PLANT SAFETY REGULATIONS DOCUMENTREFERENCEGGR 0992

REV1

PERMIT TO WORK APPENDIXI

Dept: Priority Job No: EWT: Location: No

UNIT PLANT CODE PLANT REQUIRING ISOLATION

SPECIAL REQUESTS/ CONDITIONS/DANGERS

WORK TO BE CARRIED OUT CROSS REFERENCE

PTW No

Workers' Register No

Gas Test Cert No

PotentialProductionLossRecommis-sioningRequired

I S O L A T I O N S / I N S T R U C T I O N SPLANT CODE COMPONENT/INSTRUCTION REQ LOCATION STATUS * KEY OPS

PERMIT APPLICATION PERMIT ISSUED CLEARANCED T D T D T

APPLICATION COMPLETED BY APPOINTED PERSON SIGNATURE RESPONSIBLE PERSON SIGNATURENAME ** **

RESPONSIBLE PERSON SIGNATURE KEY SAFE NO SAFETY LOCK NO REVOCATION** D T

PRODUCTION SCHEDULED PERMIT ACCEPTANCE APPOINTED PERSON SIGNATURED T **

PLANT SHUTDOWN AGREED RESPONSIBLE PERSON SIGNATURE RECOMMISSIONING COMPLETEDNAME ** D T

*SEE NOTES AND ABBREVIATIONSOVERLEAF

TARGET COMPLETION RECOMM.DEPT SIGNATURE

**SIGNATURE

PTW PSR CPTWS TM

D T **

P E R M I T T O W O R K

S I

G N

A T

U R

E S

A P

P L

I C

A T

I O

N

IMPORTANT NOTE

PERMIT TO WORK The appointed person must carry out the necessary isolations to ensure that work can proceed without danger, ensuring that the correct plant

is being isolated, using safety locks and prohibitory signs according to the requirements of the Plant Safety Regulations, applying generalgood safety practice, and adhering to any local procedure which may be in force regarding the isolation of that particular plant.

Clean Hands Approach must be followed when extracting fuses . The responsible person must ensure that the correct plant has been isolated, that the work details are correct, that the stated isolations have

been effected, and that these are adequate for the prescribed work to be carried out without danger. The responsible person must sign the permit to work, having taken cognisance of any special conditions, requests or dangers endorsed

thereon. The permit to work will be deemed to be in force after the responsible person has signed acceptance.

Supervise/Supervision - means to oversee the actions of a person(s) to such an extent as to prevent any dangerous act, as far as reasonablypracticable.

Danger/dangerous - means a condition/substance that constitutes a risk of personal injury, impairment of health, or death. Any special precautions, conditions or dangers must be stipulated on the permit to work.

PERMIT TO WORK SUSPENSION SUSPENSION - means a mutual agreement on the permit to work form between the responsible person and the appointed person, which

stipulates that the work detailed on the permit to work has been suspended for the purpose specified on the permit to work. The responsible person must inform the workers involved in the work that it is no longer safe to do any further work on that plant, and the

workers register must be withdrawn. The appointed person must ensure that it is safe to operate the plant . The appointed person must signthe permit suspension on the original and the copy of the permit to work, thus suspending the permit to work. The date and time of suspensionmust be entered and must coincide with the date and time of the sanction for test.

SUSPENSION REVOCATION - means a written declaration on the permit to work form, signed by both the appointed person and theresponsible person, stating that the suspension has been revoked, the isolations as detailed on the permit to work reapplied, and that workmay be safely resumed. A new workers register must be completed.

CLEARANCE - means a declaration on the permit to work form, signed and issued by the responsible person in charge of the work, stating thatall personnel, tools and debris have been withdrawn and that the plant is in a serviceable condition.

REVOCATION - means a declaration on the permit to work form, signed by the appointed person, formally withdrawing the authority to workpreviously given on the permit to work, and stating the date and time of the withdrawal.

1ST REQUEST FOR PERMIT SUSPENSION AS AGREED IN SANCTION FOR TEST NoTIME: DATE: TIME: DATE:

RESPONSIBLE PERSON SIGNATURE: APPOINTED PERSON SIGNATURE:

1ST PERMIT SUSPENSION REVOCATIONTIME: DATE: TIME: DATE:

RESPONSIBLE PERSON SIGNATURE: APPOINTED PERSON SIGNATURE:

2ND REQUEST FOR PERMIT SUSPENSION AS AGREED IN SANCTION FOR TEST NoTIME: DATE: TIME: DATE:

RESPONSIBLE PERSON SIGNATURE: APPOINTED PERSON SIGNATURE:

2ND PERMIT SUSPENSION REVOCATIONTIME: DATE: TIME: DATE:

RESPONSIBLE PERSON SIGNATURE: APPOINTED PERSON SIGNATURE:

CHANGE OF THE RESPONSIBLE PERSON FOR PERMIT TO WORKTIME: DATE: TIME: DATE:

FIRST NEW RESPONSIBLE PERSON SECOND NEW RESPONSIBLE PERSONNAME SIGNATURE: NAME SIGNATURE:

ABBREVIATIONS THAT MUST BE USED TO INDICATE ISOLATION STATUS

Abbreviation Description Component Abbreviation Description ComponentL/O : locked open valve R/O+L : racked out and locked breaker/contactorL/S : locked shut valve F/W+L : fuses withdrawn, barrier / cabinet locked fuse holderO : open valve T+L : tripped and locked UP, MCBS : shut valve TEST : in test position BreakerT/S : tagged/taped shut valve CaE+L : cable earthed and locked BreakerT/O : tagged/taped open valve TEMP : temporary supplied breaker/contactorT/AVL : tagged/taped available valve CLSD : closed for temporary supply breaker/contactorAVAIL : available valve L/O+CF : locked open and control fuses withdrawn Breaker