WORKING AT HEIGHTS PERMIT

Permit No.: ..................................................

Permit Requested By: Today’s Date: / /

Location of work site:SS Date of work: / /

Contractor: Contractor Site Manager:

1. The following questions must be answered YES (All boxes must be ticked) to proceed YES
Has a formal risk assessment (e.g. JHA) been completed (please attach)?
Has the highest practical control been chosen (Hierarchy of Controls)?
Have personnel received working at height training?
Are personnel who are required to wear fall arrest or restraint equipment been assessed as competent?

2. This Certificate is issued for the following control: (Please tick the appropriate box provided)

Ladder use
Fall Restraint EWP / Scaffolding
(short term work above 1.8 m)
Limited free fall System Restrained fall / arrest system*
Creating hole in flooring / grid
(less than 600 mm Fall (Sliding fall, working on a
mesh
possible) sloped roof)
Fall arrest system*
(Free-Fall greater than Removing existing handrails Other
600 mm is possible)
3. Description of work (No work outside this scope may be performed under this Permit)

4. Required Risk Controls (place a tick in the appropriate boxes) a JHA / SWI is mandatory
Please refer to the attached Working at Height Checklist

Other:

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5. Authorisation

Recipient in Direct Control of the Work: I have read and understand all the requirements for this task. I will ensure that
all person(s) working under this Permit and attached Clearance meet all the requirements as stated.

Full Name (Please print): Signature: Date: / /

Contractor HSE Advisor: I agree with the safe system of work and will monitor the work activity to ensure compliance.

Full Name (Please print): Signature: Date: / /

Contractor Supervisor: I authorise the task as stated above to commence subject to the conditions and precautions of
the Risk Assessment, Clearance to Work and Specific Controls detailed on this Permit.
Full Name (Please print): Signature: Date: / /

Emergency Services Officer (ESO): (Signature is only required where the primary means of fall protection is a fall arrest
system noted by * above.) I confirm that an approved rescue and retrieval plan has been developed.

Full Name (Please print): Signature: Date: / /

NOTE: ESOs are to be notified prior to the work activity if the primary means of protection is a fall arrest system.

6. Permit Validity

PERMIT ISSUER AUTHORISATION

I authorise this work under the specified work location, precautions, and conditions.

This permit is valid from Until

Date: / / Date: / /
(time): (Time):
Permit Issuer Name: Signature:

PERMIT EXTENSION OF TIME

I confirm the area / plant / equipment identified within this Permit is still in a safe condition for the task described to
continue.
Date: Time: Permit extended to: Date: Time:

Permit Issuer Name: Signature:

WORK COMPLETE? YES / NO WORK COMPLETE? YES / NO

Site cleaned up / Work Party’s locks / The work area has been inspected
tags removed? YES / NO and is safe for use. YES / NO

Permit Holder Cancellation Permit Issuer Cancellation

Name: Name:
Signature: Signature:

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 WORKING AT HEIGHTS PERMIT

Working At Heights Checklist

CONTROLS NO YES
Scaffolding
Do the scaffolders have the appropriate certification?
Is a scaff-tag required for this scaffolding?
What duty is the scaffolding required to be? Medium (450 kg) Heavy (675 kg)
Has a safe system of work for lifting and lowering the scaffolding been documented?
Has a safe system of work for erecting / dismantling the scaffolding been documented?
If a fall arrest system is to be used is there adequate clearance distance (refer to the table below)?
Elevated Work Platforms (EWPs)
Do the operators have the appropriate certification?
Is it the right type of EWP for the task?
Will the EWP be used on flat, firm, level ground?
Is a pre-start inspection required?
Will there be adequate clearance from power lines?
Will barricades / signs be required to protect personnel below?
Is a standby person on the ground required?
Ladders
Is a ladder the right ‘tool’ for this task? (Or should another control be used)
Is it the right type of ladder for this task? (e.g. fibreglass / electrical, extension, step ladder)
Has the ladder been inspected and found to be in good working order?
Is a standby person on the ground required? (i.e. to foot the ladder)
Can the ladder be installed at a 4:1 ratio?
Is extra fall protection equipment (i.e. harnesses) required to be used with the ladder?
Will the ladder be positioned on a firm stable load supporting surface?
Will barricades / signs be required to protect personnel below?
Fall Restraint / Arrest Equipment (Harnesses, etc.)
Are harnesses, etc. the right ‘tool’ for this task? (Or should another control be used)
Do the operators have the appropriate certification (e.g. harness/ WAH course)?
Is working in a restraint mode practical? (Shall be used if working within 2 m of an exposed edge)
If using fall arrest has a rescue plan been formulated within the JHA?
If a fall arrest system is to be used is there adequate clearance distance (refer to the table below)?
If fall arrest is to be used has the superintendent responsible for the task approved this method?
Has the work method included a safe means of accessing / egressing the work location?
Has the equipment to be used been inspected (tag in date)?
Is there a suitable anchor point for this work (location, strength, etc.)?
Open Holes
Will the task involve creating a hole that people / equipment can fall down / through?
Is a cover with a sign required for the hole?
Is solid construction barricading required for the hole?
General Controls
Will lanyards need to be fitted to tools to prevent them from falling?
Will signs / barricades be required to protect personnel below?
a chin Is strap on the hard hat required to be fitted and used during this task?

