170.8 – PERMIT TO WORK – DANGEROUS ENCLOSED SPACE

• Entry shall not be made into a dangerous enclosed space if breathing apparatus is required to make entry, other than in a rescue situation and then only when trained to do so and with extreme caution.

• Date and Time

  Date

• Prepared by

• Site Address
  Address

A. SCOPE OF WORK

• Location of Confined Space to be entered:

• Description of the work to be done:

• Name of ‘competent person(s)’ entering the confined space:

• Name of ‘responsible person’ outside the confined space:

B. CHECK LIST / ISOLATION DATA

• 1. Has a risk assessment of the proposed work been carried out and discussed with the person-s performing the job on this permit to work? <br><br>If “NO” then STOP until a risk assessment is completed.

  Yes

  No

• 2. Has a tool box meeting been carried out with all involved?

  Yes

  No

• 3. Additional specific precautions identified during on-site toolbox meeting:

• 4. Has the space been thoroughly ventilated and is on-going ventilation adequate?

  Yes

  No

• 5. Space secured for entry?

  Yes

  No

• 6. Access and lighting adequate?

  Yes

  No

• 7. Personal gas detection monitor tested and functioning?

  Yes

  No

• 8. Communications tested?

  Yes

  No

• 9. Gas monitor ID and last test date:

• 10. Personal protective equipment?

  Yes

  No

• 11. Rescue and resuscitation equipment available at entrance?

  Yes

  No

Atmosphere tested and found gas-free as follows:

• 12 .Oxygen (O2) (≥ 20.0%) REQUIRED FOR ENTRY

• 13. Combustibles – LFL (<1%)

• 14. Hydrogen sulphide – H2S (<2%)

• Or: H2S – max 5ppm PEL (8 Hr TWA) or 10ppm 15 mins STEL

• 15. Carbon monoxide – CO (<2%)

C. TO BE INITIALED BY EACH PERSON BEFORE ENTERING THE SPACE

• I have received instructions and authorization from the authorized officer to enter the dangerous space

  Yes

  No

• Section A of this permit has been completed by the authorized person

  Yes

  No

• I have agreed to and understand the communication procedures

  Yes

  No

• I have agreed upon a reporting interval of minutes (please input exact minutes in notes)

  Yes

  No

• Emergency and evacuation procedures have been agreed and understood

  Yes

  No

• I have witnessed the testing of the atmosphere within the space and am satisfied it is safe to enter

  Yes

  No

• I am aware that the space must be vacated immediately in case of ventilation failure or if the atmosphere test change from agreed safe criteria

  Yes

  No

Signatures of persons entering the space:

• 1. Name and Signature

  Sign

• 2. Name and Signature

  Sign

• 3. Name and Signature

  Sign

• 4. Name and Signature

  Sign

• I accept responsibility for carrying out the work detailed on this permit to work and no attempt will be made by me or people under my charge to work on any other area. I am satisfied that all precautions have been taken and that safety arrangements will be maintained for the duration of the work.

D. RECEIPT OF PERMIT TO WORK BY ‘RESPONSIBLE PERSON’ OUTSIDE THE WORK SPACE

• I accept responsibility for maintaining a watch over work being carried out and no attempt will be made to work on any other area. I am satisfied that all precautions have been taken and that safety arrangements will be maintained for the duration of the work.

• Name and Signature

  Sign

• Note: After signing the receipt, this permit to work shall be retained by the person in charge at the place where the work is being carried out until work is complete and the closure section signed. Second & third copies will be maintained in the Bridge and ECR.

CHANGE OF ‘RESPONSIBLE PERSON’

• If the ‘responsible person’ is no longer able to fulfil their duties, a handover must be undertaken to another appropriately experienced crewman.

• Competent person notified:

  Date

• Authorizing Officer notified:

  Date

• Duty deck notified:

  Date

• Duty engineer notified:

  Date

• New ‘responsible person (Name and Signature)

  Sign

E. AUTHORIZATION OF PERMIT TO WORK

• The work for which this permit to work was issued is now suspended or completed. All people under my charge have been withdrawn and warned that it is no longer safe to work on the apparatus detailed in this permit to work.
  
  All work equipment, tools, test instruments, etc. have been removed.

• Authorizing Officer's Name and Signature

  Sign

• Date & time permit issued

  Sign

• The work is complete or incomplete as follows:

• Duty deck watch notified at

• Duty engineer notified at

• Permit valid until

CLOSURE OF PERMIT TO WORK

• The work for which this permit to work was issued is now suspended or complete. All people under my charge have been withdrawn and warned that it is no longer safe to work on the apparatus detailed in this permit to work.
  All work equipment, tools, test instruments, etc have been removed.

• Authorizing officer and signature:

  Sign

• Time and date:

• The work is complete or incomplete as follows: