EMS-WI-085

Q-Pulse Document Number

1
Revision

WORK INSTRUCTION
Permit-to-Work Process

1. PURPOSE AND SCOPE

1.1. General
The Permit-to-Work (PtW) system is a formal written process used to control work and prevent injury
to employees, contractors and third parties as well as to property, assets and estates. The PtW sets
out the work to be carried out, identifies the hazards involved, the precautions to be taken, and the
responsibilities of individuals involved. The PtW process forms an essential part of the Safe System
of Work (SSoW), in compliance with the Health & Safety at Work Act 1974, and The Construction,
Design and Management (CDM) Regulations 2015. These regulations are applicable to not only
construction and project works; but also apply to routine maintenance works performed by the
Capability Estates and Management Services (EMS) personnel, or contractors under their control
(see Appendix 3 for the full definition of what is considered construction works under CDM
regulations 2015). This work instruction (WI) applies to work carried out or controlled by Capability
EMS personnel across the Pirbright Institute (TPI) estate including the TPI owned and managed
housing.

Implementation and correct use of the PtW work instruction will contribute to TPIs obligations in
complying with current legislation and ensures that work activities are controlled in order to minimise
the risk of harm to people and the environment.

A summary of abbreviations used throughout this document is listed in Appendix 1 for reference.

NOTE: FAILURE TO FOLLOW THIS PROCEDURE MAY RESULT IN INJURY TO PERSONNEL

OR DAMAGE TO EQUIPMENT.

2. RISK ASSESSMENT
The hazards and controls for any given activity assessed under the PtW procedure will be defined
within each task specific work instruction and risk assessment.

3. RESPONSIBILITIES
3.1. All personnel using this WI are responsible for ensuring that they have read and understood the
contents of this WI and that the procedure is followed.

Ensures the full implementation of this procedure.

Senior Capability EMS Leader Ensures all relevant personnel are trained in the legal
requirements of the Health and Safety at Work Act 1974.

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 Capability EMS Leader, Operations
Manager(Engineering &
Operations) Provide Site Operating Procedures (SOP’s) and WI’s to ensure all
and systems are implemented safely and effectively when used.
Capability EMS Leader, Operations
Manager (Projects & Process)

Ensures the operational safety of site personnel, reviewing

Capability EMS Health, Safety & documentation as required.
Risk Manager Ensure all contractors & EMS/BMS staff fully understand and
comply with the Permit-to-Work system where applicable

Senior Maintenance Owner

and
Senior Specialist Equipment Ensures the system is used correctly on all occasions where there
Owner is a mandatory, procedural or Risk Assessment requirement.
and
Senior BMS Owner
EMS Personnel or Contractors under EMS control carrying out the
work task(s).

Must understand the conditions and their responsibilities with

regards to all Work Instructions & RAMS where required.
Competent Person (CP) Only carry out the work in a competent and safe manner.
Inform the Supervisor (Responsible/Authorising person) of any
training needs or any unsafe working practices.
Ensures ALL control measures required to safeguard those who
may be affected by the activity, are identified, included on all
permits and actioned.

Person managing / arranging the works.

Reviews Risk Assessment Method Statement (RAMS) for task
Ensures ALL control measures required to safeguard those who
may be affected by the activity, are identified, included on all
permits and actioned.
Responsible Person (RP)
Ensures the competent person (CP) undertaking the work is fully
conversant with the safety implications and control measures
associated with the activity.
Ensure ALL contractors & EMS/BMS staff fully understand and
comply with their Permit-to-Work

Person authorising & issuing a Permit-to-Work.

Coordinate all technicians/BMS Engineers activities on site,
including EMS related contractors
Authorising Person (AP) Ensure ALL contractors & EMS Technician/BMS staff fully
understand and comply with their Permit-to-Work
Only issues permits after RAMS have been reviewed by the
responsible person.

To review Biosafety Risk Assessment and Biosafety Critical Steps

detailed in “RAMS for PWBCS, EMS-FORM-126” form to ensure
Health Safety and Biosafety
compliance with statutory requirements, and that suitable and
(HSBS) Advisor
sufficient controls are in place (in accordance with health, safety
and biosafety legislation) for the work being carried out.

Ensure all housing & property actions / works are performed in

Housing and Property Manager
line with relevant guidelines.

Ensures all documentation obtained from Q-Pulse is correct and

available.
Asset and Compliance Manager
Ensures the correct documents are being used for the task in
hand and where required obtained from Q-Pulse

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4. SPECIALIST MATERIALS OR EQUIPMENT
N/A
5. TRAINING REQUIREMENTS
5.1. Refer to QA-SOP-29 for training requirements.
5.2. All relevant staff must have attended PtW workshop and passed the multiple choice test (recorded
in Absorb). Subsequent refresher training in the form of toolbox talks/workshops will be arranged
when required and on significant changes in the process.
5.3. TPI staff must have attended Principles of Health, Safety and Biosafety Risk Assessment training
course as a minimum requirement for completing any Risk Assessments required as part of the
Permit process.

6. PROCESS
6.1. Introduction
PtWs for work managed by the EMS department are controlled and managed at the EMS permit
station. This process is applicable to planned preventative maintenance, reactive maintance work
and project works.

A PtW is required in the following circumstances:

• For ALL contractor work.
• For ALL EMS work where one of more mandatory permit hazard(s) exists (refer to Section 6.2.1)
• When a EMS/BMS technican deems that despite no mandatory permited hazards being present,
the remaining risks warrant increased safety protocol (refer to Section 6.2.2).

