Information

  • Site conducted

  • Document No.

  • Client Name

  • Client Contact

  • Conducted on

  • Prepared by

  • Location
  • Personnel

SECTION 1 - Risk Assessment

SECTION 1 - Risk Assessment

  • Document the hazards and analyse the risks associated with the entry and work activities to be undertaken with respect to the confined space

  • Reason For Entry

  • Description of Work Activity

  • Nature of Work to be Undertaken

  • Confined Space to be Entered

  • Description of Confined Space

  • Confined Space Catagory

  • MINIMUM STANDARD ENTRY CONTROLS

    - A pre-entry atmospheric test

  • MINIMUM STANDARD ENTRY CONTROLS

    - Pre-entry venting to ensure a safe atmosphere
    - A pre-entry atmospheric test
    - A stand-by person to be in constant communication with entry personnel

  • MINIMUM STANDARD ENTRY CONTROLS

    - Pre-entry and continuous venting to ensure a safe atmosphere
    - A pre-entry atmospheric test and continuous atmospheric monitoring
    - A stand-by person to be in constant communication with entry personnel
    - Provision of retrieval and rescue equipment at the immediate confined space location

  • Please consult your Test & Poly Supervisor

Risk Assessment Guide

  • Step 1 - Consider Concequences

    What are the consequences of this hazard occurring? Consider what is the most probable consequence (below) with respect to this work hazard

  • Concequence
  • Step 2 - Consider Likelihood

    What is the likelihood (below) of the hazard consequence in Step 1 occurring?

  • Likelehood
  • Step 3 - Calculate Risk

    1. Take Step 1 Rating and select the correct column
    2. Take Step 2 Rating and select the correct row
    3. Use the risk score where the two ratings cross on the below matrix

    E = Extreme
    H = High
    M = Moderate
    L = Low

  • Risk Matrix

Hazard Identification

  • Slips, Trips and Falls

  • Controls to Manage the Hazard

    - Tools Lanyard
    - Compliant Ladder
    - PPE

  • Other Controls Required?

  • Clearly list any other Controls required

  • Responsible Party to Implement Controls

  • Who is responsible to implement the nominated controls

  • Risk Rating with all nominated Controls in place

  • Traffic and/or pedestrians

  • Controls to Manage the Hazard

    - Barricades & Signage
    - Traffic Control & Devices

  • Other Controls Required?

  • Clearly list any other Controls required

  • Responsible Party to Implement Controls

  • Who is responsible to implement the nominated controls

  • Risk Rating with all nominated Controls in place

  • Chemical / Fume Inhalation

  • Controls to Manage the Hazard

    - Induction, Venting and/or Extraction
    - Gas Detecting & Monitoring

  • Other Controls Required?

  • Clearly list any other Controls required

  • Responsible Party to Implement Controls

  • Who is responsible to implement the nominated controls

  • Risk Rating with all nominated Controls in place

  • Drowning

  • Controls to Manage the Hazard

    - Pump out all Water
    - Check Plug Integrity Prior to Entering

  • Other Controls Required?

  • Clearly list any other Controls required

  • Responsible Party to Implement Controls

  • Who is responsible to implement the nominated controls

  • Risk Rating with all nominated Controls in place

Risk Assessment Personnel

  • Name, Employer and Signature

  • Select date

  • Name, Employer and Signature

  • Select date

  • Name, Employer and Signature

  • Select date

SECTION 2 - Entry Permit

SECTION 2 - Entry Permit

  • Isolation Controls

    This Confined Space needs to be isolated from

  • Water / Gas / Steam / Chemicals

  • Mechanical / Electrical Drives

  • Hydraulic / Electric / Gas / Power

  • Sludge / Deposits / Waste

  • Auto Fire Extinguishing Systems

  • Locks &/or Tags will be Affixed to Isolation Points

  • Other

  • Purging, Ventilation & Atmospheric Monitoring Controls

    This Confined Space requires the following

  • Depressurising

  • Opening / Venting

  • Continuous Purging / Extraction

  • Atmospheric Testing Required for

  • Oxygen (O2)

  • Carbon Monoxide (CO)

  • Hydrogen Sulphide (H2S)

  • Carbon Dioxide (CO2)

  • LEL

  • Ammonia (NH3)

  • Volatile Organic Compounds (VOC)

  • Other

  • Type of Testing / Monitoring Required

  • Initial Only - Prior to entry and each subsequent day

  • Continuous for Atmospheric Contaminants

  • Continuous for Flammable Contaminants

  • Communication & Stand By Controls

    Minimum Requirements will include

  • One Stand By Person

  • Two or More Stand By Persons

  • Rescue Team

  • Communication Via Voice and Direct Sight

  • Communication Via Radio

  • Communication Via Hand Signals and Other Means

  • Rescue / Retrieval Considerations

    Minimum Provisions are to include

  • Stand By Person to individually handle

  • Safety Harness / Rescue Kit in vicinity with competent user(s)

