Part 2.3.11: Permit to Work Systems

2 SAFETY AND ACCIDENT PREVENTION MANAGEMENT / ADMINISTRATION SYSTEM (SAMAS) ..................................................... 1
2.3 SAFETY, HEALTH AND ENVIRONMENT PROCEDURES ............................ 1

2.3.11 PERMIT TO WORK SYSTEMS ......................................................................... 1

2.3.11.1 Responsibilities .............................................................................................. 4

2.3.11.2 Definitions ...................................................................................................... 4

2.3.11.3 Action Required To Implement This Procedure ............................................ 5

2.3.11.4 Guidance to this procedure............................................................................ 7

2.3.11.5 Reference Documents ................................................................................... 9

2.3.11.6 Author........................................................................................................... 10

2.3.11.7 Approvals ..................................................................................................... 10

QCS 2014 Section 11: Health and Safety Page 2 Part 2.3.11: Permit to Work Systems
PROCESS MAP
Authorised
Supervisor
Person

Key
Activity
Guidance

PURPOSE
1 The purpose of this procedure is to assign responsibilities and establish a safe system of work to control hazards (which under normal circumstances are difficult to control), by means of a recognised permit system.
SCOPE
1 This procedure covers all COMPANY Projects and locations under the control of COMPANY. A COMPANY is defined as the organization with responsibility for management of safety at a construction site.

2.3.11.1 Responsibilities
SHE DIRECTOR
1 Authorises this procedure.
CONTRACTS MANAGER
2 Ensures that the authorised person(s) are appointed.
PROJECT/SITE MANAGER
3 Ensures this procedure is established on the project under their responsibility and where applicable a permit to work system is applied.
AUTHORISED PERSON
4 Has responsibility for the overall co-ordination and signature for the permit to work system
SHE ADVISER/MANAGER
5 Provides advice and support in the application of this.
CONTRACTORS
6 Work in accordance with this procedure.

2.3.11.2 Definitions
HAZARD/ ASPECT/IMPACT
1 Something with the potential to cause harm, this can include substances, workplaces, machines, tools, etc and includes the potential to harm/damage the environment including the potential of causing a statutory nuisance.
RISK
2 Is the likelihood that the potential harm from a particular hazard is realised.
Risk = consequence x probability and is classed as either Acceptable or Unacceptable, depending on the results of the quantifying matrix.
METHOD STATEMENT
PERMIT TO WORK SYSTEM

3 The arrangements, confirmed by a written permit, by which a competent person/s satisfies that all necessary precautions have been taken and provisions made to secure the safety of persons associated with an activity.
PERMIT TO WORK
4 A permit is a signed document that provides assurance that work may safely take place. It does not replace any requirements for risk assessments or method statements

2.3.11.3 Action Required To Implement This Procedure
1 In order to control hazards which under normal circumstances are difficult to control such as fire, dangerous substances electrical equipment, confined spaces, excavations etc. A formal written procedure shall be used to ensure a safe place of work/safe system of work strategy and full compliance with current legislation.
2 Permit to Work Systems Shall be used on COMPANY Projects in the following circumstances:
(a)
Work on/test on electrical equipment which could give rise to risk of injury or death from electrical shock or burn, including commissioning work and, particularly, work involving exposed live conductors operating at dangerous voltages. (USE ELECTRICAL PERMIT FORMS).

(b)
Welding, flame cutting, use of ignition sources, or work on electrical equipment which could give rise to an incentive spark. (USE HOT WORK PERMIT FORM).

(c)
Work in confined spaces or at any poorly ventilated place where toxic/flammable gases, fumes, or vapours are likely to be present in dangerous concentrations, or where there may be oxygen deficiency or oxygen enrichment. (USE CONFINED SPACE PERMIT FORM).

(d)
Permit to excavate to be produced prior to any ground being broken. Information relative to services etc. shall be identified on the permits. (USE EXCAVATION WORK PERMIT).

(e)
Controlling access to complete or specific areas. (USE WORK ACCESS CONTROL PERMIT FORM).

(f)
Any other clearly dangerous circumstances e.g. site radiography where formal coordination of people and precautions is necessary in order to secure safety. (BESPOKE PERMIT FORM TO BE PRODUCED REFER TO SHE DEPARTMENT FOR ASSISTANCE).

