SAFE WORK PERMIT

Work Permit Type Cold Work Hot Work Confined Space Entry Multiple Contractor Coordination
Ground Disturbance Vehicle/Site Entry
DATE: Sour Operation: Yes No __%
Date:
LOCATION:
General Description of Work:

Contractor(s)/Employer(s):
No of Workers

REVIEW SAFE WORK PERMIT HAZARD CHECKLIST

SEE NEXT PAGE for a list of general hazards you may wish to discuss as part of the work permit. Specify the job specific hazards below
Risk WORK PERMIT HAZARDS RISK CONTROLS/SAFETY PRECAUTIONS/WORK PLANS TO DEAL
(Risk assess each hazard with WITH EACH HAZARD IDENTIFIED (Reference procedures & standards
the matrix) reviewed)

RISK ASSESSMENT MATRIX PROCESS (see Company Name Matrix Criteria for Descriptions)

6 III II I I I I
5 III III II I I I
LIKELIHOOD

FOUR BASIC RISK QUESTIONS 4 IV III III II I I

3 IV IV III III II I
Increasing

What can go wrong? Identify the Hazards.

How bad can it be? Impact /Consequence/Severity 2 IV IV IV III III II
What is the Probability/Likelihood of it happening? 1 IV IV IV IV III III
What can I/we do about it? Risk controls, Work Plan 1 2 3 4 5 6
CONSEQUENCE Increasing
 SAFE WORK PERMIT HAZARD CHECKLIST
NOTE: CHECK OFF HAZARDS AND OTHER REQUIREMENTS REVIEWED AS PART OF THIS WORK PLAN
HAZARDS
Fire & Explosio Toxicity Mechanical Energy Effluents
Flammable Material H2S Kinetic Emissions
Explosive (perf. Guns.TNT etc) O2 Deficiency Equipment Dusts
Natural (e.g. forest fires) Carbon Monoxide Suspended / Potential Spills
Vapors/liquids Fumes / Vapors Trenching/Excavation Wastes
Flammable atmosphere Absorption Working at Heights Weather Conditions
Ignition Sources Chemical Slips /Trips Temperature
Welding Process People Visibility
Spark causing tools/motors Treating chemicals Physical Energy Site Conditions
Internal combustion engines Corrosives Noise/Light exposures Precipitation
Diesel Positive Air Shutoff Oxidizer/reactive Electrical Wind direction / speed
Pilot Lights Test Fluids Electromagnetic Biological
Static electricity Paints / Sealers etc. Pressurized Wildlife /animals
Identified/Controlled Asbestos Radiation (x-ray) Insects
MSDSs NORMS Bacteria/Molds/Viruses
Body fluids
RISK CONTROLS

PROCEDURES Confined Space Entry Other Overhead Power Lines

Emergency Response Work / Rescue plan Gas Test Required Identified / Clearances
Emergency Phone List Trenching/Excavation Intermittent _______min. Hazards Related to Other Work
Site First Aid Plan Work/Rescue Plan Continuous Underway __ No __Yes, Specify_____
Alarms/Conditions Isolation Gas Detection Equipment Planned __No __ Yes, Specify_______
Egress/Muster Process/Pressure Bump Tested Other___________
Rescue Procedures & /Equip Bleeds & Drains Building Entry Miscellaneous
Plan Review & Exercise Flare System Purging/Venting/Flaring/Cleaning Lock out / Tag out
Critical Task Procedures Electrical Vessels Depressuring / Venting
Reviewed Cathodic protection Lines Grounding / Bonding
Copy Attached Mechanical Tanks/Incinerators/Flare Stacks Smoking Rules I Area
Working Alone Spacing / Clearances Other Ladders / Scaffolds
Company Name Fired Equipment Hazardous Areas Fall Protection
Contractor Site Hazards Identified Buddy System
Ground Disturbance Flares/Vents/Storage Vessels Barricaded / Signed Towing Procedures
GD Checklist Completed Safe Vehicle Operation Buried Facilities / Pipelines / Waste disposal
Vehicle back up beepers Conduits / Electrical Other —

TRAINING Competency for Task Fall Protection WORKPLACE

Safety Orientation Rigging and slinging High Angle Rescue Refusal of Unsafe Work
Health & Safety Rules Reviewed First Aid / CPR Confined Space Entry & Rescue Workplace Violence
Orientation TDG Ground Disturbance NO FEAR Workplace
Contractor WHMIS Line Locating ALL incidents reported
Company Name H2S B0P / Well Control Hazard Identification Cards
Mobile Equipment, Loaders, Basic Fire Training All Certifications On Site
Cranes, Forklifts. etc Gas Detection Equipment Use Other