Each PtW requires the following documents to be used and prepared (refer to Section 6.3):
• Point of Work Risk Assessment (PoWRA)
• Task Specific Risk Assessment and Method Statement (RAMS)
• Isolation Form (if isolations are identified as a control measure in RAMS)

There are various types of RAMS required depending on the type of PtW required, and whom the
PtW is being issued to (refer to Section 6.4).

The PtW process involves the following persons:

• Competent Person (CP):- the person carrying out the work tasks. Where there is a team of people
caryring out the works there should be a named lead Competent Person known as CP1.
• The Responsible Person (RP):- The named person mananaging / arranging the works. Some
works may require a second named RP (deputy-RP) for the planned work, to cover any
unforeseen absences for works over long duration.
• The Authorising Person (AP):- The person authorising the Permit-to-Work form and co-ordinating
works across the site. This is limited to Engineering and Operations Supervisors only.
• HSBS Advisor:- The person who carries out a mandatory review of RAMS required for works
affecting bio-containment systems.

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 6.2 Hazard Categories
6.2.1 Mandatory Permit Hazards

The identification of certain hazards requires a mandatory PtW to be raised by work carried out by
EMS/BMS staff. A full list of hazards to considered are listed in Appendix 1; however the mandatory
permited hazards are listed below:

Hazard Definition
Any work in a confined space or partially confined space having restricted access or
egress and/or which is or may become hazardous to personnel because of;
Confined Space • The confined space design and construction.
• The materials, gasses or substances within the space.
• The work activities or environmental conditions (heat).

Explosive A mixture, under atmospheric conditions, of air and one or more dangerous substances

Atmospheres in the form of gases, vapours, mists or dusts in which, after ignition has occurred,
combustion spreads to the entire unburned mixture.

Any work that could create a source of ignition that could result in a fire or
Hot work explosion. Examples of hot work include, but are not restricted to, welding, burning
and torch cutting or spark producing tools such as grinders.
Any pressurised mechanical system that holds stored energy. For example; steam,
oil, coolant.
Pressure Systems Note: Works affecting equipment maintaining pressure regimes required for
SAPO4/CL3 biocontainment do not fall under this hazard; these fall under
“Biocontainment”.

Any electrical source greater than 415V and will only be worked on by a qualified and/or
High Voltage competent person. Significant consideration should be given to the use of a permit for
low voltage (LV) works dependant on the nature, type and complexity of the work.

Any work where excavation, trenching, tunnels, drilling, pile driving, ground
Excavation
disturbance, or scraping (earth removal) are done.

This is a highly heat-resistant fibrous silicate mineral that can be woven into fabrics,
Asbestos and is used in brake linings and in fire-resistant and insulating materials. Often found
in buildings built prior to 2000.

Work in any place where, if there were no precautions in place, a person could fall a

Working at Height distance liable to cause personal injury. For example you are working at height if you
are working on a ladder or a flat roof, and could fall through a fragile surface, OR could
fall into an opening in a floor or a hole in the ground.
Works on or works that require the isolation of equipment or systems designed to
protect people from injury, such as fire alarm system, fire doors, carbon dioxide or
oxygen depletion monitors, and local exhaust ventilation.
Life Safety Systems This also applies to shut down of Air Handling Units (AHUs) that facilitate temperature
control in lower risk laboratories (non-SAPO4/CL3 areas). This applies in the following
buildings; Jenner, Biological Services Unit (BSU), Insectaries (IS4L and Philip Mellor),
and animal facilities (Houghton).
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 Work on or that may affect biocontainment system (SAPO4/CL3), which if not
controlled appropriately could result in either exposure of personnel to harmful
biological agents or release of harmful biological agents to the environment, or result
in a breach of our SAPO licence requirements.
Examples could include work on;
• Ventilation systems including Air handling units, ductworks and HEPA Filters
• Effluent treatment plant and contained drains
Biocontainment
• Barrier equipment (Autoclaves, fumigation chambers, dunk tanks, pass thru
hatches etc.)
• Fabric of the building where this is part of containment barrier
• Microbiological safety cabinets
• Services associated with above systems (Electrical systems, steam systems,
compressed air systems etc.)
• BMS / controls associated with above systems

The term ‘containment’ describes the way in which biological agents are managed in the laboratory
environment so as to prevent, or control, the exposure of laboratory workers, other people and the
outside environment to the agent(s) in question. For the purposes of this document, the term
“biocontainment” or “biocontainment systems” refers to the physical building structures and
engineering systems which are in place and operate to maintain the validated parameters of
Containment Level 3 (CL3) and Specified Animal Pathogen Order Containment Level 4 (SAPO4)
facilities on site, in order to meet the requirements stated in our site SAPO licence, and applicable
biosafety regulations.

6.2.2 Non-Mandatory Permit Hazards

Certain activities will not involve hazards which require a mandatory permit to be raised. However,
the CP can ulitise the EMS RAMS form to raise a PtW for a job if the CP deems the remaining
risks warrant increased safety protocol. For example, if a large volume of hazardous chemicals
are being used for task, or any task involves changes to normal laboratory operations in lower risk
areas, such as Insectaries, Jenner building etc.

6.3. Summary of Permit-to-Work Documentation

There are several forms that are associated with the process of raising a PtW:
DOCUMENT PURPOSE: TYPE
The PoWRA booklet document provides a list of hazards to be considered
by those involved throughout the works. The document must be used for
the following purposes:
Point of Work Risk
• Used at the planning stage for all jobs to assess the hazards involved
Assessment
in a job and if a mandatory permit is required
(PoWRA) PoWRA
• Used before starting job to check if any additonal hazards are present
that were not identified at planning stage
EMS-FORM-100
• Recording any additonal controls required for hazards identified.
NOTE: A PoWRA must be reviewed daily for jobs lasting more than
one day; the same PoWRA form can be used for this purpose.

