5.

Authorisation Area Authority

Designation Date Time
Number

Name Signed:
Area Authority
WCC - PERMIT Work Order No.

Cold work Expiry

Date:

1. Take Description
IF UNSAFE - STOP WORK
6. Site Gas Test (Where Required)
Flammable %LEL H2S PPM Oxygen % Other................. Date of Application: Requested by (Name): Company: Signed:
I, Authorized Gas Tester, confirms all gas tests are within acceptable limits Equipment ID/Tag Number Location:
Monitoring Task
Name:.................................. Signed:.................................. Date:..................... Time:...............
Int:....................... Description:..............................................................................................................................................................................................................................
7. Issue __________________________________________________________________________________________________________________________________________
.......................................................................................................................................................................................................................................................
I, Authorized person, declare that a site visit has been conducted and all specified control measures are in place. ..............................................................................................................................................................................................................................................
Signed:................................................. ..............................................................................................................................................................................................................................................
Name:............................................................... Date:..................... Time:...............
...... ..............................................................................................................................................................................................................................................
I, Issuing Authrority, declare that all hazards have been identified and all specified control measures are in place. The WCC is now registered - It is Tools/Equipment:..................................................................................................................................................................................................................
now safe for the work specified on this WCC to be performed. Crafts: ...................................................................................................................................................................................................................................
Signed:.................................................
Name:............................................................... Date:..................... Time:...............
......
2. Level 2 Task Risk Assessment: Reference No:
I, Performing Authority, have read and understand the above conditions and precautions. I accept responsibility for carrying out work as specified. I
will ensure the persons under my control read, understand and comply with these conditions and precautions. I will notify the Area Authority on Hazards (General)
completion or interruption of this work.
1. Confined Space Entry 6. Spilling Hazard 11. Severe/ Adverse Weather 16. Toxic Gas /Fumes 21. Radioactive Source
Signed:................................................. 2. Awkward Access 7. Tripping Hazard 12. Overside Work 16. Hazardous Substances
Name:............................................................... Date:..................... Time:...............
......
3. Working at Height 8. Projectiles 13. Excavation Collapse 18. Asbestos 23. Mechanical Spark
8. Return and Re-issue 4. Unguarded Opening 9. Lifting Operation 14. Vibration 19. Flammable Materials 24. Pressurised Hose Failure
Authorized.P
Date Time % LEL H2S (ppm) O2 (%) I.A. Sign P.A Sign 5. Heavy/Awkward Object 10. Dropped Object 15. Stored Mechanical Energy 20. LSA Scale/NORM 25. Noise
Sign
Return
Return Hazards (Specific)
Issue
Issue
29. Proximity to
Return
Return 26. High Pressure Water Jet 27. Sharp/Abrasive Obect 28. Grit Blasting/Air Borne Particles 30. Mineral Fibre
underground
Issue
Issue
Hazards (Other)
Return
Return
Issue
Issue
.................................................................................................................................................................................................................................................
Return
Return .................................................................................................................................................................................................................................................
Issue
Issue .................................................................................................................................................................................................................................................
Return
Return .................................................................................................................................................................................................................................................
Issue
Issue
Return
Return
Issue
Issue Controls General
Return
Return
Issue
Issue Erect Signs and Barriers Check worksite for Liaise with adjacent Adhere to Specific Review and Initial Gas Test and repeat
Return
Return potential droped Performing procedure implement MSDS tests at specified intervals
Issue
Issue objects Authorities requirements
Return
Return A safe means of acess Secure loose objects Maintain radio Waste to be Sun Adhere to lifting plan
Issue
Issue to/from worksite must contact with Control disposed of protection/drinkin
Return
Return always be used Room corrected g fluids to be
Issue
Issue available
Return
Return Keep work site free of Safety harness/inertia Standby man to be in Use safe manual Personal Ensure lifting equipment is
Issue
Issue trip hazards reel to be worn attendance handling techniques isoloations certified for specific load
Return
Return
Issue
Issue
Controls Specific
Return
Return
Issue
Issue Tools and Equipments Prepare drawing for Continuous gas Isolation required
to be examined before underground monitoring in use at
9. Cancellation use services/structures work site(portable
gas detector)
I, Performing Authority, declare that the work for which this WCC was issued has been properly performed, that all personnel have been
withdrawn, and that the equipment, plant and apparatus affected by the work have been left in a safe, clean condition. Controls (Other)
................................................................................................................................................................................................................................................
The work is COMPLETE The work is INCOMPLETE ................................................................................................................................................................................................................................................
.......................................................................................................................................... ................................................................................................................................................................................................................................................
and in the following condition ................................................................................................................................................................................................................................................

Additional PPE: .......................................................................................................................................................................................................................

I, Issuing Authority/My delegate, have inspected the equipment/work area and declare that the work for which this WCC was issued has been
properly performed, that all tools and apparatus have been removed, and that the equipment, plant and electrical apparatus affected by the 3. Cross Referenced Certificates: 4. Sanction to Test
WCCs:
work have been left in a safe, clean condition. ICC No. ICC Procedure No.
The work is COMPLETE The work is INCOMPLETE and normal operations may be resumed subject to the removal of isolations
and any I, Performing Authority, declare that the proposed test is within the specified workscope and the plant / equipment is safe to be de-isolated
for test purpose. All work has stopped and copies of the applicable WCCS returned to the Area Authority.
remaining controls.
Re-issued from WCC:
10. Registry of work Completion
All copies of this WCC and any supplementary certificates have been collected. Notation of work status has been made in the WCC Register. I, Issuing Authority, declare that the proposed test is within the specified workscope and request the isolations on the above ICC be
amended for test purposes
The control measures put in place for this WCC have been removed. ICCs:

De I De I De I
Name:......................................................... Signed:................................... Date:..........................................
Time:........................................... PA
11. Lessons Learned Yes No Procedure/ SORA/ Lift Plan/ Plant Release Certificate
IA
Details: /Other
Date
Time
Name:......................................................... Signed:................................... Date:..........................................
Only work covered under the task description of this WCC can be performed