Confined Space Entry Permit

• Case Number

• Conducted on

  Date

• Prepared by

• Location
  Address

• Confined Space location

• Work to be conducted

• Asset/Manhole Number

• Is the space enclosed or partially enclosed?

  Yes

  No

• Does the space have a limited or restricted entry or exit? (It may be restricted by the size of the opening or its location. Is the space physically difficult to get in or out and/or would it be difficult to remove an injured or unconscious person)

  Yes

  No

• Is it intended or likely to be entered and is it at normal atmospheric pressure? (Is there a risk that the person may be overcome or incapacitated by the conditions within the space?)

  Yes

  No

• Does the space contain, is intended to contain, or is likely to contain:

  Select Harmful level of atmospheric contaminants? Substances that could cause engulfment? An unsafe oxygen level as defined in Regulation 5 of OHS Regulations 2017? (eg. oxygen content<19.5% or > 23.5%)

  • Harmful level of atmospheric contaminants?
  • Substances that could cause engulfment?
  • An unsafe oxygen level as defined in Regulation 5 of OHS Regulations 2017? (eg. oxygen content<19.5% or > 23.5%)

• Space is a Confined Space, please continue to complete this Permit.

Persons entering Confined Space

• Is a person entering the confined space?

  Yes

  No

• Names of person(s) entering Confined Space?

• Designated Supervisor for CS Entry

• Entry method Selected

  Top Entry

  Side Entry

  Other

• Please state:

• Are Hazardous Substances/Chemicals being used in CS?

  Yes

  No

• Please state type

• Are SDS on site?

  Yes

  No

• Communication method between standby person and person(s) in CS

  Select Verbal 2 way radio Mobile Phone Other

  • Verbal
  • 2 way radio
  • Mobile Phone
  • Other

• Please state

Emergency Rescue Plan

• Is an Emergency Rescue Procedure and/or Plan in place?

  Yes

  No

• Is all First Aid & Emergency Rescue Equipment accessible?

  Yes

  No

• Type of Entry?

  Top Entry attached

  Top Entry detached

  Side Entry attached

  Side Entry detached

• Steps:
  1. Safety Observer: Use winch system to extract injured person from
  Confined Space via top opening.
  2. Standby Person: Call 000 and make initial contact with Emergency
  Services if required.
  3. Standby Person: Provide First Aid/CPR and provide medical
  attention.

  

• Steps:
  1. Safety Observer: Use lifeline to extract injured person from Confined Space via side opening.
  2. Standby Person: Call 000 and make initial contact with Emergency Services if required.
  3. Standby Person: Provide First Aid/CPR and provide medical attention.
  

  

• Steps:
  1. Safety Observer: Use Breathing Apparatus and winch to enter Confined Space via top opening.
  2. Standby Person: Call 000 and make initial contact with Emergency Services if required.
  3. Standby Observer: Attach winch to injured person.
  4. Standby Person: Use winch to extract injured person from Confined Space via top opening.
  5. Standby Person: Provide First Aid/CPR and provide medical attention.
  

  

• Steps
  1. Safety Observer: Use Breathing Apparatus and winch to enter Confined Space via side opening.
  2. Standby Person: Call 000 and make initial contact with Emergency Services if required.
  3. Safety Observer: Attach lifeline to extract injured person and start to pull person from Confined Space via side opening.
  4. Standby Person: Assist by pulling the lifeline and extracting the injured person.
  5. Standby Person: Standby Person: Provide First Aid/CPR and provide medical attention.
  6. Safety Observer: Exit confined space.
  

  

• Person nominated to be Safety Observer

  Sign

• Person nominated to be Standby Person

  Sign

• Name and address of closest Hospital

• Emergency Rescue Plan

• Stop work immediately. Only enter once Emergency Rescue Plan is implemented.

  

Approval to Enter

• If person is entering, the confined space described in this entry permit is safe to be entered using precautions listed above and all persons are properly certified to perform this work.

  Sign

Isolations

• Isolations required

  Select No isolations required Water Chemicals Mechanical Drives Electricity Hydraulic Gas Sludge/Waste

  • No isolations required
  • Water
  • Chemicals
  • Mechanical Drives
  • Electricity
  • Hydraulic
  • Gas
  • Sludge/Waste

Water

• Location/Method

• Locks and/or Tags have been affixed to isolation points

  Yes

  No

• Name of person responsible

Chemicals

• Location/Method

• Locks and/or Tags have been affixed to isolation points

  Yes

  No

• Name of person responsible

Mechanical Drives

• Location/Method

• Locks and/or Tags have been affixed to isolation points

  Yes

  No

• Name of person responsible

Electricity

• Location/Method

• Locks and/or Tags have been affixed to isolation points

  Yes

  No

• Name of person responsible

Hydraulic

• Location/Method

• Locks and/or Tags have been affixed to isolation points

  Yes

  No

• Name of person responsible

Gas

• Location/Method

• Locks and/or Tags have been affixed to isolation points

  Yes

  No

• Name of person responsible

Sludge/Waste

• Location/Method

• Locks and/or Tags have been affixed to isolation points

  Yes

  No

• Name of person responsible

Atmospheric Testing

• Date Gas Monitor last bump tested?

