WORK PERMIT

Type of Work: Sl.No_____________

Hot Works Confined Space Entry Cold work
LOTOOT/ Isolation/
Work at height Excavation Breakdown/ Preventive
maintennace
Other

Work clearance from __________hrs of date__________To________hrs of date __________(Valid for the shift unless renewed)
Issued to (Department / Section / Contractor)
___________________________________________________________
Exact Location of work (Area / Unit / Equipment no.
etc)________________________________________________________
Description of work _____________________________________________________________________________________
_____________________________________________________________________________________________________
_
THE FOLLOWING ITEMS SHALL BE CHECKED BEFORE ISSUING THE PERMIT
(Tick mark in the appropriate box)
Sr Done Not Sr Done Not
no
Item Reqd. no.
Item Reqd
A General points D Entry to confined Space
1 Work Area inspected 1 Portable equipment / nozzles properly grounded
Standby persons provided for entry to confined
2 Surrounding area checked, cleaned and covered 2 space
Sewers, manholes, etc and hot surfaces nearby
3
covere 3 Portable equipemts inspected
Considered hazard from other operations and
4 4 Proper means of exit / escape provided
concerned persons alerted.
5 Tool box conducted 5 Proper ventilation and Lighting providing
Area cordoned off and Precautionary tags / Boards Proper Rescue Equipments identified and easily
6
provided. 6 acesible
7 PPE provided 7 24 V hand lamp provided
Gas / Oxygen deficiency test done
8. Equipments & power supply checked 5 (Oxygen level -19.5% - 23.5%)

9. All persons are EHS inducted E Work at height

Persons with medical fitness only will be
B For Hot work 1 allowed to work

Suitable and sufficient ladders/ platform

should be used and they must be securely
1 Proper ventilation and Lighting providing 2 fixed or supported?

If required suitable fall arrestor system

(rope grab and or safety net) shall be use
Gas cylinders are properly tied and stacked
2 3 and they must be securely anchoraged and
and inspected
supported?

Safety harness with twin lanyards should be

used & in good condition. Lanyards must
3 Fire watch Standby personnel provided 4 be anchored securely to lifeline
arrangements / fixed objects.

Suitable and sufficient length of life line

Checked for oil and Gas trapped behind the lining
4
in Equipment 5 should be provided.

Proper approach for work location

5 Fire Blankets provided against spark 6
Is ground free from oil/grease/ materials?
6 Fire extinguisher provided. 7
7 Fire Hose Lined Up (Applicable for Storage areas) 8 Electrical isolation is required
Is electrical supply provided through ELCB/
8 MCB? 9 Is proper scaffold provided

10 Scaffold Tag No.

 All Flammable/ Combustible materials are LOTOTO/ Isolation/ Breakdown/
9
removed F
Preventive maintenance
Equipment blinded / disconnected / closed /
10 Isolation is required 1 isolated / wedge opened

Equipment properly drained and

Equipment electrically isolated/ grounded?
11 2 depressurized

Proper platform available? Equipment de-energized

12 3
Circuit No. isolated by
13 Welding machine checklist attached 4 switches / isolators / links / fuses

Circuit breaker (lowered / removed)

14 Grinding machine checklist attached 5

Earthing lead no. provided

15 Gas cutting set checklist attached 6

LOTOTO recorded in the shift logbook

C Excavation 7
Barricading provided around the trench at the time
1 of work. 8 LOTOTO permit number

Isolation of Electric Supply shall be carried-out as

per the direction of Electrical Maintenance/Plant All tools & tackles are inspected and form:
2 9
Engineering Department. 10 is available

Manual excavation is to be carried till underground

services are exposed, if underground utility
3
services are existing
10 Appropriate access is available

Sloping / benching/ shoring should be done to

prevent cave-ins in case of loose soils/ more than
4
1.2 meters deep
G
Others: (Write down if any other
(A) “Deep excavation” Caution Boards to be point to be checked)
provided if the deep is more than 1.2 meters.

Access ladders must be provided for every 25 feet

5 of lateral distance 1

Debris / excavated soil must be 1 meter away from

6 the edge. 2

Earth moving equipment/ Material handling

equipment must be away (0.5 meter + Depth of
7 3
trench) from the edge.

All electrical connections must be approved by

Electrical Engineer. Double insulated wires and
ELCBs to be used. All electrical power lines must
8 be routed through cable trays / over head laid. 4
Ramps shall be provided over the cable trays
required for crane/hydra movement.

Mandatory PPEs as helmet, gum boots, Goggles

and hand gloves shall be used by the contract
9 workmen inside the trench, at the time of 5
excavation.

