Escalations (if you require a clarification regarding this procedure please contact): Health & Safety Manager

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1 Title of Standard Operation Procedure: Work at Height Procedure Person(s) responsible for the Health and Safety Manager production of report e Reference Number: H&S Procedure Version : 2 Issue Date: Jan 2017 Review Date: Sept 2019 Purpose and Background Scope (i.e. organisational responsibility) Vital functions affected by this procedure: To outline the process for managing Health and Safety risks of working at height. This procedure is written and issued in accordance with the Health and Safety Policy and should be read in conjunction with the Risk Assessment and Risk Register Policy. Monitoring Compliance Process to be used for monitoring e.g. Audit Responsible individual / committee for carrying out monitoring Frequency of monitoring Responsible individual / committee for reviewing the results Responsible individual / committee for developing action plan Responsible individual / committee for monitoring action plan Audit H&S Sub Committee 3 yearly H&S Sub Committee H&S Sub Committee H&S Sub Committee Escalations (if you require a clarification regarding this procedure please contact): Health & Safety Manager Committees / Group Date Consultation: Health and Safety Sub Committee Jan 2017 Approval Committee N/A internal SOP Ratified by Committee: N/A internal SOP Received for information: N/A internal SOP H&S_Procedure_25 Page 1 of 10

2 1. Background East Cheshire NHS Trust is committed to the health, safety and wellbeing of all of its staff, patients and visitors to the Trust. The Trust will avoid work at height where possible. Where work at height cannot be avoided, the Trust will manage the risks in accordance with appropriate legislation and guidance to ensure that work at height is undertaken in a safe manner. 1.1 Work at height takes place as part of maintenance; inspection and cleaning activities at all Trust locations. Construction and alteration work are also likely to involve work at height. The scale of such work will range from gaining access to articles out of reach by standing on an access step, through internal maintenance work undertaken from stepladders, to work on large scaffoldings by contractors. Falls risks from height include falling from flat roofs, falling through a roof which is fragile, such as asbestos cement sheet or fragile roof lights, or falling into a drain or pit due to a cover being removed during maintenance. Falling objects from height may also present a hazard if working at height is not adequately controlled. 1.2 Falls from heights are one of the leading causes of fatal accidents in UK workplaces and the risks during occasional maintenance work are often higher than large scale construction work, where access should be carefully planned. 1.3 The legal requirements relating to controlling the risks of falls from heights are set out within the Work at Height Regulations 2005 and the Construction (Design and Management Regulations) Responsibilities 2.1 General responsibilities are outlined in section 2.4 of the Health and Safety Policy. Specific responsibilities for work at height are as follows:- 2.2 Associate Director (Estates and Facilities) Where capital expenditure is required and there is a delay in providing fixed equipment, where required, the Associate Director (Estates and Facilities)is responsible for ensuring that the responsible person for the project has made adequate arrangements to minimise risks associated with access to roofs pending the introduction of necessary safeguards such as guard railing. Such arrangements may include restriction of unnecessary access; the provision of safe systems of work and safety harnesses or, in some cases, the use of suitable mobile access equipment. The arrangements must also include the use of permits to work where required. 2.5 All Managers must ensure that their employees involved in work at height are adequately instructed in the safe use of access equipment and safe systems of work to be followed when working at height. They should also ensure that the equipment in use is subject to maintenance and inspection. 2.5 Estates and design personnel are responsible for ensuring that projects designed under their control take account of the need for safe working at height both during the initial project and in any likely subsequent maintenance or repair. This will include the provision of appropriate access and edge protection or other fixed safeguards including appropriate fixtures and equipment where necessary. 2.6 All employees are responsible for using equipment and following safe systems of work in accordance with the instructions provided. H&S_Procedure_25 Page 2 of 10

