GU — Permit to Work Standard

Approved 27 February 2008

Version 1.0
 GU — Permit to Work Standard

Table of Contents
1.0 Purpose, Objectives and Scope......................................................................................... 4
1.1 Purpose ...................................................................................................................... 4
1.2 Objective.................................................................................................................... 4
1.3 Scope ......................................................................................................................... 4
2.0 Requirements ..................................................................................................................... 4
3.0 Terms and Definitions....................................................................................................... 5
4.0 Roles, Responsibilities and Training Requirements....................................................... 5
4.1 Initial Training........................................................................................................... 6
4.2 Refresher Training..................................................................................................... 6
5.0 Standard Instructions ....................................................................................................... 6
5.1 When is Permit to Work Required............................................................................. 6
5.2 Permit to Work Form................................................................................................. 7
5.3 Specialized Work Permits (Certificates) ................................................................... 7
5.4 Prepare All Required Permits .................................................................................... 7
5.4.1 Communication and Coordination...................................................................7
5.5 Conduct Onsite JSA and Recycle .............................................................................. 8
5.5.1 Conduct JSA ....................................................................................................8
5.5.2 Recycle JSA.....................................................................................................8
5.5.3 JSA for Work Not Requiring PTW..................................................................8
5.6 Approve/Release Permit ............................................................................................ 8
5.6.1 Method to Authorize Permitted Work .............................................................8
5.6.2 Authorization ...................................................................................................8
5.6.3 Duration of Permit ...........................................................................................9
5.7 Implement Controls ................................................................................................... 9
5.7.1 Precautions and Safety Measures ....................................................................9
5.7.2 Hazardous Energy Isolations ...........................................................................9
5.8 Work in Progress ....................................................................................................... 9
5.8.1 Display of Permits ...........................................................................................9
5.8.2 Copies of Permits...........................................................................................10
5.8.3 Monitoring and Verification ..........................................................................10
5.9 Change in Conditions .............................................................................................. 10
5.9.1 Handover Procedure ......................................................................................10
5.9.2 Interruption of Work......................................................................................10
5.9.3 Change in Work Conditions ..........................................................................11
5.10 Work Complete........................................................................................................ 11
5.11 Update/Feedback ..................................................................................................... 11
5.12 Close and File .......................................................................................................... 12
5.13 Auditing and Review ............................................................................................... 12
6.0 Records ............................................................................................................................. 12
6.1 Required Records .................................................................................................... 12
6.2 Retention Requirements .......................................................................................... 12
7.0 References ........................................................................................................................ 12
8.0 Other Guidance Documents ........................................................................................... 13
9.0 Document Control ........................................................................................................... 13

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GU — Permit to Work Standard

Appendix A: Guideline for the Permit to Work Form.......................................................... 14

Appendix B: Sample Permit to Work Form .......................................................................... 15
Appendix C: Permit to Work Monitoring Checklist............................................................. 17

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 GU — Permit to Work Standard

1.0 Purpose, Objectives and Scope

1.1 Purpose
The purpose of this standard is to provide for the effective identification, mitigation,
control and communication of Health, Environment and Safety (HES) hazards for work
requiring a Permit to Work (PTW).

1.2 Objective
This standard establishes the necessary steps and activities to plan, prepare and execute
work safely. The objective of a Permit to Work is to ensure that proper consideration is
given to the risks of a particular job, including potential impact to/from simultaneous
activities. The permit and associated specialized permits (if any) are detailed documents
that authorize certain people to carry out specific work at a specific site at a certain time,
and details the precautions needed to complete the job safely.
NOTE: Each Global Upstream strategic business unit (SBU) or location may have
additional regulatory requirements.

1.3 Scope
This Permit to Work Safe Work Practice (SWP) covers work performed by Chevron
employees and their delegates and contractors within Chevron Global Upstream
Exploration and Production (GU) operational control.

