SUP 11

Permit to work procedures – General

Unified procedures for use within NHS Scotland

May 2014
 SUP 11: Permit to work procedures - General

Contents

Page

Acknowledgements .......................................................................................... 3

1. Introduction ........................................................................................... 4

2. Aims and objectives ............................................................................... 5

2.1 Purpose .................................................................................................... 5
2.2 Scope ....................................................................................................... 5

3. Roles and Responsibilities .................................................................... 6

3.1 Duties ....................................................................................................... 6

4. Managing the Risk .................................................................................. 7

4.1 Contractors ............................................................................................... 7

5. Operational system ................................................................................ 8

6. Types of Permit .................................................................................... 10

7. Monitoring ............................................................................................. 12
7.1 Permits-to-Work ..................................................................................... 12

References....................................................................................................... 14

Disclaimer
The contents of this document are provided by way of general guidance
only at the time of its publication. Any party making any use thereof or
placing any reliance thereon shall do so only upon exercise of that party’s
own judgement as to the adequacy of the contents in the particular
circumstances of its use and application. No warranty is given as to the
accuracy, relevance or completeness of the contents of this document and
Health Facilities Scotland, a Division of NHS National Services Scotland,
shall have no responsibility for any errors in or omissions therefrom, or
any use made of, or reliance placed upon, any of the contents of this
document.

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 SUP 11: Permit to work procedures - General

Acknowledgements

Much of the material from which this procedure has been derived has been
made available by NHS Lothian. Health Facilities Scotland gratefully
acknowledges this and has taken the opportunity to make it generic rather than
Health Board-specific, while also updating the content.

Note: This unified procedures guidance has been produced for NHS Boards to
adopt or adapt to suit individual circumstances.

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 SUP 11: Permit to work procedures - General

1. Introduction

The NHS Board Estates staff and external contractors carry out repairs,
maintenance, refurbishment or installation of plant and equipment or building
alterations within the NHS Board’s premises. Some of these tasks may be
considered as potentially hazardous, carrying a higher risk than normal
activities. In order to limit or reduce the risks associated with these activities a
Permit-to-Work system is in place.

Note: A Permit-to-Work is a formal document which gives written permission

for work to be undertaken in a potentially hazardous environment, on dangerous
equipment that may be hazardous to staff, patients or visitors. The document is
part of a ‘safe system of work’ providing an organised and predefined safety
procedure providing a record of all foreseeable hazards that must be
considered in advance.

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 SUP 11: Permit to work procedures - General

2. Aims and objectives

Purpose
2.1 Permits-to-Work are an integral part of safe systems of work which will require
risk assessments to be undertaken and method statements produced.

Correct operation of the Permit-to-Work system will ensure that:

 the work being carried out is clearly defined and closely controlled;
 all potential hazards are identified and appropriate safety precautions are
applied;
 everyone associated with the work being done is aware of the safety
measures required;
 the period of time during which the work may take place is clearly specified;
 the area affected by the work is clearly identified.

Scope
2.2 These procedures apply to all staff employed by the NHS Board together with
appointed contractors who carry out repairs and services whilst on the NHS
Board’s premises and sites.

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 SUP 11: Permit to work procedures - General

3. Roles and Responsibilities

Duties
3.1 Those designated by the ensuing job titles and descriptions will carry the
following responsibilities:

Head of Estates

3.2 The Head of Estates is responsible for ensuring that safe systems of work are in
place including Permits-to-Work and that they meet the legal and NHS Board
organisational requirements.

Estates Operations Manager (where applicable)

3.3 The Estates Operations Manager is responsible for ensuring that the
requirements of these procedures are observed and adhered to in all estates-
related work carried out by staff and external contractors.

Estates Sector Manager (where applicable)

3.4 The Estates Sector Manager is responsible for ensuring that the requirements
of these procedures are implemented by staff and external contractors.

Authorised Person (AP)

3.5 The Authorised Person (AP) is responsible for the issue and sign-off of Permits-
to-Work. The AP must possess adequate technical knowledge and have the
necessary experience and training to be able to provide the appropriate advice
on any potential hazards associated with the work being carried out. The AP is
appointed by the Chief Executive of the NHS Board on the recommendation of
the Authorising Engineer (AE) for the specialist function. A register of APs shall
be maintained and will be retained by the Head of Estates.

Competent Person (CP)

3.6 The Competent Person is the person leading the actual work to be performed
and should be the recipient of the Permit-to-Work. The CP must be:

 competent in the nature of the work being performed; and

 be in attendance at the location of the work being performed as described
on the Permit.

3.7 The CP may be an employee of the NHS Board or a Contractor or Sub-

Contractor, responsible for ensuring that the work carried out is performed
safely and in accordance with their own employer’s procedures and safe
systems of work.