3 3.0 Roofs 3.1 Flat roofs Flat roofs are generally accepted as being up to 10 in pitch and are usually waterproofed with a membrane such as felt. Roof edge protection requirements for flat roofs vary according to the level of risk presented. The Health and Safety Executive has issued detailed guidance and the flowchart on the following page is designed to enable appropriate risk control measures to be selected on this basis. More detailed information including definitions of key terminology is outlined below. For each location, flat roofs should be identified and the level of protection necessary should be determined. Where roofs meet the full edge protection standard, it is extremely unlikely that any additional physical control measures would be required, although the risks of individual tasks should be included in risk assessments. 3.2 Definitions (a) (b) (c) (d) (e) (f) (g) Full edge protection A top rail height at least 950mm and no gap greater than 470mm between rails. This is usually achieved by a double rail or by a solid parapet of at least 950mm high. Toe-boards shall be suitable and sufficient to prevent the fall of any person, or any material or object, from any place of work. For fixed edge protection installed prior to 6 the April 2005, it is acceptable if the top edge of the protection is at least 910mm in height and the above toe board and gap requirements are met. Demarcation barrier A barrier whose purpose is to define a route which is 2m or more from an unguarded edge. The barrier may be to a less robust standard than that for full edge protection, for example it could be a single rail fixed onto weighted base uprights as opposed to a permanent arrangement, provided this is suitable for likely weather conditions. Temporary demarcation barriers may be utilised for nonroutine work. Safety equipment In the context of this document, this includes any safety equipment for work at height including harnesses, lines and anchor points to EN795 norm for protection against fall from heights. It also includes equipment used in large scale construction projects to prevent injury from falls such as airbags and safety nets. Fixed safety equipment In the context of this document, these are permanent fixtures such as eyebolts and latch way systems which are used as an alternative to barrier systems. Safe system of work A procedure, normally in writing, which aims to ensure safety or personnel. The system should include any necessary equipment, the required level of training of personnel, work sequence or safety instructions for carrying out the work and any emergency procedures. Permit to work A formal authorisation to operate a system of work including time boundaries and other limitations. Class A roofs rmal working areas on flat roofs and roof level access routes, whether used for emergency or routine access. H&S_Procedure_25 Page 3 of 10

4 i) Fixed guard railing to full edge protection standards should be provided in these areas. Where there is a need to pass across a flat roof, though not within 2m of an unprotected edge, a clear demarcation barrier may be used to define the safe route. Marking of the route with paint is not an acceptable alternative to a demarcation barrier. ii) Lighting should be provided to cover areas which are accessed routinely in the hours of darkness. Emergency lighting should also be provided to cover emergency escape routes and high risk areas such as changes in level and heads of stairways. (h) (i) Class B roofs Where occasional work is undertaken on the roof and there is no edge protection. Either temporary barriers or an adequate safe system of work with harness, safety lines and adequate anchorages must be used. Such a system of work needs to be adequately designed and must take account of the need to prevent a fall or where this is not possible, to minimise the distance of a possible fall before it is arrested. Class C roofs Where access is only rarely required. Access arrangements for roofs where there are no anticipated routine tasks to be carried out, should be managed on an individual basis, for example, by ensuring that safe access is made for repair works. Where there are restrictions due to planning constraints or where major alterations are planned, it may not be possible to meet the criteria set out in this section. In this case, interim measures in the form of Class B precautions may be required in a Class A situation. H&S_Procedure_25 Page 4 of 10

5 Flowchart for the selection of minimum standards of roof protection Is the roof to be accessed only rarely by employees or others? Class C Roof Ensure that safe systems of work are operated for all those accessing the roof area, including the selection of suitable access equipment Are all persons able to access the roof mentally and Physically able to do so safely? Conduct a specific risk assessment for the individuals and their activities. Make necessary adjustments. Prevent unauthorised access to service users and trespassers. Is access required on a monthly or more frequent basis? Class B Roof Use fixed safety equipment and or temporary barriers with safe Does the roof have any existing edge protection? Is there a need to work or pass within 2m of an edge which is not Fully protected? Class A Roof Install a demarcation barrier to indicate the safe route across the roof Does the edge protection meet the standard for full edge protection (see definitions)? This roof is suitably protected for all classes of use. Ensure that methods of work do not require leaning through railings unless safety equipment and safe system of work are in place. Class A Roof Install edge protection in areas where it is necessary to work or pass within 2m of an edge which is not fully protected. Install a demarcation barrier to indicate the safe route across the remainder of the roof N.B. This flow chart is to assist those responsible for Trust premises in selecting minimum standards for roof edge protection. Where it is cost effective to reach a higher level of protection than the minimum standard, this should be implemented. H&S_Procedure_25 Page 5 of 10