2.0 Requirements
1. Personnel assigned responsibilities in the Permit to Work roles shall be trained and
competent The SBU/facility shall maintain documentation of authorized Permit
Approvers and Area Controllers.
2. SBU criteria defining the application of PTW shall be documented and meet GU
criteria (refer to 5.1 When Is Permit to Work Required) at a minimum.
3. Hazard analysis shall be performed when planning the work and a Job Safety Analysis
(JSA) shall be performed on site with the work crew prior to the initiation of work.
Reference: Global Upstream – Hazard Analysis Procedure.
4. The PTW standard shall clearly indicate roles and responsibilities on how a permit is:
• Prepared
• Approved/Released
• Monitored/Verified
• Handled for changes in conditions
• Completed and closed out
5. Individuals shall not self-issue a permit; that is, the same person cannot act as Area
Controller or Permit Approver, and Work Team Leader/Permit User at the same time.
6. Identification and preparation of specialized work permits (certificates) shall be
included as necessary.
7. Permit to work documentation shall be available at the work site, and retained after
work is completed as required by local regulation, SBU policy, or for a minimum of six
months, whichever is greater.

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3.0 Terms and Definitions

The following terms and definitions apply to the Global Upstream – Safe Work Practice
– Permit to work:
Area Controller - A competent individual who is responsible for the equipment in the
area where the work is to be performed.
Permit Approver - A competent individual who has been trained and authorized by the
company to review and, where applicable, sign and approve relevant forms.
Permit Coordinator - A competent individual who is responsible for the administrative
tasks associated with permitting as delegated by the Permit Approver. The need for this
role is normally determined by the size/scope of work being performed.
Permit User – Individuals performing the work scope defined in the permit.
Site Checker - A competent individual who is assigned responsibility to verify work-site
activities are in compliance with permit conditions during normal activities.
Think Incident-Free (TIF) - Think Incident-Free is a self-assessment process that
focuses on the fact that, in order to achieve incident-free operations, each worker must
take responsibility for his or her own health and safety in all activities as well as protect
the environment. TIF enables employees to observe day-to-day operational and
procedural systems to identify potential hazards that could threaten the health or safety of
our personnel or contract workforce, company facilities, or the environment.
The steps in an effective TIF assessment are:
• Determining the potential hazards
• Determining what can be done to eliminate the hazard
• Take action to prevent any negative consequences
SBUs may use other nomenclature for their TIF assessments.
Work Team Leader - A competent individual who is responsible for the safe execution
of work. The role of the designated leader may vary among several people, depending on
the work specified.

4.0 Roles, Responsibilities and Training Requirements

There must be clearly defined roles, and personnel must meet the training and
competency requirements of this standard prior to starting work. The SBU is responsible
for establishing the methodology to achieve competence.
When selecting personnel for these positions, consideration should be given to their level
of experience and their past performance.
A number of these roles may be fulfilled by the same person. For example, on a small site
with few permits, the same person may act as Area Controller and Permit Approver at the
same time. However, the same person cannot act as Permit Approver or Area Controller,
and Work Team Leader/Permit User at the same time. That is, individuals cannot self-
issue a permit.
The following table lists generic titles and roles that are applicable to Permit to Work and
other SWP standards. These roles and responsibilities are further defined in the GU –
Training Requirements Tool. Local SBU terminology may be mapped to these terms.

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Titles and Roles within Permit to Work Systems

Generic Title SBU-Specific Title Role

Permit User Add SBU title Person(s) performing work

Permit Approver Add SBU title Approver of a permit

Work Team Add SBU title Person in charge of the work

Leader

Area Controller Add SBU title Person responsible for the

equipment in the area where the
work is to be performed

Site Checker Add SBU title Person assigned responsibility to

verify worksite activities are in
compliance with permit
conditions during normal
activities

Permit Add SBU title Person handling the

Coordinator administrative tasks associated to
(optional) permitting

4.1 Initial Training

Personnel must meet the competency requirements of this standardized safe work
practice for the role(s) they are expected to perform. Refer to the GU – Training
Requirements Tool.

