Facilities and Estates Hot Works: Standard Operating Procedure Document Control Summary Status: Version: Author/Title: Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures Contents New v1.0 Date: 8/3/2016 John Biggs - Estates Officer Robert Graves - Director of Facilities and Estates Policy and Procedures Committee Date: 17 March 2016 Policy and Procedures Committee Date: 17 March 2016 Meet the Health and Safety requirements. Safe system of working. Reduce Fire risk March 2016 March 2019 Hot works relating to Estates engineering services Health and Safety Policy. Fire Policy. Management of Contractors Policy. Permit to work SOP. Mechanical Systems SOP 1.0 Introduction... 2 2.0 Purpose... 2 3.0 Scope... 2 4.0 Operational items... 2 5.0 Process For Monitoring Compliance And Effectiveness... 6 6.0 References... 6 Appendix 1 Management Structure... 7 Appendix 2 - Guidance for the issue of a Hot Permit to Work.11 Change Control Amendment History Version Dates Amendments
1.0 Introduction Certain engineering works require hot works to be undertaken this process increases the risk of a fire breaking out. Therefore the Hot Working process requires controlling to eliminate and or minimise the risk 2.0 Purpose The purpose of this standard operating procedure is to control and manage the activity of Hot Works 3.0 Scope This procedure covers all Estates staff and contractors who are involved in Hot Works and also who could be effected by the operation. 4.0 Operational items 4.1 Management statement The Trust's Estates Department shall implement a management regime to control and Operate Hot Works within and on the Trusts properties / Estate and any other properties they may be responsible for. 4.2 Responsibilities and management structure 4.2.1 Duty Holder The Chief Executive as the Duty Holder ensures that the Trust has an effective Health and Safety management regime to ensure Hot Works are undertaken safely. 4.2.2 Designated Person This is a requirement of Health and Safety Regulations. The designated person is an individual appointed by the Trust (a board member or a person with responsibilities to the board) who has the responsibility for Health and Safety for the premises who as a duty under the health and safety at work act 1974 to prepare and issue a general policy statement on health and safety at work, including the organisational arrangement for carrying out that policy or procedure. 4.2.3 Responsible Person The Director of Facilities and Estates shall appoint suitably trained people to be the Responsible Persons for the management of Hot Works. 4.2.4 Deputy Responsible Person The Director of Facilities and Estates shall appoint suitably trained people to become Deputy Responsible Persons for the management and supervision of competent persons for Hot Works. Page 2 of 11
4.2.5 Engineering Officer / Supervisors Engineering officers and Supervisors shall have awareness training and be able to supervise Hot Works inconjuction with the permit to work system and the safe isolation and reinstatement of engineering and Fire services / Systems. 4.2.6 Competent Persons Competent persons must be trained and registered as being able to carry out Hot Works 4.3 Management of Contractors Policy Contractors shall be managed by the Facilities and Estates managers and / or supervising officers in accordance with the Trusts management control of contractors policy. 4.4 Capital works The capital works project team shall ensure that this standard operating procedure for Hot works is implemented and operated on schemes managed by them. 4.5 Method statements and risk assessments Method statements and risk assessments shall be in place and approved by the Responsible Persons and or / their Deputy before any Hot Works are undertaken Method statements and risk assessments must include the following details - The precautions and actions that are to be undertaken relating to the fire protection and the isolation and reinstatement of fire systems. Emergency escape procedures. What Firefighting equipment should be to hand and ready to use. The location of fire alarm points and automatic detection devices. The prevention of any possible false fire alarms due to the Hot works. Proposed method of Isolation and reinstatement of engineering services Reference detail to Permit to work for Hot Works Reference detail to other associated Permit to works which may be applicable. Reference detail to Asbestos / Confined spaces / Working from Heights if applicable. 4.6 Permit to Work system Specific Permit to work shall be issued for any hot works undertaken on any of the Trusts property. Page 3 of 11
