Area (sketch/description)

WORK PERMIT NO.:

❏ ❏ ❏ ❏ Work on hydro-
LEVEL 2 LEVEL 1
Hot work A Pressure testing Well operation
❏ Hot work B ❏ Work above sea ❏ Explosives carbon system N
❏ Entry (confined space) ❏ Dangerous substances ❏ Critical lifting operation
❏ Isolation of safety system ❏ Radioactive materials ❏ Other/critical operation
❏ Work level 2

1 ❏ SAFE JOB ANALYSIS: NO:

Applicant name: Discipline: Phone:
Work description: ❏ REQUIRES APPROVAL FROM ELECTRICAL DEPARTMENT
WORK ORDER NO.:
OPERATION NO.:
ISOLATION NO.:
❏ Day ❏ Night ❏ Ongoing work
Equipment/tools: : Date: From hr: To hr:
Extended to hr:
Installation: Location/modul: Deck:
Area/Operations Supervisor Sign:
Tag/line no.: Zone:
Attachment:: CCR Technician Sign:
Area Technician Sign:

OPERATIONS- AND SAFETY PREPARATIONS A B

Required Performed by area technician Signature Required Performed by executing skilled worker Signature
❏ Depressurization ❏ Portable gasdetector no. on the worksite
❏ Draining/emptying ❏ Verify mechanical isolation
❏ Cleaning/gasfreeing ❏ Electrical isolation/locking
❏ Isolation by singel valve/double block&bleed Tag. No.:
❏ Isolation by blind/Isolation plan ❏ Fire Extinguisher/fire prevention
❏ Safety tag/lock ❏ Welding machine safely located and earthed
❏ Venting/Extra ventilation ❏ Continuous guard/radio communication
❏ Prevent release of oil/gas in the area ❏ Drains blocked/covered
❏ Measures against radioactive radiation ❏ Barrier/warning sign/PA-announcement
❏ Inspection of the area every hour ❏ Cooperate with CCR/Area technician
❏ Other ❏ Follow requirements for work above sea/at height
❏ Chemical data sheet known and available
2 GASMEASUREMENTS PRIOR TO/DURING THE WORK ❏ Procedures/cheklist for the operation known
❏ Hydrocarbons every hour ❏ H2S every hour Ref. No. :
❏ Oxygen every hour ❏ every hour ❏ Control of temporary lifting equipment
ISOLATION SAFETY SYSTEM ❏ Locally ❏ CCR ❏ Follow requirements for Entry (confined space)
System: ❏ Special personal protective equipment

❏ Measures to avoid work related deseases

Location/area:
❏ Other requirements/preparations
Compensating measures:

APPROVAL/AUTHORIZATION
Area/Operations Other HSE Platform manager:
Supervisor: position: Function:
3 Remarks/requirements:

PRECAUTIONS PRIOR TO / DURING WORK EXECUTION A B

Safety system isolated/reactivated Signature: Gastest - value
Isolated locally/CCR HC
Reinstated locally/CCR O2
Remark:
H2S

4
Time/sign.
Work site cleared according to requirements Precautions understood and are/will be fulfilled
Area Technician time: Signature:
The work is cleared with CCR Executing skilled worker Name: (Block letters)
CCR Technician time: Signature:
COMPLETION A B
All locks/tags removed ❏ Yes ❏ No ❏ Work completed ❏ Work not completed
❏ Yes ❏ No
GR0216803_01_eng

5 Equipment ready for operation ❏ Work place cleaned and secured

Area Technician time: Signature: Executing skilled worker Signature:
Work cleared by CCR
Original: Work site
CCR Technician time: Signature: Copy: