PT Chevron Pacific Indonesia Revision 1

Flexible Program Management

No: 1523 – OM

FLOOR GRATING / HANDRAIL REMOVAL PERMIT

Date: Starting Time: a.m. p.m.

Company: Date : from ______________ to ______________

Location:

Nature of Work

Process Review

JSA Completed and approved Barricades In Place

Hazard Warning Signs in Place Safety harness with shock absorber lanyards

Area Inspected for Hazards Holes covered with substantial material

Observer Assigned if required Hole covers Anchored Down

The Hazard caused by the removal of the handrails or floor mesh must be barricaded or covered with hard barricading.

Fall protection must be used and processes implemented to restrict access to the hazard.
Name Signature Date

Initiator - Work Team Leader

Approver – TF CSM / HES:

Handing Back of Safe Work Area

Floor grating(with clips attached) / handrails back in place in place Yes No

If NO, what steps are being taken to verify that the area is maintained in a safe condition?

Area Inspected Yes No

Supervisor Name: Time: a.m. p.m.

Signature: Date : from ______________ to ______________

TF - FPM
Site Specific HES Procedures