Work at Height

ELLENBARRIE INDUSTRIAL GASES LTD. Document No.
: EIGL/HSE-12/WH
WORK AT HEIGHT PERMIT Revision No.: 00
(Above 2 Meter Height ) Date: 19.02.2024
1.Permit No: 2.Date From :

3.Time From :
4.Project Name: 5.Work Location:
6.Name of Contractor: 7.Name of PTW Receiver (Contractor):

8.Activity Authorized under this permit: 10.Personal Protective Equipment / Life Saving Appliances:
□ Head - Helmet □ Face - Face shield
□ Eyes - Safety goggle □ Ear - Ear plug/ Ear muff.
□ Hands gloves: Cotton gloves / leather Gloves
□ Leg - S a f e t y shoes
□ Body - □ Leather apron □ FRC Suit
□ Full body harness □ Life line □ Fall arrestor / Recitable fall arrestor (if
9.Tools & Equipment:
require)
□ Reflective jacket
□ Respiratory system: Safety mask
Other-----------
11.Identified Associated Hazards / Risks / Aspect / Impact with Control Measures: (Please tick "√" for control measures or "X" if
work which to be carried out: (Please tick "√" for respective not complied or "NA" for Not Applicable)
hazards or "X" for Not Applicable)
12.Hazards 13.Control Measures
Fall of person from height. Unprotected structure/edges/ Employee Vertigo Test. HIRA/JSA/ SOP available &
Roof discussed
Manual Handling Hazard Noise / Vibration Inspection & Tagging System Emergency Access / Rescue Kit
Fall of material / Unsecured Mechanical Hazard / Nip points / Opening / grating / hole Safety Net / Fall Protection
material Pinch points covered / protected Devices
Opening/Open holes Improper access Proper working platform & Other
Access / Suitable ladder/
crawler board
Improper Anchorage Other Overhead utilities isolation or Other
they are at safe distance
Overhead live cable Other Area Barricading / Warning / Other
Cautionary sign boards
14.The following items must be checked before issuing the permit
Sl. Sl.
No Description Yes No N/A No Description Yes No N/A
6
1 Work areas / Equipment’s inspected Working Plate forms are Provided and are found
sound /safe for use.
2 Work area cordoned off 7 Materials are not thrown from heights on to
ground.
3 Considered hazards from other routine/ non- 8 Hazards / risks involved in routine / non-routine
routine operations & concerned persons task assessed and control measures have been
alerted by toolbox talk. implemented at specific task.
4 Ladder safely attached / Fixed. 9 Medical examination of workers are made &
found satisfactory
5 Scaffoldings are checked and safe Tag used . 10 Concerned persons in & around have been
alerted .
15.Attachments: Checklists: Yes/ No/ NA, 16.JSA/ SOP: Yes/ No/ NA 17.HIRA: Yes/ No/NA 18.GAS test Record ( If required ): Yes/
No/ NA
19.Work authorization following an inspection of the work at site before commence of work.
Permit holder declaration: I have taken all necessary precautions / controls as stated above.
Permit Holder Name Signature Date
Issuing Authority: I have reviewed and authorize this work permit for the above work description and HIRA/JSA.
Issuer Name
HSE Dept./ Plant Manager : I review the permit & checklist all are found in order.
Name Signature Date
ELLENBARRIE INDUSTRIAL GASES LTD. Document No.: EIGL/HSE-12/WH
WORK AT HEIGHT PERMIT Revision No.: 00
(Above 2 Meter Height ) Date: 19.02.2024
20.PERMIT TO WORK EXTENSION

Note: Maximum validity of this permit to work is seven consecutive days, but every 12 hours this PTW need to be renewed. Validity of additional
permit under this PTW Will be as specified in other permits subject to renewal after 12 hours.
Date Date Date Date Date Date Date Date
Day
Name
Permit
Holder
Sign
Name
Permit
Issuer
Sign
21.Night Shift Date Date Date Date Date Date Date
Day
Name
Permit
Holder
Sign
Name
Permit
Issuer Sign
22.TRANSFER OF RESPONSIBILITY
Permit transferred from Permit transferred to Transfer Period Authorized
From (Date & From (Date & sign - First
Name Signature Name Signature Time) Time) issuer
Authority)
22.Closing Permit
We ensure that the workers for the respective job have withdrawn for job. The work area is made safe, all equipments are switched
off, housekeeping carried out, guards / barricades / tags are in place and work area is completely safe from potential hazard. The
permit to work is now withdrawn.
Permit Holder Name Signature Date Time Job Completed
Yes No
Issuing Authority: I have visited & inspected the site & agree the worksite and equipments affected left in safe condition. The permit to
work is withdrawn.
Issuer Name Signature Date Time
Observation If any:-………………………………………………………………………………………………………………………………………………………
……………………………..……………………………………………………………………………….......................................................................

Work at Height

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ELLENBARRIE INDUSTRIAL GASES LTD. Document No.

1.Permit No: 2.Date From :

4.Project Name: 5.Work Location:

6.Name of Contractor: 7.Name of PTW Receiver (Contractor):

20.PERMIT TO WORK EXTENSION

21.Night Shift Date Date Date Date Date Date Date

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