HAZARDOUS LINE BREAKING
WORK PERMIT
The issue of permits is strictly controlled; permits can only by authorised Permit Issuers and Subject Matter Experts
PERMIT NUMBER (from Permit Registry): ISSUE DATE: / /
PERMIT ISSUER:
PERMIT RECIEVER
(Company/Employee name):
LOCATION OF WORK (EXACT):
DESCRIPTION OF WORK:
SPECIAL INSTRUCTIONS:
Planned Date & Time of works start: ___/___/_______ ____:____
Planned Date & Time of works end: ___/___/_______ ____:____
System/ line contains:
Liquid, gas or powder that is corrosive or toxic ☐ Liquid, gas or powder that is flammable or combustible ☐
Very hot or very cold substance (eg>50oC or <- ☐ CO2 ☐
6oC)
Steam ☐ CIP chemicals ☐
Other hazards not listed above:
Which of the following hazards are associated with this work?
Impact injuries from sudden release of energy ☐ Inhalation of hazardous gas or vapour ☐
from compressed liquid or gas.
Thermal burns ( hot or cold liquids) including ☐ Skin or eye injuries from liquids or gases, eg CIP chemicals ☐
steam
Fire or explosion from ignition of materials. ☐ Asphyxiation caused by gas accumulation including CO2 ☐
Other hazards not listed above:
Safety requirements
PRE-PERMIT MEASURES taken (eg checks of equipment, tools, preparatory works, PPE in place and checked) Yes n/a
Work area demarcated with temporary barriers and warning signs.
Drawings reviewed to identify potential hazards present, and verified by site inspection.
Line and associated work equipment withdrawn from operation.
All relevant isolation points identified, and secured with LOTO
Methods for depressurizing & removing hazardous contents/residues defined
Methods for confirming depressurization & removal of residues defined
Test equipment provided for monitoring for hazardous materials
Workers are competent to work to carry out task safely.
Emergency plan in place
Emergency equipment available for use
Additional pre-permit measures to be taken:
PRECAUTIONS required during job (eg safe way of working, use of PPE) Yes n/a
Vent, drain or purge with inert gas to safely depressurize and remove hazardous contents
Test the system once depressurised, to confirm free of hazardous material
Immediately remove any liquid or solid residues
Use special tools
Protective Equipment required and available (as identified on the Safety Data Sheets)
Eye/ Face/ Hands/ Full body/ Breathing Apparatus/ Hearing – (specify below)
Additional details, precautions and PPE required:
Note: If people could fall >2m, a PTW for Work at Height should also be used. If the work could create a source of ignition,
a PTW for Hot Work should also be used.
ACCEPTΑNCE BY COMPETENT PERSON/SERVICE PRIOR TO COMMENCEMENT: I declare that I have understood the tasks
assigned and that I take full responsibility for the execution of those under the relevant legislation and Brewery
requirements for Health, Safety and Environment.
Permit receiver: Date - Signed
Permission to proceed with work:
I declare that all necessary checks have been completed, all needed documentation has been received and reviewed
that permission is hereby granted for the work to proceed.
Permit Issuer: Date - Signed
Completion of Works:
I declare that the work described above is complete all work equipment, persons and materials under my control have
been withdrawn. All safeguards have been reinstated and the work area returned to a safe status and service.
Permit receiver: Date - Signed
Permit Cancellation:
Permit Issuer Date - Signed
QUICK GUIDANCE NOTES:
(the person responsible for the works must take all the necessary precautions according to legislation, even if they are not mentioned below)
Before breaking into the line, LOTO should be correctly applied. The method of doing this will depend on the
equipment involved, and the specific sources of hazardous energy.
Particular care should be paid to ensuring that stored energy (including residual energy and residual quantities of
hazardous material) is removed and zero energy condition confirmed.
The system should be vented to atmospheric pressure before starting work. Additional ventilation or purging may be
required if there is a risk from toxic gases and/or oxygen starvation or enrichment during venting.
If there is a risk of an explosive atmosphere occurring, intrinsically safe equipment should be used. Similarly in wet or
dusty environments, special equipment will be necessary.
Approved by: XXX Issue no: 1st Date of issue: XXX Document Number: XXX
