SHIPBOARD SAFETY CHECKLIST GENERAL COMMENTS

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46 USC 3204 (a) Safety Management Plans shall be submitted to Sec. Trans.

46 USC 3204 (c) A Safety Management Plan shall be submitted to Sec. Trans. for approval.

46 USC 3203 (a) Regulatory authority is given to Sec. Trans.

See the RRF Ship Operations Manual (Contract TE-1 Section 18) for an explanation on the optional use of these forms.

PTW_EMW.DOC Electrical Maintenance Work Permit

PTW_ESEP.DOC Enclosed Space Entry Work Permit

PTW_HWP.DOC Hot Work Permit

PTW_LOTO.DOC Lockout/Tag Out Permit

PTW_OTS.DOC Working Aloft, Outboard, and Over The Side

PTW_SWS.DOC Inspection/repair Permit

Condenser/Seawater System

PTW_UWP.DOC Underwater Work Permit

PERMIT TO WORK ELECTRICAL MAINTENANCE WORK PERMIT			Form: PTW_EMW Date: Prep’d by: Apprv’d by: Page 1 of 2
This checklist must be completed prior to starting any electrical maintenance. If any of the listed conditions change, then this Permit is invalid and a new permit shall be issued before work continues.
____________________ VESSEL	____________________________ DATE & TIME (MAX 12 HRS)	______________________________ WORK TO START (TIME)
Location and Description of Work to be Done
ALL QUESTIONS MUST BE ANSWERED TO PROCEED				YES	NO	N/A
1. Is the location of the electrical maintenance work an enclosed space? NOTE: If YES, the proper Enclosed Space Entry Permit must also be completed, authorized and attached.
2. Does the electrical maintenance work involve working aloft, outboard or over the side? NOTE: If YES, the proper Working Aloft, Outboard and Over the Side Permit must also be completed, authorized and attached.
3. Does the electrical maintenance work involve any form of hot work? NOTE: If YES, the proper Hot Work Permit must also be completed, authorized and attached.
4. Has the proper electrical tagout/lockout procedure for the work detailed been carried out? NOTE: If YES the proper lockout/tagout permit must also be completed, authorized and attached
5. Can electrical maintenance work be done safely in accordance with NFPA requirements?
6. Have all electrical supplies to the work area been isolated, fuses pulled, circuit breakers tripped and switches set to “OFF”?
7. Have voltmeter confirmation checks been carried out at the work position while remote and local power-on switching is carried out?
8. Have ship’s electrical drawings been referenced to ensure all power supply routes to the work area are isolated?
9. Have appropriate warning signs been placed on equipment switches, circuit breakers and fuses?
10. If working on or near live electrical equipment, is a second man present who is competent in the treatment of electric shock and is trained in fighting electrical fires and proper medical response?
11. Have personnel been provided with the proper Personnel Protective Equipment (PPE)? SEE NEXT PAGE
12. Have all items of metallic personal jewelry such as watches, rings and identity bracelets been removed?
13. Have the correct tools and equipment required for electrical maintenance work been provided?
14. Have the tools and equipment been inspected prior to starting work and found to be in good condition?
15. Is required electrical testing equipment certified accurate and within its calibration period?
16. Have the workers done a Job Hazard Analysis in which clear instructions been given on how to minimize or circumvent these hazards?
17. Have instructions and plans been discussed in case of emergency?
IF ANY CHECK MARKS MUST BE PLACED IN THE SHADED AREAS ABOVE, THEN THIS ITEM MUST BE RECTIFIED BEFORE PROCEEDING

