CCA | Permit to Work – Work at Height

Details of Work at Height (permit requester / receiver to complete)

• Site Location

  Mt Wellington

  Putaruru

  Christchurch

• Contractor

• Location on Site

• Work to be Undertaken

• Date of Work

  Date

• Start Time

  Date

• Finish Time

  Date

Work at Height Checklist (Contractors permit receiver to complete)

• Entry and exit points identified for the work at height and where required alternate entry and exit points identified where the work will interfere with normal operations.

  Yes

  N/A

• Immediate area affected by the work at height has been barricaded and signs installed.

  Yes

  N/A

• Drop zone established, barricaded and signs installed.

  Yes

  N/A

• Risk control/s to be implemented

  Select Fall prevention / Edge protection Fall Restraint Fall Arrest

  • Fall prevention / Edge protection
  • Fall Restraint
  • Fall Arrest

• Detail equipment to be used for Fall Prevention / Edge Protection:

• Detail equipment to be used for Fall Restraint:

• Detail equipment to be used for Fall Arrest:

• A safety observer / spotter has been appointed where required?

  Yes

  N/A

• Safety Observer/Spotter (Name and Signature)

  Sign

• Work at height access equipment has been inspected and has current certification on site? (i.e. EWP, Man Box, etc.)

  YES

  NO

  N/A

• Work at height safety equipment has been inspected and has current inspection tag.

  Yes

  N/A

• Has the Work at Height checklists been completed?

  Yes

  No

• Permanent anchor points are suitable for the work activity, have been inspected and have current certification available on site.

  Yes

  N/A

• Are temporary anchor points required?

  Yes

  N/A

• Installation by a suitably qualified individual is required<br><br>Note - all temporary anchor points must be removed once work has been completed.

  YES

  NO

  N/A

• Inspector (Name and Signature)

  Sign

• A Rescue Plan has been established where:

• A worker is using a fall arrest harness to perform the work activity

  Yes

  N/A

• The risk assessment for the work activity has a residual risk score of medium or greater.

  Yes

  N/A

• Additional Instructions/information

Work at Height Check List - to be completed prior to the issue of the PTW

GENERAL - completion required for all Permits

• Has a task specific SWMS/TA been produced, reviewed and approved?

  Yes

  No

• Have all work party members read, understood and signed on to the SWMS?

  Yes

  No

• Have potential or existing hazards been identified and the risks assessed?

  Yes

  No

• Has the presence of overhead services, open excavations etc been considered?

  Yes

  N/A

• Safe means of access and egress considered and assured?

  Yes

  No

• Have all practical steps been taken to prevent falls?

  Yes

  No

• Have all fragile and temporary surfaces been identified and labelled?

  Yes

  N/A

• Does the task involve a lone worker?

  Yes

  N/A

• Is there a risk of falling objects striking people below?

  Yes

  No

• Are the weather conditions appropriate for the work being carried out?

  Yes

  N/A

• Is there adequate lighting to execute the task?

  Yes

  N/A

• Has the impact of adjacent work activities been considered and mitigated?

  Yes

  N/A

• Has access by unauthorised persons been prevented?

  Yes

  No

• Appropriate PPE identified and worn?

  Yes

  No

• Are the workers competent and adequately trained for the task?

  Yes

  No

• Are the workers physically capable of executing the task?

  Yes

  No

• • Will you be carrying out High Risk Scaffold Work?

  YES

  NO

  N/A

High Risk Scaffold Work

• Complete for High Risk Scaffold Work Only

• Has the scaffold been tagged and inspected?

  Yes

  No

• Are walkways in good condition and free from obstructions?

  Yes

  No

• Are appropriate fixed edge protection/kick boards in place?

  Yes

  No

• Have ground conditions been assessed and verified as stable?

  Yes

  No

• Is a rescue plan required and in place?

  Yes

  N/A

• Use HSE3.5.4.1 to record and appoint a spotter

• Is the rescue kit available at the work location?

  Yes

  N/A

• Does the work require a spotter?

  Yes

  No

• Safety Observer/Spotter (Name and Signature)

  Sign

• • Will you be carrying out High Risk Ladder Work?

  YES

  NO

  N/A

High Risk Ladder Work

• Complete for high risk ladder work only

• Is the ladder appropriate for the task?

  Yes

  No

• Inspected and verified as fit for purpose?

  Yes

  No

• Can three points of contact be maintained when using a ladder?

  Yes

  No

• Are fall prevention systems required and in place?

  Yes

  N/A

• Have ground conditions been assessed and verified as stable?

  Yes

  N/A

• Is a rescue plan required and in place?

  Yes

  N/A

• Use HSE3.5.4.1 to record and appoint a spotter

• Is the rescue kit available at the work location?

  Yes

  N/A

• Does the work require a spotter?

  Yes

  No

• Safety Observer/Spotter (Name and Signature)

  Sign

• • Will you be working on MEWPS?

  YES

  NO

  N/A

Working on MEWP's

• Complete for MEWP work only

• Has the device been serviced and inspected to OEM requirements?

  Yes

  No

• Is there a valid six monthly service record available?

  Yes

  No

• Have ground conditions been assessed and verified as stable?

  Yes

  No

• Are fall prevention/arrest harnesses required?

  Yes

  N/A

• Are fall prevention/arrest harnesses tagged & inspected prior to use?

  Yes

  N/A

• Are workers verifiably competent?

  Yes

  No

• Has the fall prevention system been inspected & elements which could damage it been identified & rectified?

  Yes

  N/A

• Has it been determined that a fall will be arrested before hitting the ground/other structure?

  Yes

  N/A

• Has equipment, anchor points and access methods been: inspected; rated; and confirmed as appropriate for the load?

  Yes

  N/A

• Is a rescue plan required and in place?

  YES

  NO

  N/A

• Use HSE3.5.4.1 to record and appoint a spotter

• Is the rescue kit available at the work location?

  Yes

  N/A

• Does the work require a spotter?

  Yes

  N/A

• Safety Observer/Spotter (Name and Signature)

  Sign

Verification of Risk Controls (Arrow to complete, contractor to assure understanding and compliance

• I have reviewed the risk controls listed in Category 2 - I confirm they are appropriate, and have verified they are in place.
  
  Workers involved in this work have been involved in the development of a task specific SWMS
  
  NOTE: This permit is activated at the time that the Contractor signs this section and remains valid for one week max. A daily pre-start (HSE3.16), Permit re-validation and review is required. Where site conditions change this Permit & the SWMS/TA are to be reviews and if required amended and re-issued.

• Arrow Issuer (Name and Signature)

  Sign

• Contractor Receiver (Name and Signature)

  Sign

• Contractor Receiver (Name and Signature)

  Sign

• Contractor Receiver (Name and Signature)

  Sign

• Contractor Receiver (Name and Signature)

  Sign

• Contractor Receiver (Name and Signature)

  Sign

Completion/Close-out of Work (Contractor to complete)

• I confirm that the work at height has been completed in accordance with this permit. All work is complete, all tools and equipment removed and the work area has been left in a safe condition.

• Contractor (Name and Signature)

  Sign

Completion/Close-out of Work (Site Manager to complete)

• Finish Time

  Date

• Site Manager (Name and Signature)

  Sign