SAMPLE UPDATED PERMIT TO WORK FORM- AME NOV 2013
Permit to Work #:
PERMIT TO WORK FORM
PLAN
Personnel Transfer Well operation Scaffolding Location of work:
Hot Work
Work over open water Explosives Hydrocarbon distribution system
Energy isolation
Hazardous chemicals Critical lifting operations Disconnection of safety system
Entry / confined space
Radioactive sources Pressurized systems Other: .....................................
Manriding
WORK DESCRIPTION:
Section 1
Date: From time: To time:
Day
Night
(*) Associated Isolation cert. #:
EXTEND UNTIL: (max 4 hours)
Person Perfroming Work
Supervisor signature: Section Leader signature: signature:
Equipment / tools:
Person Performing Work: <Name> Department: UHF/VHF Radio Channel Person Performing Work: signature:
SAFETY PRECAUTIONS AND WORK PREPARATION
COMPLETED BY SUPERVISOR Signature: COMPLETED BY PERSON PERFORMING WORK Signature:
TBRA Inspection of area every................................hour(s)
Equipment isolated against starting Drains to be plugged in the area
Electrical disconnection/lockout Simultaneous operations in work area
Blinding/Isolation PA safety announcements
Ventilation Restriction to the work area
Drained and empty Standby vessel
Section 2
Pressure relief FRC and crew
Other Safety watchman and check list
Entry watchman and check list
COMMENTS: Barrier/signs
Fire watchman and check list
Special PPE (as defined in TBRA)
MSDS reviewed and available
DISCONNECTION OF SAFETY SYSTEM Other
GAS MEASUREMENTS:
Fire & Gas Other
System: Gas Meter No: Hydrocarbons every hr
Location/Area: Calibration OK O2 every hr
Compensating measure: Note: H2S every hr
3
every hr
APPROVAL
Sectio
Section Leader: signature Client signature (Optional): Offshore Installation Manager or designee: signature
n
MEASURES BEFORE AND DURING WORK
DISCONN./CONN. OF SAFETY SYSTEM Signature: GAS MEASURING:
Disconnect: Time At hrs Value At hrs Value At hrs Value At hrs Value
Connect: Time Hydrocarbons
Section 4
Remarks: O2
H2S
Signature:
Safety precautions are in place and work preparation is OK The requirements are understood and will be carried out
Time at : Supervisor: signature Person Performing Work: signature
hrs:
WORK COMPLETION AND SIGN OFF
Section
All locks/signs removed Yes No Work Completed Yes No
Equip. ready to be used Yes No The work area is tidy and clean
The work area is cleared and clean
Supervisor work complete: signature and time Person Perfroming Work - work complete: signature and time
Section Leader: Sign Off Offshore Installation Manager: Sign Off
The PTW is electronically available via Maximo
