Work at Heights

Part 1: General Information (completed by Permit to Work Initiator)

Name of person in control of work (Permit
JSA Number:
to Work Acceptor):

Location of task:

Description of task:

Part 2: Considerations (completed by Permit to Work Initiator and/ or Acceptor)

Are any of the following present:

Work beyond confines of edge protection Yes Heights work within a confined space Yes
Work upon or access required to a roof Work involves use of ladders in some way
Yes Yes
(also complete section 4) (also complete section 5)
Requires use of lift/ sully box Yes Other issue: Yes
Part 3: Controls (completed by Permit to Work Initiator and/ or Acceptor)
Work shall only proceed if each statement is answered, ‘Yes’. Evidence of these shall also be provided.

All potential hazards have been identified and controls Yes Details:
implemented
Fall protection equipment is appropriate for this task Yes Details:

Work team members have inspected fall protection Yes Details:

equipment and ensured it is in an acceptable working
order and within the inspection period, and this is listed
on attached inspection tags.
Tools shall be appropriately secured throughout the task Yes Details:
to ensure there is no risk of a dropped object
Safe access and egress has been established Yes Details:

A Rescue Plan has been formulated for this work Yes Attached

Area is barricaded and signed so no pedestrian or Yes Attached

bystander is at risk
Additional Controls required for this work:

Part 4: Roof Work (completed by Permit to Work Initiator and/ or Acceptor)

There is the possibility of: brittle roofing, a fall or dropped object from or through a roof or ceiling and so the following additional controls will
be used:
crawl boards with guardrails Cat/ Roof fixed ladders Safety mesh affixed to roof full body harnesses - fall arrest
with guard rails

Edge protection Roof access ladders Walkways using planks/ mesh No loose material put on roof at
any time

Skylights/ Penetrations Work ceases during rainy/ Sarking Scaffolding

covered securely or edge windy conditions
protection placed around them
Saftey Net EWP access Positioning system Roof anchor points have been
inspected and are safe for use

These Additional Controls will also be used:

I have received approval to access this roof by a Roof Access Permit Authoriser. (Roof Access Permit Attached)

FRM-1051 V1.0 Work at Heights Permit.doc Page 1 of 3

Custodian: Estate and Facilities Management Reviewed: Feb 2017 Next Review: Feb 2018
Work at Heights
Part 4: Ladders (completed by Permit to Work Initiator and/ or Acceptor)
I confirm that there is no safer system of work for this task. Consideration was given to:
 Performing work at ground level
 Use of work positioning system (travel restraint/ rope access)
 Use of EWP
 Step Platform
 Erection of Scaffolding
 Other:
I confirm that the task has been risk assessed and the following ladder risks were considered:
 Type of task and how long it will take
 The position of ladder and person during task
 The physical surroundings and conditions
 The tools used during task
 The experience of the person performing task
 The amount of leverage required when using any tools
 The chance of overbalancing due to this work task
 Nearby services such as electrical wiring
 Whether any heavy-lifting or over-reaching is involved
 Ladder capacity compared to worker weight plus tools/
 Obstacles preventing ladder from being setup correctly
equipment
 Ensuring ladder is long enough to ensure worker stands
 Slope, sturdiness of ground on which ladder will be placed
no higher than the rung 900mm from the top of ladder
 Sturdiness of surfaces ladder will rest against
and at least 2 treads down from top plate. (at all times)
 Will worker attempt to face away from ladder at any time while
 Other:
going up/ down or working on ladder?
 Is a place the worker will attempt to stand after alighting from
ladder unsafe in any way?
The following control measures have been put in place for this work
ladder has non-slip feet that Single/ extension ladder is Single/ extension ladder is non-conductive ladder being
are in good condition at a four to one slope. Step secure at both top and bottom. used for electrical work or because
ladders in fully open position. there is a nearby electrical hazard
Ladder is protected from There will be no work Three points of contact will be Safety spotter will be used
being hit or knocked by any requiring heavy lifting/ over- used during all climbing up/
nearby activity or traffic reach or use of leverage from down
ladder
Have ensured there is a safe Will face towards ladder Will always stand at least Ladder has been checked and is
place to stand when alighting at all times during this task 900mm from top of ladder and free of any damage including:
from ladder below the second tread below warping, cracking, bruises, twisting,
any top plate. bends, crushes, worn, missing
pieces.
Tools will be hoisted up after Before climbing ladder it Ladder used to access a roof Ladder will be setup and removed
worker has climbed to top of will be tested by jumping on is more than a metre above the by two or more persons.
ladder. bottom rung roof line.
Area is barricaded and signed Installation of Side Tool lanyards, hard hats with Other:
so no pedestrian or bystander is braces / Cross braces to make chin strap
at risk the ladder rigid
Part 5: Permit Authorisation (completed by Work at Heights PTW Authoriser, and Permit to Work Acceptor).
I the Permit to Work Authoriser, authorise this work based on the control measures and precautions listed on this form. I have been informed
by the Permit to Work Initiator that the listed controls are in place. The Permit to Work Acceptor has also agreed to ensure all persons
performing work under this permit will be advised, understand and adhere to its requirements.
Name: Signature: Date: Time:
Valid until: Date: Time:
I the Permit to Work Acceptor, have discussed this work with the Permit to Work Authoriser and understand all aspects of the task. I shall
comply with all provisions of this permit and shall convey these provisions and all relevant information to all persons involved in this task.
Name: Signature: Date: Time:

Part 6: Permit Closure (to be completed by Permit to Work Authoriser and Permit to Work Acceptor)
I, the Permit to Work Acceptor have inspected the worksite describe above and certify that:
All isolations, locks and tags have been removed and the plant/ area is safe to return to normal service
PTW Acceptor: Signature Date: Time:
I, the Work at Heights Permit to Work Authoriser by signing here advise that this permit is now cancelled; any additional work requires the
issuing of a new permit. No further access is permitted until that occurs.
PTW Authoriser: Signature Date: Time:

FRM-1051 V1.0 Work at Heights Permit.doc Page 2 of 3

Custodian: Estate and Facilities Management Reviewed: Feb 2017 Next Review: Feb 2018
Work at Heights

FRM-1051 V1.0 Work at Heights Permit.doc Page 3 of 3

Custodian: Estate and Facilities Management Reviewed: Feb 2017 Next Review: Feb 2018