PERMIT TO WORK ENCLOSED SPACE ENTRY WORK PERMIT			Form: PTW_ESEP Date: Prep’d by: Apprv’d by: Page 1 of 2
This checklist must be completed prior to entering any enclosed spaces. If any of the listed conditions change, then this Permit is invalid and a new permit shall be issued before work continues.
____________________ VESSEL	____________________ DATE & TIME (MAX. 12 HRS)	___________________ WORK TO START (TIME)
Location and Description of Work to be Done
ALL QUESTIONS MUST BE ANSWERED TO PROCEED				YES	NO	N/A
1. Is the enclosed space the location for electrical maintenance work? NOTE: If YES, the proper Electrical Maintenance Work Permit must also be completed, authorized and attached.
2. Is the enclosed space the location for hot work? NOTE: If YES, the proper Hot Work Permit must also be completed, authorized and attached..
3. Has work space been ventilated?
4. Has atmosphere been gas tested and found “Safe for Men” and safe for work to be done?
5. Have all pipeline openings into the work space been tested and found free of combustible liquids or gases?
6. Have all valves on piping/interconnected with piping in the work space been blanked or closed, locked and tagged to prevent accidental opening and appropriate signs been posted?
7. Has forced ventilation been provided for use during job?
8. Have all the appropriate PPE items, rescue harness and lifelines been provided?
9. Do the workers have the tools required?
10. Has a man been assigned to stand by the workers?
11. Have approved communications been established and tested via walkie-talkies or other means between the workers, the man standing by and the Officer on Watch?
12. Has the standby been instructed what to do in case the worker(s) get into difficulties?
13. Have adequate approved lights been provided?
14. Has continuous monitoring of the work space been provided for, with approved testing equipment?
15. Have emergency procedures been reviewed and understood?
16. Is a self-contained breathing apparatus on standby for rescue?
IF ANY CHECK MARKS MUST BE PLACED IN THE SHADED AREAS ABOVE, THEN THIS ITEM MUST BE RECTIFIED BEFORE PROCEEDING

PERMIT TO WORK ENCLOSED SPACE ENTRY WORK PERMIT				Form: PTW_ESEP Date: Prep’d by: Apprv’d by: Page 2 of 2
TYPES OF GAS TESTS
Combustible Gas Test		Oxygen Reading	H2S				Benzene
% LEL		%	PPM				PPM
IGS Vessels only - CO %			Other Gases . PPM
PROTECTIVE EQUIPMENT Boxes marked with checks denote PPE to be used. This section must be filled out by Officer in Charge of Safety.
Clothing	Fire Extinguisher		Gloves			Boots
Safety Harness	Flashlight		Hard Hat			Hearing Protection
Safety Line	Gas Tester		Respirator(s)			SCBA/ELSA
Eye Protection						Other
Special Instructions:
I HAVE READ THE ABOVE PERMIT AND WILL CARRY OUT THE WORK REQUIRED IN A SAFE MANNER.
SIGNATURE OF WORKER			SIGNATURE OF WORKER
SIGNATURE OF WORKER			SIGNATURE OF WORKER
SIGNATURE OF WORKER			SIGNATURE OF WORKER
I inspected the enclosed area described on the top of this form and state that the work can be done and in compliance with rules of the US Coast Guard, ABS, and other authority whose rules I am bound to enforce.
OFFICER IN CHARGE OF SAFETY			OFFICER IN CHARGE OF WORK
MASTER .
OFFICE USE ONLY
PERMIT REVIEWED BY: .					DATE: .
Original:		Master’s File
Copy 1:		Posted
Copy 2:		Office Copy (Mail)

