SAFE
WORK
PRACTICE
COMMON ELEMENTS
OF PERMIT TO WORK SYSTEMS SAFE
WORK PRACTICES AND PERMITS
© 2023 American Institute of Chemical Engineers
www.aiche.org/ccps
Copyright
This Safe Work Practice (SWP) is one in a series of SWPs published by the Center for Chemical Process Safety (CCPS).
It is sincerely hoped that the information presented in this document will lead to an even more impressive safety record
for the entire industry. However, the American Institute of Chemical Engineers, its consultants, the CCPS Technical
Steering Committee and Subcommittee members, their employers, their employers’ officers and directors, do not
warrant or represent, expressly or by implication, the correctness or accuracy of the content of the information presented
in this document. As between (1) American Institute of Chemical Engineers, its consultants, CCPS Technical Steering
Committee and Subcommittee members, their employers, their employers’ officers and directors, and (2) the user of this
document, the user accepts any legal liability or responsibility whatsoever for the consequences of its use or misuse.
Acknowledgments
The American Institute of Chemical Engineers (AIChE) and the Center for Chemical Process Safety (CCPS) express their
appreciation and gratitude to all members of the Safe Work Practices Project Committee and their member companies
for their generous efforts and technical contributions to the development of the Safe Work Practices. The volunteer team
of authors and reviewers who developed this SWP are listed below.
Authors and Reviewers:
Andrew Bartlett: Sphera
Brian Farrell: CCPS Consultant
2 COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS
Call to Action
The US Occupational Safety and Health Administration (OSHA) publishes data annually regarding violations of
safety standards. While these standards are only applicable in the US, the reports demonstrate that the most
common violations occur in activities that are carried out on a regular basis in the process industries. Every
violation represents a potential incident or injury.
The Top Ten areas most cited in 2021 for violations were:
1. Fall Protection: 5295 violations
2. Respiratory Protection: 2527
3. Ladders: 2026
4. Scaffolding: 1948
5. Hazard Communication: 1947
6. Control of Hazardous Energy (Lock Out/Tag Out): 1698
7. Fall Protection Training: 1666
8. Eye and Face Protection: 1452
9. Powered Industrial Trucks: 1420
10. Machinery and Machine Guarding: 1113
Safe protocols for work exist for all of these topics in the form of Safe Work Practices and Work Permits.
Jurisdictional requirements are detailed in government safety standards (OSHA in this example) and related
documents. Due to the availability of these resources, there is no reason that work cannot be planned and
executed safely. This document provides guidance on how to use a Permit to Work system, Safe Work Practices,
and Work Permits to achieve safe work outcomes.
COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS 3
Call to Action
The US Chemical Safety Board (CSB) investigates significant incidents in the process industries that occur in the US.
CSB reports often include recommendations related to deficiencies in the Permit to Work system that contributed to
the incident. Examples are provided below:
Hot Work Explosion
Two contractors were performing welding atop a slurry tank when hot sparks ignited flammable vapors inside the
tank, causing an explosion that killed one contractor and seriously injured another.
Recommendations Related to Permit Process: Develop and enforce corporate-directed policies and procedures
which will require all facilities to audit their hot work permitting systems prior to initiating hot work to ensure that:
g All potential explosion hazards associated with hot work activities are identified and mitigated.
g All relevant forms required for permits are completed in accordance with corporate policies
and industry standards (including NFPA 326 and NFPA 51B).
g Appropriate personnel officially approve hot work permits, by signature or equivalent,
consistent with corporate policies.
https://www.csb.gov/e-i-dupont-de-nemours-co-fatal-hotwork-explosion/
Nitrogen Asphyxiation
Two contract employees were overcome and fatally injured as they performed maintenance work near a 24-inch (61
cm) opening on the top of a reactor. One of the workers died attempting rescue.
Recommendations Related to Permit Process: Conduct safe work permit refresher training for all permit preparers
and approvers and affected refinery personnel and contractors. Emphasize the following items:
g All proposed work requires a jobsite visit by the requestor and a unit operator to identify
special precautions, equipment status, and personal safety equipment requirements.
g The permit must clearly identify all hazards and special personal protective equipment requirements.
g Audit work permit procedures and nitrogen purge safety procedures at each U.S. refinery.
