Confined Space Evaluation & Emergency Response Plan

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

General Details

• Space Name

• Yes

  No

  N/A

• Equipment Number

• Space Location

• Team / Crew

Nature Of The Space

• Describe the Space

• Primary Intent of the Space

• What is the space made of

• Describe the entry points

• Add media

  Media

• Add drawing

  Drawing

Is Entry Necessary? (It is vital to consider the need to actually enter the space at all)

• Most probable tasks performed in the confined space?

• How often will these tasks be undertaken?

• Can the task be done without entering the space?

• Can the task be done using any other method?

Inherent Atmospheric Hazards (during normal operation)

• Oxygen enriched or deficient<br>

  Safe

  At Risk

  N/A

• Combustible gases

  Safe

  At Risk

  N/A

• Toxic gases

  Yes

  No

  N/A

Potential Atmospheric Hazards (When shutdown what could enter the space)

• Contaminants in sludge, etc

  Safe

  At Risk

  N/A

• Contaminants in fittings, etc

  Safe

  At Risk

  N/A

• Oxidation, decomposition

  Safe

  At Risk

  N/A

• Other causes

  Safe

  At Risk

  N/A

Other Inherent Hazards

• Movement of the space

  Safe

  At Risk

  N/A

• Moving equipment (in/outside)

  Safe

  At Risk

  N/A

• Engulfment

  Safe

  At Risk

  N/A

• Stored energy

  Safe

  At Risk

  N/A

• Temperature extremes

  Safe

  At Risk

  N/A

• Natural hazards, insects, snakes, rats, etc

  Safe

  At Risk

  N/A

• Electrocution

  Safe

  At Risk

  N/A

• Ergonomics, poor posture, etc

  Yes

  No

  N/A

• Difficult access / egress

  Yes

  No

  N/A

• Fire / Explosion

  Safe

  At Risk

  N/A

• Radiation

  Safe

  At Risk

  N/A

• Slips, trips or falls

  Safe

  At Risk

  N/A

• Hazardous chemicals

  Safe

  At Risk

  N/A

• Excessive noise

  Safe

  At Risk

  N/A

• Poor lighting

  Yes

  No

  N/A

• Dust

  Yes

  No

  N/A

• Remote location

  Yes

  No

  N/A

• Poor communication

  Yes

  No

  N/A

Specific Controls (Common basic controls listed below. Note: Other controls may be required to complete tasks inside the space. Refer to a risk assessment of the task)

• Isolations required (List minimum isolations below)

  Yes

  No

  N/A

• Is a standby person required?

  Yes

  No

  N/A

• Is an Emergency Response Plan required?

  Yes

  No

  N/A

• Other considerations (List below)

  Yes

  No

  N/A

CONFINED SPACE EMERGENCY RESPONSE PLAN

General Details

• Space Name

• Equipment Number

• Task Description

• Notable Hazards

Emergency Response Team Requirements

• First Aid Training

  Yes

  No

  N/A

• Confined Space Training

  Yes

  No

  N/A

• Communication

  Yes

  No

  N/A

• SDS Information

  Yes

  No

  N/A

• Emergency Phone Numbers

  Yes

  No

  N/A

Response Requirements (When do Emergency Services have to know about the task?)

• Contact upon emergency

  Yes

  No

  N/A

• Contact prior to entry

  Yes

  No

  N/A

• ERT at space prior to entry

  Yes

  No

  N/A

• Emergency Phone:

• Emergency Radio Channel:

• Nearest pick-up point:

Equipment Requirements

• Tripod / Winch

  Yes

  No

  N/A

• Harness and SRL (attach at all times)

  Yes

  No

  N/A

• Air Monitor

  Yes

  No

  N/A

• Respirator

  Yes

  No

  N/A

• Basket Stretcher

  Yes

  No

  N/A

• First Aid Kit

  Yes

  No

  N/A

• AED (If Available)

  Yes

  No

  N/A

• Lighting

  Yes

  No

  N/A

• Tyvek or Hazardous Chemical Suits

  Yes

  No

  N/A

• Fire Extinguisher

  Yes

  No

  N/A

• Other Requirements

• Equipment must be at the space:

• Upon Emergency

  Yes

  No

  N/A

• Prior to entry

  Yes

  No

  N/A

Rescue Plan (Diagram and / or notes)

• Add drawing

  Drawing

• Notes:

Rehearsal Requirements

• Is this plan required to be rehearsed

  Yes

  No

  N/A

• General notes:

• In the event of any emergency the alarm MUST be raised immediately. Standby personnel must be prepared to initiate rescue procedures. DO NOT enter the space in an emergency unless trained and if safe to do so. A qualified first-aides must be available in the event of an emergency. If trained and able to do so, attempt to extinguish a fire. If any situation is beyond control evacuate the area and wait further instructions.

• Safety Manager

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• Responsible Person

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