GENERAL
3 Only competent persons fully conversant with the COMPANY and/or client permit to work procedures shall be appointed as an Authorised Person by the Project/Site Manager
4 The Project / Site Manager responsible for the Project will ensure that the Authorised Person(s) have received suitable and sufficient training in order to execute their duties in this procedure, and should take into account the practical experience of the proposed Authorised Person of the particular plant, equipment and/or situation involved.
5 The Authorised Person shall ensure that on large sites, particularly where more than one permit system is operating, a suitable map(s) or plan(s) shall be produced and posted at a focal point(s). The map/plan shall where appropriate indicate the type of permit operating in, what areas, and shall make clear that only personnel covered by the permit shall enter those areas. The map or plan shall be updated, and removed immediately all work which demands a permit is closed.
6 N.B. Where more than one permit is issued on plant or an operating system a cross referencing procedure shall be adopted to ensure safety.
HOT WORK PERMITS
7 The Authorised Person shall ensure that conditions are safe for work to be carried out, and where necessary, carry out, or arrange for atmospheric tests to ensure safety. Additionally, the Authorised Person shall ascertain the presence, nature and properties of any flammable, combustible, or explosive agent involved in the work (e.g. LEL, UEL, WEL, Flash Point, Density, Threshold of Smell, etc).
8 In addition the Authorised Person shall consider the possible sources of ignition such as:

QCS 2014 Section 11: Health and Safety Page 6
Part 2.3.11: Permit to Work Systems
(a) Matches, lighters, cigarettes, etc.,

(b)
Oxyacetylene and other gas welding, cutting and burning, Electrical arc welding

(d)
Static Electricity

(e)
Percussive Sparks from metal tools etc.

(f)
Solar refraction

(g)
Any other source of ignition

WORK IN CONFINED SPACES
9 Before signing this Form the Authorised Persons shall be sure he knows the exact nature and properties of any gases, liquids, vapours, solids or sludges present in the confined space (LEL, UEL, OEL, WEL, density, flash point, threshold of smell etc.).
10 The Authorised Person should carry out or arrange to carry out air tests if breathing apparatus is not worn by operatives entering the confined space and ensure that any working, escape or rescue respirator or breathing apparatus is suitable for the hazard involved, users have been instructed in correct usage and the time for which it will remain effective.
11 If breathing apparatus is to be worn, the Authorised Person must ensure that the operative is attached to a trained observer outside the confined space by means of a lifeline and harness and that any necessary rescue equipment is in position, and that operatives never work unattended in confined spaces.
WORK INVOLVING THE PRESSURE TESTING OF PLANT AND EQUIPMENT
12 Pressurisation of air and gases produce a much greater hazard if a vessel or pipe bursts than when hydrostatic pressurisation is used. Therefore, hydrostatic testing shall be used whenever practicable.
13 All tests shall be carried out in full consultation with the relevant Designer. If for technical reasons air or gas pressure testing is unavoidable the Project / Site Manager shall obtain formal permission to carry out such testing from the relevant Designer and safety procedures agreed with them.
14 Where the risk of an explosion or injury through pressure testing is evident the Project / Site Manager shall ensure that the Authorised Person ultimately signing the permit is a trained and experienced engineer who fully understands the hazards involved.
OUT OF HOURS PERMIT
15 This is a delegation of control permit (it does not delegate responsibility which will still rest with the Project / Site Manager) and is intended to be used on projects where a contractor wishes to work outside normal site hours and no COMPANY supervision is available. It must only be used where the risk from the activity has been assessed as acceptable and can only be used for Single Contractor Works, where co-ordination between more than one contractor is an issue an COMPANY Manager or Supervisor must be in control of the site.
WORK ACCESS CONTROL PERMIT
16 Where an access Control permit is to be used before issuing the permit the Authorised Person must ensure clear demarcation of the area is in place by means of notices and barriers so that personnel know the existence of such an area and its limits.
17 A means of identifying personnel permitted to enter the restricted area, must be established by the Supervisor of the works (The permit shall list the names of those permitted in the restricted area).

