Confined Space Inspection and Analysis Form

• Document No.

• Audit Site / Title :

• Conducted on

  Date

• Prepared by ID & Analysis Team members

• Location
  Address

• Contact number/s:

Part A - Confined Space Details

• Exact description of Confined Space (I.e. Sump Pump Pit)

• Exact Location of the Confined Space (I.e. Bulk Fuel Bund)

Using information from part "D"

• Is this space a Confined Space ?

  No

  Yes

• Are additional controls required before entry ?

  No

  Yes

Part B - PHOTO/s

• Attach photo's

  Media

Part C - INHERENT HAZARDS (if the answer is yes to questions below, provide explanation):

• Is there a potential for an oxygen deficient atmosphere ?

  No

  Yes

• Is there a potential for an oxygen enriched atmosphere ?

  No

  Yes

• Is there a potential for toxic gasses, vapors or fumes ?

  No

  Yes

• Is there a potential for particulates ?<br>(including dust)

  No

  Yes

• Could contaminants be trapped in sludge, scale liquids etc?

  No

  Yes

• Could contaminants be trapped in fittings, joints, bends in pipes etc?

  No

  Yes

• Could contaminants be caused by oxidation, decomposition, leaks etc?

  No

  Yes

• Structural integrity, movement of the space?

  No

  Yes

• Moving parts, machinery / equipment, stored energy within the space?

  No

  Yes

• Potential for engulfment / introduction of materials / suspended loads ?

  No

  Yes

• Temperature, lighting or noise extremes ?

  No

  Yes

• Potential for exposure to elements, snakes, insects, animals etc?

  No

  Yes

• Electrical equipment, cables, services ?

  No

  Yes

• Ergonomics or manual handling issues ?

  No

  Yes

• Is there a potential for the space/access to the space to become wet?

  No

  Yes

• Entry and exit openings are large enough to allow emergency access?

  Yes

  No

• Is there a potential for slips, trips or falls?

  No

  Yes

• Is there a potential for absorption, inhalation or ingestion of substances?

  No

  Yes

Part D - ANALYSIS

Table 1

Physical Characteristic

Step A

• Is space enclosed or partially enclosed?

  No

  Yes

Step B

• Is space intended or designed primarily for other than human occupancy?

  No

  Yes

Identified Hazards

Step C

• Could the atmosphere have oxygen concentration outside the safe oxygen range?

  No

  Yes

Step D

• Could the atmosphere have a concentration of airborne contaminant that may cause impairment, loss of consciousness or asphyxiation ?

  No

  Yes

Step E

• Could the atmosphere have a concentration of flammable airborne contaminant that may cause injury from fire or explosion?

  No

  Yes

Step F

• Could the atmosphere have a stored free-flowing solid or a rising level of liquid that may cause suffocation or drowning?

  No

  Yes

Notes: 1. For an enclosed or partially enclosed space to be considered as a potential confined space, the following conditions apply: Confined Space = A + B + ( C or D or E or F ). 2. The hazards identified in Steps C to F should be confirmed Bruce risk assessment using section "C"

• Using Table 1 - Is the space determined to be a confined space? <br>(If you answer Yes to this then complete the rest of the form.)

  No

  Yes

• If the space is not classed as a confined space should additional control measures be implemented before entry?<br>( if you answer yes to this then complete the rest of the form.)

  No

  Yes

If you answered NO to both questions then there is no need to complete the rest of the form. Save and file as evidence of analysis of the space.

Part E - NATURE OF THE SPACE

• Is the space appropriately signposted at all access points?

  Yes

  No

• Dimension of the space

• Length:

• Width:

• Height / Depth:

• Diameter:

• What is the space primarily designed for?

• What is the space made of? (e.g. Metal, wood, plastic, rubber, other?)

• Type of entry (e.g. Vertical, Horizontal, Diagonal, other?)

• Is the main access point located above the ground?<br>(if YES, how high?)

  No

  Yes

• # 1 Main access point dimensions

• Height / Length:

• Width:

• Diameter:

• # 2 Additional access point dimensions

• Height / Length:

• Width:

• Diameter:

• # 3 Additional access point dimensions

• Height / Length:

• Width:

• Diameter:

• # 4 Additional access point dimensions

• Height / Length:

• Width:

• Diameter:

• # 5 Additional access point dimensions

• Height / Length:

• Width:

• Diameter:

• Are any of the access points obstructed?<br>(if YES, explain)

  No

  Yes

• Anything located near the space that may pose a concern?<br>(if YES, explain)

  No

  Yes

• Suitable anchorage point above or near access?<br>If no elaborate:

  Yes

  No

  N/A

Part F - CONSIDERATIONS

Isolations

• Is there any isolation procedure covering this space?<br>(if YES, explain, note relevant documents, isolations sheets as an example)

  No

  Yes

• List any services requiring isolation for safe occupancy:

Emergency Response

• Is there any Confined Space Emergency Response Plan available? <br>(if YES, explain, note relevant documents, isolations sheets as an example)

  No

  Yes

• Is there any concern about the ability to rescue persons from this space?<br>If YES detail the concerns and contact your Safety Co-ordinator or Emergency Services to assist develop an emergency response plane as required.

  No

  Yes

• Other considerations:

Part G - GENERAL

• What is the most credible incident that could occur from the hazards listed at Section "D" of the analysis sheet?:

• How often is the space entered?

  Daily

  Weekly

  Monthly

  Yearly

  Almost never

• How often is Hot Work undertaken?

  Daily

  Weekly

  Monthly

  Yearly

  Almost never

• Is it reasonably practicable to engineer out the need to enter the space?<br>If YES explain:

  No

  Yes

• This space should be targeted for further action as a priority?<br>If YES explain:

  No

  Yes

• Other:

Part H - LEVEL OF RISK

• Likelihood ?

  Almost Certain

  Likely

  Possible

  Unlikely

  Rare

• Consequence ?

  Catastrophic

  Major

  Moderate

  Minor

  InsignificantyI

• Risk ranking result ?

  Extreme

  High

  Medium

  Low

  Very Low

Part I - NOTES

• Enter any further notes here.