Southern Shield / Form ref: / F2001B
Version: / Issue 2
Revision date: / 1 September 2016
Accepting the principle of using safe systems of work with Site Wardens*, Equipment or Lookout Warning
In accordance with the Southern Shield Track Access Protocol this form must be completed by the (Principal) Contractor prior to undertaking any work or accessing on or about the line with either Site Warden(s)*, Equipment Warning Systems (i.e. ATWS, TOWS, LOWS) or Lookout Warning. If approved it must be retained with the Safe System of Work Pack by the Controller of Site Safety for inspection.
Application Number(Network Rail Project Code and a consecutive number issued by the Contractor’s Rail Interface Planning Manager)
Oracle Project Code
(Principal) Contractor
Contractor undertaking work
Network Rail Project Manager
Asset Discipline
Work activity to be undertaken
Route / Select from drop down list /
Location of work
Date(s) of work
Type of SSOW / Select from drop down list /
Justification for working (or accessing) with Site Warden(s), Equipment or Lookout Warning
(A separate sheet can be used)
SSOW Responsible Manager
Name:
Role:
Signature: (electronic signatures are not permitted – a “wet” signature is required)
Date application submitted: / Click here to enter a date. /
See over for acceptance of all proposed safe systems of work involving the use of Site Warden(s)+ or Equipment or Lookout Warning.
Southern Shield / Form ref: / F2001B
Version: / Issue 2
Revision date: / 1 September 2016
The Contractor’s Rail Interface Planning (RIPS) Manager must accept or reject all applications for proposed safe systems of work involving the use of Site Warden(s)* or where the use of Equipment or Lookout Warning will be used for access purposes only. No further acceptance is necessary, although the form must be forwarded to the relevant Network Rail Programme Manager, at least 7-days prior to the shift, for their information and any challenge as necessary.
Contractor’s Rail Interface Planning (RIPS) ManagerApplication: / Choose an item. /
Name:
Role:
Signature: (electronic signatures are not permitted – a “wet” signature is required)
Date accepted / rejected: / Click here to enter a date. /
Reason for rejection:
Where the all Contractor’s Rail Interface Planning (RIPS) Manager has accepted an application for proposed safe systems of work involving the use of Site Warden(s)*the form must be forwarded to the relevant Network Rail Programme Manager, at least 7-days prior to the shift, for their acknowledgement and challenge as necessary.for proposed safe systems of work involving the use of Equipment or Lookout Warning will be used for access purposes onlythe form must be forwarded to the relevant Network Rail Route Delivery Director, at least 7-days prior to the shift, for their acknowledgement and challenge as necessary.
The Network Rail Route Delivery Director/ Programme Manager must complete the section below and return it to the Contractor’s Rail Interface Planning (RIPS) Managerat least 48 hours prior to the shift to enable the safe system of work to be finalised.
Network Rail Acknowledgement and ChallengeType of SSOW / Select from drop down list /
Application: / Choose an item. /
Role: / Select from drop down list /
Name
Signature: (electronic signatures are not permitted – a “wet” signature is required)
Date proposed SSOW acknowledged and challenged (where applicable): / Click here to enter a date. /
Challenge (if not applicable state N/A):
(A separate sheet can be used to detail the challenge) (Also state in this section if no acknowledgement or challenge received)
See over for acceptance of all safe systems of work involving the use of Equipment or Lookout Warning for actual work activities.
/ Infrastructure Projects SouthernSouthern Shield / Form ref: / F2001B
Version: / Issue 2
Revision date: / 1 September 2016
Where actual work activities are proposed be undertaken using safe systems of work with Equipment or Lookout Warning then the Contractor’s Rail Interface Planning (RIPS) Manager is required to accept or reject the application. If the application is accepted then this form must be sent to the Network Rail Project Manager to enable acceptance by the relevant Network Rail Route Delivery Manager.
For applications where actual work activities are proposed to be undertaken using safe systems of work with Equipment or Lookout Warning this form must be completed and forwarded to the Route Delivery Director at least 4 weeks prior to the work being undertaken:
Network Rail Route Delivery DirectorType of SSOW / Select from drop down list /
Application: / Choose an item. /
Name
Signature: (electronic signatures are not permitted – a “wet” signature is required)
Date accepted / rejected / Click here to enter a date. /
Reason for rejection:
(If not applicable state N/A)
(A separate sheet can be used)
This form must be returned to the SSOW Responsible Manager and attached to the Safe System of Work Pack issued to every Controller of Site Safety required to work under the application.
The Contractor’s Rail Interface Planning (RIPS) Manager will arrange for copies of all accepted and rejected applications to be retained for audit purposes for at least 6 months after the last date of when the safe system of work is used.
*Where Site Warden(s) will be used as part of the safe system of work this form must be completed. Where the adjacent line is blocked for additional protection purposes only then this form is not required to be completed.
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