PERMIT TO WORK FORM COMMESSIONING

PHASE
MSRA No. :…………….. PTW No.: …………………………

Authorized Applicant (AA)

……………………
…………………………………… ……………………………………
…….
Name (In Block Letters) Company Phone Number
System: Generic MSRA: YES  if NO:
…………………………………………
…………………………………… Specific Method Statement /Risk Assessment Title or Number:

Type and scope of work: ( Description of work, where work will take place and when)
Section 01 Application

Other attached Drawings or Documents. Specify: ………………………………………………………........

…………………………………………………
……………………
…………………… ………………………….
……………
Desired date Duration (max 30 days) Signature AA
Sect.1a

Responsible HSE (Subcontractor): ……………………………………

Name, Date, Time, Signature

PTW Expiry Date: PTW Extension Date I: PTW Extension Date PTW Extension
II: Date III:
Sect.1b

Date/Signature Date/Signature Date/Signature Date/Signature

Extension only by PTW office or HSE responsible .

Cat.1 Cat.2 Cat.3 Cat.4 Cat.5 Cat.6

Categorize
Section 02

 Excavation  Blasting 
Hot Work
 High Risk  Confined  Radiographic
Work work Activities Spaces Examination

The following instructions show safety requirements for all Operational areas, taking into account site conditions and other
working parties identified by the Senior Authorized Person (SAP) which might not be known by the AA at the time of ap-
plication.
HSE Measure on operational Area

 Isolation list:  Check that system is depres-  Check isolation from  All operating fluids
 on PTW Form  surized power supply (gas/liquid) drained
Attached
 Voice communica-  Combustible material in sys-  Hazardous substance  Electrical protection
tion with tem (gas/oil) residues in system – spec- device - Residual Current
Section 03

Central Control Room ify: Device (RCD)

 Ensure compliance  Entry, rescue, and emergency  Install barriers / warning  Explosion potential /
with procedure signs gas tests / monitoring
cleanliness requirements permanently required

 Access and escape  Supervisor or other named  Observe other barriers  Specific MS/RA
routes provided & kept persons sign and required
clear labels ( attach)

 Anti-static clothing  Residual temperature  Safety extra-low voltage  Non-sparking / ATEX

(SELV) tools

DP818 Att.11 Rev.00 01 April 2020 Page 1 of 4

 PERMIT TO WORK FORM COMMESSIONING
PHASE
MSRA No. :…………….. PTW No.: …………………………

The AA’s MSRA and PTW categories have been reviewed

Section 04

Senior Authorized Person (SAP): …………………………………

Review

Responsible HSE: ………………………………...

Name, Date, Time, Signature

Isolation:
Isolation list  YES  NO
Component(s) to be isolated:
Safety from the system, measure
Section 05

System specific HSE measures:

 drained  purged/flushed  grounded/short-circuited
 vented  de-energized/isolated  de-pressurized

Actions defined by Senior Authorized Person: If applicable to be supplemented by PTW Officer:

………………………………………………..
Cross-linked Cross-linked key boxes:
Name, Date, Signature PTWs:

Confirmation of release and Release by Commissioning Manager/ Shift ………………………………….

Implementation

implementation of General Supervisor:

Section 06

Safety Measures and Isolation Mechanical systems: Action implemented ………………………………….

Actions to obtain Safety from
the System Electrical systems: Action implemented ………………………………….
Senior Authorized Person ………………………………….
System-specific HSE measures implemented:
Name, Date, Time Signature

Work released by
Work Release

Commissioning Manager or Shift Supervisor: ……………………………………

Section 07

Name, Date, Time Signature

I am (AA) fully responsible for the safe execution of the work under this permit. I understand and will
instruct the Local Supervisor on the General Safety requirements and measures taken to achieve Safety
Performance of work

from the System detailed in this document and attachments and I will ensure that:
Section 08

a. the Local Supervisor gives a tool box talk on the contents of this document to the working party.
b. the attached tool box sheet is signed.
Authorized Applicant
………………………………………….

Name, Date, Time Signature

DP818 Att.11 Rev.00 01 April 2020 Page 2 of 4

 PERMIT TO WORK FORM COMMESSIONING
PHASE
MSRA No. :…………….. PTW No.: …………………………

DP818 Att.11 Rev.00 01 April 2020 Page 3 of 4

 PERMIT TO WORK FORM COMMESSIONING
PHASE
MSRA No. :…………….. PTW No.: …………………………
LS and AA have to transfer the PTW document as if it was the first time the PTW document had been issued

LS Surrendering AA reissuing LS receiving

LS receiving Document
Document Document reissued Document
Name
Name Signa-
Transfer Record

Signa- Date, Time Name Signature, Date, Time Name Signature, Date, Time
ture,
Section 09

ture,

I (AA) confirm that all persons working under this Permit have been withdrawn from the Plant / Apparatus /
Work Completed

Area covered in Section 1. All equipment, tools and loose material have been removed and guards and access
Section 10

doors have been replaced, except for:

Authorized Applicant ……………………………………………….

Name, Date, Time Signature

Confirmation of Work completion.
Confirmation
Section 11

SAP for general safety only. …………………………………………………

Name, Date, Time Signature

Release by Contractor shift supervisor/SAP …………………………………………

Resetting and restoration of

Mechanical systems: Action implemented ...……………………………………….

Operation readiness

Electrical systems: Action implemented ………………………………………….

Section 12

Name, Date, Time Signature

Comments:

Senior Authorized Person: …………………………………………….

Name, Date, Time Signature

Name Date & Time Signature Comments

PTW Spot Check
Section 13

Other comments:

DP818 Att.11 Rev.00 01 April 2020 Page 4 of 4