ARCHIRODON GROUP NV Integrated Management System

Health, Safety & Environment (HSE) Rev. Issued For General Use Reference No. HSE-PRO-06-F03 Serial No. Page 1 of 3

FORM Diving Permit To Work

0.0

Section 1. Permit Information 1.1 Permit No. 1.2 Permit Validity from to 1.3 1.4 1.5 1.6 Issued to Issued by Job Location: Work Activity: Permit Holder Permit Authority NAME / SURNAME NAME / SURNAME HH:MM HH:MM on date on date DD/MM/YYY Y DD/MM/YYY Y

Company

Section 2.1 Required Controls 2.1 Completed by Diving Supervisor Sr Description . Primary / Secondary Breathing Media on 01 line with adequate Volume 02 03 04 05 06 07 08 09 10 11 12 DDC Operational and Ready Compressor functioning with proper intake position All Comms. checked available/ working All CCTV checked available/ working Diving flag displayed and visual Safe diver entry and retrieval Safe Weather Conditions All alarm working properly Weather Conditions Safe and Forecast Port /Employer permit in place , valid and confirmed by VHF Radio Pre-Dive check to be undertaken prior to each dive.
Yes No N/A Sr.

Description Adequate team size Stand by diver ready Diving rules and logs in place Employer and Companys safety procedure in place Approved method statement in place Operation discussed with divers and all involved parties No Over head Lifting Work Suction Inlets/Outlets isolated No scaffolding Work No Fishing Diving vessel secured Pre-Task Briefings to be carried out Prior to activities

Yes

No

N/A

13 14 15 16 17 18 19 2o 21 22 23 24

Section 2.2 Completed by Marine Master/Officer/Foreman on watch Controls Sr Yes No N/A Sr. Description Description . Employers Standing Marine Appropriate Alarms/ Monitors 01 09 instruction are met Checked Other Vessel Informed and 02 Weather OK and Forecasts available 10 Warned 03 Signals/ Lights Displayed 11 No Over head Lifting Work

Y es

N o

N/A

ARCHIRODON GROUP NV Integrated Management System

Health, Safety & Environment (HSE) Rev. Issued For General Use Reference No. HSE-PRO-06-F03 Serial No. Page 2 of 3

FORM Diving Permit To Work

0.0

04 05 06 07 08

Vessel Adequately secured Comms available and Tested Access/to/From Sea Adequate Support Equipment Available & Operated Notices placed on bridge and engine room

12 13 14 15 16

Suction Inlets/Outlets isolated No scaffolding Work / No Fishing Operation discussed with divers and all involved parties Props & Thrusters Stopped and secured Look out posted

Section 2.3 Completed by Employer Representative (If Applicable) Sr . 01 02 03 Description Employer and Contractor's Safety Requirements are met Platform Aware of Restriction and prohibitions Approved method statement in place
Yes No N/A Sr.

Description Suction Inlets/Outlets isolated Permission to Dive from Employers Port/Platform/Installation Operation discussed with divers and all involved parties

Yes

No

N/A

04 05 06

Section 3. Attachments (Method Statements, Risk Assessments, Drawings, Certificates...etc) List all documents attached to this P.T.W:

Section 4. 4.1 4.2 4.3 4.4 4.5

Permit Management

This Permit is valid only when Sections 1-3 and 5 are complete. The original Permit shall be displayed at the work place and shall at all times remain under the responsibility of the Permit Holder. A separate copy of the completed Permit at both the approval and closure stages shall be given to the Permit Authority, the HSE Department and the Employer if required. Any adverse change in circumstances shall cause this Permit to become immediately invalid. In this case, the Permit Holder shall cease the work, withdraw the workforce and report to the Permit Authority. This Permit is issued for the task specified within this PTW only and is valid for one shift or 12 hours only or between the times specified in section 1 of this document.

ARCHIRODON GROUP NV Integrated Management System

Health, Safety & Environment (HSE) Rev. Issued For General Use Reference No. HSE-PRO-06-F03 Serial No. Page 3 of 3

FORM Diving Permit To Work

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Permit No: Section 5. 5.1 Permit Approval Name Signature Name 5.2 I the marine Master/Officer/Foreman in charge of diving vessel and vicinity shall abide to the control measures mention within this P.T.W and attachments Signature Signature Name 5.3 HSE Review Signature The Permit Authority, I am satisfied that all foreseeable control measures to avoid an accident are in place prior to me authorizing this permit. Name Signature Permit No. Issued by 5.5 The local / port / Employer authority permit approval Valid from Valid to I the Employer representative shall abide to the control measures mentioned within this P.T.W and attachments. 5.6 I am satisfied that all required precautions have been met and agree to commence diving Permit Closure Name Signature Company NAME / SURNAME Employer Rep.
(If Applicable)

I the permit holder shall abide to the control measures mentioned within this P.T.W and attachments.

NAME / SURNAME

Diving Supervisor

NAME / SURNAME Marine in Charge

NAME / SURNAME

HSE Department Permit Authority

NAME / SURNAME

5.4

Port /Employer Authority Permit

(If Applicable)

Section 6. 6. 6.a 6.b Name: Name: Name:

Indicate either 6a or 6b. For 6b state the reason in the space provided [ [ ] The work covered by the Permit was completed at ] This Permit is Invalid Because: Time: HH:MM Date: DD/MM/YYYY

NAME / SURNAME NAME / SURNAME NAME / SURNAME

Signature: Signature: Signature:

Permit Holder Permit Authority Employer Rep. (If Applicable)