4.2 Refresher Training

Refresher training must be provided as follows:
• As required by applicable regulations or SBU policy
• As needed when identified by verification, inspections, incidents or audits

5.0 Standard Instructions

5.1 When is Permit to Work Required

A Permit to Work is required whenever work is conducted that may adversely affect
health, environment, safety, efficiency, or reliability of associated personnel or an asset.
PTW is not intended for low-risk activities in low exposure locations/settings.
A Permit to Work is required when:
• Specialized work permits are initiated (e.g., Hot Work, Confined Space, Isolation of
Hazardous Energy, Excavation, etc.); or
• Work or maintenance is performed in a process area that involves breaking into a line,
equipment or vessel that contains actual or potential hazards; or
• There is a transfer of work and responsibilities from one group to another; or

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• Communication across more than one area, group, or technical type is required to
accomplish the task; or
• If the Area Controller determines permit is required; or
• The work has significant potential for injury or incident
• SBU to add a list of other specific conditions where PTW is required. For example diving,
crane work near power lines, hydroblasting.

5.2 Permit to Work Form

The basis of a Permit to Work form shall be a single format work permit supported by
specialized work permits (or certificates) as required. Reference the GU SWP standards,
Guidance for Specialized Work Permits, and Suggested Color Coding for Documents for
additional information on forms.
The essential elements of a PTW form and information detailing each section of the
permit are provided in Appendix A: Guideline for the Permit to Work Form . A sample
PTW form is provided in Appendix B: Sample Permit to Work Form.

5.3 Specialized Work Permits (Certificates)

The Permit Approver and/or Area Controller shall review all applications for Permit to
Work and indicate which types of additional specific permits are required in order to
allow approval of the work (Hot Work, Confined Space, Excavation, Electrical, Isolation
of Hazardous Energy, SimOps Plan, etc.). See Section 7: Reference “Guidance for
Specialized Work Permits (Certificates)” for more detailed information.
All necessary permits are required to be fully completed and approved by all signatories
prior to Permit Users carrying out any work.

5.4 Prepare All Required Permits

Competent personnel defined by the SBU or facility shall initiate and prepare the Permit
to Work and associated specialized permits (certificates). Preparation of the permit
documentation should include a discussion with the Permit Approver on work scope,
safe work practices and necessary permits.
PTW documentation shall be available in the language appropriate for personnel
involved in the PTW approval process. Other means (i.e., translators) may be necessary
to promote clear understanding.

5.4.1 Communication and Coordination

It is important to make sure that an activity under a Permit to Work does not create
danger for another activity elsewhere. There shall be means to ensure that clear
communication and coordination of work is ongoing to address possible permit conflicts
and/or simultaneous operations (SimOps) situations.
This dialogue may need to be set up for various levels (rig site, unit, field, and
substation) in a facility to address the various organizational and span of control
arrangements that may be in place. The Permit Approver, Area Controller, SimOps
Controller or other responsible person(s) must be aware of potential interaction and
check when the PTW is prepared, whether it impinges on a PTW already issued and still
current, or could endanger another area.

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5.5 Conduct Onsite JSA and Recycle

5.5.1 Conduct JSA

A Job Safety Analysis (JSA) shall be performed onsite prior to the initiation of work.
The purpose of the onsite JSA is to:
• Involve the work team to make sure that the people doing the work understand the tasks,
hazards and mitigations
• Address on-site conditions on the day of the work
• Verify that work team has proper skill level and tools
The crew/personnel carrying out the work should be included in the development and
communication of the JSA. Communication should address the nature and extent of the
job, the hazards involved, controls in place, and limitations on the time. JSAs may be
conducted by either Chevron employees or contractors. The Work Team Leader is
responsible for ensuring that a comprehensive JSA is conducted. The Permit Approver
is responsible for reviewing the content of the JSA as part of the authorization process.
The hazard analysis used for planning the work, a qualified standard operating procedure
(SOP) or an existing JSA may be used as a starting point for the JSA. However, it must
be edited to reflect current conditions.
Language for JSA and communication delivery shall be appropriate for the work team
involved.

5.5.2 Recycle JSA

The JSA may identify hazards that were not previously identified and controlled, or not
addressed in the preparation of permits. When this situation occurs, the permit
preparation should be reviewed and updated as appropriate.

5.5.3 JSA for Work Not Requiring PTW

Although all work may not be covered by all the PTW planning and permitting steps, all
work shall be subject to the appropriate level of hazard review. A written JSA or Think
Incident-Free (TIF) self-assessment should be conducted on site prior to beginning work.