Determine if issues identified in this Case Study are occurring elsewhere. Implement corrective
action, including training, where necessary.
g The Permit contained a status box for “Nitrogen Purge or Inerted” with potential answers
of “Yes/No/Not Applicable.” Define the conditions for marking this status box.
https://www.csb.gov/valero-refinery-asphyxiation-incident/
4 COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS
Fundamental Intent
This document describes common elements of Permit to Work (PTW) Systems, Safe Work Practices (SWP),
and Permits. These elements include governance, management practices, and continuous improvement. The
effectiveness of every safe system of work is dependent upon the people involved in the process. For this reason,
several Human Factors, and their relevance to PTW, SWP, and Permits is presented.
The PTW system covers activities that are not part of the normal process for converting raw materials into finished
products, and therefore are not covered by a facility’s standard operating procedures. The PTW system includes an
integrated set of policies, procedures, practices, and permits that help protect workers from hazards and prevent
the sudden release of process materials or energy during non-routine work activities. A PTW system is part of a
company’s overall safe system of work, and should reflect the elements of the company’s Safety Philosophy including:
g All incidents and injuries can be prevented
g Safety is a management responsibility
g Safety is a job requirement and a condition of employment
g All work must be performed with a focus on safety
g No shortcuts or deviations are allowed from safety rules
g Every incident is a learning opportunity and we will learn from all incidents
g Every worker is empowered to stop and correct unsafe acts
SWP are critical elements of the PTW system and provide requirements to control hazards in specific applications
of non-routine work. These applications include Line Opening, Energy Isolation – Lock Out/Tag Out, Confined Space
Entry, Working at Height, and many others. SWP and Permits help ensure that workers understand the hazards
involved with the work and take appropriate actions to manage risk when performing non-routine work activities.
A PTW system should contain the following key elements and characteristics. These elements describe the
governance of the PTW system along with the management and application of SWP and Permits that are issued
under the authority of the PTW system.
COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS 5
Fundamental Intent
1. Documented Standards
g The procedures and supporting documents and forms associated with the Permit to Work system,
Safe Work Practices, and Permits should be fully documented, authorized, version controlled and
subject to periodic review and updating.
g These documents should be available to all personnel involved in doing permitted work including
staff and contractors.
2. Accountabilities
g A Senior Manager should be the single point of accountability for the PTW system.
g Roles and responsibilities should be specified for all personnel involved in the planning, approval,
and execution of the PTW system and issuance of work permits. The role descriptions should include
a list of all responsibilities and the necessary competence needed to fulfill these roles.
3. Training and Competency
g All individuals involved in the administration and application of the PTW system should be trained and
certified for all roles they fulfill in the system. The training should ensure complete understanding of the
planning, approval, and execution of the PTW policy, SWPs, and work permits.
g The training should include plant staff and contractors who will perform permitted work.
g The training should include a competency assessment and documentation of the outcome.
Refresher training should be included at regular intervals as an integral part of the program.
g A register of all certified individuals and the roles they are certified to fulfill should be maintained.
4. Planning and Scheduling
g The task objective, work method, and tools should be specified along with the specific location
and equipment to be worked on under the authority of the permit.
g The worksite should be visited to identify relevant equipment and to identify all task hazards
and process safety hazards.
g The SWPs that apply to the work such as (Energy Isolation - Lock Out/Tag Out or Confined Space Entry)
should be included in the permit, as well as all other special provisions needed to complete the work safely.
g The condition of ongoing plant processes and other nearby activities should be considered when
scheduling the work. Good practice is to have a matrix of allowable simultaneous operations and
those which are prohibited while the work carried out under the Permit or SWP is underway.
5. Hazard Identification and Risk Assessment
g A “root cause” of workplace injuries and incidents is the failure to identify or recognize hazards that
are present, or that could have been anticipated. A critical element of the Permit to Work program
is a proactive, ongoing process to identify and assess such hazards.
g The hazards should be identified and risk assessed with an understanding of the project scope,
work method, tools to be used, work party skills and competence, and process status. When the risk
from a hazard is unacceptable, safeguards should be specified to control the hazards to an extent
where the residual risk is acceptable.
g If the risk cannot be reduced to an acceptable level with controls, alternative approaches to the
work method, tools, people, timing, or location should be developed.