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 EMS RAMS form is used to carry out a task specific risk assessment and
a method statement for work where a permit is required where an existing
task specific Q-Pulse WI or Oshens RA or contractor RAMS are not
EMS RAMS Form
already in place. The hazard based risk assessments and ‘best practice’
RAMS
EMS-FORM-149 work instructions can be utilised to complete this form (refer to References
Section 7).
NOTE: This form must not be used if planned work could affect
biocontainment systems (see below).
This document is used to carry out a task specific risk assessment and
method statement if the scheduled may either;
• Impact directly on a biocontainment systems (or a component thereof);
OR
RAMS for Planned
Work on Bio- • Impact on services that could be directly or indirectly affect the
Containment functionality of a biocontainment system
Systems RAMS
(RAMS for PWBCS) There is a work instruction associated with this document outlining
requirements for form completion. The hazard based risk assessments
EMS-FORM-126 and ‘best practice’ work instructions can also be utilised to complete
relevant parts of this form (refer to References Section 7).

NOTE: It must be used even if a task specific Q-Pulse WI or Oshens

RA (or contractor RAMS) are already in place.

These are documents for routine activities carried out on a regular basis,
Task Specific Risk
such as those for planned preventative maintenance. Each task must
Assessment and RAMS
Work Instruction have an approved document on the quality management systems (Q-
Pulse for WI and Oshens for RA).

This document is used to list ANY isolations (including BMS/software

isolations) required under the permitted task. This will include;
• system(s) affected
• isolation method(s)
• isolation point/valve(s), and lock number(s) used.
Isolations Form It will be used in situ (at work location) by all appropriate CPs involved.
Isolations
For example, EMS will be required to record and sign isolations made for
EMS-FORM-127 List
fire alarm isolations required OR BMS will be required to record and sign
isolations required for pressure isolations via SMS.
NOTE: Isolations of site services required for any works must always
be performed by a TPI Technician or BMS engineer following LOTO
procedure. Refer to work instruction “Lock Out - Tag Out, EMS-WI-
087” for full details of this process.

This is the overarching document that authorises the permitted activity to

start. It records the reason for the permit, the names of the personnel
Permit-to-Work Form involved (CP1, RP and AP), duration of permit, and declarations of issue
(PtW) and safe return of area/systems when work is completed. Permit-to-
Issue of the Permit can only be carried out at the Permit Station by the Work
EMS-FORM-098 AP.
NOTE: Signatures supplied by the CP1, RP and AP need to be
present on this form for Permit to be valid.

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 EMS-WI-085
Q-Pulse Document Number

1
Revision

WORK INSTRUCTION
Permit-to-Work Process

6.3.1. Overview of Documentation in Permit-to-Work Process

*CONTRACTOR RAMS
EMS RAMS form can be
used if emergency work or
inadequate contractor
RAMS

Refer to
Section 6.4.1
for RAMS
application
summary

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 EMS-WI-085
Q-Pulse Document Number

1
Revision

WORK INSTRUCTION
Permit-to-Work Process

6.4 RAMS for PtW

6.4.1 Summary of RAMS Application

As outlined in Section 6.3.1 diagram (above), RAMS must be applied in the PtW process as follows:
Work Permit Type Forms Additonal Notes (for diagram in section 6.4.1) Application

Form to be completed by RP
RAMS for Preferred option for routine
PWBCS Seperate WI EMS-WI-224 provides information and
instruction on how to complete this form and content tasks that are part of part of
EMS-FORM-126 planned preventative
required.
+ maintenance (PPM) program
Reviewed copy must be available with PtW involving biocontainment
Permit affecting Q-Pulse WI &
Approved WI and RA must be referenced on RAMS for systems.
SAPO4/CL3 Oshens RA
PWBCS, EMS-FORM-126 and PtW form

Form to be completed by RP Reactive jobs that are not

RAMS for
PWBCS Seperate WI EMS-WI-224 provides information and routine and part of PPM
Internal instruction on how to complete this form and content program involving
EMS-FORM-126 biocontainment systems.
required.

Task specifc Preferred option for routine

tasks that are part of part of
Q-Pulse WI & WI and RA referenced on PtW form.
planned preventative
Oshens RA maintenance (PPM) program.
Permit NOT
affecting
SAPO4/CL3
Applicable where there is no existing approved WI or Reactive jobs that are not
EMS RAMS
RA for job. routine and part of PPM
EMS-FORM-149 program.
Reviewed copy must be available with PtW.

Contractor
RAMS Preferred option for routine
Approved WI and RA must be referenced on PtW form
+ tasks that are part of part of
Contractor RAMS available electronically or stored planned preventative
Task specifc
Permit NOT with PtW. maintenance (PPM) program.
affecting Q-Pulse WI &
SAPO4/CL3 Oshens RA

Reactive jobs that are not

Contractor Contractor RAMS available electronically or stored
routine and part of PPM
RAMS with PtW.
program.

