KCOS CONFINED SPACE PERMIT

• Document No.

• Client Name

• Client Contact

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION 1 - Identify Confined Space

• Document the hazards and analyse the risks associated with the entry and work activities to be undertaken with respect to the confined space

• Reason For Entry

• Description of Work Activity

• Nature of Work to be Undertaken

• Confined Space to be Entered

• Description of Confined Space

Hazard Identification

• Slips, Trips and Falls

  Yes

  No

  N/A

• Controls to Manage the Hazard
  
  - Tools Lanyard
  - Compliant Ladder
  - PPE

• Other Controls Required?

  Yes

  No

  N/A

• Clearly list any other Controls required

• Responsible Party to Implement Controls

  Confined Space Worker

  Confined Space Spotter

  Client Representative

  Other

• Who is responsible to implement the nominated controls

• Risk Rating with all nominated Controls in place

  Extreme

  High

  Moderate

  Low

• Traffic and/or pedestrians

  Yes

  No

  N/A

• Controls to Manage the Hazard
  
  - Barricades & Signage
  - Traffic Control & Devices

• Other Controls Required?

  Yes

  No

  N/A

• Clearly list any other Controls required

• Responsible Party to Implement Controls

  Confined Space Worker

  Confined Space Spotter

  Client Representative

  Other

• Who is responsible to implement the nominated controls

• Risk Rating with all nominated Controls in place

  Extreme

  High

  Moderate

  Low

• Chemical / Fume Inhalation

  Yes

  No

  N/A

• Controls to Manage the Hazard
  
  - Induction, Venting and/or Extraction
  - Gas Detecting & Monitoring

• Other Controls Required?

  Yes

  No

  N/A

• Clearly list any other Controls required

• Responsible Party to Implement Controls

  Confined Space Worker

  Confined Space Spotter

  Client Representative

  Other

• Who is responsible to implement the nominated controls

• Risk Rating with all nominated Controls in place

  Extreme

  High

  Moderate

  Low

• Drowning

  Yes

  No

  N/A

• Controls to Manage the Hazard
  
  - Pump out all Water
  - Check Plug Integrity Prior to Entering

• Other Controls Required?

  Yes

  No

  N/A

• Clearly list any other Controls required

• Responsible Party to Implement Controls

  Confined Space Worker

  Confined Space Spotter

  Client Representative

  Other

• Who is responsible to implement the nominated controls

• Risk Rating with all nominated Controls in place

  Extreme

  High

  Moderate

  Low

SECTION 2 - Entry Permit

• Isolation Controls
  
  This Confined Space needs to be isolated from

• Water / Gas / Steam / Chemicals

  Yes

  No

  N/A

• Mechanical / Electrical Drives

  Yes

  No

  N/A

• Hydraulic / Electric / Gas / Power

  Yes

  No

  N/A

• Sludge / Deposits / Waste

  Yes

  No

  N/A

• Locks &/or Tags will be Affixed to Isolation Points

  Yes

  No

  N/A

• Other

• Purging, Ventilation & Atmospheric Monitoring Controls
  
  This Confined Space requires the following

• Depressurising

  Yes

  No

  N/A

• Opening / Venting

  Yes

  No

  N/A

• Continuous Purging / Extraction

  Yes

  No

  N/A

• Atmospheric Testing Required for

• Oxygen (O2)

• Carbon Monoxide (CO)

• Hydrogen Sulphide (H2S)

• Carbon Dioxide (CO2)

• LEL

• Ammonia (NH3)

• Volatile Organic Compounds (VOC)

• Other

• Type of Testing / Monitoring Required

• Initial Only - Prior to entry and each subsequent day

• Continuous for Atmospheric Contaminants

• Continuous for Flammable Contaminants

• Communication & Stand By Controls
  
  Minimum Requirements will include

• One Stand By Person

  Yes

  No

  N/A

• Two or More Stand By Persons

  Yes

  No

  N/A

• Rescue Team Contacted (Local Fire department)

  Yes

  No

  N/A

• Communication Via Voice and Direct Sight

  Yes

  No

  N/A

• Communication Via Radio

  Yes

  No

  N/A

• Communication Via Hand Signals and Other Means

  Yes

  No

  N/A

• Rescue / Retrieval Considerations
  
  Minimum Provisions are to include

• Stand By Person to individually handle

  Yes

  No

  N/A

• Safety Harness / Rescue Kit in vicinity with competent user(s)