6 COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS
Fundamental Intent
6. Permit Control Process
g Hazardous work should be controlled by a permitted process which includes clear levels of authorization.
g The permit should specify all of the safeguards and controls necessary to be in place to carry out the
work safely. Examples include energy isolations, gas testing, personnel protective equipment for tasks
and substances, scaffolding, and rescue crews.
g Issuance of the permit is an important control gate and should not be carried out unless all necessary
conditions are met.
g Permits are typically valid for a single shift and should be returned to the Permit Office after work is
complete or when the permit is suspended at the end of the shift. Work that continues through the
shift handover should be approved by the incoming Shift Supervisor.
g There should be a specific location point for permit issuance where employees or contractors go
to collect permits issued to them and where they return the permits at the end of a shift.
g The control process should include a register of all permits issued, the work task(s) being carried out,
and to whom the permit was issued. The permit register would ideally be located in the Permit Office.
Copies of each permit issued should be held in this location so personnel can readily see all ongoing work.
7. Communication (Scope, Hazards, Controls, and Mitigations)
g It is the role of the Permit Issuer (typically a Supervisor or Area Authority) to communicate all hazards
in the work area to the person(s) receiving the permit (Permit Receiver or Performing Authority).
g When energy isolations are required, it is good practice for the Supervisor or Area Authority to identify
the isolations and confirm/demonstrate that the isolations are energy free before allowing the work
identified in the permit to begin.
g Where gas testing is required before work commences, the Authorized Gas Tester should communicate
the status to the work party. Permit work should not proceed if the test results do not meet the
requirements listed in the Permit.
g The Performing Authority has a responsibility to communicate all hazards and controls to the work party
before the work commences. This is normally carried out during a “toolbox talk” or briefing meeting.
In this meeting the work scope is outlined, hazards and safeguards are communicated, specific
responsibilities are discussed with the work crew, and workers sign on to the work sheet.
g The permit and all associated documentation should be posted at the work site for all members
of the work crew to see and access.
8. Monitor and Manage Ongoing Work
g After a permit has been issued, the Permit Issuer or authorized plant staff should monitor progress.
Typically, the more hazardous the task, the higher the level of surveillance necessary.
g Continuous monitoring may be necessary for specific hazards. Examples include a “Fire Watch” for
Hot Work or an “Entry Attendant” for Confined Space Entry work.
g Continuous or periodic gas testing maybe required by the permit.
g When a shift ends, the Permit Receiver (work crew chief / supervisor) should be responsible for
ensuring all copies of the permit have been returned and that work has ceased in the area.
g For jobs that span multiple shifts, a documented shift handover must take place focusing on the
status of each job covered by the work permit.
COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS 7
Fundamental Intent
9. Work Area Left in Safe Condition Upon Completion or Interruption
g When a task is complete, the work area should be cleared of all tools, equipment, and materials.
All surfaces should be cleaned to remove any tripping or slipping hazards.
g In an emergency situation, all work should immediately cease and the work area be returned to
a safe condition. After securing the work area, the work party should leave the work area, proceed
to their muster point, and await further instructions.
g Once the emergency has cleared, work should not start again without re-issuance of the permit
and confirmation of the risk assessment.
10. Verification and Assurance
g Verification or Compliance Audits and spot checks should be carried out regularly to ensure that
the Permit to Work system is functioning correctly. These checks can be used to determine whether:
• The permit has been correctly completed
• The work method described in the permit is being utilized and whether the entire work party understands it.
• All specified controls, safeguards and isolations are in place and operating as planned.
• The work party members understand the hazards and controls.
8 COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS
Fundamental Intent
11. Capture, Incorporate, and Share Lessons Learned
g PTW systems should include a process for capturing and sharing lessons learned. Areas to focus
on include the hazard identification and risk assessment process, work methods and preparation
of the work area, and the permit approval process.
g PTW systems should include a requirement to update the PTW policies, SWPs, or Permit details
when a lesson is learned. Lessons learned should be shared widely within the facility and the company.
12. Obligation and Authority to Stop Work
g The PTW policy should state that all staff and contractors on the plant site have the Authority
and Obligation to stop work when an unsafe condition or act is observed that could affect the safety
of personnel and/or the environment.
g The PTW policy should state that all staff and contractors on the plant site have the Authority
and Obligation to stop work when conditions change from the conditions approved in the permit.
g The Stop Work Authority expectation should be routinely communicated during toolbox talks
and other safety meetings to all personnel at site, including staff and contractors.
g The PTW policy should ensure that that no repercussions are directed towards personnel
who use Stop Work Authority.
COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS 9
Management Practices
Management practices that can be used to continually monitor and improve the PTW system are described
in this section.
Use Audits to Evaluate the Effectiveness of the PTW Program
Periodic audits are one of the most effective methods to ensure the PTW program is delivering the intended
results. Audits can be used to review the following items.
g The SWPs and Permit details are regularly updated based on feedback from their use.
g Roles, responsibilities, and competencies of persons involved in PTW activities.
g Training for employees and contract personnel involved with the issuance or use of work permits.
g Hazard identification and risk assessment is performed, and controls are implemented before
specified permit work activities are conducted.
g Job observations are performed on jobs as required in the Permit or SWP.
The following items can be included when auditing permits. Check for the following items.
g Permits were completely filled out
g All members of the work party signed the work permits
g Equipment-specific or activity-specific procedures were followed
g The permit writer was trained and authorized to write the permit
g The personnel performing the task were trained and competent in the work
they performed under the permit
g Permit conditions were communicated to and within the affected work team(s)
g Work was coordinated between work groups involved in the permit process
(permit writing group and group(s) that perform the work)
g Work was not extended beyond the authorized period of time without authorization
g PPE requirements were fulfilled
g Tasks/activities specified in the permit were properly executed
10 COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS
Management Practices
Continually Improve the PTW Program
Management Review of audits is an effective way of monitoring the health of the PTW system, the application
of the audit process, and for making continuous improvements. Management Review can be used to:
g Ensure the quality of the audit process
g Ensure the competency levels of the auditors
g Determine whether the PTW program is being used to simply “fill in the permit”
or is being used as a tool to facilitate the safe execution of work
g Evaluate the PTW program for:
• Procedural Compliance – Are actions and tasks in compliance with procedural requirements? (Paper Control)
• Program Health – Is the system providing the intended results? (Actual Execution)
g Share information from facility or company incidents related to a specific permit or SWP
• Have the incident causes and outcomes been discussed within the organization?
• Have the SWPs been updated based on this knowledge?
g Share information from facility or company Near Misses related to a specific permit or SWP
• Have the Near Miss learnings been discussed within the organization?
• Have the SWPs been updated based on this knowledge?
Management Reviews may also ask the following questions to determine the effectiveness of the PTW
system and identify ways to continuously improve the program.
g Are relevant incidents reported by the Chemical Safety Board (CSB), Process Safety Beacon,
or other sources communicated with all members of the organization? Are the findings from these
incidents used to improve the PTW system?
g Have metrics related to the PTW system been defined, recorded, and analyzed? Metrics can be
presented during Management Reviews to determine program effectiveness, identify gaps,
initiate improvement programs, and improve performance.
g Has the PTW program been benchmarked against other programs in the industry?
g Do senior managers visit the field to witness the application of SWPs and Permits in an
operating environment? How often do these visits occur?
g Does the PTW program include a requirement to periodically review and update program
documents (PTW policy, SWPs, Permit content) at prescribed intervals?
g Do workers who perform permit work have an easy method to suggest improvements to the program?
COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS 11
Human Factors and The PTW System
The successful application of a PTW program to prevent hazards from occurring during non-routine work activities
depends upon the actions of people who are involved in the program. Three areas that are critical to the human
element in a PTW program are Process Safety Culture, Maintain a Sense of Vulnerability, and Normalization of
Deviance. These topics and their relationship to the PTW system are described below.
Process Safety Culture
CCPS defines Process Safety Culture as “The common set of values, behaviors, and norms at all levels in a facility
or in the wider organization that affect process safety.” Klein and Vaughen define Safety Culture as “The normal
way things are done at a facility, company, or organization, reflecting expected organizational values, beliefs, and
behaviors, that set the priority, commitment, and resource levels for safety programs and performance.” A less formal
definition of Process Safety Culture is “How a person behaves when nobody is watching.” A successful PTW program
depends on the actions of individuals and those actions are based on the values and behaviors of each person.
A strong Process Safety Culture within an organization continually emphasizes values and behaviors that protect
the people in the facility, the environment, and the communities in which those facilities operate.
