Confined Space Entry Inspection

• Conducted on

  Date
• Location
  Address

• CLIENT

• C. S. SUPERVISOR/FOREMAN

• HEALTH & SAFETY MANAGER

• JOB NUMBER

• CONFINED SPACE DESCRIPTION

SITE PERSONNEL

• Foreman (Entry Supervisor) Named?

  Yes

  No

  N/A

• Knows the Hazards?

  Yes

  No

  N/A

• Knows the Duties?

  Yes

  No

  N/A

• Attendant(s) Named?

  Yes

  No

  N/A

• Knows the Hazards?

  Yes

  No

  N/A

• Knows the Duties?

  Yes

  No

  N/A

• Entrant(s) Named?

  Yes

  No

  N/A

• Knows the Hazards?

  Yes

  No

  N/A

• Knows the Duties?

  Yes

  No

  N/A

PERMIT

• All sections completed?

  Yes

  No

  N/A

• Purpose clear?

  Yes

  No

  N/A

• Duration specified?

  Yes

  No

  N/A

• Termination complete?

  Yes

  No

  N/A

• Monitoring results documented?

  Yes

  No

  N/A

• Entrant IN/OUT time completed?

  Yes

  No

  N/A

POSTING

• All entrances posted?

  Yes

  No

  N/A

• Permit posted or equivalent?

  Yes

  No

  N/A

• Unattended entrance posted/secure?

  Yes

  No

  N/A

CLIENT/CONTRACTOR

• Client/Contractor Notified?

  Yes

  No

  N/A

• Client/Contractor Contact Name

ISOLATION

• Energy sources identified?

  Yes

  No

  N/A

• Energy sources isolated?

  Yes

  No

  N/A

• Lock Out/Tag Out Permit?

  Yes

  No

  N/A

• System utilized?

• All isolation systems in place?

  Yes

  No

  N/A

• Tag out systems secure?

  Yes

  No

  N/A

• All personnel know the system (purpose/use)?

  Yes

  No

  N/A

ENTRY CONDITIONS

• Acceptable conditions documented?

  Yes

  No

  N/A

• Air monitoring appropriate for the hazard?

  Yes

  No

  N/A

• Outside the space prior to entry?

  Yes

  No

  N/A

• Full survey of the space on entry?

  Yes

  No

  N/A

AIR MONITORING

• Air monitoring equipment calibrated?

  Yes

  No

  N/A

• Oxygen level conducted?

  Yes

  No

  N/A

• LEL level conducted?

  Yes

  No

  N/A

• Toxic(s) conducted?

  Yes

  No

  N/A

• Testing appropriate for the hazard(s)?

  Yes

  No

  N/A

• Frequency appropriate?

  Yes

  No

  N/A

• Continuous

• Periodic

• Is the individual conducting the monitoring named on the permit?

  Yes

  No

  N/A

PPE

• Entrant?

  Yes

  No

  N/A

• Appropriately used?

  YES

  NO

• Properly worn?

  YES

  NO

• Attendant?

  Yes

  No

  N/A

• Appropriately used?

  YES

  NO

• Properly worn?

  YES

  NO

• Others?

  Yes

  No

  N/A

• Appropriately used?

  YES

  NO

• Properly worn?

  YES

  NO

• Attendant prepared?

  Yes

  No

  N/A

COMMUNICATION

• Voice?

• Electronic?

• Visual?

• Signal System?

• Other?

• Describe type.

• Documented / Verified Initially?

  Yes

  No

  N/A

• Documented / Verified Periodically?

  Yes

  No

  N/A

EQUIPMENT

• LIGHTING

• Natural

• Artificial

• Can all entrants actions be seen?

  Yes

  No

  N/A

• Class & Division appropriate?

  Yes

  No

  N/A

• Fire Extinguishers: 2 (10A:40B:C) on-site?

  Yes

  No

  N/A

• Acid/Caustic flushing equipment

  Yes

  No

  N/A

• EW

• SS

• Hose

• Accessible (10 ft.)?

  Yes

  No

  N/A

• Electronic communication equipment Class & Division appropriate?

  Yes

  No

  N/A

• Barriers / guards used where necessary?

  Yes

  No

  N/A

VENTILATION

• Supply

• Exhaust

• General Exhaust

• Local Exhaust

• Appropriate for hazard?

  Yes

  No

  N/A

• Sufficient Quantity? (Size of space-blower capacity)

  Yes

  No

  N/A

• Clean make-up air?

  Yes

  No

  N/A

• No recirculation?

  Yes

  No

  N/A

• Efficient set-up? (Blower location; min. Flex; str. Flex; min. Elbows, avoid sharp elbows)

  Yes

  No

  N/A

• Blower Secure?

  Yes

  No

  N/A

• Bonding ok?

  Yes

  No

  N/A

• Grounding?

  Yes

  No

  N/A

• Checked for continuity?

  Yes

  No

  N/A

• Guarded?

  Yes

  No

  N/A

• Hearing protection?

  Yes

  No

  N/A

• Appropriate for hazard?

  Yes

  No

  N/A

TRAINING

• FA/CPR-2 Persons (current certificate) on-site?

  Yes

  No

  N/A

• 1 Person outside?

  Yes

  No

  N/A

• Rescue current?

  Yes

  No

  N/A

• Safety meeting?

  Yes

  No

  N/A

• Initially documented?

  Yes

  No

  N/A

• Others documented?

  Yes

  No

  N/A

EMERGENCY PLANNING/RESPONSE

• CHES rescue?

  Yes

  No

  N/A

• Outside services planned?

  Yes

  No

  N/A

• Contracted / notified?

  Yes

  No

  N/A

• Emergency notification means set up?

  Yes

  No

  N/A

• Telephone

• 2-way

• Cellular

• Other

• Describe.

• Rescue Equipment

• Harness?

  Yes

  No

  N/A

• Lifeline?

  Yes

  No

  N/A

• Harness worn by all entrants?

  Yes

  No

  N/A

• SCBA set up and accessible?

  Yes

  No

  N/A

• Mechanical retrieval available?

  Yes

  No

  N/A

• Set up?

  Yes

  No

  N/A

GENERAL SITE CONDITIONS OR COMMENTS

• Brief description of site.

• Brief description of crew.

• Site Conditions?

  Excellent

  Good

  N.I.

  Poor

  Unsatisfactory

• Attach picture of the site if applicable.

  Media

• REVIEWED H&S MANAGER:

  Sign

• SUPERVISOR / FOREMAN

  Sign