PERMIT TO WORK HOT WORK PERMIT					Form: PTW_HWP Date: Prep’d by: Apprv’d by: Page 1 of 2
This checklist must be completed prior to starting any hotwork. If any of the listed conditions change, then this permit is invalid and a new permit shall be issued before work continues.
____________________ VESSEL		____________________________ DATE & TIME (MAX. 12 HRS)		_______________________ WORK TO START (TIME)
Location and Description of Work to be Done:
ALL QUESTIONS MUST BE ANSWERED TO PROCEED						YES	NO	N/A
1. Is the location of the hot work an enclosed space? NOTE: If YES, the proper Enclosed Space Entry Permit must also be completed, authorized and attached.
2. Does the hot work involve any form of electrical maintenance work? NOTE: If YES, the proper Electrical Maintenance Work Permit must also be completed, authorized and attached.
3. Is the location of the hot work aloft, outboard or over the side? NOTE: If YES, the proper Working Aloft, Outboard and Over the Side Permit must also be completed, authorized and attached.
4. Has the meter used to sample monitor the welding area been calibrated in the last 24 hrs. (If not, do so.)
5. Has the area to be worked on been thoroughly purged of hydrocarbons and inert gas?
6. Has the area to be worked on been thoroughly ventilated?
7. Has the work area been cleaned by machine washed and are gas free?
8a. If not, are the surrounding areas fully ballasted?
8b. Are the surrounding areas inerted?
9. Can hot work be done safely in accordance with NFPA-306?
10. If the work area if a pipe, has it been thoroughly flushed with water and disconnected from the surrounding piping?
11. Is the area free of all flammable debris and scale?
12. Have all potential source of flammable vapors that could reach the site of the hot work been prevented from doing so?
13. Have ships drawings been referenced to ensure the area is safe for hot work?
14. To assure combustible gases will not reach the work site, have winds and air currents been considered?
15. Have bilges within the hot work been inspected to assure that hot work can be done safely?
16. Have precautions been taken to ensure the personnel near the area are protected from such hazards as fumes and ultra-violet light?
17. Have personnel been provided with the proper Personnel Protective Equipment (PPE)?
18. Has a fire watch been set up with appropriate fire fighting equipment?
19. Can the fire watch continually see the worker? (If not, a safety watch must be set for this purpose.)
20. Have the workers done a Job Hazard Analysis in which clear instructions have been given on how to minimize or circumvent these hazards?
21. Have instructions and contingency plans been discussed in the event of an emergency?
22. If welding, has the ground wire been properly connected to the ship’s structure?
23. Has the equipment to be used been inspected prior to starting work and found to be in good condition?
24. If the firemain charged, hoses let out, monitors pointed out and all in good condition?
Original:	Master’s File
Copy 1:	Posted
Copy 2:	Office Copy (Mail)

IF ANY CHECK MARKS MUST BE PLACED IN THE SHADED AREAS, THEN THIS ITEM MUST BE RECTIFIED BEFORE PROCEEDING.

PERMIT TO WORK HOT WORK PERMIT

Form: PTW_HWP Date: Prep’d by: Apprv’d by: Page 2 of 2

TYPE, MAKE AND MODEL OF ALL GAS DETECTION EQUIPMENT USED:

REQUIRED PERIODIC ATMOSPHERE TEST RESULTS

DATE/TIME

LEL

O2

H2S

BENZENE

TOXIC A

TOXIC B

NAME:

NAME:

1st Hr.

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%

%

PPM

PPM

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2nd Hr.

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%

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PPM

PPM

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3rd Hr.

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PPM

PPM

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4th Hr.

/ .

%

%

PPM

PPM

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New Shift

/ .

%

%

PPM

PPM

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New Shift

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%

%

PPM

PPM

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New Shift

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%

%

PPM

PPM

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Break

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%

%

PPM

PPM

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Break

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%

%

PPM

PPM

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Break

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%

%

PPM

PPM

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.

PROTECTIVE EQUIPMENT

Boxes marked with checks denote PPE to be used. This section must be filled out be Officer in Charge of Safety.

Clothing

Fire Extinguisher

Gloves

Boots

Safety Harness

Flashlight

Hard Hat

Hearing Protection

Safety Line

Gas Tester

Respirator(s)

SCBA/ELSA

Eye Protection

Other

I HAVE READ THE ABOVE PREMIT AND WILL CARRY OUT THE WORK REQUIRED IN A SAFE MANNER.

SIGNATURE OF WORKER:

SIGNATURE OF WORKER: .

SIGNATURE OF WORKER: .

SIGNATURE OF WORKER: .

SIGNATURE OF WORKER: .

SIGNATURE OF WORKER: .

I have inspected the enclosed area described on the top of this form and state that the work can be done safely and in compliance with rules of the US Coast Guard, ABS, and any other authority whose rules I am bound to enforce.

OFFICER IN CHARGE OF SAFETY: . MASTER: .

OFFICER IN CHARGE OF WORK: .

WORK COMPLETED OR PERMIT VOIDED: DATE: . TIME: .

OFFICE USE ONLY

PERMIT REVIEWED BY: .

DATE:

Original:

Master’s File

Copy 1: Copy 2:

Posted Office Copy (Mail)