6 3.3 Pitched roofs Work on pitched roofs should be subject to a method statement and only carried out by competent roof workers. The method of working must include adequate fall protection which may involve scaffolding, mobile scaffold towers and mobile elevating platforms etc. Specialist health and safety advice should be obtained via the Health, Safety and Risk Manager if in doubt of the adequacy of arrangements. 3.4 Fragile roofs Fragile roofs should be marked using standard warning signs in accordance with Health and Safety (Safety Signs and Signals) Regulations There should be a system in place to provide information to contractors on the risks to their health and safety including fragile roofs. It is a legal requirement that work on, or in the vicinity of, fragile surfaces should be avoided where it is reasonably practicable to do so. Where valley gutters run between areas of fragile roofing, the potential fall through the fragile roof should be guarded to full edge protection standards and the floor closely boarded. 3.5 Roof lights Roof lights may be constructed of a variety of materials, the majority of which are not designed to accept the weight of a person walking or falling on them. Domed or pyramid shaped polycarbonate roof lights are generally designed to an appropriate impact standard but this should be confirmed with manufacturers. In the majority of cases, where roof lights fall within designated safe areas, they should be protected. This may be achieved by fixing steel reinforcing material on top of, or below the roof light or by surrounding the roof light with a barrier. Where a fragile surface still exists, the skylight should be marked using standard warning signs (see Fragile Roofs above). 4 Portable ladders, stepladders and kick stools 4.1 The Work at Height Regulations introduced specific requirements in relation to the use of ladders and stepladders. Further guidance can be obtained in the HSE leaflet INDG402 Safe Use of Ladders and Step Ladders. Generally for the use of ladders and stepladders to be justified, a risk assessment must show that the use is acceptable due to both the low risk and short duration of the work. The selection process has to take into account the hierarchy of controls:- firstly to avoid work at height where possible; then to prevent falls from height; and, failing that, to reduce the consequences of a fall Work normally undertaken using ladders, stepladders or kick stools should be reviewed to ensure the work is safe by means of risk assessment. The risk assessment should consider whether work at height can be avoided through relocating items to a height accessible from floor level. The safe storage of items on appropriately located and secure shelving/racking should also reduce the risk of objects falling from height. H&S Form 36 can be used for a Work at Height Risk Assessment. Standard risk assessments have been produced for the use of commonly used access equipment and these are available from the Health, &Safety Manager. 4.2 Alternatives to step ladders include the use of podium steps (with totally surrounded work platform) which can be very suitable for work involving extensive lamp changing beneath a suspended ceiling for example. H&S_Procedure_25 Page 6 of 10

