Confined Spaces - Permit to Work

• Conducted on

  Date

• Prepared by

• Location
  Address

• 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.

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.

  Yes

  No

  N/A

• 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)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is the supply of respirable air assured?

  Yes

  No

  N/A

• Is additional Ventilation required?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• Is a 10 minute Escape Breathing Set Required?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is continual gas monitoring required?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is a Rescue Team required on standby?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

ATMOSPHERE TEST 1

• Insert Time of Atmosphere Test 1

  Date

• Oxygen %

• Oxygen %

  Pass

  Fail

  N/A

• Carbon Monoxide %

• Carbon Monoxide %

  Pass

  Fail

  N/A

• Combustible Hydrocarbons %

• Combustible Hydrocarbons %

  Pass

  Fail

  N/A

• Hydrogen Sulphide H2S %

• Hydrogen Sulphide H2S %

  Pass

  Fail

  N/A

ATMOSPHERE TEST 2

• Insert Time of Atmosphere Test 2

  Date

• Oxygen %

• Oxygen %

  Pass

  Fail

  N/A

• Carbon Monoxide %

• Carbon Monoxide %

  Pass

  Fail

  N/A

• Combustible Hydrocarbons %

• Combustible Hydrocarbons %

  Pass

  Fail

  N/A

• Hydrogen Sulphide H2S %

• Hydrogen Sulphide H2S %

  Pass

  Fail

  N/A

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?

• Person in Charge of Works

• Company

• Signature

  Sign

• Authorising Person

PERMIT EXPIRY DETAILS

• Permit Expires on

  Date

• 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.

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)

  Sign

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)

  Sign

PERMIT CANCELLED

• Permit Cancelled

  Date