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 SUP 11: Permit to work procedures - General

4. Managing the Risk

Contractors
4.1 The person engaging any Contractor is responsible for ensuring that risks
associated with the works are suitably identified and managed. The measures
needed to achieve this will depend on the nature and complexity of the work
involved. Communication in relation to the hazards and risks associated with
this work along with the safe system of work should take place between the AP,
CP and the Contractor. Should any shortfalls be identified within the risk
assessment and safe system of work these must be addressed before any work
is started.

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5. Operational system

5.1 Permits-to-Work are designed to ensure that safe methods of working are
adopted in circumstances where there is a potential hazard to those carrying
out the work or to patients, staff and visitors. Appropriate Permits-to-Work are
to be obtained from the Estates Authorised Persons prior to commencing work
of this nature and must be signed off once the work has been completed. Once
issued the conditions of the Permit must be strictly adhered to at all times.

5.2 Examples of types of work potentially requiring permits are:

 low voltage electrical systems;

 high voltage electrical systems;
 steam, boiler plant and distributing systems;
 working at height;
 piped medical gases and vacuum systems;
 working within confined spaces;
 hot work;
 excavation.

5.3 The NHS Board’s staff and /or the Contractor may request a Permit-to-Work
from the AP either in person or in writing at least 5 working days prior to the
proposed planned work being carried out. This request must include the
provision of a method statement and risk assessment – specific to the task.
Permits will not be issued without prior notice.

5.4 Before a Permit-to-Work is issued the AP must visit the location where the work
is to be carried out, with the Permit recipient.

5.5 Hazardous work must not commence until a Permit-to-Work has been issued by
the AP and accepted by the CP (an NHS Board employee or the Contractor).

5.6 A Permit is not transferable and must only be issued for one specific job of
work. Where the work involves a number of associated tasks a separate Permit
should be issued for each task and cross-referenced with any others.

5.7 The CP shall retain the Permit-to-Work on his/her person at all times while
carrying out the work and may be asked to produce it. Inability to show a valid
Permit will result in the work being stopped immediately. If applicable, the
“Permit-to-Work in Use” signage must be clearly displayed on the system or
area affected.

5.8 Should the CP discover during the job of work that either additional work
outside the scope of the Permit is required, or that work described in the Permit
will take longer than the time period stated in the Permit, then the existing

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Permit must be cancelled. A new Permit must be obtained which covers the
new circumstances.

5.9 Where more than one AP is involved in any single job of work, activities must be
co-ordinated and safety documents cross-referenced to ensure that the
appropriate number of Permits are issued and the activities of the NHS Board
employee or Contractor do not prejudice the safety of another.

5.10 On completion of the work, the CP should confirm that all persons under his
control have been withdrawn and warned that it is no longer safe to work on the
equipment or system for which the Permit was issued and also that all tools etc.
have been removed.

5.11 The AP must then sign-off the Permit-to-Work and retain all appropriate
documentation in the Estates Department.

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6. Types of Permit

Note: Separate Permit forms deal with specific tasks so that sufficient
emphasis can be given to the particular hazards present and the precautions
required. The following list identifies which Permits are used by the NHS Board
and the activities they cover.

Low Voltage Permit (SHTM 06-02 – ‘Electrical Safety Guidance for LV

systems’ refers)

6.1 This Permit would be used where there could be a hazard associated with Low
Voltage distribution systems and generators.

High Voltage Permit (SHTM 06-03 – ‘Electrical Safety Guidance for HV

systems’ refers)

6.2 This Permit would be used where there could be a hazard associated with High
Voltage distribution systems and generators.

Medical Gas Pipeline Systems Permit-to-Work (SHTM 02-01 MGPS refers)

6.3 This Permit should be issued where any work is undertaken on the Medical Gas
Pipeline System for which specialist training is required.

Confined Spaces Entry Permit (SHTM 08-07 refers)

6.4 This Permit is required wherever work or inspections are undertaken in areas
such as boiler shells, ductwork, gas-passes, vessels, tanks, culverts, tunnels
and underground chambers (including biomass fuel storage) which frequently
have restricted access and poor ventilation – sometimes with limited facility for
movement within the space. In these circumstances dangerous accumulation
of gases can build up because of the restricted air circulation even though any
access door may be left open.

Hot Work Permit

6.5 This Permit should be used when “hot work” is carried out in circumstances
where flammable liquids, vapours or combustible solids may be ignited, such
as:

 where heat is used or generated e.g. welding, flame cutting, brazing,

soldering, grinding, hot air guns, etc;
 the use of tools or equipment which may generate sparks and/or dust in
flammable areas.

Permit to Excavate / Dig

6.6 A Permit to Excavate is required for all excavation work carried out regardless
of the depth of the excavation. Under no circumstances must excavations be

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 SUP 11: Permit to work procedures - General

carried out without a CAT scan, examination of any available service drawings
and a permit issued by the Authorised Person.

Working at Height

6.7 This Permit should be used where Contractors or the NHS Board employees
are exposed to a risk of falling while working at height. Only persons who have
a knowledge and experience to work safely in such situations shall be permitted
to carry out such work. The issue of a Permit for roof working must take into
account the following:

 the load bearing capacity of the roof;

 the precautions to prevent fall;
 the height above the ground;
 the slope;
 the nature of the surface covering;
 weather conditions;
 weight distribution of persons and equipment.

