12.06.06.001.03 Isolation Permit

ISOLATION PERMIT
VESSEL NAME: PORT:

This permit is valid from Date Hrs
Date Hrs
Valid only for time of work & Not to Exceed 8 Hrs.
Section 1 Description of Work & System Involved
Connected to Permits to Work (More than one check boxes may be applicable)
Permit to work aloft-over side
Enclosed space entry permit Hot work permit
permit
Permit to work on critical
Diving work permit Cold work permit
equipments and system
Permit to work on pipelines and Permit for opening manhole Work Permit For Shore Contractor
pressure vessels covers
Permit to work with Small Craft Pump room entry permit
Permit to work in Elevator
Alongside
Permit for going on deck in
Ballast Pump Room Entry Permit
heavy weather
Section 2 Specific Location of Work
.
Section 3 Personnel Assigned to the Work
Section 4 Energy Source (Circle Applicable Sources)
Electrical Mechanical Gas Pneumatic Hydraulic Gravity Steam Wind Chemical
Section 5
Isolation Steps And Verification
Yes No
Affected crew members working on or near the equipment have been notified that it is being shut
down or isolated.
Deactivation of Electrical Power sources and application of energy control means. The equipment is
de- energised by switching off the power switch (Location):
Deactivation of Mechanical / Pneumatic / Hydraulic / Steam Power to the equipment is controlled

using the following control means:
Sources of stored energy (Including their location) are:
Deactivation of (stored energy) Gravitational energy/ Cooling water/ Gas / Battery / Charged
Capacitors/ Coiled Spring / Others is controlled by using the following energy control means:
Verification of Lockout / Tag out:

Energy isolation is verified by simulating to activate / Proved Dead:
A lock-out system: A clasp with padlock, a wire seal or other similar devices which would offer
physical restraint from opening an energy source.
If lock out is not carried out use tags/placards e.g.: DO NOT START, DO NOT OPEN, DO NOT
ENERGISE.
12.06.06.001.03
ISOLATION PERMIT Page 1 of 3
Section 6 Working on Live Circuits Yes No
Location of Work:
Description of Work (If different from Section - 1) :
Isolation has not been carried out as it affects alarms or safety devises?
Give details:
Cannot be Isolated but the special precautions are adequate and that it is safe for the work to
commence.
If working on live circuits, list any special precautions / contingency measures in this
section below.
If working on live circuits, Name of the person standing by:
In cases where special conditions exist, has a risk assessment been carried out?
If fuses are removed, the person in charge has fuses in his possession
Are insulated tools used where required?
Is correct PPE (e.g. High Voltage Electrical Gloves) being used? (Ref to 12.06.15.001)
Are rubber mats placed on deck at the work place?
Shore Technical Department Concurrence:
Date: Time: (Attach copy of correspondence)
Special Precautions / Contingency Measures

(If working on live circuits, list any details and special precautions / contingency measures in this
section)
Section 7 Acknowledgement of Isolation

I acknowledge that the plant / system has been isolated in the manner identified by this permit and their
operation during the currency of this permit maybe restricted.
Signature / Rank of Person in Charge:
Name (print): Date : Time:
In the circumstances noted, it is considered safe to proceed with this work.
Chief Officer’s / Chief Engineer’s Signature:
Master’s Signature (Master to countersign for repairs

on Navigational / Communication equipment & isolation
of Fire Detection System)
Section 8
Re-Energisation of Equipment
Yes No
Once work is completed: all equipment parts are replaced; all personnel and tools are cleared;
inspection of work area completed.
Energy is reconnected to the equipment/system by:
Control means are removed from:
Affected personnel are notified that the equipment/system is ready for use.
In case of work on Live Circuits, Shore Technical Department informed.
12.06.06.001.03
Section 9 The Isolation permit closed due to: (Tick relevant check box)
Permit time expired Work completion Change in work condition Work suspended
I acknowledge that all isolations mentioned in Section 5 have been De-Isolated from the plant /system
specified on this permit. Normal operations may be safely resumed.
Signature / Rank of Person in Charge:

Name (print): Date : Time:
12.06.06.001.03

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ISOLATION PERMIT

VESSEL NAME: PORT:

Valid only for time of work & Not to Exceed 8 Hrs.

Section 1 Description of Work & System Involved

Section 2 Specific Location of Work

Section 4 Energy Source (Circle Applicable Sources)

Electrical Mechanical Gas Pneumatic Hydraulic Gravity Steam Wind Chemical

Deactivation of Mechanical / Pneumatic / Hydraulic / Steam Power to the equipment is controlled

Sources of stored energy (Including their location) are:

Verification of Lockout / Tag out:

Description of Work (If different from Section - 1) :

If working on live circuits, Name of the person standing by:

Are insulated tools used where required?

Are rubber mats placed on deck at the work place?

Shore Technical Department Concurrence:

Date: Time: (Attach copy of correspondence)

Special Precautions / Contingency Measures

Section 7 Acknowledgement of Isolation

Signature / Rank of Person in Charge:

Name (print): Date : Time:

In the circumstances noted, it is considered safe to proceed with this work.

Chief Officer’s / Chief Engineer’s Signature:

Master’s Signature (Master to countersign for repairs

Energy is reconnected to the equipment/system by:

Control means are removed from:

In case of work on Live Circuits, Shore Technical Department informed.

Signature / Rank of Person in Charge:

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