Reliance Project Management System RPMS-HSEF-CHK-HC-061

Permit to Work Date: 09/01/2018, Rev. 1

RECORD OF REVISIONS
Date Revision Details Revision Number Checked by Approved by

Issued for
19.08.2013 0 Sudhir Mishra Brian Spraker
Implementation

Issued for
09.01.2018 01 Sudhir Mishra James Thorn
Implementation
Reliance Project Management System RPMS-HSEF-CHK-HC-061
Permit to Work Date: 09/01/2018, Rev. 1

Assessment of Task Checklist

(This checklist must be completed before Permit to Work is issued)
Before issuing a Permit to Work, the Issuer must review the job
and consider the following:
1. Do you know exactly what the intended job entails?
2. Do you need to personally visit the work area?
3. Does the employee about to do the job also know exactly?
4. Does the Permit to Work fall within your level of
authorization?

Have you considered?

Hazards
Accessibility Portable Electrical Equipment
Area Classification Pressure
Cramped Work Area Process and Other Liquids
Dust, Powders, Solids Radioactive Emissions
Electric Power Residual Process Materials
Fumes, Odors Restricted Field of Vision
Gases, Flashing Liquids Services – Steam, Water, Air
Ignition of Surrounding Material Temperatures
Motive Power Traffic Ways
Noise Vapor
Obstructions, Falling Objects Weather Conditions
Other People Welding Flash
Other Sections Working at Height
Adjacent Steady State Activities
Precautions
Atmosphere Testing Frequency Hearing Protection
Auxiliary Lighting Ladder, Scaffolding
Breathing Protection Safety Spectacles
Emergency Exit Route Standby Person(s) – How many?
Permit to Work (RPMS-HSEF-CHK-HC-061) Page 3 of 8
© 2018 Reliance Industries Ltd.
Reliance Project Management System RPMS-HSEF-CHK-HC-061
Permit to Work Date: 09/01/2018, Rev. 1

Environmental Safeguards Standby Person’s Briefing

Footwear Standby Person’s Protection
Gloves Ventilation
Goggles Written Procedure
IFR Suit
Head Protection
Contractors
Supervisor Appointed Site Statutory Induction Completed
Dress Standards/Protective Clothing Names on Plant Access Board
PPE Checked ID Badging, where appropriate
Test Date of Equipment Checked Contractor Licenses Checked
Contractor Insurance Checked HSE Training Completed
Plant Standards Communicated Skill Training and Accreditation
Contractor Briefing Completed Checklist Completed
Permit to Work

Company Name: Date:

Project Name: Project No./Contract No.:
Area: Permit to Work No.:
P&ID No.(s): Equipment No.:
Equipment Description:
Activities Authorized by this Permit
(provide details, specifics, and limitations below)

Excavations (slope <1.5:1) Blasting Vegetation/Ground

Clearing
Wall Penetrations Simple Lockout/Tagout Radiography
Ceiling/roof Penetrations Performed From Below
Other (describe):
Job Description
(describe details, specifics, limitations)

Permit to Work (RPMS-HSEF-CHK-HC-061) Page 4 of 8

© 2018 Reliance Industries Ltd.
Reliance Project Management System RPMS-HSEF-CHK-HC-061
Permit to Work Date: 09/01/2018, Rev. 1

Precautions and other Information

(Describe in detail)
Is this Job a Modification? Yes No Modification No.:
Work Order No.:
Is “Assessment of Task Checklist” Current?
Client Coordinator:
Hazards

None Expected Electricity voltage: Others Working Nearby

Gas Working at Heights Solids
Liquid Hot Surfaces Overhead/Adjacent
Power Lines
Molten Metal Stored Energy Varmints
Engulfment/Hazardous Engulfment/IDLH Active/Energized Utilities
Atmosphere Atmosphere
Premature Explosion Earth Cave-in Other
Other Other Other
Additional Permit(S) Required

None Required Use of Suspended Access to High Voltage

Personnel Workbasket Areas
Hot Work Energized Electrical Work Critical Lift
Confined Space Roof Access Line Break
Entry
Hot Tap Excavation Break-In
Tagout Authorization Form (TAF) Process/Lockout- Grating/Floor
Tagout Plate/Guardrail Removal
Working Near Overhead/Adjacent Power Lines
Protective Equipment

Standard Clothing Gloves (type): Canister/Cartridge

Respirator
Hot Work Clothing Chemical Goggles Rubber Boots

Permit to Work (RPMS-HSEF-CHK-HC-061) Page 5 of 8

© 2018 Reliance Industries Ltd.
Reliance Project Management System RPMS-HSEF-CHK-HC-061
Permit to Work Date: 09/01/2018, Rev. 1

Faceshield Hearing Protection Safety Harness

Helmet and Glasses SCBA or Airline PVC Jacket
Respirator
Fall Protection Other PVC Pants
Isolations
Note: Only those isolations meeting the criteria in Table 1 of RPMS-HSEF-PRA-HC-071
can be allowed by a Permit to Work without a TAF.

