approved SMP.

TAKE TWO: Take two minutes of think through a job before the job is started (Receiver)
SECTION 12

* Do all team members have a full understanding of the task, hazards & mitigation?
YES NO

* Are the Manual call point, assembly area point & safety shower known? YES NO

If you answer NO to any of the above questions, then mitigation action shall be taken BEFORE starting work