Permit to Work - Cold Work

• Audit Category

  Select

• Audit Title

  Select

• Conducted on

  Date

• undefined

• Plant/Equipment Name

• Location of Work

• Description of Work

• Date of Work

  Date

• Expected duration of Work

• Please Read SOP

• SOP Available

  Yes

  No

• Please Fill JSEA

  Yes

  No

• Job Details

• Location of Work

• JSEA Developed by

  Sign

• Date

  Date

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Common Hazards

  Yes

  No

• Work Environment/Site Layout

• Working from Height

• Ground Surface

• Stability

• Security

• Vibration

• Confined Spaces

• Site Access/Egress

• Underground Hazards

• Lighting

• Mobil Plant/Pedestrians

• House Keeping

• Asbestos

• Thermal Comfort

• Slips & Trips

• Overhead Hazards

• Site induction

• Chemical

• Biological

• Fire/Flammability

• Corrosive

• Compatibility

• Labelling

• MSDS Available

• Absorption

• Inhalation/Ingestion

• Signage

• Spill Control

• Storage

• PPE Available

• Manual Handling

• Repetitive Actions

• Cold/Hot

• Lifting/Carrying

• Bending/Reaching

• Excessive Distances

• Awkward Postures

• High Forces- Heavy Load

• Pushing/Pulling

• Restraining/Supporting

• Stability/Size of Load

• Plant

• Crushing

• Cutting/Stabbing

• Electrical

• Entanglement

• Falling

• High Pressure

• Hot Surfaces

• Isolation

• Maintenance

• Noise

• Pre-start Checks

• Striking

• Signage

• Safe Work Procedures

RISK MATRIX

• HSW RISK MATRIX

JOB SAFETY ANALYSIS

• Job Safety Analysis

  Yes

  No

  N/A

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Safe fire exit identified and unobstructed

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Fire Fighting Equipment is available and fit for purpose

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Fire Systems are not impaired or isolated (alarms/hydrants)

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• All permit users have appropriate PPE for the task

  Yes

  No

• Suspend Permit, Please check with Permit Issuer/ Manager

• No electrical cables or wiring can be cut or damaged as a result of the task

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• All Penetrations that extend through both sides of the panel must be completed from the top side, in a downward direction

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• No pneumatic, hydraulic or liquid lines can be cut or damaged as a result of the task

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• No unenclosed electrical equipment or other potential ignition sources are to be installed on or adjacent to insulation panels

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• All tools and equipment are in good condition and testing is current

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• No Hot work is to be carried out on insulation panel

  Yes

  No

• Suspend Permit, Please check with Permit Issuer/ Manager

• Are you using tools/Equipment?

  Yes

  No

• Name of Tools

• undefined

• undefined

• undefined

• undefined

• Isolation Required

  Yes

  No

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Isolation Required

  Yes

  No

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Isolation Required

  Yes

  No

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Isolation Required

  Yes

  No

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Safety Observer Required

  Yes

  No

  N/A

• Safety Observer

  Sign

• Contact Number

• Location of nearest fire alarm

• Observer Initial area check upon completion of work

  Date

• Observer secondary area check 15 minutes post work completion

  Date

• Observer Final area check 60 minutes post work completion

  Date

• I have reviewed the hazards and control measures documented in the relevant JSEA/SOP for this task. I believe that the work can be completed safely provided all the above-mentioned precautions and the relevant JSEA/SOP are complied with

• Permit Issuer

  Sign

• Permit User

  Sign

• Permit User

  Sign

• Safety Observer

  Yes

  No

• Name and Signature

  Sign

• The permit has been suspended due to work not being completed. The following precautions have been completed in the work area

• Equipment Secured

• Area access restricted

• Isolation retested

• Signage in place

• Area Manager notified

• This Permit has been revalidated to allow suspended work to be recommenced. The following precautions have been completed

  Yes

  No

  N/A

• Area Inspected

• Environmental conditions safe

• Pre-start checks completed

• Area Manager notified

• Permit Issuer

  Sign

• Permit User

  Sign

• I have inspected the work area and certify that all personnel, tools and equipment have been removed from the area, all guards and covers have been replaced, all LOTO devices have been removed and all barriers and notices removed. I confirm that the area is safe for normal operations to resumes.

• There is no evidence of fire, hot surfaces or potential ignition sources

  Yes

  No

  N/A

• Please see Permit Issuer/ Manager

• All exposed expanded polystyrene insulation panel core material has been appropriately sealed, covered, flashed

  Yes

  No

  N/A

• Please see Permit Issuer/ Manager

• All Waster material have been removed and work area left clean and tidy

  Yes

  No

  N/A

• Please see Permit Issuer/ Manager

• Permit User

  Sign

• Permit Issuer

  Sign