LCC -21-FM-011- Confined Space Entry Permit

• LCC-21-Fm-011-Confined Space Entry Permit
  

• Work Order Number

• Document No.

• Conducted on

  Date

• Prepared by

• Location
  Address

• Relevant information must be filled in and signed by competent person prior to all confined space entries.Completed document to be forwarded to the appropriate Area Manager or Coordinator and must be kept for at least one month.This form applies to all contractors working for LCC.Contractors will remain responsible for their own records.

EMERGENCY CONTACTS

• Fire,Ambulance: 000 Remount Road Admin: 6323 3500
  Customer Service: 6323 3333 Duty Supervisor (AH): 0437 523 350

GENERAL

• Date and Time of Entry

  Date

• Description Of Confined Space

• Location

• Description Of Work

• Site Photo

  Media

HAZARD IDENTIFICATION AND RISK ASSESSMENT

• Standard Trench<br>

  YES

  NO

• Gross Polutant Trap<br>

  YES

  NO

• Pump Station<br>

  YES

  NO

• Standard Manhole / Gully Pit<br>

  YES

  NO

• Reservoir<br>

  YES

  NO

• Pipe Walk<br>

  YES

  NO

• Wastewater Treatment Plant<br>

  YES

  NO

• Other

FOR HIGH RISK SITES ATTACH COPY OF WORK INSTRUCTIONS THAT NEED TO BE FOLLOWED

• Risk Assessment completed and attached

  YES

  NO

CONTROL MEASURES ISOLATION (Isolation and Lockout to be undertaken in accordance with procedure 21-HLPr-020)

• Warning Notices/Barricades?

  YES

  NO

• Electrical Isolation

  YES

  NO

• Mechanical Isolation

  YES

  NO

• Contact with System Operator

  YES

  NO

• Isolation and Lockout complete

  YES

  NO

4. ATMOSPHERIC TESTING (Prior to entry)

• Gas Detector Serial Number

• Oxygen (%)

• Explosive Gas (LEL%)

• Hydrogen Sulphide (ppm)

• Carbon Monoxide (ppm)

• Number of atmospheric tests conducted before entering<br>

  1

  2

  3

• If two tests have failed, has Manager been notified?

  Select YES NO

  • YES
  • NO

• Gas Testing completed by:

  Sign

5. VENTILATION

• Natural<br>

  YES

  NO

• Positive Mechanical (Blow In)<br>

  YES

  NO

• Negative Mechanical (Draw Out)<br>

  YES

  NO

6. REVIEW CONDITIONS THAT MAY CHANGE STATUS OF CONFINED SPACE

• Select any of the following that will be taken into consideration before entry into the Confined Space

• Weather<br>

  YES

  NO

• Traffic<br>

  YES

  NO

• Noise<br>

  YES

  NO

• Catchment<br>

  YES

  NO

• Flow Volume<br>

  YES

  NO

7. PERSONAL PROTECTION EQUIPMENT

• Helmet<br>

  YES

  NO

• Waders<br>

  YES

  N/A

  NO

• Eye Protection<br>

  YES

  N/A

  NO

• Hearing Protection<br>

  YES

  N/A

  NO

• Harness<br>

  YES

  NO

• Gloves<br>

  YES

  N/A

  NO

• Self Rescue Respirator<br>

  YES

  N/A

  NO

• Lifeline<br>

  YES

  N/A

  NO

• Fall Arrest device<br>

  YES

  NO

• Gas Detection Meter<br>

  YES

  NO

• 2 Way Radio<br>

  YES

  N/A

  NO

• Other

OTHER PRECAUTIONS

• Warning Notices/Barricades?

  YES

  NO

• Hot Work Permit Required? (If yes use Form 21-Fm-012 and attach)

  YES

  NO

• Media

  Media

• Emergency response Equipment Available on Site:<br>

  YES

  N/A

  NO

AUTHORITY TO ENTER

• The control measures and precautions appropriate for the safe entry and execution of the work in the confined space have been implemented and the persons required to work in the confined space have been advised of and understand the requirements of this written authority.

• Name and Signature

  Sign

• Select date

  Date

• Entry Permitted

  Select YES NO

  • YES
  • NO

• Entry Not Permitted

  Select YES NO

  • YES
  • NO

• Induction Of Visitors Done

  YES

  N/A

  NO

PERSONS REQUIRED TO ENTER CONFINED SPACE

• Number of Standby Personnel (Minimum of one, but when there are three or more persons within the confined space a minimum of two standby persons will be required) Task - E Entry; S Standby; V Visitor.<br>

  1

  2

  3

  4

  5

• Competent for Entry

  YES

  NO

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

• Standby Persons

  YES

  NO

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

• Visitor

  Yes

  No

  N/A

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

IN CASE OF EMERGENCY EVACUATION

• Record Peak Gas Detector Readings and any other relevant information:

• Oxygen:

• Explosive Gases % LEL:

• Hydrogen Sulphide ppm:

• Carbon Monoxide ppm:

• Gas Detector Serial Number:

• Comments......

11. JOB COMPLETION

• All persons have left the Confined Space. No Further Entries Permitted Without New Permit

• Name and Signature

  Sign

• Select date

  Date