Part 2.3.11: Permit to Work Systems
ACTIVITIES UNDERTAKEN BY COMPANY
18 Whenever COMPANY operates a permit to work system the Project / Site Manager shall liaise with the SHE Department and agree who shall have responsibility for overall signature of the particular permit to work form. In all cases such persons shall be appointed in writing as Authorised Persons.
19 The Authorised Person who signs the Permit to Work shall assess the persons who are to carry out the work and decide in conjunction with the supervisor in charge of those persons whether they are competent to undertake the work safely.
20 The Authorised Person has a clear responsibility to satisfy themselves that the precautions required by any particular permit to work they issue are in place before work is authorised, and must be aware of any risk assessments and controls identified therein associated with the activity to be undertaken.
ACTIVITIES UNDERTAKEN BY CONTRACTORS
21 In some circumstances sub/work package contractors may wish to operate their own permit to work systems, and it may be that COMPANY will require some contractors to control their own works by a permit system. In these cases the following actions should be undertaken.
22 The Site Manager will issue an over riding permit of the appropriate type authorising the Contractor to control the works in accordance with an agree permit system, this permit shall be reviewed regularly by the Project Site Manager to verify it is still appropriate and updated as necessary. The review shall be at intervals not exceeding 7 days.
23 The Project Site Manager shall liaise with the SHE Department and agree who from the Contractors team shall have responsibility for overall signature of the particular permit to work form. In all cases such persons shall be appointed by the Contractor in writing as Authorised Persons and this appointment `notified to the Project Site Manager.
24 The Contractors Authorised Person who signs the Permit to Work shall assess the persons who are to carry out the work and decide in conjunction with the supervisor in charge of those persons whether they are competent to undertake the work safely.
25 The Contractors Authorised Person has a clear responsibility to satisfy themselves that the precautions required by any particular permit to work they issue are in place before work is authorised, and must be aware of any risk assessments and controls identified therein associated with the activity to be undertaken.

2.3.11.4 Guidance to this procedure
1 In some circumstances, particularly where COMPANY is modifying or enlarging an existing plant, the client may require his own permit to work system to be used and that sub/work package contractors working on the site be subject to it.
AUTHORISED PERSONS
2 All Authorised Persons shall be aged over 21 years.
3 Authorised Persons shall formally accept and not delegate their duties.
4 Authorised Persons shall be identified in the SHE Management Plan.
TYPES OF PERMITS AND THEIR APPLICATION ELECTRICAL WORK PERMITS

QCS 2014 Section 11: Health and Safety Page 8 Part 2.3.11: Permit to Work Systems 5 Electrical work is subject to the Electricity at Work Regulations. The procedures for complying with them are contained in SHE-PRO-004 together with any COMPANY Electrical Safety Instructions
6 All work on electrical equipment that has the potential to be energised at a dangerous voltage shall be covered by a permit to work and the necessary signs displayed.
HOT WORK PERMITS
7 The objective of these permits is to allow work that may give rise to a source of ignition in circumstances where there is risk of fire and/or explosion, and/or burns to personnel.
(a)
The permits are for use where hot work on plant or equipment is required and a permit for general hot work within buildings where flammable materials are liable to be present. The advice of the SHE Department shall be sought when determining which the appropriate permit to be used in is circumstances where there is any doubt, and should be used where one or more of the following are present in significant quantities:

(b)
Flammable liquids (particularly highly flammable liquids whose flash points lie below 32ºC). It should be remembered that vapours from such liquids are normally heavier than air, and may collect in sumps, drains etc

(c)
Flammable gases or vapours where the concentration involved could approach or exceed the lower explosive limit. (NB whilst methane is lighter than air, most other hydrocarbon gases are heavier than air e.g. propane, butane).

(d)
Flammable dusts (particularly organic dusts like grain, wood, sugar, etc. Also certain metal and other inorganic dusts which are explosive e.g. aluminium. It should also be remembered that a relatively minor initial explosion may disturb lying dust and give rise to a catastrophic secondary explosion.

(e)
Solid organic and other materials, for instance timber structures or combustible insulation materials such as paper, polystyrene, polyurethane foam, etc.

8 The permit shall also be used in circumstances where
(a)
Dangerously hot plant (e.g. steam heated) has to be isolated to avoid burns, scalds, etc., to personnel working on that plant.

