Permit to Work (PtWFC)

• PART 1:- PERMIT-TO-WORK DETAILS (To be completed by the Permit Issuer)

• Location on site where activities are to be carried out under a Permit to Work

  Select A B C D E F G H Other (Add a NOTE below)

  • A
  • B
  • C
  • D
  • E
  • F
  • G
  • H
  • Other (Add a NOTE below)

• Date of Works

  Date

• Permit Start Time

  Date

• Permit End Time

  Date

• Contractor / person(s) who will be carrying out works

• Short description of the work activity to be undertaken

• PART 2:- PRE-WORKS CHECKS (To be completed by the Permit Issuer)

• Contractor insurances have been checked on Marsh database and are appropriate for the works to be undertaken?

  Yes

  No

• Are there any other non-routine tasks ongoing that could introduce additional hazards that need to be considered?<br>(e.g. other contractor works nearby)

  Yes

  No

• Describe the hazard(s) and what additional control measures are in place to mitigate against them.

• PART 3:- PERMIT HOLDER DETAILS (To be completed by the Permit Acceptor i.e. person carrying out the works)

• Name of Person holding the permit onsite (paper or electronic copy is acceptable)

• Telephone number for Permit Holder

• Confirm risk assessment and method statement have been prepared and are specific and appropriate for the works to be undertaken. <br>If YES, attach a copy of the risk assessment and method statement; <br>If NO, complete a Dynamic Risk Assessment and record details below.

  Yes

  No

Dynamic Risk Assessment

• Hazard 1 - Description

• Hazard 1 - Control Measures

• Hazard 2 - Description

• Hazard 2 - Control Measures

• Hazard 3 - Description

• Hazard 3 - Control Measures

• Hazard 4 - Description

• Hazard 4 - Control Measures

• Hazard 5 - Description

• Hazard 5 - Control Measures

• Does the planned works require any of the following...

  Select Hot Works Confined Space Entry Work at Height None of the above

  • Hot Works
  • Confined Space Entry
  • Work at Height
  • None of the above

• (HW) What equipment is to be used for hot works...

  Select Abrasive Wheels Blow torches Cutting discs / grinders Electric welding (TIG, MIG, Stick) Gas welding or cutting Plasma cutting

  • Abrasive Wheels
  • Blow torches
  • Cutting discs / grinders
  • Electric welding (TIG, MIG, Stick)
  • Gas welding or cutting
  • Plasma cutting

• (HW) Which of the following measures are in place to mitigate against hazards identified...

  Select Ventilation, to prevent build up from gas, vapour or dust Floor/wall openings and nearby plant are protected against sparks Effective PPE is in use Combustible or flammable materials have been moved >11m away Equipment is earthed to prevent static spark Area segregated by use of welding screens or similar Equipment is fit for purpose and in good repair Work area has been prepared (e.g. damped down) Compatible fire extinguishers are near the area of works Other (Add a NOTE below)

  • Ventilation, to prevent build up from gas, vapour or dust
  • Floor/wall openings and nearby plant are protected against sparks
  • Effective PPE is in use
  • Combustible or flammable materials have been moved >11m away
  • Equipment is earthed to prevent static spark
  • Area segregated by use of welding screens or similar
  • Equipment is fit for purpose and in good repair
  • Work area has been prepared (e.g. damped down)
  • Compatible fire extinguishers are near the area of works
  • Other (Add a NOTE below)

• (HW) A Fire Watch must be maintained for SIXTY MINUTES after completion of hot works

• (HW) Name of Fire Watch

• (HW) Signature of Fire Watch Only add signature when the Fire Watch is COMPLETE!

  Sign

• (HW) Time fire watch was completed...

  Date

• (CS) Which of the following hazards may be present in the vicinity of activities to be undertaken...

  Select Flammable substances or gases (e.g. Methane) Oxygen Enrichment or Deficiency Toxic fumes or gases (e.g. Hydrogen Sulphide) Carbon Monoxide Excessive heat or cold Falls from height Presence of liquids Risk of ingress of liquids Flowing solids Moving mechanical parts Bacterial infection

  • Flammable substances or gases (e.g. Methane)
  • Oxygen Enrichment or Deficiency
  • Toxic fumes or gases (e.g. Hydrogen Sulphide)
  • Carbon Monoxide
  • Excessive heat or cold
  • Falls from height
  • Presence of liquids
  • Risk of ingress of liquids
  • Flowing solids
  • Moving mechanical parts
  • Bacterial infection

• (CS) Which of the following measures are in place to mitigate against hazards identified...