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 WORKING AT HEIGHTS PERMIT

Clearance Distance for Free-Fall Fall Arrest System

A: Height from anchor point to ground level or other structure beneath: metres
B: Height of Person (attachment at D Ring): metres
C: Length of Lanyard being used (Full extension length can be found on the lanyard tag): metres
B + C = (Must be less than A) metres
If B + C is not less than A, fall arrest techniques cannot be used.
Other means of control must be used.

Example: if using a 2 m lanyard assembly

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 WORKING AT HEIGHTS PERMIT

WORK PARTY SIGN-ON

I have read, understood and will comply with all terms and conditions of this permit

Date Name Signature Sign On Time Sign Off Time

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 WORKING AT HEIGHTS PERMIT

Working at Height Rescue Plan

Permit Number
NOTE:
The ERT, Department and Work Group must do a joint site visit to Specific Information / Hazards
determine and assess the following:
Hazardous work activities adjacent
s
Activity in Exclusion Zone
Potential Rescue Requirements Elevated work area (working at height)

Work at Heights Vertical Rescue Medical Slippery condition (work area/walkways)

Incomplete or no platforms/staircases
Resource/Equipment Requirements: Obstructed work area (steel structures, openings in gratings, etc.)
Ambulance Basket Stretcher Crane Strong winds
HSR Appliance Vertical Stretcher EWP (Boom Lift)
Other:
Rope Rescue Equip Rescue Strop Other
Tripod Rescue Man-Cage
Specify other: Method of Communications
Attendant to Rescue Phone Audible Signal Radio Visual Hand
Personnel Signal
Is required equipment available at work area? Attendant to workers: Phone Audible Signal Radio Visual Hand
Crane Yes No Signal

Man-cage Yes No
Method of Rescue
EWP Yes No
Method Comments
Rescue Ladder System
Equipment Operators
Rescue Haul/Winch System
Equipment Operators name Contact no: Hoisting to next floor system
Lowering to ground system
Suspended access equipment
Anchor overhead
Crane/Man Basket
EWP

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Working at Height Rescue Plan

Anchorage Checks Comments General considerations for rescue
Beam Self-rescue
Stairwell If a casualty is conscious after he/she had a fall and is in suspension, then self-
Support strut rescue is the first option.
Support column Different situations
Other Listed below are examples of different situations or fall protection systems from
Pre-Rigging required? Yes No which a casualty may need to be recovered and for which suitable provision
Anchor points identified? Yes No should be made. Some situations may create special difficulties, for example
attaching to a remote casualty who is suspended out of reach.
Anchor points assessed? Yes No
• steel wire fall arrest block
• textile fall arrest block
Description of Work at Height • vertical anchor line - textile
• vertical anchor line - wire
• vertical rail
• horizontal wire anchor line
• horizontal textile anchor line
• energy absorbing lanyard
• hooped ladder
All rescue planning and operations should address the following issues:
• The safety of the persons carrying out or assisting with the rescue
• The anchor points to be used for the rescue equipment.
• The suitability of equipment (anchors, harnesses, attachments and
connectors) that has already arrested the fall of the casualty for use during
the rescue.
• The method that will be used to attach the casualty to the rescue
system.
• The direction that the casualty needs to be moved to get them to the
point of safety. (raising, lowering or lateral)
• The first aid needs the casualty may have with respect to injury or
suspension trauma.
• The possible needs of the casualty following the rescue.

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Working at Height Rescue Plan

General procedure for casualty recovery Assessed & reviewed by:

• Assess the situation fully before commencing a rescue operation. EMERGENCY RESPONSE TEAM (NEWMONT)
• Request for medical assistance Location:
• Identify proper position from which to carry out the operation. Start Date:
• Identify proper anchorage points. Expiry Date:
• Identify a point of safety to move the casualty to
• Start Time:
• Make sure all involved are aware of the procedure to be End Time:
carried out and their role within it. Name/Signature:
• Ensure personnel have been trained in rescue procedures
Working at Height (WAH) Rescue Plan Extension Review Process
are competent to carry out their role. Carry out the rescue NOTE: WAH Rescue Plan validity to align with the approved WAH Permit
steadily and in a controlled manner. Rescue Plan Review
• Make sure communication is maintained at all times. Date:
• Monitor the casualty’s condition at all times and where Expiry Date:
possible provide the necessary first aid. Start Time:
• Conduct a review of the whole situation identifying
End Time:
areas of improvement for the future.
Name/Signature:

PERMIT HOLDER
Name:

Contractor:

Signature:

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