PF057.0 Exceedances Risk Assessment Form Y01-AA-FOR-031 A01 Authorisation to Exceed Working Hours Form In accordance with the company’s policy on working hours we are required to carry out a risk assessment for any excessive hours that need to be worked. An exceedance shall be declared when any of these conditions are or might be reached: a. Maximum of 12 consecutive shifts followed by a break of minimum 48 hours. b. Maximum single shift time of 14 hours to include travelling time (Door to Door). c. An individual works more than 12 hours on site in any one shift. d. A minimum rest period of 12 hours between booking off a shift/duty to booking on for the next shift/duty. e. Exceed 60 hours or more (Level 1) of working in a rolling seven-day period. f. Exceed 72 hours or more (Level 2) of working in a rolling seven-day period. g. An exceedance is declared when a person is expected to exceed a Fatigue Risk Index (FRI) fatigue score of 35 during daytime or 45 during night-time hours. h. An exceedance is declared when a person is expected to exceed an FRI risk score of 1.6 (regardless of daytime or night-time working). Authorisation was given by Authorising Manager (Head of Department), for the under-mentioned member of staff to work in excess of the Maximum Working Hours & Fatigue Management Policy limits for the reasons outlined: This authorisation to exceed working hours form shall be completed by the Line Manager / Responsible Manager and provided to the Authorising Manager for formal authorisation prior to the exceedance commencing. Go to top SITE / PROJECT LOCATION * REGION IF APPLICABLE PROJECT TITLE * LINE MANAGER / RESPONSIBLE MANAGER * DETAILS OF EXCEEDED HOURS Date * PLANNED SHIFT START * 000102030405060708091011121314151617181920212223 : 000510152025303540455055 PLANNED SHIFT END * 000102030405060708091011121314151617181920212223 : 000510152025303540455055 DETAILS OF EXCEEDENCE * A. Maximum of 12 consecutive shifts followed by a break of minimum 48 hours.B. Maximum single shift time of 14 hours to include travelling time (Door to Door).C. An individual works more than 12 hours on site in any one shift.D. A minimum rest period of 12 hours between booking off a shift/duty to booking on for the next shift/duty.E. Exceed 60 hours or more (Level 1) of working in a rolling seven-day period.F. Exceed 72 hours or more (Level 2) of working in a rolling seven-day period.G. An exceedance is declared when a person is expected to exceed a Fatigue Risk Index (FRI) fatigue score of 35 during daytime or 45 during night-time hoursH. An exceedance is declared when a person is expected to exceed an FRI risk score of 1.6 (regardless of daytime or night-time working). ACTUAL SHIFT START * 000102030405060708091011121314151617181920212223 : 000510152025303540455055 ACTUAL SHIFT END * 000102030405060708091011121314151617181920212223 : 000510152025303540455055 Reason for the exceedance and type of task being undertaken (full explanation required): * ASSESSMENT OF FITNESS TO CONTINUE How many consecutive shifts worked since last day rest day free of duty ? * Acceptable? * YESNO How many hours rest between previous shift? * Acceptable? * YESNO How many hours rest until next shift? * Acceptable? * YESNO Time left place of rest? * Acceptable? * YESNO Pre-planned finish time * Acceptable? * YESNO Projected finish time (including travel) * Acceptable? * YESNO Distance (in hours / mins) to place of rest * Acceptable? * YESNO Has the Fatigue Risk Index (FRI) been used and score defined, where applicable at time of the exceedance * YESNO Define FRI Score * Are you planning to travel to place of rest (drive / taxi / train) * YESNO Can you designate a rested driver or get a taxi / train * YESNO Do you need a hotel * YESNO Do you feel fatigued? * YESNO What Karolinska Sleepless Scale (KSS) do you believe you are at? * 1. Extremely Alert2. Very Alert3. Alert4. Rather Alert5. Neither Alert or Sleepy6. Some Signs of Sleepiness7. Sleepy, But no effort to keep awake8. Sleepy, Some effort to keep awake9. Sleepy, Great effort to keep awake Do you feel in good health * YESNO Are you taking (including over the counter) any medication * YESNO List Medications * Are you working alone * YESNO Is the site secure / safe (personal safety) * YESNO Is the site secure / safe (operational safety) * YESNO Are there any exacerbated circumstances – If YES give details * YESNO Describe any exacerbated circumstances * Do you have welfare provision (drinking water / WC) to last for the duration of the shift * YESNO How long since you last eaten or drank (hh:mm) * CATEGORY OF EXCEEDANCE DETAILS OF EXCEEDENCE * A. Maximum of 12 consecutive shifts followed by a break of minimum 48 hours.B. Maximum single shift time of 14 hours to include travelling time (Door to Door).C. An individual works more than 12 hours on site in any one shift.D. A minimum rest period of 12 hours between booking off a shift/duty to booking on for the next shift/duty.E. Exceed 60 hours or more (Level 1) of working in a rolling seven-day period.F. Exceed 72 hours or more (Level 2) of working in a rolling seven-day period.G. An exceedance is declared when a person is expected to exceed a Fatigue Risk Index (FRI) fatigue score of 35 during daytime or 45 during night-time hoursH. An exceedance is declared when a person is expected to exceed an FRI risk score of 1.6 (regardless of daytime or night-time working). Steps taken to prevent / avoid exceedance in the future: * Control measures implemented for exceedance: * Name of Individual exceeding working hours * Name of Individual exceeding working hours First Name First Name Last Name Last Name Employer * LINE MANAGER / RESPONSIBLE MANAGER NAME OF LINE MANAGER COMPLETING THE RISK ASSESSMENT * NAME OF LINE MANAGER COMPLETING THE RISK ASSESSMENT First First Last Last Position: * Signature signature keyboard Clear Method of Authorisation * Telephone Call to Head of DepartmentTelephone Call to Senior Manager / Director AUTHORISING MANAGER (DIRECTOR / SENIOR MANAGER / HEAD OF DEPARTMENT): I confirm as Authorising Manager (Director / Senior Manager/ Head of Department) I have reviewed this assessment for the member of staff named and I am satisfied with the exceedance control measures to be implemented and confirm the individual is fit to continue duty for the duration of the excess hours described, the level of risk is acceptable and authorised for this exceedance. Name Name First Name First Name Last Name Last Name Signature signature keyboard Clear Date Submit