  • Specific access to platforms/scaffolding erected

  • Specific Fire fighting provisions

  • First aid kit in vicinity

  • Other

  • Personal Protective Equipment (PPE) Requirements

    Minimum items required

  • Supplied breathing apparatus

  • Air purifying respirator

  • Particulate mask

  • Safety harness and lanyard / lifeline

  • Head protection

  • Face shield / goggles / safety glasses

  • Ear muffs / plugs

  • Gloves

  • Warning notices / barricading

  • Specific lighting provisions

  • Specific hot work controls

  • Other

Permit Request

  • This acknowledgement signifies a formal request to commence confined space entry / works. As the person requesting this permit, I hereby certify that; 1. I am competent to coordinate this confined space entry / work in accordance with the previous Risk Assessment & Entry Permit details; 2. I shall undertake to implement all planned and necessary controls to ensure safe entry / work; 3. I shall monitor confined space hazards and control methods throughout the entry / work;

  • Time & Date Signed

Permit Authorisation

  • This authorisation signifies that the planning component of the Risk Assessment & Entry Permit has been completed and that the confined space entry / work is authorised to commence in accordance with the Permit Request.

  • Time & Date Signed

SECTION 3 - Implementation

SECTION 3 - Implementation

  • Atmospheric Test Results

  • Test Time & Date

  • Oxygen (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Monoxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Hydrogen Sulphide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Dioxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • LEL (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Ammonia (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Other

  • Gas Detector Number

  • Entry Permitted?

  • Personnel taking results

  • Another test

  • Atmospheric Test Results

  • Test Time & Date

  • Oxygen (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Monoxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Hydrogen Sulphide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Dioxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • LEL (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Ammonia (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Other

  • Gas Detector Number

  • Entry Permitted?

  • Personnel taking results

  • Another test

  • Atmospheric Test Results

  • Test Time & Date

  • Oxygen (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Monoxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Hydrogen Sulphide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Dioxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • LEL (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Ammonia (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Other

  • Gas Detector Number

  • Entry Permitted?

  • Personnel taking results

  • Another test

  • Atmospheric Test Results

  • Test Time & Date

  • Oxygen (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Monoxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Hydrogen Sulphide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Dioxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • LEL (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Ammonia (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Other

  • Gas Detector Number

  • Entry Permitted?

  • Personnel taking results

  • Another test

  • Atmospheric Test Results

  • Test Time & Date

  • Oxygen (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Monoxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Hydrogen Sulphide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Dioxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • LEL (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Ammonia (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Other

  • Gas Detector Number

  • Entry Permitted?

  • Personnel taking results

  • Another test

  • Atmospheric Test Results

  • Test Time & Date

  • Oxygen (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Monoxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Hydrogen Sulphide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Dioxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • LEL (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Ammonia (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Other

  • Gas Detector Number

  • Entry Permitted?

  • Personnel taking results

  • Another test

  • Atmospheric Test Results

  • Test Time & Date

  • Oxygen (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Monoxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Hydrogen Sulphide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Dioxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • LEL (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Ammonia (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Other

  • Gas Detector Number

  • Entry Permitted?

  • Personnel taking results

  • Another test

  • Atmospheric Test Results

  • Test Time & Date

  • Oxygen (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Monoxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Hydrogen Sulphide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Carbon Dioxide (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • LEL (%)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Ammonia (ppm)

  • NOT SAFE TO ENTER

    Re-Test and confirm safe limits with supervisor

  • Other

  • Gas Detector Number

  • Entry Permitted?

  • Personnel taking results

  • Another test

Entry Authorisation

  • The procedures, control measures and precautions appropriate for the safe entry / work in this confined space have been implemented and the persons required to work in the confined space have been David of and understand the requirements of the Risk Assessment & Entry Permit

  • Time & Date Signed

  • CONSTRAINTS This Entry Authorisation is valid until the following occurs or the time and date shown

  • Select date

Personnel Entry

  • I the undersigned, hereby acknowledge that I fully understand the procedure, control measures and precautions to be observed with the entry / work and exit involved with this confined space. I will comply with these requirements at all times and report any unforeseen hazard that presents a risk to safety

  • Add signature

  • Select date

  • Add signature

  • Select date

  • Add signature

  • Select date

  • Add signature

  • Select date

Withdrawal of Entry Authorisation

  • All persons and equipment has been accounted for and the equipment and confined space has been restored correctly and safely

  • Select date

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