  Yes

  No

  N/A

• Specific access to platforms/scaffolding erected

  Yes

  No

  N/A

• Specific Fire fighting provisions

  Yes

  No

  N/A

• First aid kit in vicinity

  Yes

  No

  N/A

• Other

• Personal Protective Equipment (PPE) Requirements
  
  Minimum items required

• Particulate mask

  Yes

  No

  N/A

• Safety harness and lanyard / lifeline

  Yes

  No

  N/A

• Head protection

  Yes

  No

  N/A

• Face shield / goggles / safety glasses

  Yes

  No

  N/A

• Ear muffs / plugs

  Yes

  No

  N/A

• Gloves

  Yes

  No

  N/A

• Warning notices / barricading

  Yes

  No

  N/A

• Specific lighting provisions

  Yes

  No

  N/A

• Specific hot work controls

  Yes

  No

  N/A

• Other

Permit Authorisation

• This authorisation signifies that the planning component of the Risk Assessment & Entry Permit has been completed and that the confined space entry / work is authorised to commence in accordance with the Permit Request.

  Sign

SECTION 3 - Implementation

• Atmospheric Test Results

• Test Time & Date

  Date

• Oxygen (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Monoxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Hydrogen Sulphide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Dioxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• LEL (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Ammonia (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Other

• Gas Detector Number

• Entry Permitted?

  Yes

  No

  N/A

• Personnel taking results

• Another test

  Off

  On

• Atmospheric Test Results

• Test Time & Date

  Date

• Oxygen (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Monoxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Hydrogen Sulphide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Dioxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• LEL (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Ammonia (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Other

• Gas Detector Number

• Entry Permitted?

  Yes

  No

  N/A

• Personnel taking results

• Another test

  Off

  On

• Atmospheric Test Results

• Test Time & Date

  Date

• Oxygen (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Monoxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Hydrogen Sulphide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Dioxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• LEL (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Ammonia (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Other

• Gas Detector Number

• Entry Permitted?

  Yes

  No

  N/A

• Personnel taking results

• Another test

  Off

  On

• Atmospheric Test Results

• Test Time & Date

  Date

• Oxygen (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Monoxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Hydrogen Sulphide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Dioxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• LEL (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Ammonia (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Other

• Gas Detector Number

• Entry Permitted?

  Yes

  No

  N/A

• Personnel taking results

• Another test

  Off

  On

• Atmospheric Test Results

• Test Time & Date

  Date

• Oxygen (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Monoxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Hydrogen Sulphide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Dioxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• LEL (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Ammonia (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Other

• Gas Detector Number

• Entry Permitted?

  Yes

  No

  N/A

• Personnel taking results

• Another test

  Off

  On

• Atmospheric Test Results

• Test Time & Date

  Date

• Oxygen (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Monoxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Hydrogen Sulphide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Dioxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• LEL (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Ammonia (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Other

• Gas Detector Number

• Entry Permitted?

  Yes

  No

  N/A

• Personnel taking results

• Another test

  Off

  On

• Atmospheric Test Results

• Test Time & Date

  Date

• Oxygen (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Monoxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Hydrogen Sulphide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Dioxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• LEL (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Ammonia (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Other

• Gas Detector Number

• Entry Permitted?

  Yes

  No

  N/A

• Personnel taking results

• Another test

  Off

  On

• Atmospheric Test Results

• Test Time & Date

  Date

• Oxygen (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Monoxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Hydrogen Sulphide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Carbon Dioxide (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• LEL (%)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Ammonia (ppm)

• NOT SAFE TO ENTER
  
  Re-Test and confirm safe limits with supervisor

• Other

• Gas Detector Number

• Entry Permitted?

  Yes

  No

  N/A

• Personnel taking results

• Another test

  Off

  On

Entry Authorisation

• The procedures, control measures and precautions appropriate for the safe entry / work in this confined space have been implemented and the persons required to work in the confined space have been David of and understand the requirements of the Risk Assessment & Entry Permit

  Sign

• CONSTRAINTS This Entry Authorisation is valid until the following occurs or the time and date shown

• Select date

  Date

Personnel Entry

• I the undersigned, hereby acknowledge that I fully understand the procedure, control measures and precautions to be observed with the entry / work and exit involved with this confined space. I will comply with these requirements at all times and report any unforeseen hazard that presents a risk to safety

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

Withdrawal of Entry Authorisation

• All persons and equipment has been accounted for and the equipment and confined space has been restored correctly and safely

  Sign