Working at Height - Permit to Work

• Conducted on

  Date

• Prepared by

• Location
  Address

• WORK AT HEIGHT PERMIT TO WORK NUMBER

• What works will be undertaken?

• Special Tools / Equipment to be Used

• Job Location / Plant Identification Number

• Is any other work currently being undertaken that may interact or affect this permit? (Quote Permit numbers where applicable)

This Permit is only Valid when all sections are complete. If you are in doubt or don't understand, then please ask. Remember, all accidents are preventable and it is people who get hurt and suffer pain. Please use this permit in the spirit intended to protect yourself and others. Please ensure that you sign this permit to work. DO NOT PROCEED WITH YOUR WORK UNTIL YOUR PERMIT HAS BEEN AUTHORISED BY THE RELEVANT MEMBER OF STAFF.

PRIMARY HAZARDS - Falls from Height / Suspension Trauma / Workers Trapped against roof structure / Failure of Access Equipment / High Winds

Please answer the questions truthfully

• Are you Qualified / Trained to undertake this work?

  Yes

  No

  N/A

• Have Warning Signs been erected warning of Working at Height Taking place?

  Yes

  No

  N/A

• Has the Drop Zone been fenced or barricaded?

  Yes

  No

  N/A

• Have Overhead services i.e. Power Cables / Live Busbars been isolated / or protected with insulated covers?

  Yes

  No

  N/A

• Have Fire Alarm Beam Sensors been isolated before accessing the roof voids?

  Yes

  No

  N/A

Roof Access

• Is a safe means of access to the roof provided?

  Yes

  No

  N/A

• Are Crawl boards with hand rails & roofing ladders to be used?

  Yes

  No

  N/A

• Is there a Cable Way provided to secure workers using a Harness and Lanyard?

  Yes

  No

  N/A

• Has the Cable Way been Inspected in the last 12 months?

  Yes

  No

  N/A

• Has the Harness and Fall Arrest Lanyards to be used been inspected in the last 6 months?

  Yes

  No

  N/A

• Is the Fall Arrest Lanyard the correct length? (i.e. 3m shorter than the height of the structure)

  Yes

  No

  N/A

• Is Edge Protection Required?

  Yes

  No

  N/A

• Is edge protection correct height? (Top Rail 1100mm Intermediate Rail 600mm 150mm Toe Board)

  Yes

  No

  N/A

• Have Fragile Surfaces been Protected? (i.e. Polycarbonate Skylights - Covered or Fenced off)

  Yes

  No

  N/A

• Has the weather forecast been checked?

  Yes

  No

  N/A

• Are the wind speeds been monitored using an anemometer? Max Speed 12.5m/s or 28mph gust.

  Yes

  No

  N/A

• Is the roof free of ice / frost?

  Yes

  No

  N/A

• Is lightning forecast?

  Yes

  No

  N/A

• Is hot work been undertaken on roof? (If Yes a Hot Works permit is also required)

  Yes

  No

  N/A

• Are there any ducts / vents / chimneys on the roof?

  Yes

  No

  N/A

• If yes, are there any risks from fumes / corrosive substances etc?

  Yes

  No

  N/A

• Are you likely to encounter asbestos? (If Yes, an Asbestos Permit is required)

  Yes

  No

  N/A

• Is there a rescue plan for getting an injured or ill worker down from the roof?

  Yes

  No

  N/A

MEWP (Scissor Lift / Boom Lift)

• Do you hold a current IPAF 3a / 3b Powered Access Licence?

  Yes

  No

  N/A

• Have you checked the work area including access ways for fragile surfaces i.e. drain lids/ manhole covers etc?

  Yes

  No

  N/A

• Have you checked wind speed using a handheld anemometer if working outside? Max Speed 12.5m/s or 28mph gust.

  Yes

  No

  N/A

• Have you got a Harness and Fixed Lanyard for operating a Boom Lift?

  Yes

  No

  N/A

• Have you checked for overhead hazards to avoid crushing injuries?

  Yes

  No

  N/A

• Is there a Standby Person on the ground trained to use the lowering controls in the event of a breakdown?

  Yes

  No

  N/A

• Have you got the Remote Control Tether to use the "Walking the Dog Method" when moving the platform in congested areas or through doorways?

  Yes

  No

  N/A

• Has the MEWP got a Valid LOLER Inspection Certificate?

  Yes

  No

  N/A

Scaffolding (Fixed)

• Has the scaffold been designed / erected and inspected by a competent person - and load rated for the works to be undertaken?

  Yes

  No

  N/A

• Is the scaffold tied to the structure using approved methods i.e. Hilti Fixings / Through Ties etc. (Reveal Ties are not permitted)

  Yes

  No

  N/A

• Has the scaffold got a Licence where required? i.e. Public Road / Pavement

  Yes

  No

  N/A

• Has the scaffold been fitted with a Scafftag Inspection System?