(b)
Metal cutting is being undertaken either by gas or mechanical means

WORK IN CONFINED SPACES
9 The presence of potentially dangerous sludges or deposits shall also be considered which may, when disturbed, give rise to hazardous gas etc. Further hazards may also arise from flammable liquids, gases, and vapours, introduced by the work itself, or the ingress of steam or corrosive/hot liquids etc. or lack of oxygen.
10 The objectives of the permit are to minimise these hazards, and secure compliance with the Qatar Regulatory Document (Construction).
EXCAVATION WORK PERMIT
11 See procedure SHE-PRO-003 for the procedure to be adopted for excavation work. Work Access Control Permit
12 This permit shall be used where it is necessary to control the access of personnel to certain work areas for the following reasons:
(a)
To prevent damage and vandalism to installed plant within a particular area.

(b)
To know the exact whereabouts of personnel on "high security" sites at given times.

(c)
To restrict personnel who enter potentially hazardous areas to a limited number, all with appropriate specialist knowledge and training.

QCS 2014 Section 11: Health and Safety Page 9 Part 2.3.11: Permit to Work Systems
WARNING SIGNS AND TAPES
13 The following warning signs/tapes shall be used where applicable.
(a)
Danger Permit to Work Area Entry Forbidden Except to Authorised

(b)
Persons

(d)
Caution Men Working on Apparatus

(e)
Danger Keep Away Exposed Live Conductors

(f)
Danger No Unauthorised Person to Touch This Switchgear

(g)
Danger No Smoking or Naked Flames

(h)
Danger Plant Equipment Under Test Do Not Touch/Operate

(i)
Caution Risk of Ionising Radiation (Provided by Specialist Contractor)

(j)
Restricted Work Area Entry Only to Listed Workmen on COMPANY Access Permit

(k)
Danger Buried Cables

2.3.11.5 Reference Documents
FORMS
1 Confined Space Entry Work Permit (SHE-FRM-11-01) 2 General Permit to Work (SHE-FRM-11-02) 3 Hot Work Permit General (SHE-FRM-11-03) 4 Hot Work Permit Plant and Equipment (SHE-FRM-11-04) 5 Pressure Test Work Permit (SHE-FRM-11-05) 6 Work Access Control Permit (SHE-FRM-11-06) 7 Permit to Work on Test Electrically Isolated Apparatus 8 (SHE-FRM-11-07).Permit to Test Electrically Live 9 Apparatus (SHE-FRM-11-08) 10 Out of Hours Work Permit (SHE-FRM-11-09) 11 Permit to Excavate (SHE-FRM-3-02) 12 Site Crane Permit to Lift (SHE-FRM-10-02)
REFERENCE DOCUMENTS
13 Qatar Regulatory Document (Construction) RD1.5
14 Safety, Health and Environmental Risk Management and Written Safe Systems of Work (SHE-PRO-001)
15 Safe Working in the Vicinity of Buried and Overhead Services (SHE-PRO-003) Electricity at Work (SHE- PRO-004)

QCS 2014 Section 11: Health and Safety Page 10 Part 2.3.11: Permit to Work Systems 16 The Safe use of Cranes and Other Lifting Appliances (Excavators, Tele Handlers and Lorry Loaders (SHE-PRO-010)
17 Fire Precautions During Construction Work in Buildings (SHE-PRO-013)
2.3.11.6 Author
SECTION NAME POSITION IN COMPANY CONTACT DETAILS
SHE Manager

2.3.11.7 Approvals
NAME POSITION IN COMPANY SIGNATURE & DATE
Approved by: SHEQ Director

Location: ……………………………………………………………………………………………………………………… Description of Work: ………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Valid From …………..…hrs on (Date)…………..……To……..…. .hrs on (Date) ……..………(Max 1 shift)
Hazard Restrictions, Comments: ……………………………………………………………………………….
MANDATORY CONTROL MEASURES REQUIRED
Supervision – Nominated and Completed Mandatory
Means of Communication Mandatory
Instruments to detect adverse atmospheres Mandatory
Gas Purging Mandatory
Forced Air Ventilation Mandatory
Intrinsically Safe Lamps or Lighting Mandatory
Removal of residues (without causing additional hazards) Mandatory
Suitable Access/Egress arrangements including emergency evacuation Mandatory
Emergency Rescue equipment and procedure Mandatory

PERMIT MUST NOT BE ISSUED OR WORK COMMENCED UNTIL ALL THE CONTROL MEASURES ABOVE ARE IN PLACE
OPTIONAL CONTROL MEASURES REQUIRED
Isolation (Gases, Electrical, Mechanical) YES NO
RPE YES NO
Full BA, Escape Breathing Apparatus or External Air Feed YES NO
Fire Precautions (Intrinsically safe lamps etc) YES NO
Task and Emergency Lighting YES NO
Additional permits for specific activities i.e. hot work YES NO

