Permit to work - Non operations

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Work details

• Location of work, detailing areas of the site which will be affected
  Address

• Date of work

  Date

• Describe work to be done, including primary steps

• Photograph of site

  Media

• Permits to work may only be issued by persons authorised by the site manager to do so. This permit is for work not connected with gas operations, and is not sufficient for any work involving entry into confined spaces, hot work, crane lifts, excavation or lone work. If any of these risk factors exist in relation to the work, additional permits are required - see the site manager for further information

Hazard identification and control

• Identify items below which present a hazard in relation to the work being undertaken

• Fire - Flammable gases or liquids, hot work, flame producing equipment, ignition sources such as mobile phones, remote locking devices, lighters etc

• What controls will be implemented to control fire related hazards?

• Fire extinguishers

• Fire hose

• Elimination of ignition sources from the work area

• Use of non sparking tools

• Use of oxygen compatible materials

• Hazardous substances (asbestos, toxics, corrosives etc). Note - the presence of asbestos may not be obvious. Check with the site manager to ensure asbestos is not present in a location in the workplace which is likely to be disturbed by the work under this permit

• What controls will be implemented to control hazardous substance related hazards?

• Removal of the hazardous substance

• Use of appropriate PPE

• Has the Safety Data Sheet been checked to ensure that the controls are sufficient?

  Yes

  No

  N/A

• Plant or equipment related hazards - stored energy, potential for sudden movement or electrocution

• What controls will be implemented to control plant and equipment related hazards?

• Electrical isolation of energy sources and lock out

• Physical isolation of dangerous energy sources and lock out

• Location of isolations or isolation procedure number

• Have lock out systems been tested to ensure they are effective

  Yes

  No

  N/A

• Do all personnel at risk because of the work have an individual lock in place at the hazard control point?

  Yes

  No

  N/A

• Pressure and pipework related hazards

• What controls will be implemented to control pressure and pipework related hazards?

• System depressurisation

• Double block and bleed with valves locked in position

• Appropriately rated spade piece and removal of a pipe section

• Location of pipework isolations or isolation procedure number

• Temperature related hazards such as cryogenic liquids, hypothermia, heat stroke, steam etc

• What controls will be implemented to control temperature related hazards?

• Temperature normalisation

• Provision of appropriate PPE

• Provision of sun protection, sunscreen, hydration, adequate protection from cold

• Manual handling hazards related to the task

• What controls will be implemented to control manual handling related hazards?

• Mechanical aids such as forklifts, chain blocks etc

• Manual handling aids such as trolleys, pallet lifters etc

• Atmospheric hazards such as oxygen depletion or enrichment

• What controls will be implemented to control atmosphere related hazards? Note - if the location is not a normal work place, is at atmospheric pressure, and has the potential for a hazardous atmosphere, it may be a confined space. Seek clarification from the site manager before proceeding

• Purging or forced ventilation of work site

• Atmospheric analysis - constant monitoring at work site is preferred

• Height related hazards -risk of falls from one level to another

• What controls will be implemented to control height (risk of fall) related hazards? Note - control of height related hazards must include consideration of rescue for individuals suspended from height safety equipment such as harnesses

• Footing or securing of ladders

• Use of mobile work platform and licensed operator

• Fall arrest equipment - harness, lifeline etc

• Rescue plan for fallen individual

• Traffic hazards - vehicles, pedestrians

• What controls will be implemented to control traffic related hazards?

• Barriers or barricades

• Area isolated

• Work outside hours where traffic is a hazard

• Is there potential for spills and emissions?

• Action plan to prevent and control spills or emissions

• Is PPE required for this work

• Hard hat

• Safety eyewear

• Safety footwear

• Gloves

• Hearing protection

• Protective, static free, flame resistant clothing

• Is a first aid kit readily available?

  Yes

  No

  N/A

• Indicate location of first aid kit and name of first aid officer

Permit issue and acknowledgement of responsibility

• Responsibility acknowledgement:
  Permit issuer - i believe that sufficient personnel have been engaged in the assessment of this work to ensure the risks involved are adequately controlled. I have ensured that personnel affected by this work have been made aware of the scope of work and the controls and limitations relevant to them. I have checked to ensure that the persons conductiong the work are appropriately licensed and competent to conduct the work
  Permit acceptor - i believe that sufficient personnel have been engaged in the assessment of this work to ensure the risks involved are adequately controlled. I have ensured that all persons involved with the work are aware of the hazards and contols, and will ensure that the controls remain in place for the duration of thenwork

• Permit issuer

  Sign

• Permit acceptor

  Sign

• Are all controls listed in the permit in place and effective? All controls must be in place before the commencement of the work

  Yes

  No

  N/A

Permit checking and handback

• Are the controls specified on the permit in place, and is the work being conducted safely?

Time worksite checked

• Time stamp indicates the time at which the permit issuer checked the work site for compliance with the controls listed on this permit. The issuer must ensure that any controls not being complied with are corrected before leaving the work site

  Date

• Handback - whether the work is completed or not, the work area must be made safe for return to normal operations, or a ready state for work to continue at a later point. The signatures below indicate that the plant and worksite are safe, tested for return to work where relevant, and the worksite is left in a clean and tidy state

• Permit issuer

  Sign

• Permit acceptor

  Sign