Corporate Permit to Work SOP Document Control Summary Status: Version: Author/Title: Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures Replacement for Permit to Work: Standard Operating Procedure v1.0 v1.1 Date: July 2017 Paul Oxley/Project Manager Robert Graves/Director of facilities and Estates Policy and Procedures Committee Date: 20 July 2017 Policy and Procedures Committee Date: 20 July 2017 Health and Safety Policy August 2017 August 2020 Permit, Hazard, Risk, Hot, Access, Shutdown Facilities and Estates Management Policy and Health, Safety and Welfare SOP. Contents 1 Introduction... 3 2 Purpose... 3 3 Scope and Definition... 3 4 Roles and Responsibilities... 3 5 Procedure... 4 6 Completion of Permits... 5 7 Process For Monitoring Compliance And Effectiveness... 6 8 References... 6 Appendix 1 - GENERIC PERMIT TO WORK... 7
Change Control Amendment History Version Dates Amendments V1.1 July 2017 Change control summary page to reflect the context of this document and not that of control of contractors. Page 2 of 9
1 Introduction The South Staffordshire and Shropshire Healthcare NHS Foundation Trust (hereinafter known as the Trust) has a duty under the Health & Safety at Work etc. Act (1974), and other subordinate legislation, to ensure, so far as is reasonably practicable, the health, safety and welfare of employees, and those persons who are not employees who might be affected by the activities of the Trust. It is the Trust s policy to provide safe and healthy working conditions for its employees and to make every effort to ensure the safety and welfare of visitors, service users and contractors employed by the Trust. 2 Purpose The Management of Health & Safety at Work Regulations (1999) require employers to carry out a suitable and sufficient assessment of the risks to the health and safety of their employees, in order to identify the measures which need to be taken to comply with statutory requirements and prohibitions. It is the policy of the Trust to ensure that a programme of risk assessment is carried out and that risk assessments are reviewed as necessary. Employees also have a duty under health and safety legislation to take reasonable care of their own health and safety at work, and of others whom their acts or omissions may affect. Employees are also required to co-operate with such persons with obligations under health and safety legislation in order that those persons may carry out their statutory duties. In order to help fulfil these duties this document sets out the Trust s procedure for issuing permits to work in hazardous areas. 3 Scope and Definition The Permit to Work system applies to both employees of the Trust and any contractors employed by the Trust and this is not limited to those contactors engaged by the Facilities and Estates Directorate. An effective way of reinforcing control over hazardous activities is provided by the use of a permit to work system. A permit to work is a formal written means of making sure that the risks associated with potentially dangerous activities are properly assessed and carried out using appropriate safety procedures. Further information and guidance is contained within ING98 published by the Health and Safety Executive Permit to Work Systems. 4 Roles and Responsibilities 4.1 Authorised Person-is an individual possessing adequate professional and technical knowledge, having received appropriate training and been appointed to undertake the role. The Authorised Person is responsible for the practical implementation and operation for the Trust s Permit to Work system. 4.2 Responsible Person- is an individual who has been given permission, in writing, to undertake work where it considered that inherent risk of danger and/or injury requires extra vigilance. Permission is given by the issue and acceptance of a Permit to Work.The Page 3 of 9
individual will have sufficient technical knowledge and experience to organise, supervise and control skilled persons to prevent danger while the defined work is being undertaken. 4.3 Competent Person-is an individual who undertakes the works for which the permit is required and has the necessary knowledge, skills and training to do the works. 5 Procedure 5.1 Areas of Work where a Permit to Work may be appropriate The following areas of work where the safety issues are such that a Permit to Work might be considered appropriate (the list is not exhaustive and should be used as a guide) are as follows: Work involving the use of heating appliances (Hot Work). Limitation of Access to controlled area. Testing, repair and maintenance of lifts. Testing, maintenance and repair of fire alarm systems. Testing, maintenance and repair of laboratory equipment (where there is no infection risk). Breaches of fire compartmentation. Testing, maintenance and repair of security equipment. Testing, maintenance and repair of pressurized systems (e.g. steam, oil, air, nonmedical gas system). Testing, maintenance and repair of hot and cold water distribution systems (Legionella risks). Testing, maintenance and repair of emergency generator engines. Testing, maintenance and repair of hazardous fixed and portable equipment. Work in an area where hazardous substances are known to exist (e.g. asbestos, chemicals, clinical waste). Work of a nature likely to generate dust, smoke fumes or vapours. Working at height. Electrical Works. Confined spaces. Medical gases. 5.2 Site Visits 5.2.1 Before a permit-to-work is issued the authorised person shall visit the location where the work is to be carried out, with a representative of the contractor or the member(s) of staff undertaking the work, to determine the tasks to be undertaken. 5.2.2 In the case of routine or re-occurring work, the authorised person may not visit if they are fully conversant with the tasks involved and are satisfied that persons carrying out the work are suitably equipped to ensure a safe working system. If there is any doubt, a visit must be made. 5.3 Issue and Use of Permits Page 4 of 9