Other associated permit to works may also be required at the same time as appropriate for such as confined spaces, working at heights, Mechanical and water systems. On completion of Hot works a minimum two hour monitoring must take place to ensure no fire risk exists. 4.7 Fire Alarms Isolation and reinstatement of fire alarms while Hot Works are being undertaken shall be carried out under a permit to work system managed by the Trusts supervising officer for the works. Every effort and consideration shall be given to prevent fire alarm false alarms because of Hot Works The persons and / or the safety person carrying out the Hot Works must know where the nearest fire alarm points are and how to raise the alarm in the event of a fire breaking out. 4.8 Firefighting equipment Firefighting equipment must be adjacent to the Hot Works being undertaken and readily available to use in the event of a fire breaking out. 4.9 Isolation of services Should isolation of any services be required these shall be agreed with the supervising officer of the Trust and where appropriate a permit to work may need to be issued. 4.10 Means of escape In case of any emergency the persons involved and carrying out the work shall have identified / located and know the means of escape should it be required. 4.11 Combustible / Flammable Materials / Fabric Extreme care and consideration shall be given to the fabric and materials in the vicinity of the Hot Works to be undertaken and where necessary any combustible / flammable material or fabric shall be removed and or protected as appropriate. 4.12 Safe Working Practices Estates Operations & Maintenance South Staffordshire & Shropshire Foundation Trust SAFE WORKING PROCEDURE Identification No. SWP020 Hot Work Hot work is classified as any work involving a heat source or naked flame. The work on the Trust properties included on a day to day basis would be:- Page 4 of 11
Grinders Internal work only Welding (a permit to work is not required in designated welding areas) Paint Stripping Brazing Burning Roof Repairs 1 Before any of the above work commences an assessment will be carried out by the Tradesman, Supervisor and or contractor. Method statement AND Risk assessments will be agreed and issued, all other relevant Safe Working Procedures will be followed. 2 A permit to work will be issued, which will include:- a) The work being carried out. b) The length of time the permit is in force c) The safety precautions to be implemented including reference to any Safe Working Procedure (especially removal and or protection of combustible fabric or material in the location of the works.) d) Confirmation that the departments affected have been notified, which fire alarms have been isolated including all necessary fire precautions taken (include docket number for fire alarm isolation) e) Suitable Firefighting equipment is to hand and ready for use should the need arise f) Emergency exits are identified, located and ready to use g) Second person acting as safety man is available where appropriate such as roof spaces / confined working areas and spaces. h) At least two hour monitoring of the hot works after completion to ensure no fire risk is present. Must not leave the location / site before this time i) Name of the person or persons carrying out the work j) Name of the responsible person (Issuing Authority) Upon completion of the work the permit will be signed off by all parties, confirming that the fire alarms have been reinstated. The completed permit is then filed for record purposes in the Estates Department 4.13 Associated Policy / SOP S Health and Safety Policy Management of Contractors Policy Permit to work SOP Safe working Practices Working in Confined Spaces Page 5 of 11
Safe water Systems Policy Mechanical Systems SOP Fire Policy Asbestos Policy Lone working SOP COSHH 5.0 Process for Monitoring Compliance and Effectiveness Activity Frequency Managed By Audited By Report to Issuing of Hot Permit to works Prior to works being undertaken Responsible Person (R.P) Or Deputy Responsible Person (D..R.P) Associate Director Estates Risk Department (R.D) & Designated Person (D.P) Training Annual review A.D Director of Facilities and Estates (D F E) R.D / D.P Method statements and risk assessments are in place Fire Procedures are in place Prior to works being undertaken Prior to works being undertaken R.P / D.R.P A.D R.D / D.P R.P / D.R.P A.D R.D / D.P Safe system of working are planned and in place Annual review A.D DFE R.D / D.P 6.0 References HSE guidance on Hot works Health and Safety at Work act 1974 Regulatory Reform (Fire Safety) Order 2005 HTMS NHS Safety rules (HEFMA) Page 6 of 11