5.6 Approve/Release Permit

5.6.1 Method to Authorize Permitted Work

Permits shall be authorized by SBU designated personnel. The preferred method for
authorization is written (signatures), however if a verbal sign-off is needed due to
specific operational limitation(s) of an area/location, it needs to be clearly identified on
the permit along with any restrictions. The verbal sign-off process shall have a level of
oversight equivalent to written authorization.
Individuals cannot self-issue a permit; that is, the same person cannot act as Area
Controller or Permit Approver, and Work Team Leader/Permit User at the same time.
SBU shall describe method(s) of approval allowed.

5.6.2 Authorization
It is important to provide clear definition of each role involved in the authorization
process with regard to duties, expectations and area of responsibility. Company or
contractor personnel designated as part of the issuing authority (Permit Approver, Area
Controller) shall be specifically identified, trained and authorized by management for

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this responsibility. The SBU/facility management shall maintain documentation of

authorized Permit Approvers and Area Controllers.
The Area Controller and Permit Approver (replace with SBU/facility roles) shall sign the
permit authorizing the start of work after:
• Verifying release and condition of equipment related to scope of job
• Confirming that HES control measures are identified and/or in place (permit may include
installation of controls)
• Reviewing the JSA
The Work Team Leader (who is in charge of the people who are doing the work) does
not authorize work but shall sign the Permit to Work, confirming understanding of work
to be done, hazards involved and precautions required. The Permit User (people doing
the work) does not authorize work but confirms that the Permit to Work scope and
conditions are understood by workers who shall be directly involved.

5.6.3 Duration of Permit

In general, Permit to Work approval shall be issued for a single shift, typically a 12-hour
period. If necessary, the Permit Approver can issue a Permit to Work for a longer period
of time but not to exceed SBU defined limit. This should only be done after careful
consideration of other ongoing activities, personnel involved, etc.
SBU may define additional criteria under which permits can have durations of longer than one
shift.

5.7 Implement Controls

5.7.1 Precautions and Safety Measures

The Permit to Work must specify the precautions and safety measures to be taken in
order to conduct work safely. Controls must be implemented as listed on the Permit to
Work, specialized work permits (certificates), JSA and/or standard operating procedures.
Affected personnel are given the authority to begin work only after it is verified that
necessary control measures have been identified and/or are in place. They are required to
follow the established work plan and controls as specified by the work permit(s) or
operating procedures.

5.7.2 Hazardous Energy Isolations

Hazardous energy isolations that are required or implemented must be clearly identified
on the permit to work or isolation of hazardous energy permit (certificate). Isolations
must be applied as identified in the applicable permits.

5.8 Work in Progress

5.8.1 Display of Permits

An acceptable means for the display of permits shall be available:
• At the work site or in a recognized location near to the work site
AND
• In the central or main control or permit coordination room, with additional copies at any
local control rooms (if applicable) or in another centralized location.

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5.8.2 Copies of Permits

Copies of the PTW shall be consistent in content and actively maintained to ensure they
do not contain contradictory information.

5.8.3 Monitoring and Verification

The Site Checker or other competent personnel shall monitor and verify that work is
being performed safely and consistent with the permit conditions. The Site Checker shall
stop work if unsafe conditions are identified and initiate corrective action. If changes in
operating conditions occur that may require modifying permits or stopping work, the Site
Checker shall notify the Permit Approver.
The work site shall be monitored at least once per shift. Add SBU/facility specific
frequency or other instructions.
A sample PTW monitoring checklist is provided in Appendix C: Permit to Work
Monitoring Checklist. Documentation associated with monitoring and verification shall
be retained according to SBU retention policy.

5.9 Change in Conditions

5.9.1 Handover Procedure

When authorizing personnel for an existing Permit to Work (e.g., Permit Approver, Area
Controller, Work Team Leader) becomes unavailable (through crew change,
reassignment to other job duties, illness, etc.) then the Permit to Work is considered
invalid until a replacement signature can be obtained. Personnel new to the job site must
be briefed on the JSA and applicable permits prior to sign-off. The replacement signature
assumes all responsibilities of the previous signature.