  Yes

  No

  N/A

• Has the Scafftag been completed in the last 7 days?

  Yes

  No

  N/A

• Is the Scaffolding protected from Vehicle Impacts at the base?

  Yes

  No

  N/A

• Is Debris Netting / Brick Guards required to stop items falling?

  Yes

  No

  N/A

• Are Rubbish Chutes required?

  Yes

  No

  N/A

• Are Ladders secured correctly / protected by self closing gates and have the required 3 rungs / 1m Take off area above the scaffold platform?

  Yes

  No

  N/A

• Is the scaffold protected at night, to prevent trespassers / unauthorised access?

  Yes

  No

  N/A

Tower Scaffold

• Do you hold a valid PASMA 3T competence card?

  Yes

  No

  N/A

• Has the tower been built correctly? Correct Height:Base Ratio / Use of Outriggers etc?

  Yes

  No

  N/A

• Is the work platform set up correctly - Top Guard Rail 1100mm high / Intermediate Guard Rail 600mm & Toe Boards 150mm high?

  Yes

  No

  N/A

• Have the Wheels been levelled and Locked?

  Yes

  No

  N/A

FLT - Man-Riding Cage

• Has the Cage been secured to the FLT using Clamps?

  Yes

  No

  N/A

• Has the Cage been secured using a back up method i.e. Chained the the Back Rest on the mast?

  Yes

  No

  N/A

• Has the FLT had a LOLER Check in the last 6 months (Used for lifting persons)?

  Yes

  No

  N/A

• Has the Man Riding Cage been LOLER Inspected in the Last 6 Months?

  Yes

  No

  N/A

• Has the Tilt Control in the FLT been locked out in accordance with the HSE Guidance issued in PM28 - Issue 4?

  Yes

  No

  N/A

• Having moving parts on the FLT been guarded so that the person working in the cage, doesn't make contact with moving parts?

  Yes

  No

  N/A

• Is there a method of communication between the Driver of the FLT and the worker in the Cage? i.e. 2 way radio.

  Yes

  No

  N/A

• Has the FLT Driver been trained in the use of FLT with the Cage mounted, and understands the safety rules. i.e. using handbrake / lock out of controls / remaining with the FLT at all times.

  Yes

  No

  N/A

• Has the Operative in the Cage got a Safety Harness and Fixed Lanyard (1.5 -2.0m) securely anchored to the designated floor anchor point in the platform.

  Yes

  No

  N/A

• Has the Harness and Lanyard been Thoroughly Inspected in the last 6 months?

  Yes

  No

  N/A

Ladders / Stepladders

• Is the ladder / stepladder been used for works of Short Duration (Max 30 mins in the same location) and Light Works (Max 25kg Tools / Equipment)

  Yes

  No

  N/A

• Is the ladder / stepladder the correct height for the works been undertaken? (Work not permitted from top 2 steps of a stepladder)

  Yes

  No

  N/A

• Is the Ladder / Stepladder Industrial Rated( i.e. SWL >150Kg)?

  Yes

  No

  N/A

• Is the Ladder / Stepladder in good condition? Is an Inspection Tag in place?

  Yes

  No

  N/A

• For Extension Ladders can the safe working Angle 75 Degrees (4:1 Ratio) be achieved?

  Yes

  No

  N/A

• Can the ladder be tied or secured at Top / Bottom?

  Yes

  No

  N/A

• Is the ladder suitable for the Environment - i.e. Fibreglass Non-conductive ladder for electrical works?

  Yes

  No

  N/A

Other Precautions Required

• Do you need to undertake any other precautions to undertake works safely?

• Do you require any further safety / rescue equipment to undertake works safely?

• Person in Charge of Works

• Company

• Signature

  Sign

• Authorising Person

PERMIT EXPIRY DETAILS

• Permit Expires on

  Date

• Name of Person trained to undertake Rescue

• Rescue Method - i.e. IRATA Level 3 Abseil / Lower or Spanset GOTCHA System / Use of Ground Mounted MEWP Controls

• Emergency Contact Phone Number

I confirm that the work has been completed, checked by myself, tools and materials have all been removed and the area left in a safe and tidy condition.

• Person in Charge (Print Name)

• Person in Charge (Signature)

  Sign

I have inspected the completed work, confirmed worksite is safe and returned any isolated fire protective equipment (Beam Detectors / Sprinklers) to its normal status. I hereby cancel this permit.

• Authorised Person (Print Name)

• Authorised Person (Signature)

  Sign

PERMIT CANCELLED

• Permit Cancelled

  Date