Information
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Date / Start Time
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Permit Required (check if YES)
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Observer
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Work Group
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Job Description
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Work Area / Location
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Equipment
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Is there a Permit to Work for the job?
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Do you have an SOP for the Job task?
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Did you share the SOP with the crew prior to performing the job task?
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Has the crew performed this task within the last 6 months?
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% of SSE
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Result
Section 1
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A) As the PLW, what are some things you should know about the work being performed?
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* Work Practices, SOP’s, and Standards
* Chemicals and/or Hazardous Materials
* Emergency Plan Location and Requirements
* Appropriate Means of Hazard Control -
B) As the PLW do you communicate to your crew that you support them in the use of Stop Work Authority?
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C) Are the permit conditions clearly understood and communicated to the PLW?
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D) Is a JSA performed on-site with the work crew prior to the initiation of work?
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Was JSA presented and reviewed to V&V Team upon arrival to location?
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E) When is Permit to Work Required?
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* When work tasks include: HW, CSE, IHE, E&T
* Line breaking
* Transfer of work & responsibilities from one group to another.
* SIMOPS
* Whenever an API or Permit Approver deems necessary.
* The work has significant potential for injury or incident. -
F) Are specialized MSW permits (certificates) complete as required for this work?
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G) Is PTW documentation available at the work site?
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H) Are PLW Roles and Responsibilities clearly understood as outlined in the SJVBU Safety Manual?
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* Representing the group performing the work by:
o Being familiar with the planned job tasks.
o Assist in the planning and coordination of permitted work.
o Giving direct supervision to the permit users and remaining at the work site during the permitted portion of the work.
o Notifying API when the work is complete -
I) Does the PLW understand why a PTW is necessary / required for this work?
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* It establishes necessary steps and activities to plan, prepare, and execute work safely. It creates communication between the API and the PLW
Section 2
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1) Was site hazard identification/recognition discussed with the crew?
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Hazards discussed/identified with crew
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Comments/Nuggets
