Title Page
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Description of Activity
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Location of Activity
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Date
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Authority to Access Number
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Work Party Lead
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Supervisor
Task Readiness Verifications
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This section to be completed by the Work Party Lead
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All members of the work party are competent to perform their nominated roles
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The site / confined space conditions are compatible with the conditions noted on the Authority to Acess
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STOP. Check with MW Operations - conditions must be compatible with Authority to Access conditions
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The risk assessment is still appropriate for this work
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STOP. Review the risk assessment and add additional identified hazards and risk controls as required.
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Consideration has been given to the following:
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Weather Conditions?
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Traffic conditions?
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Water flow?
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Noise?
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Barricades?
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Signage?
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Site security?
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Communications?
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Ventilation?
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Hazards outside the confined space are being appropriately controlled (eg. Public)
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STOP. Control the external hazards before proceeding.
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Correct signage and barricades are in place
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Other control checks have been completed (eg. working at heights, hot work, excavations etc)
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Continuous communication can be achieved for this entry (visual / verbal)
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STOP. Ensure appropriate communications have been established and are implemented and functional before proceeding.
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The relevant MW system operator has been notified of the current intention to enter
Controls Page
- Controls Before Entry
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List the controls you are going to implement before entry (eg: purging, ventilation etc. Consider all hazards and issues)
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Control
Controls During Entry
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List the controls you are going to implement while the work is being done (eg: continuous mechanical ventilation, RPE etc)
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Control
Equipment Page
- Equipment Being Taken Into the Space
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Equipment
Equipment Exclusions
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Exclusion
Emergency Preparedness
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To be completed by Work Party Lead
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The rescue plan has been rehearsed (desktop, physical, videoed) and is appropriate for this entry
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STOP. You cannot enter this space until an appropriate rescue plan has been developed by the team, rehearsed and found to be functional.
Calibration and Bump Testing
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Detector Calibration
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Date Tested:
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Expiry Date:
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Serial Number
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Bump Test Conducted
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Date Bump Test Done:
Atmospheric Test Readings
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Enter peak readings prior to entry and when alarm sounds
Atmospheric Readings
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Name
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Time
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LEL (%) (Safe level <5)
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Oxygen (%) (safe level 19.5 to 23.5)
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H2S (ppm) (Safe level < 10 ppm)
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CO (ppm) (Safe level < 30 ppm)
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VOC (ppm) (Safe level < 10 ppm)
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NH3 (ppm) (Safe level < 25 ppm)
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Observer Initials
Entry Team
- Entry Team
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Name
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Role
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Observer
Entry and Exit Record
- Entry and Exit Record (Observer Completes)
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Name
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Time In
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Time Out
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Observer Initials