5.9.2 Interruption of Work

A Permit to Work shall be suspended:
• If there is a general alarm/emergency
• For operational reasons as necessary
• If an "essential" signatory (defined by SBU) departs the field unless a
delegated/designated person is assigned
When an emergency alarm sounds, work in the affected area must stop and everyone
must follow the required emergency action for the area. The Permit to Work shall not be
reactivated until the Permit Approver and/or Area Controller has verified that it is safe
for work to resume and the permit conditions have been revalidated.
In the event of work stoppage due to an emergency drill, authorized work may resume
upon official notification by the designated SBU/facility personnel that the drill has
ended.
If the job site is left unattended for more than 30 minutes, the permit conditions must be
revalidated before work can be restarted. Revalidation requires the Permit Approver or
designee to verify that conditions and requirements on the permit to work and any
specialized work permits remain in effect. The work may be resumed only after the
Permit Approver or designee has given approval to restart the permitted work and
provided any required signatures.
If a Stop Work Authority is initiated, follow the SBU/facility procedure for resolution.

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5.9.3 Change in Work Conditions

The Permit to Work is valid only as long as the specified permit conditions are
maintained. Continuity of the safe condition of the job shall remain uninterrupted. This
applies to any other permits that accompany the Permit to Work.
Work crews should remain vigilant of changing conditions, be prepared to stop work,
and report changed conditions as soon as possible to the Work Team Leader and the
Permit Approver, as applicable. The JSA shall be revisited if steps, hazards or site
conditions change.
If personnel believe a work plan change is necessary, they first notify their Work Team
Leader, supervisor or other person in charge of work who next notifies the Permit
Approver. If changes are necessary, the existing permit shall be revised or cancelled and
a new permit is issued.
If changes are sufficiently significant that they cause conditions to be outside the scope
anticipated in the original JSA, the work must be stopped and the permit cancelled. A
new permit must be developed by re-initiating the Managing Safe Work (MSW) process.
A change in scope may require a management of change. If so, the work shall be
stopped, and the SBU Management of Change process shall be followed before
proceeding.

5.10 Work Complete

The Work Team Leader shall sign the permit and inform the Area Controller and Permit
Approver when work is complete, control devices specific to the permit are removed,
and proper housekeeping has been verified. The Work Team Leader should
communicate any Stop Work conditions or errors in documentation (e.g., procedures,
application of permitting process) to the Permit Approver.
When applicable, the Site Checker or other person in control of operational activities on
the permit shall communicate to the Permit Approver that the plant or equipment has
been returned to the control of operations.
The Permit Approver shall verify that work is complete and sign the Permit to Work and
specialized work permit as appropriate to close out the permit.
The preferred method for close-out is written (signatures): however if a verbal sign-off is
necessary because of specific operational limitation(s) of an area/location, it needs to be
clearly identified on the permit along with any restrictions. The verbal sign-off process
shall have a level of oversight equivalent to written authorization.

5.11 Update/Feedback
The Permit Approver or designee is responsible for communicating potential hazard
situations encountered during work (i.e., isolation incomplete, procedure
confusing/incorrect, access was inadequate) to the responsible facility management or
HES team as appropriate.
In addition to the post-job communication between the Work Team Leader and Permit
Approver, the SBU may choose to conduct a post-job review, at their discretion,
depending on the risk and scale of the work. The post-job review may be informal for
small jobs or more formal for large projects.
Any documentation (e.g. procedures, tools, training materials, JSA) gaps identified are
communicated to the SBU/facility responsible person(s)/department for update.
Deficiencies identified in personnel competency or SWPs are communicated to facility
management or the HES team as appropriate.

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5.12 Close and File

When complete, Permit to Work documentation shall be closed and filed as described in
section 6.0 Records.

5.13 Auditing and Review

The SBU shall have a process to ensure that adequate sampling of active permits is
conducted to identify and understand gaps in the Permit to Work standard. In addition to
checks carried out during work, permit to work monitoring checks should be undertaken
to validate compliance with detailed work instructions and control measures. This can be
integrated as part of the SBU Behavior-Based Safety (BBS) process, as part of the SBU
or facility review process or handled separately.

6.0 Records

6.1 Required Records

Permit to Work documentation includes the Permit to Work, specialized work permits,
work plan, JSA and other records identified by the SBU/facility.
Insert any additional SBU language here.

6.2 Retention Requirements

Permit to Work documentation shall be retained as required by local regulation, SBU
policy or for a minimum of six months, whichever is greater.
Insert any additional SBU language here.

7.0 References

Table 1. Document List

Title File Name

Global Upstream – Hazard Analysis GU_MSW_HazardAnalysisProcedure.doc

Procedure

Global Upstream – Training Requirements GU_MSW_TrainingRequirementsTool.doc

Tool

Guidance for Specialized Work Permits Guidance for Specialized Permits

(Certificates) (certificates).doc

Suggested Color Coding for Documents Suggested Color Coding for Documents.doc

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8.0 Other Guidance Documents

Table 2. Document List

Amendment Date Detail

GU – Bypassing Critical Protections GU_MSW_BypassingCriticalProtectionsStanda

Standard rd.doc

GU – Confined Space Entry Standard GU_MSW_ConfinedSpaceEntryStandard.doc

GU – Excavation Standard GU_MSW_ExcavationStandard.doc

GU – Hot Work Standard GU_MSW_HotWorkStandard.doc

GU – Isolation of Hazardous Energy GU_MSW_IsolationofHazardousEnergyStandar

Standard d.doc

GU – Lifting and Rigging Standard GU_MSW_LiftingandRiggingStandard.doc

GU – Simultaneous Operations Standard GU_MSW_SimultaneousOperations.doc

GU – Work At Height Standard GU_MSW_WorkatHeightStandard.doc

9.0 Document Control

Table 1: Document Control Information

Description GU Common SBU-Specific

Approval Date 27 February 2008 Insert last approval date

Next Revision Due 27 February 2011 Insert next revision due date

Control Number Optional

Table 2: Document History

Version Date Notes

Number

1.0 27 February 2008 Initial Release

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Appendix A: Guideline for the Permit to Work Form
Items included in a Permit to Work form are listed below:
• Unique permit reference number
• Location of the work site
• Identification of the equipment to be worked on
• Description of the work to be done
• Date and duration of permit
• Details of hazards identified and control measures to be used to mitigate the hazards.
Reference and attach hazard analysis, qualified SOP and JSA.
• Information on current permits and supporting specialized permits (or certificates) that
impact the work are cross-referenced and attached.
• Authorization releasing equipment to be worked on and/or confirming safety controls in
place
• Authorization confirming control measures in place and confirming issue/approval of the
permit
• Date and time of permit.
• Acceptance signatures of Work Team Leader and Permit Users confirming understanding
of work to be done, hazards involved and precautions required. These signatures also
confirm that permit information has been explained to all workers involved.
• Signature of Approver to start work
• Address the suspension, extension and hand-over procedures and includes the signatures
of the new Work Team Leader, Permit Approver, etc., confirming that the plant remains
safe to be worked on, site checks have been repeated and all are fully aware of the work
scope, hazards and precautions.
• Signature of the Work Team Leader confirming the work is complete and control devices
specific to the permit are removed
• Signature of Approver confirming work is complete and the permit can be closed out
• Date and time of the permit completion
• Description of any Stop Work Authority or safety issues that occurred during the scope of
the permitted work
• Documentation updates required (e.g., SOP, JSA, training)

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Appendix B: Sample Permit to Work Form
Permit # PERMIT TO WORK Emergency #: ___________
AN ALERT, GAS RELEASE, EVACUATION OR OTHER EMERGENCY SUSPENDS/CANCELS THIS PERMIT
Before restarting work, contact Permit Approver to complete Section 4b

Facility/Area: _________________________ ______ Date: ________ Valid From: ___________ To:_____________

Permit Requested by: (name of group or contractor to perform work)

SECTION I GENERAL AREA WORK PERMIT Complete for all permitted work.
1a Work LIMITED to the following: (Job scope/description/tasks & area/equipment & boundaries):

