Information
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The version control will be maintained by the SHEQ team and is controlled via the Safety Equipment Inspections Document 2073838157-15.
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Document No.
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Maximo Work Order Number
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Checklist
The version control will be maintained by the SHEQ team and is controlled via the Safety Equipment Inspections Document 2073838157-15.
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
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State which Fall Protection Equipment is Required: Restraint or Arrest
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Select 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.
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Are personnel operating EWPs and hoists certified to do so?
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Are all single-person fall-arrest anchor points capable of withstanding 15kN?
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Have controls been put in place to ensure no person at height will be working in isolation?
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Do personnel working at height have chin straps fitted to their helmets?
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Does the work method protect workers on lower levels?
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Have personnel working or operating equipment at height received adequate information, instruction and training?
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Do all fall-arrest systems use a full-body harness with a shock-absorbing lanyard or inertia device?
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Is all fall protection equipment tagged with current inspection dates?
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Do all elevated work platforms, lift boxes, work boxes and sully boxes comply with the relevant standards?
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Is a dual lanyard system in use if the work method requires a worker to detach and reattach at height?
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Is an emergency response plan in place to recover a person who has been injured, suspended or trapped at height?
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Has an exclusion zone been established below the work area?
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.
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Will there be any interaction between the activity and its environment (general public or surrounding operations)?
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Does the work area interface with mobile plant or passing traffic?
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Will building materials or large tools/equipment need to be manually carried to the work area?
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Will workers be performing tasks in adverse weather conditions?
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Does the work area contain energised services (e.g. electricity, steam, gas, chemicals)?
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Will there be work at height involving demolition or dismantling of a structure?
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Is the work in, over or adjacent to a pit or shaft?
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Does the work area include potentially unstable surfaces (e.g. ground conditions)?
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Will work be performed over or on water?
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Will plant or equipment be accessed at height under operational conditions (e.g. mast of piling rig or crane)?
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Will plant or equipment be inspected or maintained at height outside of an encapsulated platform?
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Will work take place on fragile surfaces (e.g. fibreglass roofs)?
STEP 4: WERE YOU REQUIRED TO PERFORM A RISK ASSESSMENT FOR STEP 3?
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Are all required controls in place? If No You Can Not Work At Height.<br>If Yes Go To Step 5
STEP 5: PERSONS WORKING AT HEIGHT
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Add signature
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Add signature
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Add signature
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Add signature
STEP 6: AUTHORISATION TO WORK
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Add signature
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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.
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Add signature
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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.
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Add signature
STEP 7: COMPLETION, SUSPENSION OR CANCELLATION OF WORK
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All work associated with this permit has been: Completed Cancelled or Suspended
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The work area & adjacent areas have been inspected after completion of the work & all hazards have been made safe:
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Person in Control of the Work (e.g. Supervisor, senior person performing work)
STEP 1: WORK DETAILS
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Work Description