Authority to Work Permit (ATWP)

PERMIT NUMBER: ATW     

PART A: WORK DETAILS & PERMIT VALIDITY (To be completed by permit issuer in consultation with contractor in charge of work)

Date of Issue:

      Time:       Permit Expiry: (maximum 12 months)

     

Name of Contracting Company:      

Site or Project:      

Description of Work:      

Name of Contractor in Charge of Work:

      Online Induction Reference #      

PART B: SCOPE OF WORK (To be completed by permit issuer in consultation with contractor in charge of work)

(To be completed by QAC)

Will Hot Work Be Required ☐Yes ☒ No Hot Work Permit      

Will Structural Penetration be required? ☐Yes ☒ No Wall Penetration Permit      

Will Smoke Detector Isolation be required? ☐Yes ☒ No Impairment Notice      

Will Electrical isolation be required? ☐Yes ☒ No Isolation Permit      

Will Sprinkler Isolation be required? ☐Yes ☒ No Isolation Permit      

Will Water Shut Down be required? ☐Yes ☒ No Shut Down Permit      

Will Ground Penetration be required? ☐Yes ☒ No Penetration Permit      

Will Traffic Management be required? ☐Yes ☒ No Traffic Management Plan      

Will there be risk of a fall? ☒Yes ☐ No Work at Heights Permit      

Will you be working on any IT systems or associated cabling? ☐Yes ☒ No IT Permit TBC     

Will work be performed in a Confined Space? ☐Yes ☒ No Confined Space Permit      

Will work be performed Airside? ☐Yes ☒ No Temp Obstruction Permit      

Advice of On Site Hazards attached ☐Yes ☒ No

Asbestos Containing Materials identified in the area ☐Yes ☒ No Asbestos Management Plan      

Other Permits required? ☐Yes ☒ No      

Is equipment protection required ☐Dust ☐Water ☐Noise ☐Other      

Is there anyone who will be working who is NOT QAC Airport Inducted? ☐Yes ☒ No

PART C: SAFE WORK REQUIREMENTS (To be completed by permit issuer in consultation with contractor in charge of work)

Risk Assessment

Risk Rating (RR): ☐ Low(1-5) ☒ Medium (5-10) ☐ High (11-17) ☐ Very High (18-25) ☐ JSA Required (>10)

JSA Complete and Attached ☐Yes ☒ No Notifiable Works ☐Yes ☒ No Isolation Required ☐Yes ☒ No -Type:      

Safe Work Method Statements (SWMS) :

☒N/A(RR <10 )

☐SWMS supplied by the Contractor and approved by Permit Issuer. (RR >10)

☐Persons performing the work trained in QAC SWMS

Comments: Isolate any requisite equipment, individual permits will be issued as needed

Site Induction Provided:

☐ Record details on Contractor Induction Card

Licences & Certificates Required:

Examples: Cranes / Hoists / Scaffolding / Rigging / Dogging / Electrical Work

EWP

PPE Required: ☒Hi-visibility clothing

☒Safety footwear

☐Long shirt & pants

☐Eye Protection

☐Gloves ☐Hard Hat ☐Hearing Protection ☐Respirator

y protection

☐Other:

Special Training / Other

Confined Space Entry Training etc.

QAC Document: QAC-I-FRM-002 Page 1 of 3Queenstown Airport Corporation Internal Use Only Version: 5.0

Authority to Work Permit (ATWP)

Requirements:      

PART E: SIGN-OFF & AGREEMENT BY CONTRACTORS PERFORMING THE WORK

Contractor in Charge of Work:

I,      understand the above Safe Work Requirements and agree to comply with this permit.I warrant that all persons under my control are trained in the safe work procedures submitted for the job, and hold the necessary licence and competency to perform their work.

Signature:___________________________ Date: ____ / _____ / _______

Other Team Members Performing the Work : - I have reviewed the safe work procedures submitted for the job and agree to comply with this permit.

Name(s) of other crew members authorised to perform the work:**All persons must complete the QAC Contractor Induction program prior to starting work

Name: Signature Online Induction Ref #

Name: Signature Online Induction Ref #

                       

                       

                       

                       

                       

                       

PART F: ACCESS REQUIREMENTS To be completed by permit issuer.

