Applicable Not Applicable
ARJAS STEEL WORK PERMIT (IWP) SERIAL NO.: 001 WORK WITH SOURCE OF ENERGY DISCLAIMER AND AUTHORIZATION FOR EXECUTION OF THE JOBS:
Y NA Y NA
Check the interference with the other Check Isolation of live parts/ I swear that I am aware of my responsibilities and after evaluation of the dangers inherent to the work
nearby equipment automatic feed disconnects to be performed. I agree upon to follow the
Check the interference with the other Check Isolation of live parts/ precautions and safety rules jointly agreed with the applicant and Releaser
nearby equipment automatic feed disconnects
WORK PERMIT FOR NON ROUTINE ACTIVITIES Ensure there is no electrical voltage Is Arc flash dress required for
AREA (SEVERITY A B C) (Zero Energy) before beginning the work the job EMPLOYEE DAY WORKED
NAME
WORK STATION: EQUIPMENT: The job executers are qualified / trained Whether 8.3 Cal Flame retardent uniform worn /ID 1 2 3 4 5 6
Is special high voltage gloves Is there requitement for removal of fuses
DATE MONTH. YEAR : TIME
WORK AT HEIGHT Applicable Not Applicable
Department Performing Agency Whether tools are secured from fall Use Tall arrest system at the access
Job Description Material/tools lifting bag/baskets Executer are trained for work
are required at heights
Use lifting mobile platform cleared Keep area below where service is
OTHERS / SPECIFY inspection as per checklist performed barricaded and maked
USE PPE'S AS APPLICABLE PROTECTIVE MEASURES FOR PERFORMING JOB Block nearby moving/Lifting Equipment Check life line on the roof and calculate
the number of people per line installed
Y NA Y NA Y NA Workers must have been approved
Is life line required for the task.
Check intrference with other activity & by medical examiner.
Isolate the job Location Use safety ne for falling people/material Warning Signs around the area below
Welding Shield Hand Gloves any work at height are in place
Check energy need for lock. tag The job need to have an observer/watcman
Review interferences with source of
energy and edestrian in traffic
Additional sign boards required for the job HOT WORK Applicable Not Applicable
Face Shield CO Monitor
Ensure safe access Check the welding machine including Keep flammable sources at a distance
earthing and free from damages of 15 M from heat sources
Install adequate ventilation
Safety Harness Cutting Goggles Surrounding of 15 mtrs. inspected for the Keep Gas cylinders in upright position
Keep fire extinguisher near lob location availability of combustible ma
Protect the equipment against dust, heat, Fire Protection system verified to be in place Instal screens against non ionizing radiation
chemical product, fire and in working conditions that have been inspected and approved
SCBA Leg Guards
IS there any requirement of fire blanket
Availability of Install complementary/emergency lighting Is Fire watcher assigned /sheets for protecting existing services
mean to
Ear Muff
contain leaks Drain/clean/relieve piping, depressurizing equipment Additional point which is not covered in HIRA
Ensure availability of emergency equipment Activity Potential Hazards Preventive Measures
Availability of measuring devices
(Explosimeter CO, O2) Provide adequate containers for disposal of residue (Step to Step (What can go wrong) (To avoid heaving hazards)
Preventive measures for performing Hand tools are Inspected
the job identified by the risk analysis ?
On rainy days, stop the work at heights
Job Specific training given for performer in shelter less areas
LOTO APPLICABLE NOT APPLICABLE MECHANICAL ELECTRICAL
Identify Power Sources :
SAFE WORKS
5 STEPS FOR
Turn off / de-energize :
Lock and tag :
Release residual energy :
Test and verify :
lf Applicable No off Locks required for the PTW and Key Nos.________&____________________
Pre Use checklist available for the Equipments/Machines Required
Hydra Crane Welding M/C Grinding M/C
Gas Cutting M/C Others
Cutting
APPROVAL OF WORK PERMIT ( PERMIT TO WORK)
RELEASER REVALIDATION & EXTENSION REVALIDATION & EXTENSION REVALIDATION & EXTENSION REVALIDATION & EXTENSION REVALIDATION & EXTENSION
Total No. of person worked
NAME SIGN. NAME SIGN. NAME SIGN. NAME SIGN. NAME SIGN. NAME SIGN.
DATE EMERGENCY CONTACT NUMBERS (List telephones number and attach directions to the site.)
APPLICANT Ambulance/OHC : 169 Fire : 186 Dept. Safety Officer
RELEASER
AREA SHIFT INCHARGE Security : 186 Issuer : Assembly Point :
CLOSURE OF PERMIT Note : 1. HIRA & PTW should be explained to all team members before execute the job or activity by Applicant /Releaser.
Applicant (Name & Sign) : Releaser (Name & Sign) : AREA/SHIFT INCHARGE (Name & Sign) : DATE : TIME 2. All field in this permit are mandatory. If any check boxes found empty, the work permit shall be treated as invalid.
