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Equipment To Be Used : ___________________________________________
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Names / Ranks authorized to work: ____________________________________
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| 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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