Contractor
RAMS RAMS for PWBCS form to be completed by RP.
+ Seperate WI EMS-WI-224 provides information and Preferred option for routine
RAMS for instruction on how to complete this form and content tasks that are part of part of
PWBCS required. planned preventative
Contractor EMS-FORM-126 maintenance (PPM) program
Contractor RAMS available electronically or stored
+ with PtW. involving biocontainment
Task specifc Approved Contractor RAMS and WI and RA must be systems.
Q-Pulse WI & referenced on PtW form.
Permit affecting Oshens RA
SAPO4/CL3
RAMS for PWBCS form to be completed by RP.
Contractor Seperate WI EMS-WI-224 provides information and
RAMS instruction on how to complete this form and content Reactive jobs that are not
+ required. routine and part of PPM
RAMS for Approved Contractor RAMS must be referenced on program involving
PWBCS RAMS for PWBCS, EMS-FORM-126 and PtW form. biocontainment systems.
EMS-FORM-126 Contractor RAMS available electronically or stored
with PtW.

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6.4.2 Review of RAMS
A summary of the review of RAMS in PtW process is outlined below:
EMS-FORM-149 EMS-FORM-126 Task specific RA & WIs
Contractor RAMS Q-Pulse & Oshens
EMS RAMS RAMS for PWBCS

RP Specialist
CP / RP RP
Equipment Owner

EMS Technical
Review
Further Review co-
EMS Technical Review ordinated by EMS Health, EMS Managers
Safety Risk Manager Review
(if required)
Other
Departmental
Review (if required

Further Review co-

ordinated by EMS HSBS Mandatory
Health, Safety Risk HSBS Review (if Review (if
Manager HSBS Mandatory required) biocontainment
Review
(if required) systems involved)

EMS RAMS/RAMS for PWBCS will be developed between the CP1 and the RP. All EMS RAMS
must have an EMS technical review by personnel who have sufficient knowledge and experience of
the tasks being carried out. The Health, Safety and Risk Manager can be involved in review process
as required, depending on the scope of the works planned.

HSBS Advisor MUST carry out mandatory review on ALL completed RAMS for PWBCS forms before
Permit-to-Work can be requested. HSBS will advise if further assessment needs to be carried out
on planned work, such as a SWIFT and/or HAZOP assessment, as part of this mandatory review.
Refer to “Completion of RAMS for PWBCS form, EMS-WI-224”.

Contractors must have provided site and task specific RAMS in advance of works to the RP. It is
the responsibly of the RP to ensure the RAMS are suitable and sufficient and that the reviewed
copies have been sent to APs ([email protected]). The Health,
Safety and Risk Manager and/or HSBS team can be involved in review process as required,
depending on the scope of the works planned.

Task specific Work Instructions are located on Q-Pulse; WIs must be “Active” under Register section
to be approved for use in PtW process. Task specific Risk Assessments are located on Oshens;
RAs must be listed as “Reviewed” under Status column to be approved for use in PtW process.
Please note: Hazard based risk assessments differ from task specific RAs.

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6.4.3 Point of Work Risk Assessment

The PoWRA form is an active document throughout the PtW process. It must be used at the
following stages:
• Review stage (planning)
• At point of work before starting work (daily)
• By Contractors to do site assessment (in addition to their RAMS)

6.5 Permit-to-Work Issue

6.5.1 General
Once all relevant documentation has been prepared (i.e. WI/RA, RAMS and Isolation list), the Permit-
to-Work can be raised at the EMS Permit Station by the CP1, the RP and an AP. It is the responsibility
of all involved in the Permit to sign the relevant sections on the form at the Permit station. The PtW
can be arranged in advance by RP with agreement with AP.

Authorisation to carry out work MUST be obtained from an AP at the Permit station for all work
detailed under RAMS, including those for biocontainment systems.

It is the responsibility of the AP to sign a PtW only after checking and considering other site activities
being carried out on site at that time, and any potential conflicts discussed with relevant RP. The AP
can contact the duty-BSO to discuss any potential conflicts relating to biocontainment
systems/permits if required. For work organised by Engineering and Operations Supervisors the RP
may also be the AP.
For Permit duration, a copy of the PtW form will go to AP’s file, one copy to the CP1, and the original
will go onto the Permit Board. Copies of all RAMS and Isolation forms must be filed with Permit-to-
Work form by AP.

The AP has the right to refuse approval for a Permit-to-Work for any work to be carried out by
EMS/BMS technicians if suitable and sufficient RAMS are not in place.

6.5.2 Contractor Work

Contractors must be managed as per site Contractor management Process (RISK-COP-4).
On the day of planned work, before starting any activity the contractor must go to the EMS Permit
Station to collect a PoWRA form to complete at work location (refer to section “Work undertaken within
SAPO4/CL3 restricted biocontainment areas” Section 6.7.3).
Reviewed RAMS must be available and provided by the RP or the Contractor (CP1) at the Permit
station. EMS RAMS form (EMS-FORM-149) may be utilised by contractors if:
• Upon site inspection and PoWRA, the Contractor/CP/RP identifies additional significant hazards
that were not accounted for in original contractor RAMS; OR
• In event of emergency reactive work where contractor RAMS have not been received or are not
suitable and sufficient.
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 If work cannot be completed safely, the Contractor may be required to leave site and return at a later
date, after the risks have been reassessed and RAMS have been revised.

*NOTE: In the case of Contractor work, or Project work, the RP must sign the PtW for the Permit
to be valid: This is to ensure that the information listed on the Permit is correct and to confirm
that RAMS have been reviewed.

Contractors who are based permanently on site must follow the PtW process. Any deviations or
amendments to the PtW process must be agreed with the Principal Contractor, and the EMS
Managers (including the Heath, Safety and Risk Manager).
Some work carried out by Contractors is defined as Projects Work (refer to Section 6.8.4).