ISSUE OF PERMIT
I confirm that all atmospheric checks have been made and all persons required to enter the Confined Space for any reason are medically fit and have proof of having received the relevant training in Confined Space Entry to the correct category.
Authorised Person: …………………………… Signed: …………………………………Date:……………….
Names of persons entering the Confined Space are attached
RECEIPT OF PERMIT
I confirm that work by myself or by any person under my control in the Confined Space will be carried out in accordance with this permit, all statutory requirements and company safety policy. All persons entering the Confined Space will receive information and instruction in the requirements of this permit and safety measures necessary prior to entry into the Confined Space.
Competent Person: …………………………… Signed: …………………………………Date:……………….
CLEARANCE (Competent Person Confined Spaces)
I certify that all persons have been withdrawn and warned that it is no longer safe to enter the Confined Space above and that all tools and equipment have been removed.
Competent Person: …………………………… Signed: …………………………………Date:……………….
CANCELLATION – AUTHORISED PERSON I acknowledge receipt of the clearance of this Permit. THE PERMIT IS NOW CANCELLED
Name: …………………………………… Signed: …………………………………Date:……………….
Distribution: White copy – Workplace recipient Pink copy – Distribute as required Blue copy – Retain in book (file copy)

QCS 2014 Section 11: Health and Safety Page 12 Part 2.3.11: Permit to Work Systems
This Permit is valid only for the period specified
Contract Name: Contract No: Permit No:
Location of works: Description of works:

Part 1 Names of persons in working party:
Part 2 Details of work to be carried out (risk assessment, method statement, etc, to be attached)
Part 3 Precautions to be observed (e.g. other permits, lock off, access control)
Protective clothing required Y N Breathing apparatus Y N Gloves Y N Other Y N
Safety helmet Y N Eye protection Y N Ear defenders Y N
Safety harness Y N Wellingtons Y N Overalls Y N
Safety boots Y N Face mask Y N RPE Y N

Part 4 Other hazards Action to be taken
Heat source Y N
Steam Y N
Electricity Y N
Noise Y N
Work at height Y N
Mechanical power Y N
Others (specify) Y N

Part 5 Issue of Permit:
I hereby certify that the precautions detailed above have been carried out and that it is safe to commence work.
Signed: (Authorised person) Name: (Print)
Date: Time:
Valid from: Valid to:

Part 6 Receipt of Permit:
I hereby declare that I accept responsibility for carrying out work detailed in this permit including all precautions noted.
Signed: (Authorised person) Name: (Print)
Date: Time:

Part 7 Clearance of Work Area
I hereby declare that the work for which this permit was issued is now complete and that all employees under my control have been withdrawn. All equipment, tools, material and gear has been removed. All guards have been replaced and the area has been checked as safe.
Signed: (Authorised person) Name: (Print)
Date: Time:

Part 8 Permit cancellation
I declare that this permit and all copies of it are cancelled
Signed: (Authorised person) Name: (Print)
Date: Time:

Distribution: White copy – Workplace recipient Pink copy – Distribute as required Blue copy – Retain in book (file copy)

CONTROL MEASURES REQUIRED
Combustible materials to be removed from the working area
Suitable Fire Fighting Equipment (FFE) is in position
Person received appropriate fire safety training
No combustible liquids, vapours, gases or dusts within the work area
Work location has been thoroughly examined
Exposed wooden flooring or skirting etc, covered to prevent ignition
Gas cylinders secured upright and flash back arrestors fitted
Hot work to cease one hour before end of shift
Operatives familiar with emergency procedures
Screens positioned when welding, cutting or grinding operations

Contract: …………………………………………………………Permit No: ………………………. Location: ………………………………………………………………………………………………… Description of Work:
…………………………………………………………………………………………………………… …………………………………………………………………………………………………………… Valid From ………………hrs on (Date)…………………. To ……….hrs on (Date) ……………… Hazard Restrictions, Comments: …………………………………………………………………….. ……………………………………………………………………………………………………………
ISSUE OF PERMIT I confirm that all persons carrying out hot work have been made aware of the contents of this permit Weekly Issue Fire Watch Checks
Day Initial
Authorised Person…………………………….Signature…………………… Mon
Tues
RECEIPT OF PAYMENT Wed
I confirm that work by myself or by any person under my control carrying out hot work will do so in accordance with this permit, all statutory requirements and company safety policy. All persons involved will receive information and instruction in the requirements of this permit and safety measures necessary prior to work commencing. Competent Person…………………………….Signature…………………… Thur
Fri
Sat
Sun
Initials confirm temporary cancellation for weekly issue