The following questions can be used to assess the effect of Process Safety Culture on the successful execution
of the PTW system.
g Has management established safety as a core value?
g Does management provide strong safety leadership?
g Does management reinforce desired behaviors to ensure they become integrated into the group’s values?
g Has management formalized the safety culture emphasis and approach?
g Does management work to ensure employees maintain a sense of vulnerability?
g Are individuals empowered to successfully fulfill their safety responsibilities?
g Does management ensure open and effective communication exists?
g Does management support and foster mutual trust?
g Does management establish and enforce high standards of performance?
g Does management defer to technical and safety expertise?
g Has management established a questioning/learning environment?
g Does management provide timely responses to safety issues and concerns?
12 COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS
Human Factors and The PTW System
Maintain a Sense of Vulnerability
A Sense of Vulnerability Is healthy. Just because a particular incident has not yet happened does not mean it will not
happen in the future. Just because there was a Near Miss without serious consequences does not mean that there
will be no serious consequences the next time it occurs. Just because a worker did not follow procedures or a work
permit, and an incident did not occur, does not mean that an incident will not occur the next time a procedure is not
followed. The following questions can be used to determine whether a facility maintains a sense of vulnerability.
g Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
g Do people believe that “yes, it can happen here”?
g Do people believe that “yes, we have similar vulnerabilities”?
g Does management require consistency in practice from everyone in the organization?
g Are there systems in place to determine if inconsistencies in practice exist?
g Has the facility experienced Near Misses without serious consequences?
g Is it recognized that organizational overconfidence may be an unexpected outcome
from past good Process Safety performance?
g Do discussions on potential vulnerabilities take place between operations personnel and senior leadership?
Prevent Normalization of Deviance (also known as Normalization of Deviation)
Normalization of Deviance is defined by CCPS as “A gradual erosion of standards of performance as a result of
increased tolerance of nonconformance.” Normalization of Deviance was cited as a contributing cause to the
Space Shuttle Challenger disaster. Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)
defined Normalization of Deviance as “The gradual process through which unacceptable practice or standards
become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social
norm for the organization.”
There are many warning signs that Normalization of Deviance may be an issue at an operating facility.
Here are the questions to ask to determine whether there is a problem.
g Are willful or conscious violations of established procedures tolerated without investigation
or without consequences for the persons involved?
g Can employees be counted on to strictly adhere to safety policies and practices when
supervision is not around to monitor compliance?
g Are practices or conditions tolerated that would be considered unacceptable under different
circumstances? For example:
• Are maintenance tasks allowed to proceed without proper SWP procedures being utilized if the work can be
done more quickly by not following procedures or if the hazardous energy involved is considered to be minor?
g Are all employees empowered to stop work and correct unsafe conditions for any situation or act deemed unsafe?
g Is plant operation outside of established safe operating limits allowed without a detailed risk assessment?
g If plant operation outside of safe operating limit is absolutely necessary, are there defined steps that
must be taken, such as a written variance procedure?
• Do these defined steps (or variance procedure) require a detailed risk assessment
and approval from multiple levels within the organization?
• Are expectations clear that no one individual alone is permitted to determine
whether a deviation is permissible?
COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS 13
Human Factors and The PTW System
A facility that has a Normalization of Deviance problem is unlikely to have an effective and safe PTW program
as the requirements of the SWPs and Permits will not be fulfilled on a consistent basis.
In closing, the best PTW policy, set of SWP, and Permits will not achieve the objective of completing non-standard
work safely without a strong human element. Establish a strong Process Safety Culture with visible and real leadership
from the highest levels of management. Maintain a sense of vulnerability even when Process Safety performance
is excellent. Do not tolerate Normalization of Deviance. Engage the workforce and help them to realize that by
working safely they will protect themselves and their fellow workers from the hazards that are continually present
in the process industries.
14 COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS
Reference Materials
James A. Klein and Bruce K. Vaughen, Process Safety: Key Concepts and Practical Approaches,
CRCPress, Boca Rotan, FL, 2017, Page 32.
Contributory factors for an assessor to consider concerning Permit to Work Systems
https://www.hse.gov.uk/comah/sragtech/techmeaspermit.htm
COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS 15
Center for Chemical Process Safety – An AIChE Technology Alliance
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