“SAFETY PLAN OF ACTION”

DATE
TASK: Model Risk Assessment Number
Permit to Work Number
Safety Critical Rules I will - Comply with the PTW Manual, and in particular “No Tag No Break”, and First Break.- Wear fall

protection when unprotected at height.- Comply with Confined Space and Critical Lift procedures.- Wear appropriate PPE

as required, including additional PPE as identified by the Permit to Work or Model Risk Assessment process.- Operate

with safety control devices and systems in place and functioning.- Establish and respect temporary barriers as required for

Operations purposes, Permit to Work or Model Risk Assessment process.

1. GENERAL WORK AREA ACCESS AND EGRESS

(a) Are there suitable and safe means of access / egress to the work location? Y N NA
(b) Is the work area lighting adequate? Y N NA

(c) Have any slip, trip, fall hazards been removed or controlled? Y N NA

(d) Have barriers been erected to keep people outside the dropped object zone? Y N NA
(e) Have you liased with those working in the vicinity, above, below, to ensure no Y N NA

2. Hand Protection
(a) If the work requires it, do you to have a Finger Saver to keep your hands out of the line Y N NA
(b) Do you have suitable gloves for the task in good condition and being worn? Y N NA

(c) Have any potential pinch points been identified and controlled? Y N NA

3. NOISE
(a) Are the noise hazards in the work area controlled? (Consider double hearing protection Y N NA
4. HOT SURFACES
(a) Have you checked the work area for hot surfaces? Y N NA
(b) Have you checked whether the hot surface can be isolated to remove the hazard? Y N NA
(c) Have you taken precautions to prevent you coming into contact with those hot surfaces? Y N NA

5. VEHICLE MOVEMENTS Applicable? YES NO

(a) Has the risk of vehicle collision with objects/people been controlled? Y N NA
(b) Is the vehicle load secure and the terrain suitable for vehicle movements? Y N NA
(c) Is a banksman/traffic marshal in use and a gas monitor attached to the vehicle? Y N NA

6. MANUAL HANDLING Applicable? YES NO

(a) Is the work site unrestricted and suitable for manual handling? Y N NA

(b) Have you ensured the manual handling does not place you in a hazardous position? Y N NA
(c) Can the task be undertaken safely using manual handling (approx 25kg personal lift Y N NA
7. TOOLS AND EQUIPMENT Applicable? YES NO

(a) Are all tools and equipment in good order and fit for purpose? Y N NA
(b) Are the tools clearly indicated on the PTW as those being used? Y N NA
(c) Are you trained in the use of the tools? Y N NA
8. RIGGING & LIFTING Applicable? YES NO

(a) Are you trained to use the lifting/rigging equipment? Y N NA

(b) Is the lifting/rigging equipment in good condition, fit for purpose and within its inspection Y N NA
(c) Are suitable signs and barriers in place to prevent uncontrolled access to the lift area? Y N NA
9. ELECTRICAL ISOLATION Applicable? YES NO

(a) Has the equipment identification been agreed with you and operations? Y N NA
(b) Have the isolation checks been verified by you e.g. STOP / START & SUBSTATION Y N NA
(c) Have electrocution hazards been controlled against where you are responsible for Y N NA

10. CONFINED SPACE Applicable? YES NO

(a) Is there a VEA present and have they signed on to this checklist? Y N NA
(b) Have any slip, trip, fall hazards been removed or controlled (inside or outside the Y N NA
(c) Is there a valid emergency rescue plan attached to the entry point? Y N NA

11. EXCAVATIONS Applicable? YES NO

(a) Are barriers and signs erected around the perimeter? Y N NA

(b) If the excavation is 1.2m or deeper, is it ‘Tagged', do you have a VEA? Y N NA

(c) Where applicable is there adequate shoring or cutting back to prevent collapse? Y N NA

12. HOT WORK Applicable? YES NO

(a) Are all control measures of the Hot Work Certificate in place? Y N NA
(b) Do all members of the work crew understand the requirements of the Hot Work Y N NA
(c) Is a continuous LEL gas monitor available and working at the worksite? Y N NA

13. WORKING AT HEIGHT Applicable? YES NO

(a) Is the Scaff tag valid by date and type of scaffold required for task? Y N NA
(b) If using alternative access solutions are you trained? Y N NA
(c) Is the work platform sheeted/netted, gaps closed and lanyards in use to prevent falling Y N NA
14. MECHANICAL WORK ~
Applicable? YES NO
ISOLATION REQUIRED
(a) Has the potential for stored energy release been negated and verified? (Ops standby Y N NA
(b) Are the necessary tags for breakpoints fitted? (No tag No break) Y N NA
(c) Has the type of hazardous substance associated with the task been Y N NA

15. INSULATION Applicable? YES NO

(a) Have you checked the work area for Insulation being present? Y N NA
(b) Are any non insulation materials associated with your work stored securely and tidy? Y N NA
(c) Are you aware of the site emergency procedure if an asbestos release occurs? Y N NA
16. SCAFFOLDING ERECTION /
Applicable? YES NO
DISMANTLE
(a) Do you have adequate means of lifting equipment? (Gin Wheel/Crane etc) Y N NA
(b) Have you checked your fall arrest equipment, tools and other equipment being used for Y N NA

17. TRIP,SHUTDOWN SYSTEMS Applicable? YES NO

(a) If sensitive instrumentation is identified by operations have the full workgroup been Y N NA
(b) Are you aware of stop buttons in your immediate work area? Y N NA
(c) If your work may affect shutdown systems have Operations been informed? Y N NA

18. PLANT AND MACHINERY Applicable? YES NO

(a) Are the necessary drip trays/bunds in situ? Y N NA

(b) Are earth bonding / grounding cables attached and in good order? Y N NA
(c) Is the cerificate in date? Y N NA
Confirm Location:
I have read and understood the workplace risk assessment and permit to work for this job.

I have the correct PPE detailed in the workplace risk assessment and permit to work for this job.

Print Name Signature NP