  Date

• Date last Gas Monitor calibrated?

  Date

• Frequency of Monitoring

  Continuous

  30mins

  Hourly

  Other

• Please state

• Is venting required?

  Yes

  No

• What type?

  Natural

  Forced/Mechanical

• Is Purging required?

  Yes

  No

• Gas used?

Hot Works

• Hot Works required?

  Yes

  No

• Hot works must not be performed if the LEL is above 5%

• Clear of combustibles (incl) atmosphere

  Yes

  No

  N/A

• Type of fire prevention equipment available:

• Is it a Total Fire Ban Day?

  Yes

  No

• Is it emergency works?

  Yes

  No

• Hot works not permitted.

  

• Has the area been cleared of combustible material for 15 metres?

  Yes

  No

  N/A

• If not, why?

• Are appropriate Fire Extinguishers available on site?

  Yes

  No

• If not, why?

  Yes

  No

  N/A

• What type?

  Water

  Dry Powder

  Foam

  CO2

  Wet Chemical

• Is a Water Hose or 2 Knapsack Water Sprays available and tested on site?

  Yes

  No

• If a water hose or 2 knapsack water sprays are not available, hot works must not commence.

• Is extra ventilation required?

  Yes

  No

• What type, and where is it to be located?

• Are welding machines/gas bottles at least 8 metres from entry?

  Yes

  No

  N/A

• Reason?

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Personal Protective Equipment - what is required?

• Required Personal Protective Equipment

  Select Head protection Eye protection Hearing protection Hand protection Safety Harness Respirator Breathing Apparatus Dust Mask Oxy Box Gumboots Other

  • Head protection
  • Eye protection
  • Hearing protection
  • Hand protection
  • Safety Harness
  • Respirator
  • Breathing Apparatus
  • Dust Mask
  • Oxy Box
  • Gumboots
  • Other

• Please state other PPE used

• Harness / Lifeline (with valid inspection TAG) required?

  Yes

  No

• Safety Equipment required

  Select Winch Tripod Harness Davit arm Lifeline Other

  • Winch
  • Tripod
  • Harness
  • Davit arm
  • Lifeline
  • Other

• Type used?

• Is equipment tagged and in date?

  Yes

  No

• Other type of PPE required?

  Select Platforms Waders Man Cage Road Signage Bosun Fire Extinguisher Chemical suit 2 way radio Lighting Airline Ladders First Aid kit

  • Platforms
  • Waders
  • Man Cage
  • Road Signage
  • Bosun
  • Fire Extinguisher
  • Chemical suit
  • 2 way radio
  • Lighting
  • Airline
  • Ladders
  • First Aid kit

Atmospheric Testing

Oxygen (O2) Concentration between 19.5 & 23.5%

• Fresh Air Reading

• Reading 1

• Reading 2

• Reading 3

• Reading 4

• Reading 5

Flammables (LEL) <5% of its LEL

• Fresh Air Reading

• Reading 1

• Reading 2

• Reading 3

• Reading 4

• Reading 5

Hydrogen Sulphide (H2S) TWA <10ppm

• Fresh Air Reading

• Reading 1

• Reading 2

• Reading 3

• Reading 4

• Reading 5

Carbon Monoxide (CO) TWA <30ppm

• Fresh Air Reading

• Reading 1

• Reading 2

• Reading 3

• Reading 4

• Reading 5

Ammonia (NH3) TWA <25ppm

• Fresh Air Reading

• Reading 1

• Reading 2

• Reading 3

• Reading 4

• Reading 5

Volatile Organic Compounds (VOC) <10PPM

• Fresh Air Reading

• Reading 1

• Reading 2

• Reading 3

• Reading 4

• Reading 5

Other

• Reading 1

• Reading 2

• Reading 3

• Reading 4

• Reading 5

CWW Enter/Exit times

• Contact GWW for Entry and Exit Times - 1800 057 981 or 9313 8499

• Time Phoned in

  Date

• GWW Operators name

• Time Phoned out

  Date

• GWW Operators name

Completion

• If CSE entered, all persons have left Confined Space. (No further entries permitted without a new Permit)

  Sign

• Shift time out

  Date