Title Page
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
1.0 Confined or Restricted space requirements
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1.1 If a CONFINED SPACE assessment please tick box
A Contractors assessment has been carried out and ALL FOUR assessment criteria to determine a Confined Space (A) Enclosed or Partially Enclosed (B) Normal Atmospheric Pressure (C) Restricted Entry or Exit (D) Contaminants / Unsafe Oxygen or Engulfment have "Yes" as an answer then a confined space procedure is planned or underway
Site Setup
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1.2 Has the Contractor set up the site safely , signs ,barricades, traffic control (if required) No Smoking on site
Equipment
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1.3 Has the Contractor all the necessary equipment on site for the entry, safety harnesses, lanyards, tripod, lifting block, breathing apparatus, Gas detector, Ventilation fans, appropriate PPE
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1.4 Confirm the equipment is in good condition and test dates are OK
Prior to Entry
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1.5 Confirm the Contractor has at least three personal with current Confined Space Entry training and a minimum of level two First Aider on site
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1.6 Ensure the permit conditions for gas testing and monitoring have been met
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1.7 Ensure ventilation requirements are in place
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1.8 Have all necessary Isolations been done ?
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1.9 Has an emergency plan been discussed and understood by everyone?
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1.10 Risk analysis undertaken and permit filled out correctly?
During Entry
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1.11 Confirm ventilation is adequate or BA is being used
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1.12 Is the gas level continuously monitored if required?
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1.13 Are there at least two people at ground level at all times?
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1.14 Confirm that appropriate communication can be maintained with personal in Confined Space area
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1.15 If "Hot Work " is being undertaken ensure the appropriate precautions and permits are in place
Completion of Work
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1.16 Confirm the Contractor has in place a procedure to ensure all personal have exited the restricted space and that the site has been made safe, Isolations restored, covers in place etc
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1.17 CSE permit to be signed off and completed.
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2.0 If a RESTRICTED SPACE assessment please tick box
A Contractors assessment has been carried out and the FIRST THREE assessment criteria to determine a Restricted space (A) Enclosed or Partially Enclosed (B) Normal Atmospheric Pressure (C) Restricted Entry or Exit have "Yes" as an answer and (D) Contaminants / Unsafe Oxygen or Engulfment Has " No" then a Restricted Space procedure is planned or underway
Site Setup
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2.1 Has the Contractor set up the site safely , signs ,barricades, traffic control (if required)
Equipment
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2.2 Confirm the Contractor has all the necessary equipment on site for the entry, safety harnesses, lanyards, tripod, lifting block, appropriate PPE and is all equipment in good condition and within test date
Prior to Entry
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2.3 Confirm a risk analysis been undertaken
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2.4 Have all necessary Isolations been done ?
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2.5 Confirm that appropriate communication can be maintained with personal in restricted area
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2.6 If "Hot Work " is being undertaken ensure the appropriate precautions and permits are in place
During Entry
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2.7 Ensure that at least one person is at ground level at all times
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2.8 Is appropriate communication maintained with personnel in the restricted space?
Completion of Work
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2.9 Confirm the Contractor has in place a procedure to ensure all personal have exited the restricted space and that the site has been made safe, Isolations restored, covers in place etc
Additional comments
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Add any additional comments or information
Action required
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Contractor is to review the comments, and consider the recommended actions within this audit. The contractor needs to demonstrate they are complying with their obligations as an employer, what specific remedial action they propose for this site, and if any overall modifications are required to their Health and Safety Plan / safety procedures / supervision. Prompt corrective action is required to eliminate any agreed deficiencies, and any areas of disagreement need to be further explored in writing. All “failed responses” need to be addressed/resolved.
Signatures
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Gippsland Water responsible officer
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Auditor
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Contractor's representative