6.6 Permit Board, Work Control Board and Site Map:

For the Permit-to-Work system, here are two boards, located in the immediate vicinity of the EMS
Maintenance Supervisors, alongside a site map:

1. Permit Board:
The Permit board is utilised once a PtW form has been fully
completed. This board houses active PtW forms and
associated documents as well as isolation padlocks with
corresponding keys in a key safe.

2. Work Control Board:

This provides summary information for all permitted activities
on site that are ‘open’ or active. The board lists the work
details, the name of the person conducting the work, and the
location of the work. Each activity has a number allocated to
it. A marker with a corresponding number will be displayed on
a site map adjacent to the Permit Board.

6.7 Work Started under Permit

6.7.1 General
For the majority of work, the length of time for any Permit should not exceed more than 5 working
days. If a PtW task is scheduled to require more than 5 days to complete, this must be discussed
with the AP / RP / EMS Health Safety and Risk manager. Under agreement, the work may be
seperated into several stages and a Permit-to-Work raised for each stage of the work.

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 The PoWRA form must be updated daily in order to reassess hazards and record additional controls
required. If work under Permit cannot be completed safely, the CP1 must stop/not start work and
review the work, where the risks have been reassessed and in the RAMS.

For the duration of work under Permit, system isolations and any other information affecting normal
or safe operation of buildings systems must be communicated via BMS shift handover report. An
email must be sent by RP to BMS team via [email protected] with appropriate
details. This will inform HSBS, Animal Services, and Science Group Leaders of work/isolations in
progress.

6.7.2 Work undertaken Out-of-Hours:

Normal working hours are defined as Monday to Friday 0700-1715. All forms required for the PtW for
works scheduled outside normal working hours must be prepared in during normal working hours as
far in advance as possible. This includes the review of associated RAMS (by the RP/HSBS) and
raising of PtW (by the AP). A PoWRA must be completed/updated by CP1 before work is started out
of hours. The on-call EMS Technician must be available and present to supervise any contracted
work scheduled out-of-hours.

In the event of unplanned emergency reactive maintenance where the work is critical to avoiding an
incident occurring (e.g. breach of SAPO licence conditions), the duty-BSO must be informed
immediately to report the issue and advise on appropriate action to take. In this instance the PoWRA
form alone can be utilised (by BMS engineer/on-call EMS technician) to assess the risk on the job
and record control measures taken in order to make the situation safe. The PoWRA record may be
used as part of subsequent incident investigation for works carried out (if required).

6.7.3 Work undertaken within SAPO4/CL3 restricted biocontainment areas

There are restrictions on movement of materials and equipment into and from specific biocontainment
areas on site. Any equipment taken into a SAPO4 high containment must be suitable for validated
decontamination procedures (refer to References section for relevant Plowright and ISO COPs).
HSBS Advisors / Research Services / Animal Services personnel must be contacted to arrange
decontamination procedures for tools and equipment BEFORE materials are taken into high
containment areas. This is particularly relevant for Contractor owned equipment.

Before entering a SAPO4 biocontainment area (Plowright or ISOs) the scope of work will be reviewed
and any mandatory permit hazards identified by the CP1 or RP. RAMS will be prepared by CP/RP if
a Permit is required for the task to be carried out inside the containment area. The CP/RP will enter
the restricted area with a copy of the PtW (and Isolation form if required) and complete the PoWRA
inside the containment area.

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 PoWRA forms are available in the following areas in each containment building/area:
• Plowright ETP
• Plowright EMS ‘inside’ workshop
• ISO ‘inside’ office area
• ISO ETP

If the point of work is located within the laboratory or animal areas, the CP must carry out a visual
inspection of the area to check for any additional hazards, and then return to the above areas (listed)
to complete a PoWRA form. Completed PoWRA (and any other Permit documents such as an
Isolation form) must be scanned and emailed out of the containment area upon completion of work.
If the PoWRA relates to a Permitted activity the form must be sent to the APs as the following address:
[email protected]. There are scanners available in all areas (as listed
above) except the ISO ETP. A local digital camera can be utilised to take photos of forms in this area.
The Plowright SAPO4 lab manager, CL3 lab manager, or animal services should be contacted for
assistance with scanning/photo requirements if required.
Paperwork must not be removed from laboratory areas or from animal rooms during normal
building operations.

If the PoWRA has identified additional hazards, control measures to be taken must be recorded on
the PoWRA form. If the PoWRA has identified a need for a PtW which was not already identified in
planning stage (or an amendment to an existing Permit), the CP must contact the RP/AP to discuss
issues identified. If work cannot be completed safely, the CP/RP must leave restricted area and return
to complete the work at a later date, after the risks have been reassessed and appropriate RAMS (for
Permit) are in place.

NOTE: Any work required in CL3 laboratory suites will normally be carried out during a planned
shutdown period. The activities and rules for movement of materials and paperwork will be detailed
in a specific Control Transfer Document, prepared by the CL3 lab manager at the time of the planned
shutdown.

6.7.4 Works defined under ‘Projects’

Any works carried out that are neither planned or reactive maintenance tasks are deemed to be
Project Works. For the purposes of the next two sections (small and large projects), please refer to
Appendix 2 for the definitions of Construction Site and Construction Work, taken from the CDM
Regulations 2015.