Permit-to-Work for Steam Services – Boiler Plant or Distribution

6.8 This Permit is required to control work on steam-raising boiler plant and steam
distribution systems.

Pharmacy/Laboratory Department Permit-to-Work for Laminar Flow

Station

6.9 This Permit is required for work on safety cabinets and controlled areas within
Pharmacy and Laboratory areas where exposure to hazardous substances may
occur.

Accelerator Treatment Rooms Roof Permit-to-Work

6.10 This Permit is required for work on roof areas where exposure to radiation
emissions may occur.

Laboratory Sinks Permit-to-Work

6.11 This Permit is required for work on drainage systems within Laboratory and
Imaging areas where exposure to hazardous substances may occur, including
sinks receiving radioactive waste.

Permit-to-Work for Infectious Diseases Unit Roof Access

6.12 This Permit is required for work on roof areas where exposure to hazardous
substances may occur from discharges from local ventilation systems.

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7. Monitoring

Permits-to-Work
7.1 Permit-to-Work (PTW) systems are a feature of safe systems of work. They
involve a documented procedure for assessing particular areas or conducting
certain activities that pose a specific risk. This requires a formal and written
assessment of the location or work person(s) – planned, vetted and approved in
advance. The safe system for access or work defines and records activities
and actions by persons at a proven level of competence in advance to make a
task safe before further work is carried out.

Examples of locations and activities where Permits-to-Work would be

implemented are listed below: (this is not an exhaustive list)

 laboratories and post mortem rooms, biohazards, preparation works, (to

defined COSHH Hazard Group Categories 2, 3 or 4);
Note: Contractors working in the above accommodation can seek additional
advice from the NHS Board’s Infection Prevention & Control and / or
Occupational Health departments).

 work on any live service or system;

 confined spaces (such as sewage systems, tanks, tank rooms, ducts, etc);
 local exhaust ventilation systems (LEVs);
 medical gases and associated pipeline systems;
 X-ray, radiography gamma irradiators and all other equipment producing
ionizing radiation and areas containing, or in the proximity of radioactive
sources and materials (e.g. plant rooms or stores);

Note: Contractors working on, or in the proximity of radiation generating

equipment, sources and materials or ionization equipment should only do so
after consultation with the NHS Board’s Radiation Protection Advisor.

 specific electrical works (high and low Voltage)

 hot work (welding, burning, brazing, roof felting, etc);
 certain hazardous work on machinery and plant;
 work in a location where the accidental or unauthorised starting of plant or
machinery could cause harm;
 work where the existence of a known hazard such as flammable or toxic
fumes, lack of oxygen, oxygen enrichment, spontaneous combustion or the
presence of corrosives might cause injury to that person;
 work with hazardous or dangerous substances or materials (i.e. with
approved workplace occupational exposure limits – HSE EH40);

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 SUP 11: Permit to work procedures - General

 work on remotely controlled plant;

 routine or emergency maintenance;
 work on roofs and at heights;
 use of suspended access / cradles (including by boson’s chair or abseiling);
 work on pressure systems;
 work on hot water systems;
 work on water isolation;
 work with asbestos;
 work on lifts and lifting equipment;
 excavation work.

Note: The above paragraph is replicated in the Unified Procedures

documentation for Control of Contractors.

7.2 To ensure that the Permit-to-Work system is operating correctly and that safety
is being maintained during any hazardous activity, the issue of all safety
documents and monitoring of compliance is recorded on a ‘Record of Issue of
Permits-to-Work’ and, where appropriate, on a ‘Record of work activities
requiring the issue of multiple permits’. This may be done manually. However,
an electronic copy must be updated monthly to facilitate periodic reviews by the
Estates Operations Manager and the Head of Estates.

7.3 Checks on the use of Permits-to-Work will be carried out by:

 the review of the electronic log book;

 detailed investigation into any incidents under Permit-to-Work conditions;
 checks being made that the CP is working within the limits of the Permit;
 checks to ensure that all safety documents are completed correctly;
 checks on the standard of completion of Permits.

(The latter two checks would fall within the audit carried out by the AE for the
discipline concerned.)
Note: The procedure will be reviewed and updated annually or sooner if
regulations or documentation are revised.

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References

Health and Safety Executive Guidance – HSG 65 Successful Health and

Safety Management.

Health and Safety Executive Guidance – HSG 250 – Guidance on Permit-to-

Work Systems: a guide for the Petroleum, chemical and allied industries.

HSE ACOP L101 – Safe Work in Confined Spaces.

Scottish Health Technical Memoranda

SHTM 06-03 High Voltage Systems

SHTM 06-02 Low Voltage Systems

SHTM 02-01 Medical Gas Pipeline Systems

SHTM 08-07 Confined Spaces

SHTM 08-08 Pressure Systems

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