This permit relates to any work in a hazardous or dangerous area, which will not involve generation of temperature conditions likely to be of sufficient intensity to cause ignition of combustible gases, vapours or liquids in, or adjacent to the area involved.
| General
This permit is valid From ______________________________hrs
Date: ___________________
(Maximum validity 12 Hrs) To _____________________________ hrs
Date: ___________________
Work Location: __________________________________________
___________________________________________________________
Description of work to be done: ______________________________________
____________________________________________________________
Equipment To Be Used : ___________________________________________
_______________________________________________________
Names / Ranks authorized to work: ____________________________________
____________________________________________________________ |
| Section 1
Preparation and checks to be carried out by Officer in Charge of the work |
Yes |
N/A |
| 1 |
Has a formal risk assessment been prepared and discussed by the personnel working ? |
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| 2 |
Has the Equipment /Pipeline been sufficiently drained/cleaned ? |
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| 3 |
Has the area been thoroughly cleaned free from debris /hazards ? |
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| 4 |
Is the Equipment /Pipeline free of oil residues and adequately vented to atmosphere? |
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| 5 |
Has the space been positively segregated by blanking off or isolating all connecting pipelines? |
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| 6 |
Has the Equipment/Area been tested for gases ( HC ,H2S ,Others )? |
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| 7 |
Are Lock Out tags/notices in place where applicable? |
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| 8 |
Are all equipment in use of an approved /certified type and intrinsically safe to use? |
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| 9 |
Have all personnel used the appropriate personal protective equipment?(specify) |
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| 10 |
Any other permits involved with this job ? Please specify? |
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| SECTION 2 : AUTHORISATION |
| I am satisfied that all appropriate safety measures are in place and that the work can be conducted safely. |
Name, Rank and Signature of Responsible Person |
| Work Authorised By: |
Master / Chief Engineer |
First Copy for display at work area.Second copy for Ship’s recordsNOTE:Cold Work permit to be issued for all jobs involving blanking / disconnecting / connecting pipe work, removing and fitting of valves, blanks, spades or blinds, work on pumps, clean-up of oil spills and any such other work.
| SECTION 3 : PERMIT CLOSURE/CANCELLATION |
| Equipment /system has been de-isolated and returned to the “in-service condition” |
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| All notices and tags removed |
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| The work area and equipment is in a safe condition |
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| Work Completed |
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Permit is time Expired |
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Work suspended |
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| Permit Closed By Responsible Person : |
Signature : |
Date :
Time: |
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