For Isolation and De-Isolation Processes, Refer to the Following Page

Isolation Permit

Project Name : / Project No. :
Document No. :

ISOLATION PERMIT

ISOLATION PERMIT / No:
This Permit is for Isolation to:
Issued To : / Work location: / Type of Work:
Permit Holder:
Print Name / Signature / Date
AUTHORIZATION
Validity Period from : / a.m./p.m. / / / / to: / a.m./p.m. / / /
Verified By :
Print Name / Signature / Date
Authorized by:
Print Name / Signature / Date
ASSESSMENT OF POTENTIAL HAZARDS
ENVIRONMENT & ISOLATION ASSESSMENT
What is involved? / Yes / No / N/A / What is involved? / Yes / No / N/A
1)Pipelines (water, steam, gas) /  /  /  / 2)Vessel pressurization /  /  / 
3)Sludges/storm water (inrush) /  /  /  / 4)Electricity /  /  / 
5)Fall of ground (excavation) /  /  /  / 6)Fire /  /  / 
7)Chemicals /  /  /  / 8)Harmful materials /  /  / 
CONTROLS REQUIRED
9)Main power source isolation /  /  /  / 10)Local area power isolation /  /  / 
11)Circuit breaker isolation /  /  /  / 12)Emergency stop /  /  / 
13)On-off switches /  /  /  / 14)Removable fuses /  /  / 
15)Moveable parts blocked /  /  /  / 16)Suspended parts lowered /  /  / 
17)Compressed fluids/gases drained /  /  /  / 18)Spring tension released/blocked /  /  / 
19)All valves closed & locked /  /  /  / 20)All lines blinded & tagged /  /  / 
21)Double block & bleed /  /  /  / 22)Extreme heat/cold dissipated /  /  / 
23)Atmospheric testing /  /  /  / 24)Continuous monitoring /  /  / 
25)Monitoring every ____ hrs /  /  /  / 26)Ventilation forced/natural /  /  / 
27)Red Locks and tags /  /  /  / 28)Yellow Locks and tags /  /  / 
29)Lockout Hasps /  /  /  / 30)Plug lock out device /  /  / 
CONTROLS REQUIRED / Yes / No / N/A / CONTROLS REQUIRED / Yes / No / N/A
31)Circuit breaker lockout devices /  /  /  / 32)Cable lockout devices /  /  / 
33)Valve lockout devices /  /  /  / 34)Pneumatic lockout devices /  /  / 
35)Barricades /  /  /  / 36)Signage /  /  / 
37)Ground support system stable /  /  /  / 38)Batters & benches stable /  /  / 
39)Access for personnel /  /  /  / 40)Emergency rescue access /  /  / 
PERSONAL REQUIREMENTS
41)Risk management completed /  /  /  / 42)JSEA training/communicated. /  /  / 
43)Head protection /  /  /  / 44)Eye protection /  /  / 
45)Face protection /  /  /  / 46)Fume/dust protection /  /  / 
47)Hand protection /  /  /  / 48)Hearing protection /  /  / 
49)Foot protection /  /  /  / 50)Clothing protection /  /  / 
51)Fall protection /  /  /  / 52)Other body protection /  /  / 
53)Additional PPE training /  /  /  / 54)Sentry /  /  / 
55)Hot work permit / 56)Emergency equipment
57)Notification - other departments /  /  /  / 58)Other requirements (continuing) /  /  / 
EMERGENCY EQUIPMENT
List any emergency equipment required:
OTHER REQUIREMENTS and ASSOCIATED DOCUMENTATION
List any relevant documentation/work-specific method statements/drawings or manufacturer’s instructions:
SHUT DOWN PROCESS
Operating Plant & Equipment shall be shut down using the following steps :

For Isolation and De-Isolation Processes, refer to the following page.

START UP PROCESS
After Plant & Equipment has been de-isolated and energized, it shall be started up using the following steps :
CLEARANCE FOR ISOLATION / Refer form I0216-SAF-FM-009C, Isolation Entry/Exit Log
All persons are clear of the area that was isolated by this Permit. Further work requires a new Isolation Permit.
Permit Holder:
Print Name / Signature / Date
COMPLETION OF WORK
Work covered by this Permit is Completed / Suspended. Further work requires a new Isolation Permit.(select one)
Permit Holder:
Print Name / Signature / Date

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Isolation Permit

ISOLATION TYPE CODES / Isolation Permit No.:
LVI / Low Voltage Isolation (< 1,000V) / HVI / High Voltage Isolation ( 1,000V) / DCR / De-Contactor Removed / GI / Gravitational Isolation
VLC / Valve Locked Closed / VLO / Valve Locked Open / SR / Spool Removed (blank fitted) / BI / Blank Inserted
RI / Radiation Isolation / HI / Hydraulic Isolation / MI / Mechanical Isolation / BE / Barrier
ISOLATION AND DE-ISOLATION PROCESSES
No. / Isolation Point / Isolation Type / Isolation by / Cross Checked by / Special Precautions
(Verification & Monitoring Req’ts.) / De-Isolation
Print Name / Initials / Print Name / Initials / Print Name / Initials

Where isolation extends beyond one shift, the New Permit Holder shall complete one of the sections below to indicate he has received adequate handover of this Isolation Permit

New Permit Holder / Time: …… ..…am/pm / New Permit Holder / Time: ….…am/pm
Print Name / Signature / Date:……./……./…… / Print Name / Signature / Date: ….../……/…

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