EQUIPMENT_REQUIRED Breathing Apparatus Communication Equipment Barricades

PPE Appropriate for Task SCABA (Intrinsically Safe) Miscellaneous
Monitors (LEL. H2S, 02, CO) SABA / Air Trailer Intrinsically Safe Cords, Lights, Welding / Splash Shield
Other _______________ Respirator Flashlights, Equipment Ventilators / Air Moving Equip.
First Aid Kit / Equipment Safety / Fire Watch/Stand by Fall Protection Equipment Air Hood
Eye / Skin Wash / Shower Personnel Assigned to _______ Fall Arrest Devices Watertight Equipment
Shower Truck Ignition Equip./ Flare Gun) Harness Spill / Pollution Control Equip.
Emergency Transport Vehicle Firefly Signaling Device Equipment Spacing Tag Lines
Ambulance & EMT Fire Suppression Other Sewage Containment Equip.
Auto Resuscitator Portable Rescue Equipment Garbage/Recycle Bins
Auto Defibrillator Wheeled Ladders / Platforms / Scaffolds Supplemental Lighting
Fire Truck(s) Warning Signs Other
FOR WORK PERMITS:
1. Review generic hazards list above (memory tickler). Identify only those hazards related to the task to be completed.
2. Run each hazard identified through the risk matrix process to determine the risk level. Put a mark/write on the matrix.
3. Check off only those hazards that indicate medium to high risk (yellow to red on the matrix). There should be very few (1 to 5). Example - Confined space (2) - toxic atmosphere
and/or restricted ingress/egress. If you have more than 5, you are probably doing a site orientation, not a work permit.
4. List these hazards in Job specific terms in the Work Permit Hazard column on page 1.
5. For these identified hazards, check off all appropriate (task specific) risk control measures in the Procedures, Training and Equipment Required sections of the Hazards Checklist.
6. For each hazard identified in the first column on page 1. document specific risk controls, safety precautions, work plans (using the items checked off in the Procedures, Training,
and Equipment Required columns as a reference / memory tickler) in the second column on page one.
7. Where work plans/procedures are available, you need only reference them as being reviewed. Example - Reviewed contractor “xyz’s” procedure for ‘xxxx” and assigned work
specific tasks.
8. Where work plans do not exist, then they need to be developed prior to commencing work. Document on Work Permit, or as an attachment to the permit based on complexity.
9. Have safety checks done by qualified individual to ensure work site is safe for workers to enter based on conditions of permit. Person doing checks to sign off on page 3.
10. Permit Issuer and Permit Receiver(s) sign Work Permit Validation Agreement page 3. Review meeting attendees sign meeting attendee list page 3.
11. Permit issuer and Permit receiver close out work permit (work complete, program change, permit expired. etc.) by signing,
12. Permit issuer sends original permit(s) to Calgary for review and retention.
 SAFE WORK PERMIT VALIDATION AGREEMENT

SAFETY CHECKS
COMPLETED BY:
Name Signature Contact Number Date/Time
Permit Date & Time Permit Valid Date & Time Permit Date & Time
Issued Until Extended

PERMIT ISSUER/Print Name Signature

I understand the work explained to me and the requirements and safety precautions to be followed. I understand that
work conditions change or hazards occur (ex: flammable/toxic material leaks, spills, drastic operating change in
adjacent equipment/process, etc.) I am to stop work and contact the permit issuer immediately.

PERMIT RECEIVER / Print Name Company - Signature - Permit Returned . Signature

PERMIT RECEIVER I Print Name Company Signature Permit Returned - Signature

PERMIT RECEIVER / Print Name Company Signature Permit Returned - Signature

PERMIT RECEIVER I Print Name Company Signature Permit Returned - Signature

PERMIT RECEIVER / Print Name Company Signature Permit Returned - Signature

Permit Returned (Date & Time Permit Issuer (Signature)

Work Complete

ORIGINAL — ISSUER COPY — WORKSITE / WORK-GROUP

WORK PERMIT MEETING ATTENDEE LIST

Name (Print) Employer Signature Name (Print) Employer Signature