F-AMLAK-HSES-PTW001-01

Revision: 00
14 DEC 2022
Page 1 of 2

PERMIT TO WORK
Part A: GENERAL INFORMATION
Work Request No.: Name of Company: Al Jaber Steel Co Location: ☒ QNCC ☐ ECGC ☐ 44WBT Permit No.:
Work Area: QNCC – 07/M06 ☒ Elec ☐ Mech ☐ Hvac ☒ Inst ☐ Civil ☐ AV ☐ HK ☐ Other(s): ______________________________
Work Duration (days): 5 days Date & Time (Start): 06.05.2024 Date & Time (End): 11.05.2024 Equipment(s):
Description of work: Name of workers: Permit Type / Classification:
1. Mohd. Ramzan Usman 7. Tarachand ☒ General work ☐ Excavation
2. Manikandan Sekar 8. Ajeeb Ur Arehman
3. Anil Yadav 9. Ibrahim Ezz Aldeen ☐ Height work ☐ Electrical Isolation
4. Ram Ekwal 10. Sajruddin ☐ Hot work ☐ Mech/ Fluid Flow Isolation
5. Hemant Kumar 11. Muhammed Ashiq ☐ Confined Space ☐ Fire Protection System
6. Al Badry Ali ☐ Lifting Operation ☐ Hazmat /Chemicals
Certification / Documents Required (must be attached to the permit)
☒ Method Statement, Work Instructions ☐ Lifting Plan; Load Chart ☐ Technical Data Sheet / OEM Manual ☒ Copy of Vehicle Registration (Istimara)
☒ Risk Assessment; Env. Aspect & Impact ☐ 3rd party thorough examination / inspection certs ☒ Drawings (i.e., P&ID, Single Line Diagram, etc.) ☐ Copy of Motor Vehicle Insurance Policy
☒ Safety Data Sheet (SDS) ☐ 3rd party training certificates & licenses ☐ Toolbox Talks / Meeting / Briefing ☐ Other(s):
Identification of OHS Hazard & Environmental Aspect
☐ Slip, trip & fall at same level ☐ Exposed or faulty wiring / equipment ☐ Thermal (hot/ cold) surface or objects ☐ Repetitive movement
☐ Fall from heights ☐ Contact with live electrical parts ☐ Restricted working space ☐ Sustained/ awkward posture
☐ Load lifting / suspended load ☐ Electrical arcing / high fault current ☐ Remote and isolated work ☐ Excessive force exertion
☐ Falling objects ☐ Damage cable / fixed wiring ☐ Chemical ingestion, contact, inhalation ☐ Handling unstable or awkward loads
☐ Moving/ rotating /crushing parts ☐ Stored electrical energy / static shock ☐ Uncontrolled spillage ☐ Sudden force; handling heavy loads
☐ Sharp objects / parts ejection ☐ Buried/overhead utilities (cable/pipes) ☐ Chemical burn / splash ☐ Water pollution
☐ Excessive noise ☐ Poor lightings / illumination ☐ Exposure to biological agents ☐ Air pollution
☐ Vibration equipment / tools / objects ☐ Uneven/ unstable ground/work surface ☐ Presence of ignitable gas / dust ☐ Land pollution
☐ Pressurize energy release ☐ Adverse weather condition ☐ Handling flammable/ combustible materials ☐ Resource depletion
☐ Spring / tension energy release ☐ Non-ionizing radiation (i.e., UV, infrared, etc.) ☐ Hot work, spark potential/ ignition source ☐ Other(s): __________________________
Tools/ Equipment / Materials Required for the Work
☒ Hand/ mechanical tools ☐ Mobile plant equipment (i.e., forklift) ☐ Truck / HGV ☒ Ladder – specify type: __________________
☒ Electrical/ power tools ☒ Cleaning tools/equipment (i.e., scrubber) ☐ Mobile Work Elevated Platform (i.e., manlift) ☐ Chemical agent: ______________________
☒ Electric/ mechanical equipment ☐ Lifting equipment (i.e., crane, boom truck) ☐ Hot work eqpt (i.e., welding machine, brazing kit) ☒ Power / energy supply
☒ Compressor/pressurized tools/ equipment ☐ Lifting gears (i.e., chain block, shackle, slinging) ☒ Scaffolding ☐ Other(s): _______________________________
Precautionary and Protective Measures
☒ Helmet / hard hat ☐ Chemical respirator mask ☐ Thermal coverall
☒ Work activity is properly planned, and workers clearly understand the task they will be performing.
☒ Safety shoes ☐ Breathing apparatus ☐ Chemical coverall
☒ Method statement and risk assessment are available, communicated and implemented.
☒ Safety glass /goggles ☒ Ear protection ☒ Safety boots
☐ Workers are assessed regarding their skills, competencies, and training to carry out the task.
☒ Coverall ☒ Electrical gloves ☐ Harness & lanyard
☐ Workers are provided with PPEs intended for the task and training regarding its proper usage.
☒ High visibility jacket ☒ Mechanical gloves ☐ Shock absorber
☐ Adequate supervision, information, training, and instructions given to workers.
☒ UV glass / goggles ☒ Chemical gloves ☐ Gas Detector
☐ Routine inspection and maintenance carried out for all tools and equipment used for the task.
☒ Face shield ☐ Biological gloves ☐ Tripod / hoist / winch
☐ Appropriate tools and equipment are used for the task and are inspected prior usage.
☒ Welder face shield ☐ Thermal gloves ☐ Fall restraint device
☐ Installation of temporary barriers/ barricades and signage or hazard communication.
☒ Dust mask ☐ Dust coverall ☐ Lifeline/ Self-retracting lifeline
Environmental Measures
☐ Waste tipper available on-site & waste disposal by approved contractor ☐ Presence of retention tank / spill containment / secondary containment
☐ Recovery / recycling of waste by approved contractor ☐ Waste segregation bins
☐ Presence of emergency spill kit ☐ Other(s):
Part B: VALIDATION, ENDORSEMENT AND APPROVAL
Permit Applicant Permit Controller Safety Assessor Authorized Manager or delegate
Name Ahmed Khiyari
Designation Division Manager
Signature
Date & Time 17/04/2024
Contact Number 66527384
Undertaking or declaration
Permit Applicant I have prepared the undertaking of the tasks relevant to this PTW application and am satisfied that with the information provided and precautions taken this work can be safely conducted
I have examined the work location for safety, cleanliness, and readiness to undertake the applied permit tasks and satisfied that with the precautions detailed herein.
Permit Controller
The tasks have been verified to have no incompatible work and can be performed safely.
I have examined the work location, met, and discussed the permit conditions including risk assessment and safe control of work location with permit applicant and accept that work can
Safety Assessor
be safely conducted.
Authorized Manager I reviewed PTW with attachments and endorse signed above, therefore this PTW is now in effect.
Part C: DAILY RENEWAL BY PERMIT CONTROLLER
Name
Designation
Signature
Date & Time
Name
Designation
Signature
Date & Time
ISOLATION / DE-ISOLATION (FDAS)
ISOL DE-ISOL ISOL DE-ISOL ISOL DE-ISOL ISOL DE-ISOL ISOL DE-ISOL ISOL DE-ISOL ISOL DE-ISOL
Device No.
Name
Date
Time
Signature