10 Excavation checklist attached 6

REMARKS:
1. The activity has the following expected residual hazards (Tick the relevant items): Lack of
Oxygen / H2S, Toxic Gases / Combustible gases / Pyrophoric Iron / Corrosive Chemicals / Steam – Condensate / Others
2. Following PPEs to be used in addition to standards PPEs (Helmet, Safety Shoes, Hand gloves,
Boiler suit): Face Shield / Apron / Goggles / Dust Respirator / Fresh Air Mask / Lifeline / Full body Safety Harness with
double lanyard / Airline / Earmuff etc.
3. Additional precautions if
any:.___________________________________________________________________________
___________________________________________________________________________________
 1. Contractor (Receiver) Contractor
2. Applicant Name &
Representative Name & Representative Applicant Signature
Designation
Designation Signature

3. Issuer Name & 4. EHS (Concur) Name &

Issuer Signature EHS Signature
Designation Designation

Clearance renewal
Additional Issuer Name,
Contractor
Time precautions Designation and
Representative Applicant Name,
if any, Signature EHS Name, Designation
Name, Designation &
Date Otherwise Sign
From To Designation, & Signature
mention
Signature
“NIL”

Closing of the work permit:

Contractor (Receiver): Certified that the subject work has Applicant: Certified that the subject work has been
been completed / stopped and area cleaned. completed / stopped and area cleaned.

Date & Time Name & Designation Signature Date & Time Name & Designation Signature

Issuer: Verified that the job has been completed and area EHS (Concur):
cleaned and is safe from any hazard.

Date & Time Name & Designation Signature Date & Time Name & Designation Signature

Authority:
Issuer: Any area incharge/ Plant manager/ Maintenance manager/ Plant head engineer and above, responsible for the area can
be an issuing authority.
Receiver: Site –in-charge or his representative from the contractor who has good knowledge about the work to be the receiver
of the permit.
Applicant: Any supreme engineer followed which work can be started.
Concur: supreme SO/E will be the Concurring party. Once the Work started after the receiver, applicant, issuer. Supreme
SO/E will be re ensure the Permit compliances.

Supreme Supervisor/ Engineer Must Ensure

1. Safe working conditions.
2. Proper protective equipments are used.
3. Proper tools are used. Ensure good housekeeping.
4. Likely hazards and remedial actions are made known.
5. Do not carry out any job on running equipment / machine without clearance.
Your Self (Labor):
1. Acquaint yourself with job and its hazards thoroughly.
2. Inform regarding unsafe condition.
3. If in doubt, consult the supervisors.
 Caution:
1. Do not commence work without a valid work permit.
2. All safety precautions, indicated should be meticulously followed.
3. If any violation from prescribed norms is observed then safety department has right to cancel the permit & Hold the job.

TOOL BOX TALK DETAILS

Conducted by job supervisor Name & Signature ……………………………………………………

Topic discussed: ……………………………………………………………………………………

Sub topic discussed…………………………………………………………………………………

………………………………………………………………………………………………………

Name Designation signature

General Instructions:
1. The work permit shall be filled up carefully and accurately in clear handwriting ensuring that complete information is provided in all sections / subsections and none of column is
left blank. Sketches should be provided wherever possible to avoid miscommunication.
2. Appropriate safe guards and required personnel protective equipment shall be determined by a careful analysis of the potential hazards and the operations to be performed prior to
starting the work.
3. In case of fire alarm / siren, all work must immediately be stopped.
4. Only certified vehicle / engines and permitted type of electrical equipment and tools are allowed in operating areas.
5. Welding machines should be located in non-hazardous and ventilated areas.
6. No hot work should be permitted unless the explosive meter reading is Zero.
7. When a person is entering confined space, the receiver must keep minimum two standby-designated persons at the manhole or entry point.
8. Before box up of any vessel manhole cover, ensure that no men / materials are inside the vessel.
9. For renewal of work clearance, the issuer shall ensure that the conditions are satisfactory for the work to continue. If the conditions have changed, it may be necessary to issue a new
permit or amend the existing permit.
10.This clearance on the same permit can be renewed / extended upto a maximum of seven calendar days.
11.This permit must be available at work site at all times.
12.On completion of the work, the permit must be closed and kept as record.
13.The industry may add other relevant instructions based on their operating and maintenance practices.
14.Tool box talk conducted by job supervisor
15.Relevant inspection checklist must be attached with permit
16.Job safety analysis must be attached with permit
HSE: 07 REV : 01 Issue No: 02 Issue Date : 03.02.2019