7 4.3 Particular care should be taken with higher risk tasks, such as lamp changing in stairwells where ladders may have been traditionally used. It will be unacceptable to use such a ladder in these circumstances it both hands are required for the work. 4.4 When selecting the correct standard of ladder, stepladder, step stool or podium steps, it is important to understand the type of use to which they will be put. Such ladders/steps can be constructed from aluminium, fibre glass, wood etc., each having their own British Standard. Within the British Standard there are three different classes of ladders. These equate to limits for maximum vertical static load which are set out within the European Standards, BSEN131: Class 1 ladders (maximum vertical static load 175kg) are intended for industrial work and are therefore suitable for all maintenance and construction work. Class 1 ladders should be used for maintenance activities. Class 2 ladders (maximum vertical static load 150kg) are suitable for light commercial use including housekeeping activities. Class 3 ladders (maximum vertical static load 125kg) are suitable only for light and infrequent work in a domestic setting. 4.5 Adherence to these classes is particularly important because the majority of ladders and stepladders used within Trust premises are aluminium. Whilst aluminium ladders are lightweight and therefore safer from a manual handling perspective, aluminium may fail without warning when subject to repeated stress and therefore failure may not necessarily be anticipated through inspection. 4.6 Ladder inspections should be carried out and recorded annually for all ladders, stepladders and kick stools using the H&S Form 12 and checklist H&S Form , Ladders must be used safely. H&S Form 35 may be used as a briefing note for employees involved in ladder work. 4.8 As indicated above, ladders are only suitable to work from height for light, short duration work. Under the majority of circumstances, where two hands are required to carry out the work, a ladder would not be suitable and alternative access equipment might be required such as a cherry picker or tower scaffold. 4.9 Eyebolts will need to be subject to an inspection regime by a specialist contractor including periodic load testing in accordance with current British Standards. Lanyards and harnesses should be subject to a visual pre-use check and a detailed thorough inspection at least every six months. Detailed inspections should be recorded. More frequent inspections may be required where harnesses and lanyards are subject to arduous use It is important to remember that where work at height takes place and there is a risk of a fall which leaves an employee/contractor suspended at height in a safety harness, there is a requirement for a rescue plan to be devised as part of the control measures within the overall safe system of work The rescue plan should be such that the suspended employee/contractor is recovered quickly before suspension trauma sets in generally within 16 to 20 minutes of suspension. For details on rescue at height refer to the Work at Height Safety Association (WAHSA), Technical Guidance te.5 Guidance on Rescue during Work at Height. H&S_Procedure_25 Page 7 of 10

8 5 Fixed Ladders 5.1 Fixed ladders are frequently used to provide access to roof areas for maintenance. A fixed vertical ladder is not normally suitable for providing routine access to a place of work such as a regularly accessed plant room. 5.2 Where there is a risk of falling more than 2m, a fall arrest system or a safety cage should be installed on the ladder. A fall arrest system is generally safer and more effective. For safety cages, the lowest loop of the safety cage should be approximately 2,500mm above the ground. The highest hoop should be in line with the landing handrail. Hoops should be not more than 900mm apart. The hoop dimensions should be such that the distance measured horizontally from the ladder to the back of the hoops is 760mm and the radius of the tube created should be 350 to 380mm (assuming that the hoops are round). Further details can be obtained from BS5395: Part Users of fall arrest equipment inside a caged ladder should also be aware of the possibility of injury from striking the cage following a fall. The use of climbing helmets to reduce the risk of injury may need to be considered. 5.3 Where materials or equipment are required to be taken to the top of the ladder, other than in a tool belt or shoulder bag, alternative means should be provided, for example by providing a block and tackle or by replacing the ladder with steps. Do not carry tools, equipment/materials to the top of a ladder where they weigh in excess of 10kg. 5.4 Where the ladder is located in a general access area, the lower part of a fixed ladder should be provided with a lockable cover to prevent unauthorised access. 6 Lofts 6.1 Loft areas are frequently accessed for repair and maintenance of services. These areas should be boarded or alternative measures taken to prevent the risk of falling through fragile ceilings. 6.2 Ladders which are used to access lofts via ceiling hatches should extend for 1m beyond the opening. Alternatively a vertical handrail of a minimum 1m length may be installed above the loft hatch to improve the safety of persons climbing from the top of the ladder into the plant rooms. Loft hatches should also be designed so that they can be readily opened from the ground, or by one hand when on the ladder below, and should be counterweighted or have such fixtures as will prevent the door from falling back unexpectedly. 6.3 Where there is a risk of falling back through the open loft hatch whilst working in the loft space, a rail or self-closing gate to full edge protection standards should be installed. 7 Other Access Equipment 7.1 Access equipment such as mobile elevating work platforms, scaffolds and mobile towers are effective in reducing the risks of work at height provided that they are erected and operated safely by competent people. 7.2 Cherry pickers and other mobile elevating work platforms must only be operated by trained persons e.g. IPAF s Powered Access Licence (PAL) or Construction Skills CPCS card, which clearly identifies the bearer and lists the categories of MEWP they are trained to operate. A full body safety harness, complying with BS EN 361, must be worn and secured to a proper anchorage in the cage when working in the elevated cage of a cherry picker or mobile elevating work platform (other than scissor lifts). In most cases the lanyard securing the harness should be fitted with a restraint lanyard to stop the user from reaching the fall area (subject to lanyard length). H&S_Procedure_25 Page 8 of 10