Appendix 1 Management Structure Duty holder CEO Designated Person Associate Director Estates Responsible / Deputy Person Estates Officer / Supervisor Capital projects managers Competent Person Direct labour Competent Person Contractors Contractors capital works Page 7 of 11
Appendix 2 Guidance for the issue of a Hot Permit to Work Discuss content of work with the contractor. Be wary of flame lances sometimes used when sealing bitumen on roofs. Check the area where the proposed work is to be undertaken, observe the following Position of fire detection Location of flammable substances / structures / liquids Fire escape routes Means of raising the alarm i.e is there a manual call point in the area, telephone, or the use of a mobile. Shield / cap off all detectors in the area of work, even in adjacent areas if there is a likelihood that they may be activated If Hot Work is extensive, organise an isolation of the detectors in the work area Ensure all the shields / caps are removed and alarms are re-instated at the end of each working day. Check that the contractor has access to an extinguisher. If they utilise a local extinguisher, ensure that this is replaced to its rightful place upon completion. Consult and ensure method statements and risk assessments are correct and acceptable, subject to satisfactory preparation for the works Issue the Permit On satisfactory completion of the works and full and correct monitoring as been completed and the fire alarm system as been re-instated and firefighting equipment is all back in place close down the permit to work. Page 8 of 11
Page 9 of 11 Hot Works SOP/March 2016
Work Activity Risk Assessment Reference no. RA020 Activity /Job / Task title Hot Works 1. Activity and area to be assessed Expected staffing DEL Method Statement required YES/NO YES Assessment date 09/02/2015 2. Persons Exposed Area(s) Multi Task Specific YES/NO YES Method Statement reference: YES Review date (max 12mths) 09/02/2016 Employees exposed Y Initial Assess-ment YES/NO NO Permit to Work required YES / NO YES Assessment agreed by: SJ, MB, KI Other Employees exposed Potential Frequency As required Safe Working Procedure Ref. SWP020.d oc Permit to Work Type & ref HOT WORKS Public / patients exposed Potential Hazards Identified Initial Risk Rating Risk Rating Following Control Measures Controls Required Likelihood Severity Risk Rating Likelihood Severity Risk Rating Fire 4 5 20 Employ the Hot Work Permit. Only trained staff may implement. Refer to SWP020 for further details. Complete a specific risk assessment where necessary. Check the area post work for signs of smouldering or burning. All hot work is to end 1 hour prior to leaving the area. 3 4 12 Burns 3 4 12 As above. Plus, wear appropriate gloves, goggles and other PPE. 3 3 9 Explosion 3 5 15 As above. Avoid sources of ignition and ensure flammable and explosive materials are not present. Ensure systems worked on are free of explosive materials (e.g. fine dusts, oxygen, explosive gases etc). 2 5 10 Fumes 3 4 12 Ensure that the area is well ventilated. Use ventilation if necessary. If not feasible, employ breathing apparatus. 3 3 9 Loss of Utilities 3 5 15 Confirm end user is aware of work and schedule properly. Label any services out of action and indicate point at which they will be returned to service. Use the permit system. 2 5 10
Patient exposure 3 5 15 Cordon off the area. Employ a second member of staff where necessary. 2 4 8 Items ejected 3 3 9 Wear appropriate gloves and eye protection. 2 3 6 Likelihood: Severity: Risk Rating: 1. Rare (unlikely) 1. Insignificant ( No Injury ) 2. Unlikely (may occur) 2. Minor (Mild Injury) Scores multiplied 3.Likely (could occur) 3. Moderate (Some Injury, emotional, psychological or physical) Likelihood X Severity 4. High Likely (likely to occur) 4. Major (Serious Injury, emotional, psychological or physical) Risk Rating Priority 0-8 Low risk (L) 9-15 Medium risk (M) 16-25 High risk (H) 5. Certain (near certain to occur) 5. Catastrophic (Death or significant permanent disability) 1. If possible avoid the risk altogether 2. Where possible combat risk at source 3. Give priority to measures which protect the whole workplace 4. Wherever possible, adapt work to the individual 5. Take advantage of technological & technical progress Page 11 of 11