FINAL CANCELLATION – Sub-contractor Representative
I confirm that all sources of ignition have been removed and the relevant fire watch stood Name……………………………………………………… Signed ......................................... Date……………
FINAL CANCELLATION – Authorised Person I acknowledge receipt of the cancellation of this Permit. THE PERMIT IS NOW CANCELLED
Name ..............................................................................Signed .......................................... Date…………...

Permit Serial No. Date of Issue Hot Work Permit - Plant/Equipment
1. Details of location and work to be carried out
Plant/equipment no.
2.
This permit is valid from hrs on (date) to hrs on (date)

3.
Description of fire/explosion/hazards involved: Quote flammable gases, liquids, vapours involved, and give lower and upper explosive limits etc. or steam

4.
Description of other hazards: Give details of noise, toxic dangerous chemicals, steam, hot liquids etc. Quote OELs where applicable

Precautions YES NO Comment
Valves (designate) padlocked off Total disconnection Spades fitted Open-ended pipes/vessels sealed Fire-fighting systems locked off Other isolation methods (specify) Drains, sewers within 25 metres sealed Mechanical ventilation Flame-proof electrical equipment or equivalent Fire blankets 'Don't Touch' labels Local electrical circuits isolated Dangerous machinery isolated/guarded Earthing against static electricity Smoking/naked lights prohibited Danger area demarcated Operators instructed in hazards and precautions Caution signs posted Standby fire-fighting equipment

Other necessary precautions (including breathing apparatus)
6.
Atmospheric tests (not for steam) Reading taken by Print Name Explosimeter reading: Date:

Time: Title Gas detector reading Specify gases

7.
Authorisation I have personally checked the above conditions and consider it safe to carry out this work Authorised person Print Name Title: Signature: Date: Time:

8.
Acknowledgement I understand the hazards of this work and the precautions to be taken. These have also been fully explained to the operatives carrying out this work, and I consider them competent to do it safely. I will return my copy of this permit to the authorised person when this work has been safely completed

Competent supervisor Print Name Title:
Signature: Date: Time:

9.
Time extension Subject to the following precautions Mark N/A if none are required the expiry time of this permit is extended from hours on (date) to hours on (date) Signed Authorised person Date:

10.
Cancellation

10.1 I have completed the work detailed in this permit, and have restored the location to a safe condition. I have returned my copy (white) of this permit to the authorised person Signed Competent supervisor Date:
10.2 I accept that the work has been safely completed. The top (white) copy of this permit has been destroyed Signed Authorised person Date: Time:
Notes
a) Permit is automatically suspended upon sounding of emergency alarms, instructions via public address system etc. Check with authorised person before recommencing work.
b) Where the authorised person is also the competent supervisor he should sign all parts of the form and issue the top original (white) copy to himself as a check on procedure.
c) Signatures for paragraphs 10.1 and 10.2 to be placed only on duplicate (blue) copy which is to be retained for record purposes.

Permit Serial No…………………………………. Date……………………………
1.
Details and location of plant to be pressure tested:

2.
This permit is valid from:

......................... hrs on (date) ……………………to …………………hrs on (date) …....................

3. Nature of pressure test:
Hydrostatic

Gas

Air

Pressure involved………………….
4. Description of any other hazards associated with pressure test (noise, hot liquid, steam, toxic/corrosive agents etc.):
5. Precautions Applicable Comment
Yes No

6. Authorisation
Authorised Person : Print Name…………………………………………Title…………………………............. Signed …………………………………… Time (hrs)…………………. Date………………………………
7. Acknowledgement:
I understand the hazards of this work and the precautions to be taken. These have also been fully explained to the operatives carrying out this work, and I consider them competent to do it safely. I will return my copy of this permit to the authorised person when this work has been safely completed.
Competent Supervisor: Print Name………………………………………Title…………………………..........

