PetroChina (Halfaya) Permit To Work System

COLD WORK PERMIT No.:

I. TASK
Brief description of the proposed task: Work Request Period (Planning)
From Date Time
To Date Time
Equipment / System: ID / TAG No. Work Order No.
Equipment Isolation Required
Location: Instrument Electrical Mechanical
(Tick as applicable)
Name (Permit Originator): Signature & Contact No.: Date Time
II. CERTIFICATES AND SUPPORTING DOCUMENTS
Certificates YES NO Cert. No. Supporting Documents YES NO Attached & No.
Confined Space Entry Job Hazard Analysis
Isolation / De-Isolation Method Statement
Working at Height Toolbox Talk
Lifting Operations Drawings
Excavation, Digging and Building Penetration SIMOPS
Other necessary permissions, specify: Safety Critical Isolations (F&G Detectors, ESD etc.,)
Other open permits in the area that could interfere, specify:

III. HAZARD IDENTIFICATION & CONTROLS

Req'd Req'd Req'd
WORK SITE PREPARATIONS
(Y/N) (Y/N) (Y/N)
Equipment Depressurization Equipment Isolation (Electrical) Purging of Lines
Equipment Flushing/Draining Barrication Area free from Combustibles
Ventilation Shielding/Screening Gas Test
Earthing for equipment & engines Spark Arrestor for engines/vehicles Others, Specify
Equipment Isolation Safe Access/Egress Others, Specify
Blinding Disconnection
(Mechanical) Adequate Lighting (Safe) Others, Specify

POTENTIAL HAZARDS (Tick as applicable)

Electrical Shock Dust Pinch / Caught in (Rotating Machinery)

Electrical Fire / Short Circuit Chemical (Toxic & Corrosive/Flammable) Crush / Physical Injury
Slip / Trip / Fall Ergonomics Struck by (Mass Acceleration)
Noise Mechanical (Vibration) Others:
Heat Pressurized System / Equipment

SPECIFIC HSE REQUIREMENTS (Tick as applicable) PERSONAL PROTECTIVE EQUIPMENT (Tick as applicable)

Safety Barriers / Warning Signs / Welding Booth Standard PPE (FRC, hard hat, boots, glasses) Goggles
Safety Harness Leather Gauntlet / Gloves Respirator
Warning Beacons Leather Aprons Ear Protection
Portable Gas Detector Face Shields High Voltage PPE
Portable Exhaust Fan Gas Masks Other PPE, specify:
Running Water/ Fire Extinguisher/ Hose/ Fire Truck Air Supplied Masks (SCBA)
Fire Blanket / Habitat BA Escape Set
IV. ATMOSPHERE / GAS TESTING ( this section is only applicable when the Issuing Authority idenifies the requirement for gas testing)
LEL Toxic
Oxygen Others, Specify
Date Time Name & Authorisation No. (Ideal = 0%) H2S CO Signature & Contact No.
<5% 19.5% - 23.5 % 0 ppm 0 ppm

Additional gas testing to be carried out every ____________mins/hrs. (If above rows are not enough, additional gas testing shall be recorded in the Additional Sheet For PTW Atmosphere / Gas Testing )
Additional Controls / Precautions: (In case the atmospheric air composition is excess of allowed level, Issuing Authority shall conduct specific JHA for appropriate additional controls)
V. HSE REVIEW (HSE SUPERVISOR) (To be confirmed by Issuing Authority) VI. TECHNICAL REVIEW (To be confirmed by Issuing Authority)
HSE Review Required? (circle as necessary) YES NO Technical Review Required? (circle as necessary) YES NO

Name: Signature & Contact No.: Name: Signature & Contact No.:

Comments: Date Comments: Date

Time Time
VII. PERMIT APPROVAL AND ISSUANCE
PERFORMING AUTHORITY AREA OPERATOR / CUSTODIAN ISSUING AUTHORITY
I understand the work scope and accept the conditions and precautions specified in this permit. I will explain I declare that all hazards have been identified and all specified control measures are I declare that all hazards have been identified and all HSE requirements and worksite preparations specified in
them to the work party through a toolbox talk prior to commencing the work and ensure adherence in place and it is safe to carry out the work defined. this permit are in place. The permit and any supplementary certificates have been completed. The control
throughout the work. I fully accept the responsibility to carry out the above work in the safest possible measures defined are in place. I hereby authorize the work to proceed.
manner.
Name: Name: Name:
Employee No.: Employee No.: Employee No.:
Signature: Signature: Signature:
Date/Time: Date / Time: Date / Time:
VIII. PERMIT EXTENSION / RENEWAL
Issuing Authority signature required ? (circle as necessary) (To be determined by Issuing Authority) Yes NO Complete as Required
PERFORMING AUTHORITY AREA OPERATOR / CUSTODIAN ISSUING AUTHORITY
Date Time
Name Signature Name Signature Name Signature

Revalidation for Brownfield Sites: 1 shift plus 6 shifts with revalidation. Maximum 7 continuous calendar days.Use Additional Sheet For PCH Work Permit Extension as required.
Revalidation for Greenfield Sites: 1 shift plus 9 shifts with revalidation. Maximum 10 continuous calendar days. Use Additional Sheet For PCH Work Permit Extension as required.
IX. PERMIT CLOSURE
PERFORMING AUTHORITY AREA OPERATOR / CUSTODIAN ISSUING AUTHORITY
I declare that the work has been completed, worksite is clear, housekeeping is satisfactory and the equipment I have inspected the equipment/work area and declare that the work defined in this I confirm that the work has been completed, worksite is clear, housekeeping is satisfactory, overrides of HSE
affected is left in a safe condition. permit is complete and that the area is clean and safe. critical system(s) are returned to normal service, de-isolations are complete and the equipment affected is in a
safe condition for start up.

THE PERMIT IS NOW CLOSED

Name: Name: Name:
Employee No.: Employee No.: Employee No.:
Signature & Contact No: Signature & Contact No: Signature & Contact No.:
Date / Time: Date / Time: Date/Time:
Top Copy: Performing Authority (To be displayed at job site) Second Copy: Permit Control Facility/CCR Third Copy: Issuing Authority

NOTE: The permit will be automatically suspended in case of an emergency and re-issued only if the conditions stated above remain unchanged Version 2.1 Jan 01 2018