Small Project Work

This is defined as a single Contractor (without the use of subcontractors) delivering a package of
work. These works will be controlled by TPI central permit station and follow the procedure outlined
in section 6.6.2 “Contractor Work”.
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 Large Project Work
This is defined as multiple contractors delivering a package of work, led by a Principal Contractor.
The construction phase plan, construction site set up, enabling works and how the TPI PtW system
will be applied to these works should always be discussed and agreed on a case by case basis
between the Project Manager, the Capability EMS Health Safety & Risk Manager and an EMS AP in
advance of any works commencing.

A Principal Contractor performing enabling and/or construction site set up works on behalf of the client
(TPI) must always have PtWs issued to them from the TPI central permit station (“Contractor Work”
section 6.6.2).

In General, works will be controlled by TPI central permit station and follow the procedure outlined in
“Contractor Work” section 6.6.2.
However, once a construction site is set up, it may be appropriate for a Principal Contractor to control
works within the construction site by running either their own or the TPI PtW system locally from the
construction site office. In this situation the AP would be the principal contractor’s site manager.
The construction site permit system must be followed by all contractor and TPI personnel working
within the construction site boundary. Where there are multiple principal contractors, one must be
identified to manage the site. If running the principal contractors Permit-to-Work system locally is
deemed inappropriate, then this must be reviewed by the Project Manager and an alternative system
developed, implemented and monitored via an appropriate TPI and contractor working group.

6.8 Permit Closure:

Once work has been completed, the CP1 must return to the Permit Station in order to close the Permit,
and return the completed PoWRA. The CP1 will sign the bottom of the Permit indicating that the work
is complete. If applicable to the Permit, the CP1 must provide an updated Isolation form to AP to verify
that all system isolations have been re-instated, and system returned to normal operation.
In some circumstances (such as Contractor work) the AP may check with the RP to confirm the work
has been completed as required. The AP will then sign the Permit to indicate the PtW has now been
closed.
All documentation associated with the Permit, including PoWRA and RAMS/PWBCS, will be filed by
the AP and kept at the Permit Station. Completed Permits paperwork will be kept for a minimum period
of seven years. The work annotated on the ‘Work Control Board’ will be removed, the site marker will
also be removed from the map.

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6.9. FLOWCHARTS
6.9.1.

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6.9.2.

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6.10. INSTRUCTIONS
FLOW CHART 1: INTERNAL WORK
Step by step actions <The numbered Steps correspond with the Flowchart in 6.9.1>
Review Scope of Work.
The nature and scope of the work / project involved will be reviewed at this
1 stage, using hazards listed in PoWRA booklet. Higher risk hazards will be
identified, e.g. work in confined space. Assessment at work location should be
carried out.

Will a Permit be required?

If ‘YES’ go to Step 3. If ‘NO’ go to Step 15.
2 NOTE: A permit may be required if other ‘non-permit’ hazards are identified at
review stage and the risks warrant increased safety protocol.
E.g. Hazardous chemicals, excessive noise, pollution (environmental impact).

Biocontainment Permit required?

3 If ‘YES’ go to Step 4. If ‘NO’ go to Step 5.

Prepare task specific RAMS for Planned Work on Biocontainment Systems, EMS-FORM-
126, and send to HSBS.
4 RP to prepare biocontainment risk assessment, and bio-critical steps must be identified.
Must be reviewed by EMS and other appropriate personnel involved in task.
Send to HSBS [email protected] for final mandatory review in advance of planned work.
Prepare task specific RAMS for Permitted task.
Can be in the format of either:
5
 EMS RAMS form (EMS-FORM-149) – must be reviewed by appropriate EMS personnel.
 Q-Pulse Work Instructions and Oshens Risk Assessment

Will any Isolations of services or systems be required under Permit?

6
If ‘YES’ go to Step 7. If ‘NO’ go to Step 8.

Prepare list of isolations

RP will prepare using isolation form EMS-FORM-127,
which will include;
7  the system(s) affected
 isolation method(s)
 isolation point/valve(s)
 and lock number(s) used (if applicable)
Request Permit.
Reviewed RAMS (and Isolation form) must be brought to Permit station.
If work has been organised on behalf of the CP then the RP must make sure paper copies of
8 signed RAMS are available.
Both the CP and RP must sign Permit-to-Work form.
NOTE: Authorising Person has the right to refuse raising a Permit if suitable RAMS are
not available.

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 FLOW CHART 1: INTERNAL WORK
Step by step actions <The numbered Steps correspond with the Flowchart in 6.9.1>

Raise Permit and update Permit

Board.
APs signs and issues a PtW.
9 EMS staff issued with signed copy.
AP updates Permit Station and display
copy of Permit.

Final Assessment of hazards at work location - PoWRA.

If not completed at review stage, EMS staff must go to work location and
complete final hazard review of area before starting planned work. This is to
ensure no additional hazards are present which were not accounted for in
original RAMS.
10
SAPO4 Restricted Areas:
Visual PoWRA made in lab/animal areas.
Complete PoWRA in ‘lower risk’ spaces.
Scan and email PoWRA form out of containment.

Work under Permit started.

11 CP starts work under SSoW Permit process.
Update Isolation form at work location (if applicable).
RP to provide Isolation form to CPs involved in task, if required

Any additional hazards identified at point of work during work?

12 If ‘YES’ go to Step 13. If ‘NO’ go to Step 13.
Job must be stopped / postponed if work cannot be done safely.

Ensure additional controls in place and recorded.

CP implements and records extra controls needed on PoWRA daily. Same
13 PoWRA form can be used over several days. RP may record extra controls
taken on RAMS forms depending on the severity of hazard identified.
Job must be stopped / postponed if work cannot be done safely.

