FSA Confined Space Assessment

• Conducted on

  Date

• Prepared by

  Sign
• Location
  Address

• Confined Space identification

• Type of space

• Photo of space

  Media

AS 2865-2009 - Confined spaces

• Is the space enclosed or partially enclosed?

  Enclosed

  Partially Enclosed

• Is not designed or intended primarily to be occupied by a person?

  Yes

  No

  Other

• Is, or is designed or intended to be, at normal atmospheric pressure while any person is in the space?

  Yes

  No

  Other

• An oxygen concentration outside the safe oxygen range

  Yes

  No

  Other

• A concentration of airborne contaminants that may cause impairment, loss of consciousness, or asphyxiation.

  Yes

  No

  Other

• A concentration of flammable airborne contaminants that may cause injury from fire or explosion.

  Yes

  No

  Other

• Engulfment in a stored free-flowing solid or a rising level of liquid that may cause suffocation or drowning.

  Yes

  No

  Other

• This Space can be classified as :

  Select Confined Space Restricted Space Non - Confined Space

  • Confined Space
  • Restricted Space
  • Non - Confined Space

Details of the Space

• Types of works being undertaken within space

• Entry type:

  Door

  Hatch

  Other

• Number of Entrances:

• Access type:

  Stairs

  Horizontal - Crawl space

  Ladder

  Vertical - Lowering system

  Other

• Photo of Inside the Space

  Media

• Hazards:

  Select Slips trips and falls Engulfment Restricted movement Biological Entrapment Atmospheric Falls from height Mechanical movement Chemical Physiological "claustrophobia" Electrical

  • Slips trips and falls
  • Engulfment
  • Restricted movement
  • Biological
  • Entrapment
  • Atmospheric
  • Falls from height
  • Mechanical movement
  • Chemical
  • Physiological "claustrophobia"
  • Electrical

• Types of work to be conducted in space

• Signage:

  Present

  Absent

  Other

• Additional Comments

Entry provisions

• Atmospheric Testing Required:

  Yes

  No

  Other

• Atmospheric Testing Type:

  Once off

  Continuous Gas Testing

  Other

• Ventilation Required:

  Yes

  No

  Other

• Ventilation System

  Select Natural Positive Pressure Negative Pressure Positive and Negative Pressure

  • Natural
  • Positive Pressure
  • Negative Pressure
  • Positive and Negative Pressure

• Lock out, Tag out Required:

  Yes

  No

  Other

• Entry Equipment Requirements:

  Select Hard Hat Bump Cap Hard toe boots Long and long PPC Gloves Safety Glasser's Safety Goggles P2 Dust mask Half Face Respirator Full Face Respirator Positive Pressure Respirator Self Contained Breathing Apparatuses Gas Detector Tripod Winch Rope lowering system Ladder Self Retracting lanyard Safety System Harness Lanyards Radios Communication

  • Hard Hat
  • Bump Cap
  • Hard toe boots
  • Long and long PPC
  • Gloves
  • Safety Glasser's
  • Safety Goggles
  • P2 Dust mask
  • Half Face Respirator
  • Full Face Respirator
  • Positive Pressure Respirator
  • Self Contained Breathing Apparatuses
  • Gas Detector
  • Tripod
  • Winch
  • Rope lowering system
  • Ladder
  • Self Retracting lanyard Safety System
  • Harness
  • Lanyards
  • Radios Communication

• Rescue Plan Required:

  Yes

  No

  Other