Title Page

  • Conducted on

  • Prepared by

  • Location

JOB DETAILS

  • CONFINED SPACES PERMIT TO WORK NUMBER

  • What works will be undertaken?

  • Special Tools / Equipment to be Used

  • Job Location / Plant Identification Number

  • Is any other work currently being undertaken that may interact or affect this permit? (Quote Permit numbers where applicable)

This Permit is only Valid when all sections are complete. If you are in doubt or don't understand, then please ask. Remember, all accidents are preventable and it is people who get hurt and suffer pain. Please use this permit in the spirit intended to protect yourself and others. Please ensure that you sign this permit to work. DO NOT PROCEED WITH YOUR WORK UNTIL YOUR PERMIT HAS BEEN AUTHORISED BY THE RELEVANT MEMBER OF STAFF.

HAZARDS & PRECAUTIONS TO BE TAKEN

PRIMARY HAZARDS - Fire, Fumes, High or Low Oxygen Levels / Presence of asphyxiant gases / Machinery Start up whilst personnel are inside / High Temperatures (Heat Exhaustion / Heat Stroke) / Drowning

Please answer the questions truthfully

  • Are all Entrants confined space trained to the appropriate level. Breathing Apparatus requires entrants to have undertaken High Risk Training.

  • Has the confined space been isolated from all connected Pipework - if this has ben undertaken my valves are they Locked Out and Tagged Out (LOTO)

  • Has the confined space been purged with steam / nitrogen / water or air?

  • Has the Confined space been Electrically Isolated - LOTO applied and Proven Dead by use of Test Equipment?

  • Is the Confined Space below 30oC on full cooling?

  • Is the supply of respirable air assured?

  • Is additional Ventilation required?

  • Is there an acceptable means of access and escape from the confined space? Can all entrants fit through the escape point?

  • Is breathing apparatus (Tank or surface mounted) been used?

  • Is the low air alarm set correctly on tank mounted equipment i.e. alarm sounds 10 minutes before supply runs out.

  • If Surface mounted RPE is used, does each member of the team have an emergency mouthpiece they can connect to another workers supply line, if there own supply pipe fails?

  • Is a 10 minute Escape Breathing Set Required?

  • Has the Entrant been trained in the use of the escape breathing set?

  • Is continual gas monitoring required?

  • Are all Gas Detectors in Calibration Date and Bump Tested PRIOR to entry into the confined space?

  • Are all Gas Detectors fully charged before entering the confined space?

  • Is intrinsically safe equipment required i.e. Non-Sparking CuBe Tools or ATEX Rated Electrical Equipment?

  • Are personnel wearing flame retardant overalls / boots and gloves?

  • Are personnel wearing eye protection / head protection if required?

  • Is a harness required for access / egress or emergency rescue?

  • Is a Standby Person present at the Confined Space Entrance at all times?

  • Has the Standby person got a method of accounting for all persons entering and leaving the confined space - i.e. Tally Board.

  • Is a Rescue Team required on standby?

  • Has the Standby person explained the rescue plan to all the entrants?

  • Has the rescue team set up all the required equipment before work commences - i.e. Tripod / Winch / Stretcher / Harness / 1st Aid Resuscitation Equipment.

  • Have the means of communication been established and tested - i.e. Radio Checks on 2 Way Radios.

  • Is there an alternative means of raising the alarm from the confined space i.e. Rescue Bell?

  • Is Hot Work been undertaken within the confined space? If Yes - a Hot Works permit is also required.

  • Is atmosphere test required? If yes, complete section below.

ATMOSPHERE TEST 1

  • Insert Time of Atmosphere Test 1

  • Oxygen %

  • Oxygen %

  • Carbon Monoxide %

  • Carbon Monoxide %

  • Combustible Hydrocarbons %

  • Combustible Hydrocarbons %

  • Hydrogen Sulphide H2S %

  • Hydrogen Sulphide H2S %

ATMOSPHERE TEST 2

  • Insert Time of Atmosphere Test 2

  • Oxygen %

  • Oxygen %

  • Carbon Monoxide %

  • Carbon Monoxide %

  • Combustible Hydrocarbons %

  • Combustible Hydrocarbons %

  • Hydrogen Sulphide H2S %

  • Hydrogen Sulphide H2S %

OTHER PRECAUTIONS REQUIRED

  • Do any other precautions need to be put in place to allow the works to proceed safely?

  • Is any other safety equipment required for the works to proceed safely?

AUTHORISATION & ACCEPTANCE - I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the works as defined above and the permit has been explained to all workers involved. I accept responsibility for this work.

  • Person in Charge of Works

  • Company

  • Signature

  • Authorising Person

PERMIT EXPIRY DETAILS

  • Permit Expires on

RESCUE PLAN

  • Name of Person leading Rescue Team

  • Rescue Method to be used - i.e. Tripod / Stretcher / Rescue Harness

  • Telephone Number for Rescue Team

Confined Space Entry not permitted until a rescue plan has been established.

HAND BACK & CANCELLATION

I confirm that the work has been completed, checked by myself, all entrants have been accounted for and have left the confined space and the area left in a safe and tidy condition.

  • Person in Charge (Print Name)

  • Person in Charge (Signature)

I have inspected the completed work, confirmed all entrants have left the confined space safely. I hereby cancel this permit.

  • Authorised Person (Print Name)

  • Authorised Person (Signature)

PERMIT CANCELLED

  • Permit Cancelled

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.