HOTWORK, PIPELINE OPENING, WORK AT HEIGHT, LOTO PERMIT FORMAT Page 1 of 1

GACI _ HSE/F 011 _ V.01

Effective date: Review date: 2 years starting effective date or when needed

Required Permit Nature: HOT WORK / PIPELINE OPENING / WORK AT HEIGHT / LOTO

Work Description
Equipment / Area:
Name:
Permit Receiver Designation :
Dept:
Date:
Permit valid
From Time: To Time:

A) ACTIONS TO BE TAKEN BY PERMIT ISSUER

A1- Hot Work YES N/A A2 – Pipeline Opening YES N/A A3 – WORK AT HEIGHT YES N/A
1) Isolated inlet, outlet service lines &Process lines by 1) Isolated inlet, outlet service lines &Process 1) Weather adequate ladder and platform with railing
closing valves/blinding lines by closing valves/blinding and scaffolding provided.
2) Equipment/Pipeline Depressurized to Atmospheric 2) Equipment/Pipeline Depressurized to
2) Ladders lashed at top
pressure Atmospheric pressure
3) Equipment/Pipeline Drained and Sludge removed 3) Equipment/Pipeline Drained and Sludge
3) Anchorage for Safety Belt provided and checked
found free from toxic 4hemicals. removed found free from toxic 4hemicals.
4) Equipment/Pipeline Purged and Free from 4) Equipment/Pipeline Purged and Free from
4) Area Barricaded and Danger Boards displayed.
gases/vapors gases/vapors
5) Equipment/Pipeline cleaned with
5) Equipment/Pipeline cleaned with steam/Chemical
steam/Chemical cleaning /water Flushed and 5) Life line for anchoring safety belt provided.
cleaning /water Flushed and Cooled
Cooled
6) Equipment Electrically Isolated by removing fuses and 6) Equipment Electrically Isolated by removing 6) Double lanyard safety belt with third party
safety tags displayed fuses and safety tags displayed certification provided
7) Mechanically Isolated and safety tags
7) Mechanically Isolated and safety tags displayed 7) All sharp objects removed
displayed
8) Danger / Caution Boards displayed 8) Danger / Caution Boards displayed 8) Proper lighting and ventilation provided

9) Ensure good housekeeping .Remove cotton waste, 9) Ensure good housekeeping .Remove cotton
gunny bags, drums combustible material waste, gunny bags, drums combustible material

10) The area around is wet with water and kept water 10) The area around is wet with water and kept A4 – LOCK OUT TAG OUT (ELECTRICAL &
YES N/A
flow running. water flow running. MECHANICAL ISOLATIONS)

11) Job safety analysis prepared and enclosed 11) Job safety analysis prepared and enclosed 1) MCC/PCC Breaker switched off

12) Area Cordoned and Barricaded 12) Area Cordoned and Barricaded 2) Control fuses removed
13) Information to be given nearby departments/area 13) Information to be given nearby
3) Tag No.
authorities departments/area authorities

14) Proper lighting and ventilation provided 14) Proper lighting and ventilation provided 4) Key No.

15) Equipment/Pipeline/plant surrounding area checked 15) Equipment/Pipeline/plant surrounding area

5) Prime mover isolated
for LEL, LEL should be 0% checked for LEL, LEL should be 0%
16) load cells disconnected 16) load cells disconnected 6) Tag No.

17) Earth lead connection to the equipment under hot 17) Earth lead connection to the equipment
work is disconnected and independent earthing under hot work is disconnected and 7) Key No.
provided independent earthing provided

B) ACTIONS TO BE TAKEN BY PERMIT RECEIVER

YES N/A
1) Proper railing, working P F and scaffolding provided and Inspected.
2) Worthiness of tools and tackles checked mention the Identification no.
3 ) Condition of the welding machine checked and mention the Identification no.
4) Welding Return Cable provided and connected to the equipment under welding
5) Welding Cables/holders lugs are in good working condition and well insulated
6) Welding machine power supply routed through ELCB
7) Isolator with fuses provided
8) Gas cylinders valve guards, regulators and hoses are in good working condition
9) Flashback arresters provided for both the cylinders and cutting torch.
10) Gas cylinder are kept in cylinder trolley.
11) Ladders lashed at the top
12) All hoses/equipment grounded
13) Fire water hose, Sand bucket, Fire Extinguishers provided at work place.

C) REQUIRED PPE

Safety Helmet B.A Set Hand Gloves

Airline Respirator Cartridge Mask Safety Shoe
Gum Boots Safety Net PVC Suit
Dust Mask Face Shield Safety Goggles
Ear Plug Safety Belt Fall Protection

D) PERMIT APPROVAL:
We certify that the above precautions have been taken and the area, equipment / Vessel / Tank is free from combustible. Flammable toxic and dangerous fumes and it is safe to carry out the work

PERMIT ISSUER SECTION HEAD SAFETY REPRESENTATIVE PERMIT RECIEVER

(Name/Signature/Date) (Name/Signature/Date) (Name/Signature/Date) (Name/Signature/Date)

[Link] :

Extended From: ___________________ Hrs. To: ___________________ Hrs.

Initiating Dept. Head Approving Authority / Unit Head

(Name/Signature/Date) (Name/Signature/Date)

F. PERMIT CLOSURE:
Job Executed Equipment Handed Over.
PERMIT ISSUER PERMIT RECEIVER
(Name/Signature/Date) (Name/Signature/Date)

Prepared by Reviewed and Approved by

(Signature & Date) (Signature & Date)