Confined Space Permit

• Work specified in the Permit is conditional on all contractors having read, understood and signed the Integral Induction Pack.

• Permit Number:

• Work Request Number:

• Associated PTW Number?:

• Company name:

• Competent person in charge:

• Other personnel engaged in the works:

• From:

  Date

• Until:

  Date

Where

• Where will the works take place?:

• Description of works:

• How will the works be carried out:

• Comments / Special conditions:

Condition of Confined space / Plant:

• The confined space / plant is isolated from all sources of danger, heat, fumes and chemicals

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• The confined space / plant main valves are closed and locked

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• The confined space / plant has been drained and vented

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• Dangerous sludge and other deposits have been removed

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• The confined space / plant has been inert gas purged

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• Mechanical drives have been disconnected, electrical circuits have been isolated and locked off

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• The atmosphere has been tested and is free from toxic or flammable substances

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• There is an adequate supply of fresh air to the location

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

Special precautions to be taken:

• Protective clothing shall be worn, as per risk assessment

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• Safety harness and lifelines shall be worn

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• Forced ventilation shall be provided

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• Fresh air / self-contained* breathing apparatus shall be worn

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• Flame proof, intrinsically safe lighting shall be used

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• Access, egress and rescue plans agreed

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• Observer / rescue personnel shall be posted outside the space

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• Adequate rescue, resuscitation and first aid equipment is provided

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• Continuous air monitoring to be carried out with automatic alarm

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

• Suitable communication equipment will be available

  Yes

  No

  N/A

• Suspend permit and do not proceed further.

Atmospheric test results prior to entry:

• Is Atmospheric testing required prior to entry?

  Yes

  No

  N/A

• To be retaken every:

• Record on Gas Test Record sheet

• Oxygen sufficiency / deficiency test result, entry not permitted below 20% or above 20.8%

• Flammable gas test result:

  Pass

  Fail

  N/A

• If positive, permit is not to be issued

• Toxic gas results:

• CO PPM

• H2S PPM

• Dust / fibre count result:

• Reading Taken By:

• Title:

• Date:

  Date

• Breathing apparatus must be worn

  Yes

  No

  N/A

Approvals

• Approved By:

• Signature:

  Sign

• Date:

  Date

Authorisation:

• I confirm that I have personally checked that the control measures above are in place and consider it safe to carry out this work.

• Issued By:

• Signature:

  Sign

• Date:

  Date

Acceptance:

• : I understand the hazards of this work and the precautions to be taken. These have been fully explained to the operatives carrying out this work and I consider them to be adequately equipped, trained, competent and fit to do it safely. All safety equipment is present and working properly. I will closely supervise these works to ensure that they are carried out in accordance with the terms of this Permit. I will return my copy of this permit to the authorised person when this work has been safely completed. In the event of an emergency I will cease the work safely and comply with the Site emergency procedures. Work will only recommence when a new risk assessment has been done and a new permit issued.

• Accepted By

• Signature:

• Date:

Clearance:

• Clearance: The work *has / *has not been completed and uncompleted work will not restart until a new Permit is issued. (*Delete as applicable). I confirm that personnel and equipment have been withdrawn. The location has been restored to a safe and orderly condition. I have returned my copy of this Permit to the authorised person.

• Returned By:

• Signature:

• Date:

Closure:

• Closure: I accept that the work has been safely completed / stopped. This permit is closed and invalid.

  Yes

  No

  N/A

• Closed By:

• Date:

  Date

• Permit remains open until all works have been completed safely.

Test 1

• Time

• Oxygen %

• Exp Lel %

• CO PPM

• H2S PPM

• Other

Test 2

• Time

  Date

• Oxygen %

• Exp Lel %

• CO PPM

• H2S PPM

• Other

Test 3

• Time

• Oxygen %

• Exp Lel %

• CO PPM

• H2S PPM

• Other