SLS - Working at height - Permit

• This document is controlled via the Ventia Safety Cloud and managed by HSEQ Team.

• Document No.

• Maximo Work Order Number

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Information This permit must be completed for:  Any work requiring personnel to wear harnesses as the primary control (fall restraint / fall arrest)  Using a workbox – refer to Crane workbox permit TP-CSC-CL-112  Ladders more than 4 metres in length (except when used by specialists, e.g. workers on electrical poles)  Working within two meters of roof edge without edge protection A Work at Height permit is not required for:  Work performed on a solid construction with edge protection  Routine work performed from completed scaffolding, EWPs (even where a harness is required) or portable work platforms  Routine plant maintenance conducted wearing a safety harness  Access and egress using ladders or hoists

• Select date

  Date

STEP 2: MANDATORY REQUIREMENTS Answer ‘Yes’ , ‘No’ or ‘N/A’ for each question If you answer “No” to any of these questions you can not work at height.

• Are personnel operating EWPs and hoists certified to do so?

  Yes

  No

  N/A

• Are all single-person fall-arrest anchor points capable of withstanding 15kN?

  Yes

  No

  N/A

• Have controls been put in place to ensure no person at height will be working in isolation?

  Yes

  No

  N/A

• Do personnel working at height have chin straps fitted to their helmets?

  Yes

  No

  N/A

• Does the work method protect workers on lower levels?

  Yes

  No

  N/A

• Have personnel working or operating equipment at height received adequate information, instruction and training?

  Yes

  No

  N/A

• Do all fall-arrest systems use a full-body harness with a shock-absorbing lanyard or inertia device?

  Yes

  No

  N/A

• Is all fall protection equipment tagged with current inspection dates?

  Yes

  No

  N/A

• Do all elevated work platforms, lift boxes, work boxes and sully boxes comply with the relevant standards?

  Yes

  No

  N/A

• Is a dual lanyard system in use if the work method requires a worker to detach and reattach at height?

  Yes

  No

  N/A

• Is an emergency response plan in place to recover a person who has been injured, suspended or trapped at height?

  Yes

  No

  N/A

• Has an exclusion zone been established below the work area?

  Yes

  No

  N/A

STEP 3: WORK ASSESSMENT–HIGH-RISK WORK SITUATIONS Answer ‘Yes’ , ‘No’ or ‘N/A’ for each question If you answer “Yes” to any of these questions you must perform a Risk Assessment.

• Will there be any interaction between the activity and its environment (general public or surrounding operations)?

  Yes

  No

  N/A

• Does the work area interface with mobile plant or passing traffic?

  Yes

  No

  N/A

• Will building materials or large tools/equipment need to be manually carried to the work area?

  Yes

  No

  N/A

• Will workers be performing tasks in adverse weather conditions?

  Yes

  No

  N/A

• Does the work area contain energised services (e.g. electricity, steam, gas, chemicals)?

  Yes

  No

  N/A

• Will there be work at height involving demolition or dismantling of a structure?

  Yes

  No

  N/A

• Is the work in, over or adjacent to a pit or shaft?

  Yes

  No

  N/A

• Does the work area include potentially unstable surfaces (e.g. ground conditions)?

  Yes

  No

  N/A

• Will work be performed over or on water?

  Yes

  No

  N/A

• Will plant or equipment be accessed at height under operational conditions (e.g. mast of piling rig or crane)?

  Yes

  No

  N/A

• Will plant or equipment be inspected or maintained at height outside of an encapsulated platform?

  Yes

  No

  N/A

• Will work take place on fragile surfaces (e.g. fibreglass roofs)?

  Yes

  No

  N/A

STEP 4: WERE YOU REQUIRED TO PERFORM A RISK ASSESSMENT FOR STEP 3?

• Are all required controls in place? If No You Can Not Work At Height.<br>If Yes Go To Step 5

  Yes

  No

  N/A

STEP 5: PERSONS WORKING AT HEIGHT

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

STEP 6: AUTHORISATION TO WORK

• Add signature

  Sign

• Person in Control of the Work (e.g. person performing work) I accept this permit, agree to be bound by the conditions above and the associated procedures, and accept responsibility as the person directly in charge of the work. I have communicated the attached risk assessments/JSEA, post-fall recovery plan and have implemented the risk controls.

• Add signature

  Sign

• Person Giving Authorisation (DTL, Leading Hand) I authorise the work at height subject to the conditions & precautions of the permit as indicated on the risk assessment.

• Add signature

  Sign

STEP 7: COMPLETION, SUSPENSION OR CANCELLATION OF WORK

• All work associated with this permit has been: Completed Cancelled or Suspended

  Yes

  No

  N/A

• The work area & adjacent areas have been inspected after completion of the work & all hazards have been made safe:

  Yes

  No

  N/A

• Person in Control of the Work (e.g. Supervisor, senior person performing work)

  Sign

STEP 1: WORK DETAILS

• Work Description

  Yes

  No

  N/A