9 7.3 Mobile scaffold towers must be erected and inspected by a person who holds a PASMA Certificate of Competency and inspected by a competent person at least every seven days. The persons using the scaffold tower should receive instruction in safe use and again this can normally be obtained as part of the hire agreement. Mobile tower scaffolds must never be moved whilst people are on the tower. The obvious risks arising from scaffolding work are falls from heights, collapse or overturning of the scaffold and inadequate protection to prevent falls from those subsequently using the scaffold. Where scaffolding is erected, a specialist scaffolding contractor with CITB certified scaffolders must be used. The NASC is recognised as the national trade body for access and scaffolding in the UK, producing a wide range of industry guidance for scaffolding contractors, their operatives and their clients. Members of the NASC are strictly regulated to ensure a continuous high standard of practice. Before the scaffolding is taken into use it must be inspected by a competent person. These inspections are also required every seven days, or if the scaffolding is altered, after periods of inclement weather (high winds) or if any event has occurred which could have affected the stability of the scaffold. Records of inspections must be kept. A written assembly, use and dismantling plan must be available on site. 7.4 Very occasionally, competent contractors may be employed for specialist tasks involving abseiling or other forms of suspended access equipment. Such contractors should be qualified to IRATA standards (Industrial Rope Access Trade Association) and should be asked to provide a detailed site specific method statement. 8 Protection of Trespassers, including Children All access to roofs must be restricted to authorised persons and this will normally include locked gates, doors or ladder covers with restricted issue of keys. Access equipment such as ladders should also be secured. A specific risk assessment should be carried out on preventing access to heights. 9 Window Cleaning When selecting window cleaning contractors, it should be ensured that they will have a system for safe working at height for example ladder less techniques or a safe system of work involving the securing of ladders. The method used including the safe system of work should be specified within the contract. Where possible, the use of ladders should be avoided and use made of ground based systems. Window cleaning from inside a building which gives rise to a risk of falls should be similarly controlled, by use of safe access equipment. Where required safety harnesses should be used with adequate lifelines and shock absorbers. These must be secured to an eyebolt which has been tested. Safety harnesses and lines must be subject to regular inspection and a record kept. 10 Permits to Work 10.1 Work on roofs (other than roof plant rooms, or areas provided with permanent access and guard railing), or work involving scaffolding, or mobile or suspended access equipment will always require a permit. A safety checklist, H&S Form 32, is designed to accompany the permit to work at height Even in the case of flat roofs with permanent access and guard railing, a permit to work may be required if work is undertaken near the exhausts of boiler flues or other fume discharge points and special precautions will be needed to restrict access or shut such plant down to avoid such risks. H&S_Procedure_25 Page 9 of 10

10 10.3 Roof working involving hot bitumen will give rise to a significant fire risk and the precautions for hot work should be adopted including the issue of a permit to work. 11 Design issues in the Construction and Alteration of Premises It is essential that new buildings, alterations and extensions take into account the requirements of safe working at height and the principles outlined in this document. The designer of the facility has a specific legal responsibility to include precautions to enable subsequent maintenance to be undertaken safely. For any significant alteration or new building, the safety file for the building should identify safe access arrangements for maintenance. H&S_Procedure_25 10 Page 10 of