Signed …………………………………………………Time (hrs)…………………. Date…………………………
8. Time Extension: Subject to the following precautions – Mark N/A if none required
The expiry time of this permit is extended from …........................ hrs on (date) …………………………
To …........................hrs on (date) …………………………

9. Cancellation:
9.1 I have completed the work detailed in this permit, and have restored the location to a safe condition. I have returned my copy (white) of this permit to the authorised person.
Signed Competent Supervisor…………………………………….. Time (hrs)…………………. Date……………………………………..
I accept that the work has been safely completed. The Top copy (white) of this permit has been destroyed.
Signed Competent Supervisor…………………………………….. Time (hrs)…………………. Date……………………………………..
Notes
a) Permit is automatically b) Where the authorised person is c) Signature for paragraphs 9.1 and
suspended upon sounding of also the competent person, he 9.2 to be placed on duplicate
emergency alarms, instruction via should issue the top copy (white) copy (blue) which is to be
public address system etc. to himself as a check on retained for record purposes.
Check with authorised person procedure. Top copy (white) to be destroyed
before recommending work. to prevent re-issue.
Distribution: White copy - Workplace recipient
Pink copy - Distribute as required
Blue copy - Retain in book (file copy)

1.
Project:

2.
Description of controlled work area:

3.
The above work area has been demarcated in the following manner:

4.
This permit is valid from: …................ hrs on (date) ………………. to
……….….hrs on (date) ………............

5. The person(s) designated below is hereby authorised to enter and work in the controlled area described in 2. above Name and initials Title Name and initials Title Name and initials Title Name and initials Title
6.
Special conditions (if any):

7.
I hereby agree to return my copy of this permit to the authorising person in 8. Below immediately after the expiry time /date at 4. above

Signed person requesting access………………………….. Date……………….
8.
Signed Work Access Controller…………………………… Date……………….
Notes
a) Top copy (white) to be b) Duplicate copy (blue)
issued by Works to be retained in file
Access Controller to
person requesting

Distribution: White copy -Workplace recipient Pink copy -Distribute as required Blue copy -|Retain in book (file copy)

1. Details of apparatus and work on/test* to be done:
Contract No:…………………………………….. Location:…………………………………………………………………..
2. Precautions and authorisation
2.1 Isolation: State isolation point(s), whether or not isolators have been padlocked off, fuses drawn, etc.
2.2 Warning notices and access control: State where caution/danger notices have been posted and if appropriate, how work area has been fenced off.
2.3 Prove apparatus dead: State what tests have been made, where and with what instruments.
2.4 Earthing: State where apparatus has been earthed and, for testing, which earths may be removed.
2.5 Other precautions: Specify if required for special circumstances.
2.6 Validation period: This permit is valid from ……hrs on (date)………to……..hrs on (date)……… I hereby declare that the above precautions have been taken and made known to the competent person in charge of the work. I consider that the apparatus specified in paragraph 1 is safe to work on/test*
Signed (Authorised Person)…………………………Time (hrs)………………Date…………………
3. Acceptance and receipt of Top copy (White) by competent person
I acknowledge receipt of this permit and understand the safety precautions described above. Neither I nor the men under my control will work on/test* any other electrically dangerous apparatus. I will return this permit to the authorised person when the work on/test is complete.
Signed (Authorised Person)………………………… Time (hrs)………………Date…………………
4. Cancellation
4.1 I hereby declare that the work on/test*- detailed in paragraph 1 has been completed/stopped, earths removed, and men/gear withdrawn. The apparatus is now in safe condition.
Signed (Authorised Person)………………………… Time (hrs)………………Date…………………
4.2 I hereby declare this permit cancelled. The top copy (white) has been returned to me by the competent person and destroyed. The apparatus detailed in paragraph 1 may be reconnected for service.
Signed (Authorised Person)…………………………Time (hrs)………………Date…………………
Notes
b) Top copy (white) is to be a) Where the authorised person is c) Signature for paragraphs 4.1 and
retained by competent person also the competent person, he 4.2 to be placed only on duplicate
whilst work on test is going on should sign all parts of the form copy (blue) which is to be
and returned to authorised and issue the top (white) coy to retained for record purposes. Top
person for destruction when work himself as a check on procedure. copy (white) to be destroyed to
is complete. prevent re-issued.
Distribution: Top Copy – White 2nd Copy - Blue
This form is intended to be used in a PAD format only

