Académique Documents
Professionnel Documents
Culture Documents
A. TO BE FILLED BY ORIGINATOR.
□ Originator______________________________ □ Executing Dept. : ______________________________________
Plant & site location : _____________________________________________________________________
Equipment No. & Location : _____________________________________________________________________
Description & nature of work : _____________________________________________________________________
Name of the agency involved : _____________________________________________________________________
Validity : From:-____________ Hrs to ___________ Hrs
B. HAZARD ASSESSMENT AND PRE-WORK SAFETY MEASURES
B1. TO BE CHECKED BY CONCERNED PLANT.
Equipment earlier used for Material (Mention last Content):____________________________________
Hazard associated with last content: □ Flammable □ Toxic □ Corrosive □ Oxidizing
□ Water Reactive □ Others______________
Expected Hazards : □ Toxic gas release □ Fall in to depth □ Fire/Explosion □ Chemical exposure □ Asphyxiation /Oxygen
deficiency □ Burns due to high Temperature □ Burns due to low Temperature □ Rotating Part □ Electrical Shock
No /
Precautions Yes If NO/NA, tell why?
NA
1. Has Equipment been □depressurized, □emptied, □cleaned, □washed □Cooled to room
temperature? Cleaned /flushed with □ water □ steam □ nitrogen □ Air □
Other(Specify)_________
2. Have all pipelines (Process & Utility) connected to the equipment been effectively
□disconnected □ blinded □isolated? (Use marker blind of proper rating.)
3. Has 24 volt portable flame proof lamp been provided for proper lighting inside the equipment ?
If anything unexpected happens, stop work immediately and notify the shift in-charge/ Plant HOD
Important In case of Emergency siren; stop work and bring job to safe mode immediately and follow On-site Emergency Plan
B2. TO BE CHECKED BY EXECUTING DEPT:
8. Have Provisions made by concerned □ plant □ Dept. been checked & found acceptable for the
work?
9. Name & Signature of persons entering in Confined Space after Tool Box talk.
Name : 1)______________________2)_______________________3)____________________
Sign : 1)______________________2)_______________________3)____________________
C. EXTENSION OF PERMIT:
All the permit conditions have been rechecked and the permit is extended.
Request for Extension up to time _________Hrs by (Department, Name & Signature) _______________________________________________
Request for Section B Extension may be Section B3 Extension Approved Extension Accepted
extension. rechecked and given rechecked and Head-Safety/ HOD – Executing Engineer/
(HOD-Exec. certified HOD (Concerned Certified HSE (G Shift) HOD
Dept.) Shift In-charge plant) (Safety Officer) Unit Head (For
(Concerned plant) Beyond G Shift)
Date: □Yes □No □Yes□ No □Yes □ No □Yes □No □Yes □ No
Sign:__________ Sign:__________ Sign:__________ Sign: _________ Sign: _________ Sign:__________
Name:_______ Name:_______ Name:_______ Name:_______ Name:_______ Name:_______
Time : ________ Time : ________ Time : ________ Time : ________ Time : ________ Time : ________
Date From To (Hr’s) Name & Sign of Name & Sign of HOD Name & Sign of HOD/ Name & Sign of Safety
(Hr’s) Shift In-charge Concerned plant. Engineer (Executive dept.
department.)
O2% ___ LEL%____
Sign Time
_______ _________
NOTE 1:
RESPONSIBILITY OF STAND BY OBSERVER:
i) Observer will maintain an accounting of all entrants in the confined space at all times.
ii) Observer will be knowledgeable of and will be able to recognize potential confined space hazards, and monitor activities inside
and outside the space to determine if it is safe for entrants to remain in the space.
iii) Methods of communication will be established so that the attendants can maintain effective and continuous contact with during
entry, and order individuals in the confined space to immediately evacuate for any of the following reasons:
(1) The Observer observes a condition, which is not allowed in the entry permit.
(2) The Observer detects behavioral effects of hazard exposure.
(3) The Observer detects a situation outside the space, which could endanger the entrants.
(4) The Observer detects an uncontrollable hazard within the permit space.
NOTE 2:
1) Hot Work Permit is to be followed in case of hot work at the confined space.
2) Violation of any of the above precaution will be treated as a cancellation of the permit.
3) This permit is not valid in case of emergency. In that case, stop the work in safe mode and follow onsite emergency plan.
4) The First issue of permit is to be in duplicate, 1st copy should be with executing department for display at work site while 2 nd copy is that of
safety dept. whenever renewal is required, authorization is to be taken in 1 st copy.
5) After completion of the work, 1st copy of permit is to be given to Originator Plant/Department who in turn will give to safety dept .
Sr. Name Company E. code / Signature Sr. Name Company E. code / Signature
No. Contract Name No. Contract Name