Al Ghubrah III IWP – RO Desalination Plant
Permit Number
General Work Permit Number of workers
SECTION A-WORK DESCRIPTION
Company AL NEHAD Start Time End Time Start Date End Date
Exact location of work
Scope of work
Tools or Equipment to be used MSRA Doc #
SECTION B- HAZARD IDENTIFICATION
Fall from Height Adverse Weather Flying Particles Moving Vehicle/Equipment
Falling Debris / Objects Protruding Objects, Parts Tripping/ Slipping Faulty Tools/Materials
Noise Heat Vibration Poor Illumination
SECTION C-IDENTIFY& ATTACH SUPPLIMENTARY DOC. REQUIRE TO PERFORM/CONTROL THE WORK
Method Statement Risk Assessment Job Safety Analysis Drawing/Layout
Rescue Plan TBT Attendance Checklist Other (Specify)
SECTION D- SAFETY PRECAUTION MEASURES
# DESCRIPTION YES NO N/A # DESCRIPTION YES NO N/A
Flash back arrestor provided for Oxygen/Acetylene
1 Appoint Fire Watch/Flag Man 12
cylinders.
2 Gas Detector Required 13 Warning signs has been Provided
3 Adequate Ventilation 14 Respirators/SCBA Provided
4 Isolated Mechanical. /Electrical & Tagged 15 Safety Harnesses is Provided
5 Ignition sources eliminated/Controlled 16 Fire Blanket ( )Fire Extinguisher ( ) Area Wet ( )
Combustible /Flammable Materials
6 17 Access & Egress Provided.
Removed/Area is Barricaded
7 Tools & Equipment Inspected 18 Workers/Welder are Competent and Trained
8 Cables Management 19 Joint site Inspection done by Issuer and Receiver?
9 Is there any SIMOPs? 20 Is JSA communicated to worker crew?
10 Adequate Illumination Provided? (Night) 21 Is Security Notified of the Night?
11 Flagmen with Night Signaling Device? 22 Is the Required Safety Coverage?
SECTION E- PERSONAL PROTECTIVE EQUIPMENTS
Helmet Safety Shoes Safety Gloves Safety Ear Plugs/Muff Face Shield Other (Specify):
Safety Goggles Reflective Vest Dust Mask FRC Uniform Other (Specify) Other (Specify):
Acceptance by the Person in Charge of the Operation (Permit Issuer & Holder):
I Confirm that I fully understand and will Implement All the Safety Requirements Detailed in This Permit.
Permit Issuer Name & ID MUTHU KUMAR Permit Holder Name & ID
SECTION F- WORK PERMIT AUTHORIZATION AND REVALIDATION
Authorization Position Name
Requested by Permit Applicant
Issuer Name Name Name Name Name Name Name
Issued By Name Signature
Issuer Signature
Accepted by Permit Holder Instruction: EPC Area HSE must be informed before starting activity
Reviewed by EPC Area HSE
Controlled by PTW Controller Comments:
SECTION G- EXTENDED HOURS AUTHORIZATION
Extended Time up to up to up to up to up to up to up to
Requested by Permit Applicant
Issued By Permit Issuer
Reviewed by EPC Area HSE
Controlled by PTW Controller
SECTION H- EMERGENCY ARRANGEMENTS
Site First Aider (Name & Contact #) Supervisor (Name & Contact #)
Assembly Point Number In Case of any emergency please contact on emergency hotline Number Immediately 92737906
SECTION I- WORK PERMIT CLOSURE
It will be verified by joint site inspection of permit issuer and receiver both that work has been completed and confirm that wok site has been restored to a safe condition. In case of
continue work, will apply new work permit:
Requested by Permit Applicant Approved by Permit Issuer
