Hen - SF32 - Confined Space Permit To Work Template

• Contract

  VM-PIA

• Permit Number

• Contractor

• Site Location
  Address

• Build Area

  Select

• Conducted on

  Date

• Prepared by

General Details

• Purpose of Entry

• Communication Procedures

  Life line

  Voice Contact

  Radio Signal

• Refer to Heneghan RAMs

• Have you read and understand the RAMs

  Yes

  No

Training:

• Has the standby person been trained in rescue?

  Yes

  No

• Stop Work

• Have you been trained in the proper use of a Respirator

  Yes

  No

• Stop Work

• Have you or Entrants received proper training for confined space entry

  Yes

  No

• Stop Work

• Have all personnel on site received First Aid / CPR training

  Yes

  No

• Stop Work

Clothing/Equipment:

• Correct PPE on site

  Yes

  No

• Stop Work

• Has the personal protective equipment hazard analysis been conducted per 29 CFR 1910.132(a)?

  Yes

  No

• Stop Work

• Have the entrants been trained and certified in the use of personal protective equipment<br>per 29 CFR 1910.132(d)?

  Yes

  No

• Stop Work

• Is special clothing required (boots, chemical suits, glasses, etc.)? If so, specify:

  Yes

  No

• specify:

• Is all relevant equipment on-site(i.e. rescue equipment, communications equipment, etc.)?<br>If so, specify:

  Yes

  No

• specify:

• Lighting (Explosive Proof) Required on site

  Yes

  No

RAMs & Rescue Procedures:

• Are RAMs available and on site for working in confine spaces:

  Yes

  No

• Works to Stop

• Are Rescue Procedure available & on site for confine spaces:

  Yes

  No

• Works to Stop

Permit Requirements for Confined Space entry Checklist

Testing:Are the instruments used in atmospheric testing properly calibrated?

• Was the atmosphere in the Confined Space tested?

  Yes

  No

• Works Stop until test as taken place

• Was oxygen at least 19.5 percent and not more than 21.5 percent?

  Yes

  No

• Stop Work

• Were toxic, flammable or oxygen-displacing gases/vapours present?

  Yes

  No

• Hydrogen sulfide

  Yes

  No

• Stop Works Until the Ventilation section as been adhere to.

• Add Comments

• Methane

  Yes

  No

• Stop Works Until the Ventilation section as been adhere to.

• Add Comments

• Carbon dioxide

  Yes

  No

• Stop WorksUntil the Ventilation section as been adhere to.

• Add Comments

• Oxygen

  Yes

  No

• Stop Work Until the Ventilation section as been adhere to.

• Add Comments

• Has the authorized entrant or the entrant’s authorized representative been provided an opportunity to observe<br>the periodic testing of the permit space?

  Yes

  No

• Must retest while all personell in attendance

  Yes

  No

Monitoring:

• Will the atmosphere in the space be monitored continuously while work is going on?

  Yes

  No

• If works stop for Any reason i.e, personell leave the Chamber a Full retest is to take place before re-entry

  Yes

  No

• Stop Works

Ventilation: (to be completed if Gas is detected from above Testing Question)

• Is respiratory protection required (i.e. air-purifying, supplied air, self-contained breathing apparatus, etc.)?<br>If so, specify type:

  Yes

  No

  N/A

• Specify type:

  Yes

  No

  N/A

• Are the appropriate operator’s instructions available?

  Yes

  No

  N/A

• Stop Work

• Has the space been ventilated before entry?

  Yes

  No

  N/A

• Stop Work until the space as been Ventilated

• Will ventilation be continued during entry?

  Yes

  N/A

• Is the air intake for the ventilation system located in an area that is free of combustible dusts<br>and vapours and toxic substances?

  Yes

  No

  N/A

• Stop Work until the air intake for the ventilation system is free of combustible dusts<br>and vapours and toxic substances.

  Yes

  No

  N/A

• If the atmosphere was found unacceptable and then ventilated, was it retested before entry?

  Yes

  No

  N/A

• A retest must take place

Respiratory Protection:

• Emergency escape Breathing Apparatus on site

  Yes

  No

• Stop Work

• Can you get through the opening with a respirator on? If you do not know, find out before you try to enter.

  Yes

  No

• Stop Work

• Resuscitator - Inhalator on site

  Yes

  No

Standby/Rescue/Entry Attendant:

• Topman Safety Personnel on site

  Yes

  No

• Stop Work

• Full Body Harness Body with D ring on site

  Yes

  No

• Stop Work

• Lifelines

  Yes

  No

• Stop Work

• Emergency Escape Retrieval Equipment on site

  Yes

  No

• Stop Work

• Will there be an Entry Attendant on the outside in constant visual or auditory communication with the<br>person on the inside?

  Yes

  No

• Stop Work

• Are you familiar with emergency rescue procedures?

  Yes

  No

• Stop Work

• Do you know who to notify and how in the event of an emergency?

  Yes

  No

• Stop Work

• Fire Extinguishers on-site

  Yes

  No

• Type of Fire Extinguisher (Foam Only)

• Stop Work

  Yes

  No

Completion

Personell on site Involved with undertaking the confined space works

• Name of Person

• Name of person

• Name of Person

• Name of Person

Person Completing the on-site Risk assessment

• Permit to Work Granted

  Yes

  No

• Signature of person Issuing or refusing the permit to work

  Sign