______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________
1b
Equipment number(s) involved: ____________________________________________________________________________________________
1c
Type equipment to be used: _______________________________________________________________________________________________
1d
The scope of work requires the following additional permits/certificates: SBU lists all permits/certificates used for location
Line/Equipment Opening (see Section II) Excavation Fresh Air
Hot Work Working at Height Lifting
Confined Space Entry Other: __________________________________________
Isolation of Hazardous Energy Refer to:
SECTION 2 HAZARDS and CONTROLS
2a Material Hazards. Last contained process material or job specific chemical(s). See MSDS(s )for safety & health hazards. Doesn’t Apply [ ]
Material (Name): Hydrocarbon [ ] ______________ ______________________ _____________________ ________________
Hazards: [ ] Flammable [ ] Toxic [ ] Corrosive [ ] Reactive [ ] Inhalation [ ] Skin Irritant [ ] Other: _____________

2b Does work scope have potential for environmental release or spill? Yes [ ] Doesn’t Apply [ ]
Waste Handling and Disposal Requirements: ________________________________________________________________________________
2c Physical Hazards. List the hazards of the area, the work and the equipment for the specific task in #1 Doesn’t Apply [ ]
[ ] Noise (>area requirement) [ ] Pressure / Stored energy [ ] Pinch Points [ ] Dust [ ] Inert Atmosphere
[ ] Thermal Burn [ ] Falls ____<6 ft ____ >6 ft [ ] Sharp Edges [ ] Flying Debris [ ] Asbestos
[ ] Flash Fire [ ] Electrical/High Voltage [ ] Heat Stress [ ] Radiation [ ] Other: _________
2d Protection Required for Hazards. List PPE, precautions and safeguards required to protect against hazards. SBU to tailor as appropriate
Clothing Foot/leg protection Elevated Work Barricading
[ ] Long Sleeves [ ] Steel Toed Footwear Fall Prevention: [ ] Caution [ ] Danger
[ ] Flame Retardant [ ] Dielectric Boots [ ] Guardrail Warning Signs
[ ] Cooling Vest [ ] Metatarsal Protection [ ] Restraint Line [ ] Hearing [ ] X-ray
[ ] Suit, Type: ___________ [ ] Rubber Boots [ ] Designated Area [ ] N2 purge
[ ] Other: __________________ [ ] Other:_______________ Fall Protection: Other:_________________
Face / Head protection Hearing protection [ ] Full Body Harness Additional Requirements
[ ] Hard Hat [ ] Face Shield [ ] Single [ ] Double Lanyard: [ ] GFCI
[ ] Hood, Type ________________ [ ] Limit time exposure:____ [ ] Single [ ] Dual [ ] Limit time exposure (breaks, etc.):
[ ] Other: __________________ Eye protection [ ] Retractable [ ] Written Operating Procedure
Respiratory [ ] Safety glasses [ ] Horizontal Lifeline [ ] Communication Equip:
[ ] Dust mask [ ] Supplied Air [ ] Chemical Goggles [ ] Vertical Lifeline Channel: _______________
[ ] Air Pack (SCBA) [ ] Cutting Goggles [ ] Safety Attendant [ ] Other:________________________
[ ] Respirator, Type:____________ [ ] Other:_______________ [ ] Gloves, Type:__________
Special requirements:

SECTION 3 SITE PREPARATION / CONDITON To be completed by Permit Approver

3a Verify equipment has been identified and is safe to release for work (isolation/blinds, depressurize, drain, purge) [ ] Yes [ ] N/A
3b Lockout and tag of potential energy sources complete [ ] Yes [ ] N/A
3c Emergency procedures and alarms, locations of assembly points, evacuation routes, crew accountability [ ] Yes [ ] N/A
3d Location of emergency equipment, including nearest safety shower, eye wash, fire extinguisher and telephone and/or
intercom have been reviewed and are understood. [ ] Yes [ ] N/A

3e The scope and boundaries of any other work in the area that could impact this work has been reviewed and is understood. [ ] Yes [ ] N/A
3f Others in the area have been notified that this work could impact their work, including the locations of any barricades. [ ] Yes [ ] N/A
3g Responsibilities communicated to Work Team Leader: [ ] Conditions for work stoppage [ ] Reporting changes that affect job safety
[ ] Work completion & permit return [ ] Reporting a change in the Permit Receiver

