Confined Space Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Confined Space Details

• Take Photo of the Confined Space

  Media

• Name of Space

• Description of the space

  Select Air Handling Unit Tunnel Pipe Chase Manhole Sewer Pit Boiler Crawl Space Electrical Vault Storm Water Pit Tank Lift Pit Other

  • Air Handling Unit
  • Tunnel
  • Pipe Chase
  • Manhole
  • Sewer
  • Pit
  • Boiler
  • Crawl Space
  • Electrical Vault
  • Storm Water Pit
  • Tank
  • Lift Pit
  • Other

• Confined Space Construction

  Select Steel Concrete Plastic Fibreglass Brick Other

  • Steel
  • Concrete
  • Plastic
  • Fibreglass
  • Brick
  • Other

• Main Purpose of Entry

  Emergency Only

  Cleaning and Maintenance

  Inspection

  Corrective Repair

• Frequency of Entry

  Select Daily Weekly Monthly Quarterly 6 months Yearly Never

  • Daily
  • Weekly
  • Monthly
  • Quarterly
  • 6 months
  • Yearly
  • Never

• How many entry / exit points exist?

  Select 1 2 3 4 5 More

  • 1
  • 2
  • 3
  • 4
  • 5
  • More

• Primary Means of Entry?

  Vertical

  Horizontal

• Primary entry / exit is

  Above Ground Level

  Ground Level

  Below Ground Level

• Description and Size of Primary Entry / Exit?

Confined Space Classification

• The space is enclosed or partially enclosed?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Harmful concentrations of any airborne contaminants?

  Yes

  No

  N/A

• Engulfment from any free moving solid or liquid?

  Yes

  No

  N/A

Hazards and Control Measure

Oxygen

• Low Oxygen

  Yes

  No

  N/A

• High Oxygen

  Yes

  No

  N/A

• Likelihood

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• Consequence

  Catastrophic

  Major

  Moderate

  Minor

  Insignificant

• Continuous Oxygen Monitoring

  Yes

  No

  N/A

• Natural Ventilation

  Yes

  No

  N/A

• Mechanical Ventilation

  Yes

  No

  N/A

• Air Supplied Respiratory Protective Equipment

  Yes

  No

  N/A

Atmospheric Contaminants

• Dust

  Yes

  No

  N/A

• Gas

  Yes

  No

  N/A

• Vapour

  Yes

  No

  N/A

• Likelihood

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• Consequence

  Catastrophic

  Major

  Moderate

  Minor

  Insignificant

• Continuous Gas Monitoring

  Yes

  No

  N/A

• Purge

  Yes

  No

  N/A

• Wash Down

  Yes

  No

  N/A

• Natural Ventilation

  Yes

  No

  N/A

• Mechanical Ventilation

  Yes

  No

  N/A

• Air Supplied Respiratory Protective Equipment

  Yes

  No

  N/A

Harmful Substance or Biological Contaminant

• Likelihood

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• Consequence

  Catastrophic

  Major

  Moderate

  Minor

  Insignificant

• Remove substance prior to entry

  Yes

  No

  N/A

• Contain or enclose substance

  Yes

  No

  N/A

• Respiratory Protection

  Yes

  No

  N/A

• PPE

  Yes

  No

  N/A

Fire or Explosion

• Flammable Gas or Vapour

  Yes

  No

  N/A

• Flammable Liquid

  Yes

  No

  N/A

• Combustible Solid

  Yes

  No

  N/A

• Combustible Dust

  Yes

  No

  N/A

• Likelihood

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• Consequence

  Catastrophic

  Major

  Moderate

  Minor

  Insignificant

• Purge

  Yes

  No

  N/A

• Gas / Vapour <5% LEL

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Removal of ignition sources

  Yes

  No

  N/A

• Removal of flammable materials

  Yes

  No

  N/A

• Standby Extignuisher

  Yes

  No

  N/A

Introduction of substances to confined space

• Flooding

  Yes

  No

  N/A

• Engulfment

  Yes

  No

  N/A

• Likelihood

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• Consequence

  Catastrophic

  Major

  Moderate

  Minor

  Insignificant

• Isolate plant & services

  Yes

  No

  N/A

• Work restraint system

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Energisation of equipment

• Moving Parts

  Yes

  No

  N/A

• Stored Energy

  Yes

  No

  N/A

• Collapse

  Yes

  No

  N/A

• Likelihood

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• Consequence

  Catastrophic

  Major

  Moderate

  Minor

  Insignificant

• Isolate plant & services

  Yes

  No

  N/A

Contact with electricity

• Likelihood

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• Consequence

  Catastrophic

  Major

  Moderate

  Minor

  Insignificant

• Isolate plant & services

  Yes

  No

  N/A

• Use Low Voltage Equipment

  Yes

  No

  N/A

• Earth Leakage Breaker

  Yes

  No

  N/A

Thermal Stress

• Likelihood

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• Consequence

  Catastrophic

  Major

  Moderate

  Minor

  Insignificant

• Allow space to reach tolerable temperature

  Yes

  No

  N/A

• Rotate work or increase work / rest ratio

  Yes

  No

  N/A

• Maintain water intake

  Yes

  No

  N/A

Other

• Other Hazards

PPE Requirements

• Chemical Resistant Gloves

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Electrical Gloves

  Yes

  No

  N/A

• Welding Shield

  Yes

  No

  N/A

• Eye Protection

  Yes

  No

  N/A

• Respiratory Protection

  Yes

  No

  N/A

• Safety Boots

  Yes

  No

  N/A

• Coveralls

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Entry Equipment Requirements

• Tripod

  Yes

  No

  N/A

• Davit Arm

  Yes

  No

  N/A

• Pulley Raising and Lowering System

  Yes

  No

  N/A

• Winch Raising and Lowering System

  Yes

  No

  N/A

• Full Body Harness

  Yes

  No

  N/A

• Gas Detector

  Yes

  No

  N/A

• Fall Protection Equipment

  Yes

  No

  N/A

• Rescue Retrieval System

  Yes

  No

  N/A

• Communications

  Yes

  No

  N/A

• BA

  Yes

  No

  N/A

• Rescue Retrieval System

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Rescue Plan Requirements

• Tripod

  Yes

  No

  N/A

• Davit Arm

  Yes

  No

  N/A

• Pulley Raising and Lowering System

  Yes

  No

  N/A

• Winch Raising and Lowering System

  Yes

  No

  N/A

• Full Body Harness

  Yes

  No

  N/A

• Gas Detector

  Yes

  No

  N/A

• Fall Protection Equipment

  Yes

  No

  N/A

• Rescue Retrieval System

  Yes

  No

  N/A

• Communications

  Yes

  No

  N/A

• BA

  Yes

  No

  N/A

• Rescue Retrieval System

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A