  Select Removal of residues Use of intrinsically safe tools Purge atmosphere before entry Forced ventilation or extraction System of communication in place (top man) Rescue plan (and team) in place Safety harnesses and lifelines Defined access and egress routes Full Breathing apparatus Escape breathing apparatus First aid / Emergency procedures Tools and equipment checked for suitability (e.g. welding torches) Warning signs and/or barriers in place Competency of workers checked Medical questionnaire completed for Confined Space Work Other (Select "Add notes")

  • Removal of residues
  • Use of intrinsically safe tools
  • Purge atmosphere before entry
  • Forced ventilation or extraction
  • System of communication in place (top man)
  • Rescue plan (and team) in place
  • Safety harnesses and lifelines
  • Defined access and egress routes
  • Full Breathing apparatus
  • Escape breathing apparatus
  • First aid / Emergency procedures
  • Tools and equipment checked for suitability (e.g. welding torches)
  • Warning signs and/or barriers in place
  • Competency of workers checked
  • Medical questionnaire completed for Confined Space Work
  • Other (Select "Add notes")

• Atmospheric Monitoring must be completed BEFORE any entry into a confined space to confirm the air in the confined space is safe.
  Record readings from your gas meter in the spaces below.

• Hydrogen Sulphide, H2S (ppm)

• Carbon Monoxide, CO (ppm)

• Oxygen, O2 (%)

• Lower Explosive Limit, LEL (%)

• (W@H) Which of the following environmental, and other factors present hazards to the activities to be undertaken...

  Select Wind Rain Ground Conditions Stored materials Trees Traffic (vehicular and pedestrian) Nearby work activities Heat or Cold

  • Wind
  • Rain
  • Ground Conditions
  • Stored materials
  • Trees
  • Traffic (vehicular and pedestrian)
  • Nearby work activities
  • Heat or Cold

• (W@H) Which of the following measures are in place to mitigate against hazards identified...

  Select Safe means of access (e.g. scaffold staircase) Signage, barriers and/or cones Edge protection (e.g. safe wire system) Overhead obstruction or power lines - mitigation Full body harness checked and worn Restraint (positioning) harness used Fall Arrest Harness used Fragile roof panels identified Safe means for transport and storage of tools MEWP licence - correct for equipment, and in date LOLER cert - correct for equipment, and in date Pre-use checks completed Fall arrest and descent equipment used Rescue Plan documented and trained out Other (Select "Add notes")

  • Safe means of access (e.g. scaffold staircase)
  • Signage, barriers and/or cones
  • Edge protection (e.g. safe wire system)
  • Overhead obstruction or power lines - mitigation
  • Full body harness checked and worn
  • Restraint (positioning) harness used
  • Fall Arrest Harness used
  • Fragile roof panels identified
  • Safe means for transport and storage of tools
  • MEWP licence - correct for equipment, and in date
  • LOLER cert - correct for equipment, and in date
  • Pre-use checks completed
  • Fall arrest and descent equipment used
  • Rescue Plan documented and trained out
  • Other (Select "Add notes")

• Are any Isolations (and discharge tests) required for the planned works?<br>(e.g. Smoke/Heat detectors, Hydraulics, Pneumatics, Chemical, Gravity, Electrics)

  Yes

  No

• List details of isolations/discharge tests below.

• PART 4:- AUTHORISATION TO CARRY OUT WORKS

• The Contractor is hereby given permission to carry out the work described above, applying the appropriate controls identified in the RAMS and/or this Permit.

• Permit issued by... (Permit Issuer)

  Sign

• Time...

  Date

• WORK MUST NOT BE CARRIED OUT IN ANY OTHER AREA OR ON ANY OTHER EQUIPMENT.
  CONFIRM ALL ISOLATIONS BEFORE STARTING WORKS.
  TREAT ALL OTHER EQUIPMENT AS DANGEROUS.

• I declare that I have read and understand the conditions of this permit and will ensure that all those under my charge also understand and apply the requirements.

• Permit issued to... (Permit Acceptor)

  Sign

• Time...

  Date

• PART 5 - CANCELLATION

• I hereby declare this Permit To Work is Cancelled, work activities covered herein have ceased and the area has been vacated.

• Permit cancellation requested by... (Permit Acceptor)

  Sign

• Permit cancellation confirmed by... (Permit Issuer)

  Sign

• Time

  Date