M.V./S.S.:

POSITION/ PORT

Location, Description of Work and Equipment to be used:

Condition of Area / Space/Work Activity

Section 1 – Preparation and checks to be carried out by the Senior Officer in Charge of Cold Work.

Yes

No

Remarks

1.1

The Equipment/Pipeline has been

prepared as follows:

Vented to Atmosphere

Washed

Drained

Purged

Other

1.2

The Equipment/Pipeline has been

Isolated as follows:

Lines Blanked

Valves Closed

Lines Disconnected

Other

1.3

Is Equipment free from:

Oil

Pressure

Gas

H 2 S

Steam

1.4

Is surrounding area free from Hazards?

1.5

If work is to be performed on

Electrical Equipment, has that

equipment been Isolated?

1.6

Has risk removed carried out

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M.V./S.S.:

POSITION

VALID FOR

FROM

hrs

DATE:

PERIOD *

TO

hrs

DATE:

Section 2 – Information and instructions to person carrying out cold work.

The following Personal Protections must be worn: (spacify)

Equipment/Pipeline contained following material in service:

Equipment expected to contain the following Hazardous Material when opened:

Special Conditions/Precautions:

In the circumstances noted, it is considered safe to proceed with this cold work.

Senior Officer in Charge Signature:

Master’s Signature:

Section 3 – The Coldwork has been completed and all Persons under my supervision, Materials and Equipment have been withdrawn.

Senior Officer in charge Signature:

Date

Time

*  Valid only for time of work, not to exceed 8 hours.
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