5.3.1 Under no circumstances must anyone be allowed to start any hazardous work before the authorised person has completed a permit-to-work certificate, and it has been accepted by the contractor/ Trust employee (and verified as appropriate by the authorised person where necessary). 5.3.2 The responsible person and the competent person must never be the same person. 5.3.3 A permit is not transferable and must only be issued for one specific job of work. Where the work involves a number of associated tasks, a separate permit should be issued for each task and each permit should be cross referenced with the others. 5.3.4 Where more than one responsible person is involved in any single contract or job of work, all such persons shall co-operate with each other and coordinate their activities to ensure that the appropriate number of permits-to work are issued and the activities of one contractor/member of staff does not prejudice the safety of another. 5.3.5 In such cases one of the responsible persons shall be nominated to take the lead role to ensure continuity of approach and consistency of control. 5.3.6 A permit-to-work is issued under certain specific conditions. The precautions originally considered necessary and appropriate will therefore only be applicable if the task is carried out as originally intended and agreed. 5.3.7 If it is necessary in any way to depart from the task as originally agreed when the permit was issued, the original permit should be signed off and a replacement permit issued containing new conditions. 5.3.8 In some circumstances it may be necessary to restart operations in a plant or on a site before the work covered by the permit has been completed. This must only be allowed if the responsible person is satisfied that it will be safe to do so, or can be made safe to do so 5.3.9 If operations in a plant or on a site are allowed to restart, all precautions that are considered necessary to make it safe must be implemented, and the permit-to-work signed off. A new permit must be issued on recommencement of the work. 5.3.10 On completion of the work, the competent person shall sign off the original copy of the permit and return it to the responsible person. 5.3.11 The responsible person who issued the permit-to-work must ensure that all persons who were working under the permit are clear of the area and that all equipment, brought in to do the work, is removed. All guards and safety devices must have been re-fitted, and any plant must be safe for its intended use. 6 Completion of Permits 6.1 In most circumstances, the document to be used to authorise hazardous work being undertaken in premises or areas under the control of the Trust, is the Permit-to-Work Page 5 of 9
Certificate (Appendix 1). Appendix 1 is a generic certificate and specific certificates will be found in the relevant Standard Operating Procedure. 6.2 The responsible person must take a photocopy of the original permit after the competent person has completed and signed it. The original permit should then be handed to the competent person and the photocopy retained by the responsible person for reference purposes. 6.3 The competent person/s carrying out the work must be advised that the original permit is to be kept at the job location and produced by them if requested to do so. 6.4 The competent person/s must also be reminded of the responsibilities, conditions and precautions detailed in the permit, and of the requirement to return the permit to the responsible person on completion of the work and final departure from site 6.5 On completion of the work, the original permit and the photocopy must be returned to the authorised person who shall retain them for the period of two years after issue, to provide an accessible record in the event of an accident or incident in an area where hazardous work has been carried out. 7 Process For Monitoring Compliance And Effectiveness To ensure the permit-to-work system is operating correctly and that safety is always being maintained during any hazardous activity, the responsible person( or any other responsible person nominated by them to act on their behalf )must monitor the system on a periodic basis. This will be achieved by undertaking the following checks: Regular spot checks on the use of Permits to Work Questioning or tests to establish the contractor/staff competence Investigation of any untoward incidents under permit to work conditions Where the monitoring identifies deficiencies, recommendations for improvement will be made and an action plan produced and implemented. 8 References Health and Safety at Work etc. Act, 1974 Management of Health and Safety at Work Regulations Confined Spaces Regulations Personal Protective Equipment at Work Regulations Provision and Use of Work Equipment Regulations Electricity at Work Regulations Workplace (Health, Safety and Welfare) Regulations Control of Hazardous Substances (COSHH) Regulations Page 6 of 9
Appendix 1 - GENERIC PERMIT TO WORK FACILITIES AND ESTATES DIRECTORATE (TO BE COMPLETED IN DUPLICATE) Part 1 AUTHORISED PERSON DECLARATION Permit No 1. A PERMIT IS TO BE ISSUED ONLY BY A PERSON WHO IS AUTHORISED TO DO SO Permission is granted to: Name. Company.. Location/Description of Work From Date.. Start Time.. To Date.. Finish Time.. The Person/Company detailed above is responsible for ensuring compliance by all sub contactors they employ. 2. Hazards and Risks 2. Precautions to be taken before the work is undertaken.. 3. Precautions to be taken during the works.. 4. A safe method of work has been agreed with the authorised trust representative. 5. Testing Arrangements... Page 7 of 9
6. Any special requirements (e.g. Authorisation of Ward/department Manager, other permits in force) Part 2 Signature of Authorised Officer/Name in Block Capitals:.. Date.......... Signature of Responsible Person/Name in Block Capitals:........... Date Part 3 COMPETENT PERSON COMPLETION I hereby declare that the work for which this Permit-to-Work was issued is now suspended / completed* and that all the personnel under my charge have been withdrawn and warned that it is no longer safe to work on the apparatus/installation* on this Permit-to-Work and that all gear, tools, etc. have been removed. The following tests have been carried out and the results have been recorded on the form ref. Page 8 of 9
Signed Status Time Date Part 4 AUTHORISED PERSON CANCELLATION The Permit-to-Work is hereby cancelled. The original has been returned to me and destroyed in the presence of the signatory to Part 3. Signed Status Time Date * Delete as applicable After signing two copies, one copy of the permit is handed to the Responsible Person carrying out the work and the other retained by the Authorised Officer. Page 9 of 9