Hot Work Permit

Permit No:

Planned Start Time:

Planned Date of Work:

Approval and Authority to Commence

Validity Period:

Remote site approval applies (PH signature required)

Task Description:
Area Authority (AA): I authorize this work permit and the work can proceed as planned.

Task Location:
Task Area:

Print Name:

Signature:

Time/Date:

Secondary Location:
Area Operator (AO): I have demonstrated zero energy to the Permit Holder (when required and not delegated). I believe it is safe to perform this work and the Permit
Holder is aware of the equipment to be worked on.

Task Description Details:

Zero Energy:

Not Required

Demonstrated to the PH

Delegated to the PH

Note: At times, the zero energy demonstration will be done with the assistance of other Isolating Authorities or delegated in the case of Personal Isolations or Remote
Field Operations (RFO).
Print Name:

Signature:

Time/Date:

Permit Holder (PH) Acceptance to Commence Work: I understand the precautions that must be taken and Zero Energy (when required) has been demonstrated to
me or delegated to me (Personal Isolations or RFO). The Permit Pack has been reviewed with the work team members and I will notify the Area Operator of the job status
when work is completed/ceased. The procedures and checklists included in this Permit Pack are correct for the task and are current. Individuals who will be using these
procedures and checklists are competent in their use.
Print Name:

Signature:

Time/Date:

Area Interface Authority (AIA): I have reviewed this work permit and the work can proceed as planned.
Print Name:

Signature:

Permit Shift Handover/Extension/Reissue*

Equipment ID/Tag Number:

Equipment Description:

Date/Time
Number of People:

Lead Discipline:
Isolations Required:

ICC

Time/Date:

RFIC

Personal

Is this a Handover,
Extension, or Reissue?

Area Authority

Area Operator

Permit Holder

Area Interface
Authority

None

Work Order Number:

Requested by:

Company:

Permit Pack Required Documents:

Atmospheric Test Record

Cross Referenced Certificates:

Lifting Plan

Rescue Plan

Temporary Defeat

MSDS

SWP Checklist

Isolation Certificate

P&ID/Drawing

SIMOP Deviation

JSA/THA

Procedure

Work Aid

Type

Certificate/Permit Number(s)

Isolation:
Temporary Defeat:
* 1. Any changes of AA, AO, PH, and AIA personnel on this permit must sign accepting their responsibility.
2. Shift extensions must be signed by the AA to a maximum of 4 hours.
3. Reissued permits must be signed each shift by the AA, AO, PH, and AIA.

Work Permit(s):

List Required Checklists:

Permit Close-Out

Work associated with this permit has been completed?

Yes

Other (describe):
PH: I confirm that all personnel have been accounted for and the worksite has been restored to a safe and tidy working condition.
Print Name:

Signature:

Time/Date:

Area Authority (AA) Reviewer: The task description accurately details the permit work activity. The required permit pack documentation has
Work Status comments:

been identified.
Print Name:

Signature:

Time/Date:

AO: I am satisified that the worksite has been restored to a safe and tidy condition. All isolations relevant to this permit must follow the de-isolation procedure prior to
reenergizing, or a long term isolation (LTI) must be applied.

Person In Charge (PIC): I have endorsed this work and it will not conflict with other

RFO - PIC notified:

Signature:

(Initial)

Have isolations been removed?

activities. It can commence when the permit conditions are fulfilled.

Print Name:

Yes

Time/Date:

Print Name:

Yes

No

PIC or the AA has been notified?

Signature:

Yes

No
Time/Date:

No

Work Management System Permit Pack Requirements Matrix

M

Permit Pack Requirements

Work/Job Activity
Isolation
Work
Permit

LO/TO
Blinding
Defeat

Hot Work

Work Team Declaration:

Job
Safety
Analysis

Safe Work
Practice
Checklist

Work
Procedure

Atmospheric
Test Record

Mandatory for permit pack

To be reviewed and considered
for permit pack by Permit Holder,
Area Authority, and PIC.

Work team members must sign before commencing work for the first time to indicate that they have reviewed the Permit Pack with the Permit Holder.
Each person understands the scope of work, their responsibilities and is competent to execute their part of the Permit Pack (including JSA, Procedures,
and Checklists) to complete the work safely.
If any person observes an unsafe situation developing they must immediately stop work, inform their co-workers, make the worksite safe, and inform the
Permit Holder and the Area Operator.
Note: Workers reassigned, crew changing, or no longer working on this permit while the permit is valid must sign off.

Date

Work Management System Atmospheric Test Record

Area to be Tested:

Test Frequency:
Prior to work commencing:
Hour(s):

Every
Yes

Continuous gas testing required:

Yes

No

Yes

No

No

Required Tests:
O2

LEL

H 2S

CO

VOC

Benzene

SO2

CO2

Other

Calibration Date:

Detector used:
Comments/Special Precautions:

Results (Pre Start + Work Period Tests)

CSE Class 1
Limits

CSE Class 2
Limits

19.5 to 23.5%

16% to 19.5%
or > 23.5%

Date
Time
Oxygen (O2)
Lower Explosive Limit (LEL)
Flammability General Work

1% of LEL (HC)

< 10% of LEL (HC)

Flammability Hot Work/Critical Work

Spark Potential

0% of LEL

0% of LEL

Total Hydrocarbon Content (THC)

< 500 ppm

< 1000 ppm (IDLH)

Hydrogen Sulphide (H2S)

< 5 ppm

< 100 ppm (IDLH)

Carbon Monoxide (CO)

< 25 ppm

< 1200 ppm (IDLH)

Benzene

< 0.5 ppm

< 500 ppm (IDLH)

Sulphur Dioxide (SO2)

< 0.5 ppm

< 100 ppm (IDLH)

Other
Authorized Gas Tester (AGT) Initials:

Pre-Start
Test
Result

Result

Result

Result

Result

Result

Result

Name

Sign On

Date
(if different)

Sign Off