None Required As Below

Item Description Method Check for Isolation De-isolation
Dead
INTL Date Time INTL Date Time

All Authorized Workers must hang personal locks and Danger Tags on each isolation.
The building or plant item described above is, in my opinion, in a safe condition for the
job to be done provided the conditions above are fully observed. These conditions
have been discussed with, and understood by, the persons involved.

Permit to Work Issuer

Issuer Name Signature Date Time Valid Until Time

Acceptance and Return

This permit is only valid when above parts have been completed.

Recipient Taking Permit to Work:

I have read this Permit to Work and have had the hazards and precautions explained to
me; I will comply with these provisions. Should there be a change in conditions that
introduces new hazards to the task, I or the work party will stop work and notify the
Permit to Work Issuer. Work will only proceed with approval from the Issuer. I, or the
work party, will vacate area on request or alarm. I will not interfere with online
equipment.
Recipient Signature Organization Date Time Completed

Permit to Work (RPMS-HSEF-CHK-HC-061) Page 6 of 8

© 2018 Reliance Industries Ltd.
Reliance Project Management System RPMS-HSEF-CHK-HC-061
Permit to Work Date: 09/01/2018, Rev. 1

Name
Yes No
Yes No
Yes No
Yes No
Responsible person has signed on for others.
All Authorized Workers must hang personal locks and Danger Tags on each isolation.

Recipient Handing Back Permit:

I or my work party have withdrawn from the job. Unless the job is incomplete, tools,
materials, and equipment from the immediate vicinity of the work area have been
removed, flange guards replaced, personal locks and Danger Tags removed, and the area
cleaned.
Recipient Signature Organization Date Time Completed
Name
Yes No
Yes No
Yes No
Yes No
Job Complete
The plant/system/area is, in my opinion, available for safe return to service. This Permit
to Work is now withdrawn.

Permit to Work Issuer

Issuer Name Signature Organization Date Time (24 hr)

Permit to Work Extension

The plant/system/area described above is, in my opinion, in a safe condition for the job
to be done provided the conditions above are fully observed. These conditions have
been discussed with, and understood by, the persons involved.

Permit to Work Issuer

Issuer Name Signature Date Time Valid Until Time

Permit to Work (RPMS-HSEF-CHK-HC-061) Page 7 of 8

© 2018 Reliance Industries Ltd.
Reliance Project Management System RPMS-HSEF-CHK-HC-061
Permit to Work Date: 09/01/2018, Rev. 1

Acceptance and Return

This permit is only valid when above parts have been completed.

Recipient Taking Permit to Work:

I have read this Permit to Work and have had the hazards and precautions explained to
me; I will comply with these provisions. Should there be a change in conditions that
introduces new hazards to the task, I or the work party will stop work and notify the
Permit to Work Issuer. Work will only proceed with approval from the Issuer. I, or the
work party, will vacate area on request or alarm. I will not interfere with online
equipment.
Recipient Signature Organization Date Time Completed
Name
Yes No
Yes No
Yes No
Yes No
Responsible person has signed on for others.
All Authorized Workers must hang personal locks and Danger Tags on each isolation.

Recipient Handing Back Permit:

I and /or my work party has withdrawn from the job. Unless the job is incomplete, tools,
materials, and equipment from the immediate vicinity of the work area have been
removed, flange guards replaced, personal locks and Danger Tags removed, and the area
cleaned.
Recipient Signature Organization Date Time Completed
Name
Yes No
Yes No
Yes No
Yes No
Note: This form is referenced in Practices RPMS-CONS-PRA-CM-001, RPMS-HSEF-PRA-HC-
016, RPMS-HSEF-PRA-HC-065, RPMS-HSEF-PRA-HC-068, RPMS-HSEF-PRA-HC-071, RPMS-
HSEF-PRA-HC-078, and RPMS-HSEF-PRA-HC-079.

Permit to Work (RPMS-HSEF-CHK-HC-061) Page 8 of 8

© 2018 Reliance Industries Ltd.