Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Confined Space Details

  • Take Photo of the Confined Space

  • Name of Space

  • Description of the space

  • Confined Space Construction

  • Main Purpose of Entry

  • Frequency of Entry

  • How many entry / exit points exist?

  • Primary Means of Entry?

  • Primary entry / exit is

  • Description and Size of Primary Entry / Exit?

Confined Space Classification

  • The space is enclosed or partially enclosed?

  • The space is not designed or primarily intended to be occupied by a person?

  • Is or is designed to be at normal atmospheric pressure while a person is in the space?

Is the space likely to pose a risk to health and safety from one or more of the following

  • An atmosphere that does not have a safe oxygen level?

  • Contaminants for example airborne gases, vapors and dusts that may cause injury from fire or explosion.

  • Harmful concentrations of any airborne contaminants?

  • Engulfment from any free moving solid or liquid?

Hazards and Control Measure

Oxygen

  • Low Oxygen

  • High Oxygen

  • Likelihood

  • Consequence

  • Continuous Oxygen Monitoring

  • Natural Ventilation

  • Mechanical Ventilation

  • Air Supplied Respiratory Protective Equipment

Atmospheric Contaminants

  • Dust

  • Gas

  • Vapour

  • Likelihood

  • Consequence

  • Continuous Gas Monitoring

  • Purge

  • Wash Down

  • Natural Ventilation

  • Mechanical Ventilation

  • Air Supplied Respiratory Protective Equipment

Harmful Substance or Biological Contaminant

  • Likelihood

  • Consequence

  • Remove substance prior to entry

  • Contain or enclose substance

  • Respiratory Protection

  • PPE

Fire or Explosion

  • Flammable Gas or Vapour

  • Flammable Liquid

  • Combustible Solid

  • Combustible Dust

  • Likelihood

  • Consequence

  • Purge

  • Gas / Vapour <5% LEL

  • Gas / Vapour >5% & <10% LEL & continuous monitoring of LEL

  • Removal of ignition sources

  • Removal of flammable materials

  • Standby Extignuisher

Introduction of substances to confined space

  • Flooding

  • Engulfment

  • Likelihood

  • Consequence

  • Isolate plant & services

  • Work restraint system

  • Other

Energisation of equipment

  • Moving Parts

  • Stored Energy

  • Collapse

  • Likelihood

  • Consequence

  • Isolate plant & services

Contact with electricity

  • Likelihood

  • Consequence

  • Isolate plant & services

  • Use Low Voltage Equipment

  • Earth Leakage Breaker

Thermal Stress

  • Likelihood

  • Consequence

  • Allow space to reach tolerable temperature

  • Rotate work or increase work / rest ratio

  • Maintain water intake

Other

  • Other Hazards

PPE Requirements

  • Chemical Resistant Gloves

  • Hearing Protection

  • Electrical Gloves

  • Welding Shield

  • Eye Protection

  • Respiratory Protection

  • Safety Boots

  • Coveralls

  • Other

Entry Equipment Requirements

  • Tripod

  • Davit Arm

  • Pulley Raising and Lowering System

  • Winch Raising and Lowering System

  • Full Body Harness

  • Gas Detector

  • Fall Protection Equipment

  • Rescue Retrieval System

  • Communications

  • BA

  • Rescue Retrieval System

  • Other

Rescue Plan Requirements

  • Tripod

  • Davit Arm

  • Pulley Raising and Lowering System

  • Winch Raising and Lowering System

  • Full Body Harness

  • Gas Detector

  • Fall Protection Equipment

  • Rescue Retrieval System

  • Communications

  • BA

  • Rescue Retrieval System

  • Other

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.