Page                 1 of 2
HSE PROCEDURE                          Doc. No.         NUS-HSE-PTW/01
                                                                               Rev                   01
                                 PERMIT TO WORK PROCEDURE                        Date            10/11/2014
                                                                  HOT WORK PERMIT
                                                 N :________
                                                  o
                                                                PERMIT INITIATION
Initiator:                                                                ID No :
Date:                               Start:                                 Finish:
Location:                           No of workers:                         Vehicle No:
Work Description :                                                         Tools:
Rig Manager                                                                Rig Manager
Remarks :                                                                  Signature :
                          PRE WORK INSPECTION & HSE REQUIREMENTS
Presence of flammable/combustible             Should fire system be bypassed
materials nearby                              Yes
                                                          No
Is Energy Lock- out Implemented :                 Yes     Will gas be vented to atmosphere
(pneumatic/hydraulic/capacitance)                N/A      Yes
                                                          No
Fluid transfer Present :                                  Should H2S precations be taken
Yes                                                       Yes
N/A                                                       No
Special precautions : (Always wear proper PPE)
Operator (doing the        Fire Watchman                Responsible Supervisor          HSE Officer
Work)                      Signature :                  Signature:                      Signature:
Signature :
                                             COMMUNICATION
Responsible Supervisor                             Phone No :
Operator                                           Phone No :
                                               CLOSE OUT
Job complete               Yes      Area cleaned                 Yes       Safety system                  Yes
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                                   HSE PROCEDURE                   Doc. No.      NUS-HSE-PTW/01
                                                                     Rev                01
                              PERMIT TO WORK PROCEDURE               Date          10/11/2014
                         No                               No      Reconnected                   No
Original  Rig Manager                 Copy- Supervisor                  Copy- HSE Officer
Copy- designate person
           Any person can invalidate this Work Permit if conditions are considered as unsafe.
          1) Inform the manager in charge
          2) Remove the site copy of permit
          3) Return to manager in charge
                                          CHECK LIST
          1. Adequate escape route
          2. Remove flammable & combustible materials
          3. Trash removed
          4. Isolation checked
          5. Welding equipment grounded
          6. Check fire equipment
          7. Consider fire watch
          8. Proper & Adequate ventilation
          9. Check communications
          10.Correct equipment identification
          11.Check ladders/scaffolds
          12.Proper PPE
            Close out Permit with the Supervisor When Work is Complete