Health, Safety & Environmental Management System Doc. No.
: PER-HSE 002
Rev. No.: 00
Safe Work Permit Rev. Date: 12/03/2021
TYPE OF SAFE WORK PERMIT (Tick Relevant Box )
Working at Height Lift Shaft Contractor Start Working Work Near Power Lines
Roof Work Hot Work Excavation Work Confined Space
Date: Contract: Contract No.:
Working Area / Location: Permit No.:
Contractor:
Description of Area Where Work to be Carried Out:
Description of Work to be Carried Out:
This permit is valid from (date): Time: AM / PM
Until (date) Time: AM / PM
RELATED DOCUMENTS COMPILED, APPROVED, COMMUNICATED, SIGNED & ATTACHED TO THE SAFE WORK PERMIT
(Please Note: When conditions change, the documentation & permit need to be reviewed & updated)
Document Communicated &
Document
Ref. No. Register Signed by All
Method Statement Number
Risk Assessment
DSTI / JSA
Pre-Use Checklist completed
Emergency Preparedness &
Response Procedure in place
Contractor Approved HSE Plan
Page 1 of 4
Health, Safety & Environmental Management System Doc. No.: PER-HSE 002
Rev. No.: 00
Safe Work Permit Rev. Date: 12/03/2021
1 IDENTIFIED RISKS / HAZARDS
Proximity to ‘LIVE’ equipment Confined space entry Hazardous substance
Working on commissioned equipment Excavation Hot work
Work requiring electrical lock out procedure to be implemented Grating removal Scaffolding
Proximity to overhead lines Mobile plant works Demolition mechanical
Demolition manual At fall risk position Overhead work
Poor communication Roof work
Other: (Specify)
2 HEALTH & SAFETY PRECAUTIONS
Valid medicals available for all employees All employees and contractors declared competent
Specific hazards identified during site inspection and Mitigated Employees trained on Working at Height (Fall Risk)
All electrical panels / switch gear is locked out Extraction equipment is available & serviceable
All flammable, combustible, toxic, corrosive materials & vapors have been
No uncontrolled overhead activities allowed
removed 10m from source of heat
All sources of energy are closed, locked out or isolated Pre work gas tests have been carried out in confined space
Trained and responsible person(s) will be Supervising the work spaces Risk Assessments and SOP/SWP in place and training done
Pre-use equipment inspections / checklists done & declared
Method Statements in place and training done
safe to use
All edges and openings barricaded Equipment tagged according to color code after inspections
Fire protection equipment available and operational Latest drawing in use
No pipelines, plumbing, graves, sewerage, gas lines or fiber
Works Order / Job Card available for job
optic cables in path of work
Excavation inspected daily by appointed person Inspections to be done after inclement weather conditions
Underground services been detected and moved / protected Emergency equipment available near area of work
Well-lit and ventilated work area Vehicles and plant are kept 5m away from excavation
Excavation sides battered to the required angle of repose or shored Area clean, material stacked properly and not leaning over
No person(s) in excavation while excavating machines are operating Spill kit available
All employees and contractors notified of associated
Vessels, equipment drained, purged, ventilated and cleaned
hazards
Inspection Records / Checklists on file Safe access and egress available
Frequency for checking flammable / combustible gas and oxygen levels
Continuous monitoring of atmospheric conditions
for confined spaces
Automatic fire sprinkler system operational (where
Fire watch provided during work and 30 min after completion
applicable)
Special danger, caution or warning signs posted Risk Assessment PPE in use and in good condition
Specific respirators in use and filters clean for Hazardous Chemicals Leather aprons in use and in good condition
Page 2 of 4
Health, Safety & Environmental Management System Doc. No.: PER-HSE 002
Rev. No.: 00
Safe Work Permit Rev. Date: 12/03/2021
2 HEALTH & SAFETY PRECAUTIONS
Breathing equipment available and in working condition (confined
Safety harness in use and inspected
spaces)
Lifeline erected and inspected before work starts Safety rope available (confined spaces)
Earmuffs in use at high noise areas (jack hammers, etc.) Rescue plan for activity approved and available
Ladders inspected and safe to use in place Approved Fall Protection and Rescue Plan in place
All welding equipment inspected and declared safe Emergency contact numbers available
First Aider available Standby person available
Gas testing equipment inspected and working Ladder firmly secured at top and bottom
Portable & movable elevated work platforms and suspended
Anchors and tie-off points identified, checked and secured before use work cages conform to approved design standards & are
inspected before use
Scaffold erected, inspected, signed off and tagged (SANS
No material within 1.5m from drop off edges, excavation sides
10085)
Hand and knee rails with toe board in place for edge barricading Crash decks above working areas in shaft installed
Permission for removal of any platforms only (Permitted by Construction Methods in place preventing other employees entering At
Manager) Fall Risk Area
No work if any conditions are hazardous to HS&E Working platforms to be cleared of any tripping hazards
Shaft openings barricaded to prevent unauthorized access Legal appointments signed and in Safety File
Communication levels established for persons working in shaft e.g. two Fall Protection Plan with proof of communication for
way radios and or cell phones working at heights in Safety File (if work requires)
Safety File audited by Safety Officer (CHSO) and passed the audit criteria Contractor H&S Plan approved by WBHO Construction
before work starts Manager
37.2 Mandatory Agreement signed Competency / Training certificates available in file
HS&E Induction done by all employees DSTI’s / JSA conducted and records on file
Certified copies of ID/Passports in file
Other: (Specify)
3 SPECIAL INSTRUCTIONS
Page 3 of 4
Health, Safety & Environmental Management System Doc. No.: PER-HSE 002
Rev. No.: 00
Safe Work Permit Rev. Date: 12/03/2021
Trained Trained
Name of Team Members Name of Team Members
Yes No Yes No
5 APPROVALS, RESTRICTIONS & AUTHORIZATIONS
• The validity of this permit is based on the continued site conditions and risk profile of the job at hand as at the
time of issue. Should either the site conditions, method of work or risk of the job change, the permit is no longer
valid
• All work at height is to cease in the event of an emergency situation being raised on the site and al emergency
protocol is to be followed
I, _____________________________________, the appointed Construction Manager (CR 8(1)), hereby declare that I
have verified the above information and ensured that the necessary safety precautions have been taken to ensure work
will be carried out safely. I authorize the work to be performed
APPROVED NOT APPROVED
Responsible Person Print Name Signature Date
Construction Manager
Site Construction Health & Safety
Officer / Manager (CHSO / CHSM)
Supervisor / Foreman
THIS PERMIT MUST BE READILY AVAILABLE ON THE JOB SITE. THIS PERMIT IS ONLY VALID FOR THE INDICATED DATES
Page 4 of 4
