RAILROAD MAINTENANCE SAFE WORK PERMIT

Section 1 – Railroad Supervisor or Delegate

Date: ___________________________ Expected duration of work: ____ hours

Provide brief explanation of type of work:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Mainline protected by flagging Yes No

Yard work protected by flagging Yes No

Hot work planned:

Grinding/welding switch points/frogs Yes No
Slotting joints Yes No
Cutting Rails Yes No
Torch use Yes No
Joint welding Yes No

Worker (s) has been made aware of any special procedures? Yes N/R
Provide brief explanation of special procedure:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Equipment working around overhead wires? Yes No
Chainsaw work being done? Yes N/R
If yes has worker received safe chainsaw handling course? Yes No
Worker (s) has been made aware of any potential work place hazards? Yes N/R
Hazards identified: 1) ___________________________________
2) ___________________________________
3) ___________________________________
4) ___________________________________

Precautions required to perform work safely:

Issue Date: Revision Date: Rev. # Document Number Page

June 4, 2012 0 FRM -2571-3016 1 of 4
 Req’d Comments Reviewed with crew
PVC Clothing Y N _______________________________ _____
Full Face Shield Y N _______________________________ _____
Chainsaw chaps Y N _______________________________ _____ Leg
spats Y N _______________________________ _____
Flags Y N _______________________________ _____
Life jacket Y N _______________________________ _____
Chainsaw boots Y N _______________________________ _____
Screen shield Y N _______________________________ _____
Chainsaw gloves Y N _______________________________ _____
Other (specify) Y N _______________________________ _____

Section 2 Track Inspection/Work

From KM: ____ to KM: ____ Area within yard limits: ________________________

Railroad class 3 requirements met for:

Roadbed: Yes No Turn outs: Yes No
Track Geometry: Yes No Rail and rail fastenings: Yes No
Remedial Action Required? Yes No

If yes what? Repair Restrict Remove

If restricted were slow order flags installed? Yes No Where? KM: ____ to KM: ____

If requirements not met provide brief explanation:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Accepted by Railroad Supervisor or delegate

Signature _______________________________________

Print _________________________________________

Issue Date: Revision Date: Rev. # Document Number Page

June 4, 2012 0 FRM -2571-3016 2 of 4
 RAC / SAFETY CHECKLIST
Travel ways, walkways
Working place clean
Equipment in good order
Housekeeping
Blocking, bars, jacks, stands
Tools, good order and clean
Safety ropes, slings and chains
Staging good order
Safety chains in place
Personal equipment in use
Fire extinguisher
Barricades and/or flags in place
Proper signs posted
Proper ventilation, air / water
Proper permits available

Workers made aware of any work place hazards:

Print: ________________________ Sign:________________________
Print: ________________________ Sign:________________________
Print: ________________________ Sign:________________________
Print: ________________________ Sign:________________________
Print: ________________________ Sign:________________________

Railroad Maintenance Safe Work Permit Stub Portion

THIS PAGE IS TO BE HELD BY PERMIT ISSUER FOR DURATION OF JOB TASK

Confined space permit issued: Yes No

Issue Date: Revision Date: Rev. # Document Number Page
June 4, 2012 0 FRM -2571-3016 3 of 4
Hot work permit issued: Yes No
The work has been completed, all flags have been removed. Yes No N/R
Switches spiked/locked are made operable. Yes No N/R
All track machinery and tools clear of live tracks not left foul. Yes No

If No to any of the above, is an Operating Bulletin required? Yes No

Supervisor made aware of any special precautions? Yes No

Train crews been given clearance to use mainline/yard track(s): Yes No N/R

Returned to service by: _____________________________ Track Maintainer

Accepted by: _____________________________ Railroad Supervisor/delegate.

Hot work permit is to be forwarded to the area safety coordinator.

Track Maintainer will submit completed permit stub to the railroad supervisor/delegate.

Railroad Supervisor will retain Railroad Maintenance Safe Work Permit and file.

Issue Date: Revision Date: Rev. # Document Number Page

June 4, 2012 0 FRM -2571-3016 4 of 4