• SPACE / EQUIPMENT IDENTIFIER:

STEP ONE: (If all three are checked, it is a Permitted - Confined Space)

  • Is the space large enough for an employee to bodily enter and perform work?

  • Are there limited means of entry or exit?

  • Is it NOT designated for continuous occupancy?

STEP TWO: (If ANY one hazard is present, it's a "PERMIT-REQUIRED" Confined Space)

  • Is there a potential for an atmospheric hazard?

  • Is there a potential for an engulfment hazard?

  • Is the space so configured that it poses a hazard?

  • Is there any other recognized hazard (not listed here)? If Yes, list.

ATMOSPHERIC HAZARDS ......................REQUIRED PPE and/or Equipment.......................RESCUE/ENTRY PROCEDURES

  • Oxygen Deficiency (<19.5%)?

  • Flammable Materials?

  • Toxic Substances?

  • OTHER Hazard? If Yes, List.

  • Monitoring Equipment Required? If Yes, List.

  • Ventilating Equipment Required? If Yes, List.

  • Communication Equipment Required? If Yes, List.

  • Is a Rescue Team on site?

  • Is an Off-Site Rescue Team on Standby? If Yes, list who & where.

  • Is a retrieval system required and/or available?

  • Are wristlets required and/or available?

  • Is a Tripod & safety harness required and/or available?

  • Are Communication Devices Required and/or available?

  • Is an Emergency Call list available?

  • OTHER requirement not identified? If Yes, List.

ENGULFMENT HAZARDS ......................REQUIRED PPE and/or Equipment.......................RESCUE/ENTRY PROCEDURES

  • Is there a potential for Flowable Materials?

  • Are Hard Hats required and/or need to be available?

  • Is Eye Protection required and/or needs to be available? If REQUIRED, list type(s).

  • Is Hearing Protection required and/ or needs to be available? If REQUIRED, list type(s).

  • Are Gloves required and/or needs to be available? IF REQUIRED, list type(s).

  • Is special Safety Footwear required and/or needs to be available? If REQUIRED, list type(s).

  • Is Respiratory Protection required and/or needs to be available? If REQUIRED, list type(s).

  • Is Special Clothing required and/or needs to be available? If REQUIRED, list type(s).

CONFIGURATION HAZARDS ......................REQUIRED PPE and/or Equipment.......................RESCUE/ENTRY PROCEDURES

  • Are there downward sloping floors?

  • Are there inwardly converging walls?

  • Is Special Lighting required and/or needs to available? If REQUIRED, list type(s).

  • Are Explosion-Proof or Spark-Proof Tools required and/or needs to be available? If REQUIRED, list type(s).

  • Is Special Electrical Personal Protective Equipment required and/or needs to be available? If REQUIRED, list type(s).

  • Are Ladders required and/or needs to be available? If REQUIRED, list type(s).

  • Are SDS (Safety Data Sheets) required and/or needs to available?

  • OTHER requirement NOT listed:

  • Is cleaning or purging required?

  • Is Ventilation required and/or needs to be available? If REQUIRED, list type(s).

  • Is Isolation and/or Block & Bleed required?

  • Is Testing and/or Monitoring - Oxygen (19.5 - 23.5%) required?

  • Is Testing and/or Monitoring - Flammable (<10% LEL) required?

  • Is Testing and/or Monitoring - Toxics (<PEL) required?

  • Review of applicable SDS (Safety Data Sheets) required?

  • Is a HOT WORK PERMIT required?

  • OTHER requirement NOT listed?

OTHER HAZARDS ............................REQUIRED PPE and/or Equipment............................RESCUE/ENTRY PROCEDURES

  • Are there Mechanical Hazards? If Yes, list.

  • Are there Electrical Hazards? If Yes, list.

  • Are there Wet/Slippery Conditions? If Yes, Explain.

  • Are there Heat and/or Cold Safety Concerns? If Yes, Explain.

  • Is there a potential for Reduced Visibility? If Yes, Explain.

  • Is there a Noise Concern? If Yes, Explain.

  • OTHER Hazardous Concern NOT listed?

COMMENTS / ADDITIONAL INFORMATION

  • Photograph of Space #1 OPTIONAL

  • Photograph of Space #2 OPTIONAL

  • Photograph of Space #3 OPTIONAL

  • Photograph of Space #4 OPTIONAL

  • Can the space be locked or sealed?

  • Is it possible to eliminate all the hazards without anyone entering the space?

  • Permanently?

Signatures

  • Ground Safety Rep

  • Concur

  • Fire Protection Rep

  • Concur

  • Bio-environmental Rep

  • Concur

  • Group Commander

  • Concur

  • Wing Commander

  • Concur

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