M.V./S.S.:			POSITION / PORT
		VALID FOR			FROM			hrs		DATE:
		PERIOD *			TO			hrs		DATE:
Specific Location, Description of Work and Equipment to be used:
Special Precautions
Personnel Assigned to Work:
Officer Responsible for Supervision of Work:
Officer Responsible for Safety:
Agreement Received From Office (where applicable):
Date / time received:
From whom (name):
By method (i.e. e-mail, phone etc)
We are satisfied that the hotwork permit instructions, and checklist requirements have been complied with, and that it is safe to proceed with the work as described.
N.B. Any alteration to the conditions required to comply with the checklist items will invalidate this permit.
Officer Responsible for Supervision of Work Signature:
Officer Responsible for Safety Signature:
Master’s Signature:
I am satisfied that the work described has been completed on or before the end of the above mentioned period*
and that all persons under my supervision, materials and equipment have been withdrawn.
Officer Responsible for Supervision of Work Signature:
Date:					Time:
*Valid period not to exceed 8 hours.

PAGE 1 OF 3

 

CHECKLIST

YES

NO

REMARKS

1.0

Have the following operations

If applicable been suspended:

¨

Cargo

¨

Ballast

¨

Tank Cleaning

¨

Gas Freeing

¨

Purging

¨

Inerting

2.0

Is the Oxygen Content of the space 21% and has the company

Enclosed Space Entry Permit

been issued?

3.0

Has the space been gas freed to

Less than 1% L.F.L?

4.0

Has the Work Area been checked

with a Combustible Gas Indicator,

for Hydrocarbon Vapours?

5.0

Has the surrounding area been

checked with regard to

Combustible Flammable Materials

and Gasses?

6.0

Has the surrounding area been

cleaned and rendered safe and if

applicable continuously ventilated?

7.0

Are the adjacent spaces clean and

Gas Free or Inerted?

8.0

Have arrangements been made to

check the work area for

combustible gas at 2 hourly

intervals whilst the work is in

progress?

9.0

Are the pipelines in the space or

entering the space clean and

additionally Gas Free, Inerted or

filled with clean water or blanked?

10.0

Is all electrical equipment

Isolated?

Officer Responsible for Safety Signature:

Masters Initials:

PAGE 2 OF 3

		CHECKLIST (Cont)
			YES			NO				REMARKS
11.0	Is all Electric Welding Equipment
	securely Earthed?
12.0	Is any Oxy-Acetylene or other
	Burning Equipment being used in
	safe working order?
13.0	Is additional Fire Protection in
	place?
14.0	Are Smoking Regulations in force?
15.0	Has Walkie/Talkie emergency
	communication been established?
16.0	Has the relevant management
	office  approval if applicable been
	obtained  for this Hotwork?
17.0	Has Wx condition monitored for
	Duration of work
17.0	Has a Risk Assessment been
	carried out?
Officer Responsible for Safety Signature:
Masters Initials:

The Responsible officer shall ensue, at an interval not exceeding 2 hrs, that there are no alterations to above conditions. Repetitive checks are to be recorded in the table mentioned below:

 

	After 2 hrs of Commencing Hot work	After 4 hrs of Commencing Hot work	After 6 hrs of Commencing Hot work
Name
Rank
Signature

PAGE 3 OF 3