Completion of work – Closure of Permit and return

of PoWRA
After work finished, CP must return completed PoWRA
form to Permit Station, and close PtW.
14 AP will file all Permit documentation including RAMS
in Permit Office.
Documentation will be subject to EMS internal audit
program, external audits and for incident investigation (if required).
END OF FLOWCHART LINE.

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 FLOW CHART 1: INTERNAL WORK
Step by step actions <The numbered Steps correspond with the Flowchart in 6.9.1>
Work started.
15
CPs starts work under SSoW process, but not under Permit.

Any additional hazards identified during work which require Permit to

16 be raised?
If ‘YES’ go to Step 3. If ‘NO’ go to Step 17.
Job must be stopped / postponed if work cannot be done safely.

Any other hazards identified at point of work during work?

17 If ‘YES’ go to Step 18. If ‘NO’ go to Step 19.
Job must be stopped / postponed if work cannot be done safely.

Ensure additional controls in place and recorded.

CP implements and records extra controls needed on PoWRA
18 daily. Same PoWRA form can be used over several days. RP
may record extra controls taken on RAMS forms depending on
the severity of hazard identified.
Job must be stopped / postponed if work cannot be done safely.

Completion of work – return of PoWRA

After work has been completed, CP must leave work
area in safe condition and return completed PoWRA
to Permit Station for archive.
19
Documentation will be subject to EMS internal audit
program, external audits and for incident
investigation (if required).
END OF FLOWCHART LINE.

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 FLOW CHART 2: CONTRACTOR PROCESS
Step by step actions <The numbered Steps correspond with the Flowchart in 6.9.2>
Review Scope of Work.
The nature and scope of the work / project involved will be reviewed at this
stage by RP using hazards listed in PoWRA booklet. Higher risk hazards
will be identified, e.g. work in confined space. A site survey should be carried
1 out on site by Contractor in advance of planned work, where possible.

Task specific RAMS requested from Contractor. RAMS must be reviewed by the RP.
RAMS for higher risk activities may need to be escalated to the Health, Safety and Risk Manager
for further review.

Are suitable and site specific site RAMS in place?

2 If ‘NO’ go to Step 3. If ‘YES’ go to Step 4.

Contractor RAMS updated OR EMS RAMS form utilised

Contractor must provide suitable and sufficient RAMS. If these are not available Contractor
3
(CP) to complete RAMS for task utilising EMS-FORM-149 when they arrive on site, before
starting any work.

Biocontainment Permit required?

4 If ‘YES’ go to Step 5. If ‘NO’ go to Step 6.

Prepare task specific RAMS for Planned Work on Biocontainment Systems, EMS-FORM-
126, and send to HSBS.
5 RP will prepare biocontainment risk assessment, and bio-critical steps must be identified.
Must be reviewed by EMS and other appropriate personnel involved in task.
Send to HSBS [email protected] for final mandatory review in advance of planned work.

Will any Isolations of services or systems be required under Permit?

6
If ‘YES’ go to Step 7. If ‘NO’ go to Step 8.

Prepare list of isolations

RP will prepare using isolation form EMS-FORM-127,
which will include;
7  the system(s) affected
 isolation method(s)
 isolation point/valve(s)
and lock number(s) used (if applicable)
Site assessment - PoWRA.
Contractor and RP must go to work location and complete hazard review of
area before starting planned work. This is to ensure no additional hazards are
8
present which were not accounted for in original RAMS.

NOTE: If work located within SAPO4 containment areas, apply step 12.

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 FLOW CHART 2: CONTRACTOR PROCESS
Step by step actions <The numbered Steps correspond with the Flowchart in 6.9.2>
Request Permit.
Reviewed RAMS (and Isolation form) must be brought to Permit station.
If work has been organised on behalf of the CP then the RP must make sure
9 paper copies of signed RAMS are available.
Both the CP and RP must sign Permit-to-Work form.
NOTE: Authorising Person has the right to refuse raising a Permit if suitable RAMS are
not available.
Raise Permit and update Permit
Board.
APs sign and raise a PtW.
10 Contractor issued with signed copy.
AP updates Permit Station and display
copy of Permit.

11 Any additional hazards identified at point of work?

If ‘YES’ go to Step 12. If ‘NO’ go to Step 13.
Site assessment – PoWRA – SAPO4 Restricted Areas only
Same as Step 8.
Visual PoWRA made in lab/animal areas.
Contractor completes PoWRA in ‘lower risk’ spaces.
12
SAPO4 host/RP scans and emails PoWRA form out of containment.

RP is responsible for ensuring Permit is still valid after PoWRA.

Job must be stopped / postponed if work cannot be done safely.
Ensure additional controls in place and recorded.
CP implements and records extra controls needed on PoWRA
daily. Same PoWRA form can be used over several days. RP
13 may record extra controls taken on RAMS forms depending on
the severity of hazard identified.
Job must be stopped / postponed if work cannot be done
safely.
Work under Permit started.
Competent person(s) starts work under SSoW Permit process.
Complete Isolation form at work location (if applicable).
14 RP responsible for maintaining regular contact with contractor and
react to any issues that arise.
RP to provide Isolation form to BMS staff if required.
Job must be stopped / postponed if work cannot be done safely.
Completion of work – Closure of Permit and return
of PoWRA
After work finished, Contractor must leave work area in
safe condition, return completed PoWRA form to
15 Permit Station, and close PtW.
AP will file all Permit documentation including RAMS in
Permit Office.
Documentation will be subject to EMS internal audit program, external
audits and for incident investigation (if required).