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 SECTION 4 AUTHORIZATION All signatures required to begin work. Transferred to (Name/Signature):
SBU titles can be utilized
4a Area Controller: (print): ____________________ Signature: ______________________

Permit Approver: (print): ___________________ Signature: _______________________

Contact information: ext:_________________ radio channel: ____________________

Work Team Leader (print): __________________ Signature: _____________________

Contact information: ext:_________________ radio channel: ____________________

Permit Users - Attach list
4b Authorization to restart work or extend permit validation [ ] Restart /Time ________________
SBU sets limits for extension
Permit Approver: (print): ___________________ Signature: _______________________ [ ] Extension / Time: _________________
SECTION 5 ON-SITE VERIFICATION Most jobs require an on-site inspection while permit is active. Doesn’t Apply [ ]

5a Time Completed: ___________________ Site Checker (name): _______________________________________________

SECTION 6 CLOSEOUT These signatures indicate that this permit is no longer active and that workers have stopped working. On-Site inspections are required
when, but not limited to, the work includes a line or equipment opening or the work is not complete and a review of the area is needed to determine if conditions are safe.
Yes No Yes N/A
6a Close-out inspection required? [ ] [ ] 2. On-Site inspection completed? [ ] [ ]
Work Team Leader Signature: Time________am/pm Approver Close-out Signature:
____________________ __________________________
6b Close-out remarks, instructions, precautions, limitations, SWA or safety issues during work, other remarks:
_________________________________________________________________________________________________________________________________________

6c Documentation updates identified:

Authorized Worker List

I understand the specific safety requirements of the job, have received a pre-job briefing and understand
my Stop Work responsibility.

Printed Name Signature Printed Name Signature

16 Version 1.0 Revised 27 February 2008.

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GU_MSW_Permit to Work Standard.doc
Appendix C: Permit to Work Monitoring Checklist

This checklist is intended to be used for the day-to-day monitoring of permits in use.

Date: Time:
Permit Type: Reference No.:
Reviewer: Position: Installation:
Specialized Permits (certificates):

If any unsafe conditions are found, the work shall be stopped and the Permit Approver
shall be notified immediately.

Yes No N/A

1. Are hazard analysis (e.g., JSA or SOP) available for review? ‰ ‰ ‰

2. Did workers discuss the hazard analysis prior to starting work? ‰ ‰ ‰

3. Are control measures (including isolations) listed on the Permit to Work? ‰ ‰ ‰

4. Is there a clear description of the work to be performed? ‰ ‰ ‰

5. Is the time limit of the permit clear? ‰ ‰ ‰

6. Are specialized permits (certificates) completed properly? ‰ ‰ ‰

7. Are other area or system activities cross-referenced correctly? ‰ ‰ ‰

8. Are copies of permits, certificates and attachments legible? ‰ ‰ ‰

9. Are site instructions or procedures attached to the Permit to Work? ‰ ‰ ‰

10. Does the permit contain signatures authorizing and accepting the work? ‰ ‰ ‰

11. Are signatures and initials traceable and legible? ‰ ‰ ‰

12. Are copies of permits and certificates posted at correct locations? ‰ ‰ ‰

13. Are attachments, drawings, etc., held at the correct locations? ‰ ‰ ‰

14. Were users briefed on the Permit to Work and have they signed the ‰ ‰ ‰
permit?
15. Do people know what to do in the event of emergency? ‰ ‰ ‰

16. Were control measures (including isolations) properly applied? ‰ ‰ ‰

17. Are the right people aware of isolated equipment? ‰ ‰ ‰

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 Yes No N/A

18. Is the Area Controller aware of the work? ‰ ‰ ‰

19. Is the work being carried out as written in the permit? ‰ ‰ ‰

20. Is personal protective equipment appropriate for the task and being ‰ ‰ ‰
used?
21. Are the tools and equipment suitable and in good condition? ‰ ‰ ‰

22. Is housekeeping satisfactory? ‰ ‰ ‰

23. Are workers aware of Stop Work Authority? ‰ ‰ ‰

Comments:

Reviewer: Signature:
Performing Authority: Signature:

18 Version 1.0 Revised 27 February 2008.

Printed 16 April 2008. Uncontrolled when printed.
GU_MSW_Permit to Work Standard.doc