Device No.
Name
Date
Time
Signature
Part D: CLOSURE / CANCELLATION
☐ Permit is CLOSED – Job is to be CONTINUED of New Permit No. ☐ Permit is CLOSED – Permit CANCELLED as present condition are not valid.
☐ Permit is CLOSED – Job is COMPLETED, area is Normalized and System Reinstated. ☐ Permit is CLOSED – Permit CANCELLED due to:
Permit Applicant Permit Controller Safety Assessor Authorized Manager or delegate
Name Ahmed Khiyari
Designation Division Manager
Signature
Date & Time 17.04.2024 & 2.30PM
 F-AMLAK-HSES-PTW001-01
Revision: 00
14 DEC 2022
Page 2 of 2

☐ ELECTRICAL ISOLATION ☐ MECHANICAL / FLUID FLOW ISOLATION

If chemical-based fluid
☐ Electrical face shield / arc flash shield ☐ Electrical coverall
Specific PPE ☐ Mechanical gloves ☐ Other: _________________________ ☐ Face shield ☐ Chemical Gloves & Boots
☐ Electrical gloves ☐ Other(s): ________________________
☐ Chemical Coverall ☐ Other: ________________________

☐ Turning off the power source (i.e., turn off local isolator or circuit breaker)
☐ Removing fuse
Isolation Method ☐ Removing key (emergency button in lock position)
☐ Shut Down Electrical Backup (UPS, generator, etc.)
☐ Other(s): _____________________________________________________________
☐ Uncoupling of belts, chain, pulleys, ... ☐ Stop arrivals of solids, liquids, gases (penstock, stoplog, blind flange, closing valve, …)
☐ Secure moving/ rotating parts ☐ Stop auxiliary circuits / manifolds (pneumatic, hydraulic, ….)
☐ Turning off the power source (pump, compressor, ….) ☐ Other(s): ______________________________________________________________

☐ Relax the springs or metal cables

☐ Drain fluids contained in the equipment
☐ Discharge Capacitors ☐ Set a low position sprung mass
Discharge ☐ Purge (achieve and maintain up to atmospheric pressure zone)
☐ Other(s): _____________________________________________________________ ☐ Wait a complete stop of the equipment
☐ Other(s): ______________________________________________________________
☐ Immobilization mechanical components (pins, candles ...)

☐ Padlock (Indicate Lock Number) ☐ Padlock (Indicate Lock Number)

Lock Out
☐ Tag Out ☐ Tag Out

☐ Check absence of:

☐ Check absence of voltage / current ☐ Check absence of:
Testing / Try-Out ☐ Tension ☐ Movement
☐ Try Out: Control start locally and/or remotely ☐ Flow ☐ Pressure
☐ Pressure ☐ Power

ISOLATION / LOCK-OUT TAG-OUT & TRY-OUT DE-ISOLATION / LOTO REMOVAL

LOTOTO/ LOTO Removal / Lock Removal / Lock Removal /
Isolation & Lock Isolation / Lock LOTO / Isolation Lock Removal &
Equipment / Equipment Isolation Padlock Try-out Done By De-Isolation De-Isolation De-Isolation
Means of Isolation Installed Installed By Verified By De-Isolation
Device Name Tag No. Authorized By Number (Name & Sign) Authorized By Done By Verified By
(Date & Time) (Name & Sign) (Name & Sign) (Date & Time)
(Name & Sign) (Name & Sign) (Name & Sign) (Name & Sign)
☐ Electrical
☐ Mechanical / Fluid Flow

☐ Electrical
☐ Mechanical / Fluid Flow

☐ Electrical
☐ Mechanical / Fluid Flow

☐ Electrical
☐ Mechanical / Fluid Flow

☐ Electrical
☐ Mechanical / Fluid Flow

☐ Electrical
☐ Mechanical / Fluid Flow

☐ Electrical
☐ Mechanical / Fluid Flow

☐ Electrical
☐ Mechanical / Fluid Flow

☐ Electrical
☐ Mechanical / Fluid Flow

☐ Electrical
☐ Mechanical / Fluid Flow

☐ Electrical
☐ Mechanical / Fluid Flow

☐ Electrical
☐ Mechanical / Fluid Flow