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7. REFERENCES & RELATED DOCUMENTS
7.1. Q-pulse Work Instructions:
EMS work instruction template version EMS-FORM-045v4
Training at The Pirbright Institute QA-SOP-29
Point of Work Risk Assessment EMS-FORM-100
Permit-to-Work Form EMS-FORM-098
EMS RAMS Form EMS-FORM-149
RAMS for Planned Work on Biocontainment Systems (PWBCS) Form EMS-FORM-126
Isolations form for Permitted Activities EMS-FORM-127
Working at Height – Work Instruction EMS-WI-086
Lockout Tag Out – Work Instruction EMS-WI-087
High Voltage – Work Instruction EMS-WI-088
Hot Work – Work Instruction EMS-WI-089
Explosive Atmosphere – Work Instruction EMS-WI-090
Excavation – Work Instruction EMS-WI-091
Confined Space Work Instruction EMS-WI-092
Asbestos Work Instruction EMS-WI-093
WI for completion of RAMS for PWBCS form EMS-WI-224
Code of Practice (COP) for the Plowright SAPO4 Restricted Area BAG-COP-3
Code of Practice for the Isolation Complex AS-COP-1

7.2. Hazard Based Risk Assessments

Working in confirmed space RA000097
Slips, trips and falls RA000098
Working with noise and vibration RA000101
Falling objects RA000102
Working with sharp objects or edges RA000103
Working with hazardous substances and materials RA000104
Working with asbestos RA000105
Working with excavations RA000106
Working with biohazards RA000107
Activities involving manual handling RA000108
Working with traffic RA000109
Working on biocontainment systems RA000120
Lone working RA000123
Pressure systems RA000124
Working with electrical systems RA000125
Working at height RA000129
Working with equipment and machinery RA000130
Working with lifting equipment RA000131
Explosive Atmospheres RA000143
Working with flammable substances RA000144
Hot working RA000145
Working with hot water/hot water systems RA000157
Working with hot/cold surfaces RA000158

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8. Appendices

8.1. Appendix 1: List of abbreviations:

PtW Permit to Work
SSoW Safe System of Work
PoWRA Point of Work Risk Assessment
RAMS Risk Assessment and Method Statement
RA Risk Assessment
PWBCS Planned Work on Biocontainment Systems
CP1 The lead Competent Peron
RP Responsible Person
AP Authorising Person
CP Competent Person
HSBS Advisor Health, Safety and Biosafety Advisor
CL3 Containment Level 3 (human viruses handled in these areas)
SAPO4 Specified Animal Pathogen Order Level 4 (animal pathogens handled in these areas)
ISO Isolation Unit (animal housing facility)
CDM regulations Construction Design and Management regulations
EMS Estates and Management Services (team)
BMS Building Management Systems (team)
WI Work Instruction

8.2. Appendix 2: Hazard List (as listed on Point of Work Risk Assessment)

Mandatory Permit Hazards Other Hazards

Asbestos Present Biohazards

Biocontainment Electricity (LV)

Confined Space Environment & Access/Egress
Excavation Equipment/Machinery
Explosive Atmospheres Falling Objects
High Voltage Flammable Substances
Hot Works Hazardous Materials & Substances
Life Safety Systems Hot/cold surfaces/systems
Pressure Systems Lifting Equipment
Working at Height* Lone Working
Manual handling
Noise/Vibration
*Refer to Working at Height work
instruction and risk assessment EMS-WI- Sharp Objects/edges
086 and RA000129 for further Slips, Trips and Falls
information.
Traffic
Pollution

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8.3. Appendix 3: ‘Construction’ Definitions (as per CDM Regulations 2015)

Construction Site:
Includes any place where construction work is being carried out or to which the workers have access,
but does not include a workplace within the site which is set aside for purposes other than
construction work.

Construction Work:
Means the carrying out of any building, civil engineering or engineering construction work and
includes
a. the construction, alteration, conversion, fitting out, commissioning, renovation, repair, upkeep,
redecoration or other maintenance (including cleaning which involves the use of water or an
abrasive at high pressure, or the use of corrosive or toxic substances), de-commissioning,
demolition or dismantling of a structure;
b. the preparation for an intended structure, including site clearance, exploration, investigation (but
not site survey) and excavation (but not pre-construction archaeological investigations), and the
clearance or preparation of the site or structure for use or occupation at its conclusion;
c. the assembly on site of prefabricated elements to form a structure or the disassembly on site of
the prefabricated elements which, immediately before such disassembly, formed a structure;
d. the removal of a structure, or of any product or waste resulting from demolition or dismantling of
a structure, or from disassembly of prefabricated elements which immediately before such
disassembly formed such a structure;
e. the installation, commissioning, maintenance, repair or removal of mechanical, electrical, gas,
compressed air, hydraulic, telecommunications, computer or similar services which are normally
fixed within or to a structure

Structure:

a. any building, timber, masonry, metal or reinforced concrete structure, railway line or siding,
tramway line, dock, harbour, inland navigation, tunnel, shaft, bridge, viaduct, waterworks,
reservoir, pipe or pipeline, cable, aqueduct, sewer, sewage works, gasholder, road, airfield, sea
defence works, river works, drainage works, earthworks, lagoon, dam, wall, caisson, mast, tower,
pylon, underground tank, earth retaining structure or structure designed to preserve or alter any
natural feature and fixed plant;
b. any structure similar to anything specified in paragraph (a);
c. any formwork, falsework, scaffold or other structure designed or used to provide support or means
of access during construction work, and any reference to a structure includes part of a structure;

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