Over-riding Machine Guards - Permit to Work

• Conducted on

  Date

• Prepared by

• Location
  Address

• OVER-RIDING MACHINE GUARDS PERMIT TO WORK NUMBER

• What works will be undertaken?

• Special Tools / Equipment to be Used

• Job Location / Plant Identification Number

• Is any other work currently being undertaken that may interact or affect this permit? (Quote Permit numbers where applicable)

This Permit is only Valid when all sections are complete. If you are in doubt or don't understand, then please ask. Remember, all accidents are preventable and it is people who get hurt and suffer pain. Please use this permit in the spirit intended to protect yourself and others. Please ensure that you sign this permit to work. DO NOT PROCEED WITH YOUR WORK UNTIL YOUR PERMIT HAS BEEN AUTHORISED BY THE RELEVANT MEMBER OF STAFF.

PRIMARY HAZARDS - Electric Shock / Arcing / Arc Flash / Fire / Trapping / Crushing / Entanglement / Amputation / Severing / contact with Hazardous Substances

Please answer the questions truthfully

• Are you Qualified / Trained to undertake this work?

  Yes

  No

  N/A

• Are Caution / Danger Signs required?

  Yes

  No

  N/A

• Can a Temporary Guard be fitted, i.e. Mesh Guard / Polycarbonate - that allows vision but protects maintenance worker?

  Yes

  No

  N/A

• Does the Machine have an Engineering Mode in the PLC Program - that allows slow movements / jog mode/ safety pendant control / hold to run functions to be operated?

  Yes

  No

  N/A

• If Moving Parts are present can the Emergency Stop be accessed from the work position and is it functional?

  Yes

  No

  N/A

• Is all lose clothing / long hair etc secure to prevent contact with moving parts?

  Yes

  No

  N/A

• Are 1000V VDE Insulated Tools in Use? Must meet DIN EN 60900:2004

  Yes

  No

  N/A

• Has Lock Out Tag Out been undertaken, if appropriate? i.e. between tests / when equipment is left unattended.

  Yes

  No

  N/A

• Are you likely to come into contact with asbestos? If Yes, an Asbestos Permit to Work will be required.

  Yes

  No

  N/A

OTHER PRECAUTIONS

• Other Precautions Required to undertake the work safely:

• Other Safety Equipment required to undertake the work safely:

• Person in Charge of Works

• Company

• Signature

  Sign

• Authorising Person

PERMIT EXPIRY DETAILS

• Permit Expires on

  Date

• Name of Standby Rescuer (Live Running with Guards Removed)

• Emergency Contact Number

• Rescue Method to be deployed: Emergency Stop / Reverse Control / Remote Pendant

Live Running Testing Works are not permitted without a Standby Person trained in effecting a safe rescue if guards are removed.

I confirm that the work has been completed, checked by myself, guards have been refitted and interlocks reinstated and the area left in a safe and tidy condition.

• Person in Charge (Print Name)

• Person in Charge (Signature)

  Sign

I have inspected the completed work, confirmed that guards have been refitted and interlocks have been reinstated in accordance with the manufacturers instructions. I hereby cancel this permit.

• Authorised Person (Print Name)

• Authorised Person (Signature)

  Sign

PERMIT CANCELLED

• Permit Cancelled

  Date