Delta Company Ltd.

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Confined Space Assessment Study Form

Information

• Assessment Study Conducted By:

• Location of Identified Space:

  Select Al Maather Al Hazem Al Waha Hindawiah Khuzam 69 KV Dammam Al Khatam Al Lith Bawat Murjan Taima Tabuk

  • Al Maather
  • Al Hazem
  • Al Waha
  • Hindawiah
  • Khuzam
  • 69 KV Dammam
  • Al Khatam
  • Al Lith
  • Bawat
  • Murjan
  • Taima Tabuk

• Time of Study:

  Date

• Definition : An enclosed or partially enclosed space that is not intended or designed for human occupancy, within which there is a risk of:
  • Oxygen concentration less than the safe level;
  • Airborne contaminant that may cause impairment, loss of consciousness or asphyxiation;
  • A presence of a gas or substance that displaces oxygen
  • Flammable airborne contaminant that may cause injury from a fire or explosion;
  • Engulfment in a stored free-flowing solid or rising level of liquid that may cause suffocation or drowning.
  It is important to note that a confined does not necessarily have to be small and “confined” it simply has to be “not designed for continuous human occupancy”.

QUESTIONS

• 1. Is the space enclosed or partially enclosed?

  Yes

  No

• 1. Floors- clean and free of dirt or other dangers

  Yes

  No

• 2. Is the space intended or designed primarily for other use other than human occupancy? Would you put your desk there to do work

  Yes

  No

• 3. Is the place being entered a limited or restricted means for entering and exiting the space.

  Yes

  No

• 4. May the oxygen concentration levels be outside the safe oxygen level range?

  Yes

  No

• 5. May the atmospheric contaminants cause impairment , loss of consciousness or asphyxiation?

  Yes

  No

• 6. Are there atmospheric contaminants which may cause injury from fire or explosion?

  Yes

  No

• 7. Is there a possibility of free-flowing solid or a rising liquid that may cause suffocation or drowning by engulfment?

  Yes

  No

• 8. Is there a possible presence of a gas which displaces oxygen [such as SF6]

  Yes

  No

• 9. Is the access to the confined spaces is via a ladder or perhaps a spiral staircase or through a hatch or small opening.

  Yes

  No

Other Details:

• Other item- If there is a Yes answer to any of the above questions, then it is a “Confined Space”s

Report by Inspector:

• Signature:

  Sign

• Assessor:

• Select date

  Date

• Signature of Department Manager:

  Sign

• Name of Department Manager

• Time Accepted:

  Date