Part 2.3.11: Permit to Work Systems
1. Details of apparatus and test to be done
Contract No. Location
2.
Reasons why test cannot be carried out with apparatus isolated

3.
Person(s) involved in test Only authorised or competent persons may work on/test live apparatus at or above 55 volts AC/DC

Competent person name and initials
Observer name and initials

4. Precautions and authorisation
4.1 Safety equipment: The following safety equipment will be provided and used throughout the test insulating rubber gloves Max safe voltage insulating rubber boots Max safe voltage insulating rubber mats Max safe voltage insulating push bars Max safe voltage
Other tools and equipment: State type and when to be used
4.2 Adjacent live equipment: The following precautions are to be taken to ensure that the persons named in paragraph 3 cannot come into contact either adjacent live equipment
4.3 Danger and caution notices have been posted at
4.4 Atmospheric conditions: The following precautions are to be taken to avoid danger from wet and humid conditions
Important: No electrical test is to be carried out in potentially flammable atmospheres unless a hot work permit is in force
4.5 Validation period: This permit is effective
From hrs on (date) to hrs on (date)

4.6 Authorisation: I declare that all precautions specified in paragraph 4 are in force and that the test described in paragraph 1 may now begin.
Signed Authorised person Time hrs Date
5 Acceptance by competent person and observer
5.1 I acknowledge receipt of the top (white) original of this permit and understand/will use the safety precautions listed in paragraph 4. I will work only under the surveillance of the observer, and will return this permit to the authorised person when the test is complete.
Signed Competent person Time hrs Date
5.2
I acknowledge receipt of the first (pink) copy of this permit and will monitor the safe progress of the competent person. I have been instructed what to do in the case of emergency, and will return the permit to the authorised person when the test is complete.

Signed Observer Time hrs Date

6.
Clearance I hereby declare that the test described in paragraph 1 is complete. The apparatus is safe and tools/gear have been withdrawn.

Signed Competent person Time hrs Date

7.
Cancellation For cancellation complete blue copy

I hereby declare this permit cancelled. I have received back respectively from the competent person and the observer the white original and pink copy of the permit. These copies have been destroyed.
Signed Authorised person Time hrs Date
NOTES
a) Top original (white) and first copy (pink) to be issued by b) Where the authorised person is also the competent authorised person to competent person and observer person he should issue the top original (white) to respectively and retained by them during the work/test. himself as a check on correct procedure. Both copies to be returned to authorised person for destruction on completion of test.

CONTRACT: ...................................................................................... Permit No. ................ LOCATION: .................................................................................................. DESCRIPTION OF WORK: .............................................................................. DATE & DURATION OF WORKS: / / Hours: ........................
IS THE WORK TO BE CARRIED OUT A HIGH RISK ACTIVITY (e.g. Steel erection, roofwork, cladding, asbestos removal, work at height, excavations over 600mm deep etc.) Refer to initial risk assessment Construction Phase Safety Plan. (circle appropriate risk rating)
HIGH LOW
If the work is high risk or multi discipline, COMPANY supervision must be on site at all times.
Name and position of competent person supervising work activities. (person named must stay on site at all times) Name ................................................Position .............................. South West Architecture Safety Courses attended
FURTHER CONTROL MEASURES YES OR
Is there a first aid trained person on site?
Is there access to welfare and washing facilities?
Can the emergency services be called?
Is there sufficient lighting and access to work areas?
Have emergency contact numbers been passed to the supervisor?
Are all staff inducted and aware of fire and emergency procedures?
Have all applicable risk assessments / method statements been accepted?
Confirm tool-box talk has been held to communicate this permit?
Are there any specific environmental considerations i.e. consented noise levels
IF NO IS INSERTED IN THE RESPONSE BOX THEN THE WORK MUST NOT CONTINUE
OTHER SITE SPECIFIC CONTROLS:
Site Manager: ................................................... Signed: ............................................................
Contract Manager: ......................................... Date Approved:.....................................................
RECEIPT OF PERMIT I confirm that work by myself or by any person under my control carrying out work out of hours or without on-site COMPANY supervision will do so in accordance with this permit. All persons involved will receive information and instruction in the requirements of this permit and safety measures necessary prior to work commencing
Named Supervisor: Sub-contractor:
Signature: Date:

Works Completed: YES / NO Permit Return Date:
Further Permit Required: YES / NO Site Manager Signature:

*Out of hours