Permit for Working Aloft Form SMM 16

GENERAL: Complete this section before carrying out any work at heights were there is a risk of falling.
Personnel with less than 12 months experience at sea must not work aloft unless accompanied by an
experienced person.

Ship name: ………………………………….. Permit no: …………………………………………………….

Date: ……………………………………… Permit validity (as granted in sec. 3):

From…………………………. To ……………………………
(Date/time) (Date/time)

Work location: ……………………………………………………………………………………………………………………………………………………………..

Reason for work …………………………………………………………………………………………………………………………………

Risk Assessment: RA no. ………………………….. Rev…………………………….. Date: …………………………………

SECTION 1: To be completed by the responsible person (CO / CE / 2E)

1. Was a tool box meeting conducted for the job YES / NO

2. Do any of the following require to be isolated?
a. Aerials YES / NO
b. Boiler soot blowers YES / NO
c. Cranes YES / NO
d. Lighting YES / NO
e. Radar scanners YES / NO
f. Ship’s whistle YES / NO
g. Others - please specify: YES / NO

I am satisfied that the equipment above has been isolated and suitable warning notices posted:

Required duration of permit: From ………………………………………. To…………………………………………..

Name / signature ………………………………………………………………………………………….

( Chief Officer/ Chief Engineer/ Second Engineer )

Date: …………………………………….. Time: …………………………………………..

SECTION 2: To be checked by the person, or team leader where more than one person is
going aloft:

Rev No. 00 Page 1 of 2

 Permit for Working Aloft Form SMM 16

1. Have you been instructed on the requirements for the work? YES / NO
2. Are you and the assistants competent to carry out required works? YES / NO
3. Are you wearing a safety harness? YES / NO
4. Was the equipment listed above checked by the supervisor and yourself? YES / NO
5. Where possible, has a safety net been rigged? YES / NO

Names / ranks of personnel going aloft ……………………………………………………………….……….……….……….…………

Person going aloft / team leader: Name / signature ………………………………………………………………………..

Date: …………………………. Time: …………………………

SECTION 3: To be completed by the Master or Chief Engineer

I consider it safe to carry out the work stated during the following period provided the conditions laid
down are followed.

Remarks / special precautions: ……………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………
…

PERMIT GRANTED: From……………………………………… To………………………………………….

Name / signature ………………………………………………………………………………….

(Master / Chief Engineer)

Date:……………………………………………….. Time: ………………………………………………..

SECTION 4: To be completed by the Master or responsible person (CO / CE / 2E)

The work has been completed / suspended and all persons under my supervision, materials and equipment
have been withdrawn.

PERMIT CLOSED: Date ……………………………….. Time………………………………..

Name / signature ……………………………………………………………………………………

( Master / Chief Officer / Chief Engineer / Second Engineer)

Rev No. 00 Page 2 of 2