MULTI DAY PERMIT TO WORK CoNTINUATIoN Form

Associated PTW No.: Day _________________________of____________________________ Step 9. ATMOSPHERIC CHECK Recorded at Intervals of ____________ % Oxygen (19.5 - 23.5%) * LFL (<5% of LFL)
Other

QCOPS-BX00-HSS-FRM-000014_0

Permit Issuer Name _______________________________________________Signature ________________________________ Date _______/_______/______ Initial Result

The conditions, hazards and controls set and agreed in the day 1 PTW and supporting documentation must be reviewed and followed each day. Before entering the work area contact the Area Owner. Step 7. WORK PARTY SAFETY BRIEFING JSEA Scribe: Name __________________________________________________ Position ________________________________ Time ____________am/ pm (i) Review and discuss the conditions of the PTW and supporting documentation, including SWMS details and identify any new hazards. (ii) Consider the conditions on the day. For Example: Rain, wind, lightning, dust or other weather conditions and/or work at night Known unsafe plant conditions or hazards specific to the work location Other hazards that could be created by a separate work crew nearby Plant isolation requirements or known plant modifications Work environment related hazards or situations such as: - overhead powerlines - compression plant - underground services - previously excavated ground, loose or sloping ground - gathering system pipelines or plant - close interaction with the public or a roadway (iii) Have all hazards been identied and / or are the controls adequate?
Step # Task Step and / or Hazard Risk

Time

Time

Result

Time

Result

Time

Result

Time

Result

Time

Result

Other

* * *

Gas Tester Initials Step 10. WORK PARTY SIGN ON Step 11. WORK PARTY SIGN I acknowledge that I clearly understand the controls / safeguards to be used for this task; my competencies All work party members must sign off the permit at completion of are current to undertake the task; I will comply with all of the controls identied in the PTW including SWMS task or shift. & JSEA; and I have been consulted and had the opportunity to ask any questions. Personal Lock Print Name Sign On Time Sign Off Time Removed Y / NA
1 2 3 4 5 6 7

*Yes

*No If No, complete the JSEA below:

Control Residual Risk

Risk Level
rem

8
25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1

Risk must be reduced to as low as reasonably practicable. Extreme Risk: The work cannot proceed. High Risk: Seek input from the Area Owner and/or an expert; if risks are still high, Superintendant approval is required (alternative controls must be considered to minimise risk; approval will only be permitted in rare cases) Low Medium Risk: Task can proceed once approved by the Area Owner. Always consult with the Area Owner after conducting the JSEA or if conditions change. Any person is expected to stop work if they believe that conditions under which the PTW was issued have changed or that hazards are not being controlled adequately. Step 8. AREA OWNER APPROVAL TO COMMENCE WORK Area Owner Checklist Site Inspected Scope of Work Agreed Controls in Place Tested for Dead / Stored Energy Yes No
Not Applicable

of an incident

of people to the risk

Ex t

Likelihood

Exposure

Consequence Injury Impact

9 10 11 12 13 14 15

Has happened Possible Remotely possible Practically impossible Conceivable but unlikely

Medium

Yearly Quarterly Monthly Weekly Daily Continuous

Fatality Lost Time Injury Medical Treatment First Aid

Major Serious Moderate Minor

High

Almost certain

Multiple Fatalities

Catastrophic

Step 12. HANDBACK Permit Holder to complete with Area Owner, then both Area Owner and Permit Holder sign Yes Confined space cleared of all Personnel and Equipment Blanks Out Guards Replaced Isolations Removed Leak Tight No-Load Run Plant Physically Complete Purged No N/A

Additional Area Controls Required

* * *

* * *

* * Yes * No * Not Applicable

Rotation Services Restored Post Work Fire Inspection The Task is Complete The Plant / Equipment is Safe & Serviceable The Area has been left Safe & Clean List Incomplete Work on Attached Sheet (only applies where work is incomplete) THIS PERMIT IS CLOSED Permit Holder Area Owner Print Name Sign Off

Atmospheric Check requirements as per step 5B. Initial Recordings within safe limits

Permit Holder: I am aware of the Site Emergency Response system and understand the precautions to be taken during the period covered by this permit and will instruct all those who are working under this permit accordingly. If environmental, site conditions or scope of work change, I will immediately consult with the Area Owner. Area Owner: I have reviewed the PTW conditions , discussed the proposed work , including potential SIMOPS and work site conditions with the Permit Holder and authorise the work to commence. TAN This permit is valid for the duration of one shift from the date and time documented below. Print Name Permit Holder Area Owner New Permit Holder New Area Owner
Work shall not start until the Area Owner has reviewed the permit and associated documents & issued a TAN.

Sign On

Time

Date

Phone No.

Transfer Sign Off

Time

Date

* * * * * * * * * * * * * * *
Time

* * * * * * * * * * * * * *
Date

* * * * * * * * * * *

Lo w

Area Owner notifies Permit Issuer of TAN closure and task status Permit Holder returns completed permit and all supporting documentation to the Permit Issuer.

Step 13. PERMIT FINALISATION The Permit Holder has returned all of the documentation to the Permit Issuer Permit Issuer Name _______________________________________________Signature ________________________________ Date _______/_______/______