Please provide access to the following areas:

Access Door Start Date Finish Date

Name:       Signature:

PART D: LIABILITY ACCEPTANCE To be completed by permit holder.

I hereby agree to complete the work as described to the highest standards and agree that QAC may engage a third party without my agreement to rectify any items and that I am liable for the cost of this rectification work.

Name:       Signature:

PART E: WORK AUTHORISATION To be completed by permit issuer.

I hereby authorise the persons nominated above to perform the work specified in Part C of this Permit.I have also validated all contractors licenses / certificates of competency required for the relevant activities they have been engaged for

Name:       Signature:

QAC Document: QAC-I-FRM-002 Page 2 of 3Queenstown Airport Corporation Internal Use Only Version: 5.0

Authority to Work Permit (ATWP)

WHO REQUIRES AN ATWP? All Contractors must be named on a valid ATWP before commencing any work for Queenstown Airport Corporation

Individual members of a work crew may be covered by a single ATWP provided:

The name and induction / ID card number of each member is recorded on the permit (induction cards / ID must be inspected at the time of permit issue);

The Contractor in charge of the work has verified all crew members are properly trained, licensed and competent to perform their work;

All crew members have signed Part C of the permit acknowledging their responsibilities.

VALIDITY OF ATWPSATWPs are only valid for:

The persons named on the permit (provided they have satisfied the conditions detailed above);

The type of work specified on the permit;

The location(s) specified on the permit;

The date range specified on the permit (i.e. up until the expiry date specified on the permit – Max 12 months).

ISSUING AN ATWP – TO BE DONE IN CONSULTATION WITH THE CONTRACTOR IN CHARGE OF THE WORKCompleting Part A – Work Details & Permit Validity

1. Record the date and time the ATWP was issued;2. Determine the expiry date of the permit. A validity period of up to 12 months (maximum) may be selected if the Contractor is likely to

perform the same work over an extended period of time. If the work is considered to be a “one-off” job then the expiry date should be limited to the expected completion of the work;

3. Record the name of the Contracting company;4. Specify the Scope of Work or project to which the work relates. The term “various” may be inserted into this field only if the

Contractor will be engaged to perform the same work across numerous worksites;5. Describe the work the Contractor is being authorised to conduct;6. Record the name and the Induction user ID number of the Contractor in charge of the work (this person will usually be the

Supervisor of the work crew). If only one person is performing the work then they are deemed to be the person in charge;7. Record the name and Online Induction user ID number of other crew members performing the work. All persons named on the

permit must complete the Queenstown Airport Corporation Contractor Induction program and present their Contractor Induction Card for inspection.

Completing Part B – Safe Work Requirements

1. Perform Risk Assessment and indicate risk rating. For Risk rating greater than 10 a JSA is required and a Safe Method of Works Statement is required for all Risk ratings greater than 11.

2. Indicate any additional permits required for the job and ensure these are issued before commencement of work (e.g. Hot Work, Confined Space Entry etc);

3. If the work is considered “High Risk*” the Contractor in charge of the work must submit a Safe Work Method Statement (SWMS) and verify all crew members have been properly trained. The Permit Issuer must approve the work procedure and ensure it remains freely accessible at the worksite. Where applicable, a Queenstown Airport Corporation SWMS may be used, however in such instances the Permit Issuer is responsible for ensuring all relevant persons are properly trained;

4. Indicate any licences, certificates, PPE or special training required for the job. Verify these requirements have been met before authorising the work;

Completing Part C – Sign-Off & Agreement by Contractors Performing the Work

Work cannot commence until Part C of the permit has been signed by the Contractor in charge and all crew members performing the work.Completing Part D – Work Authorisation

Work cannot commence until the Permit Issuer has signed Part D indicating they are satisfied all permit conditions have been met.CHANGING OR AMENDING AN ATWPA new ATWP must be issued following any changes to permit conditions or the introduction of new crew members.

QAC Document: QAC-I-FRM-002 Page 3 of 3Queenstown Airport Corporation Internal Use Only Version: 5.0