Niblock Site Management-Confined Spaces Permit to Work

• Conducted on

  Date

• Prepared by

• Nature of confined space:

• Location:

• Names of persons entering confined space:

• Names of persons acting as rescue team

• Description of works to be carried out:

Section 2: Precautions

• Risk Assessment and Safe Method of Work Statement checked and agreed

  Yes

  No

  N/A

• Adequate safe means of access and egress

  Yes

  No

  N/A

• All necessary work equipment, PPE, safety and rescue equipment has been provided

  Yes

  No

  N/A

• Work equipment, PPE, safety and rescue equipment has been examined by a competent person

  Yes

  No

  N/A

• Work equipment has all necessary Test Certificates

  Yes

  No

  N/A

• All operatives are adequately fit, in good health and suitable for work in confined spaces

  Yes

  No

  N/A

• All operatives are fully trained and competent in confined space procedures

  Yes

  No

  N/A

• A trained First Aider and Rescue Team is in attendance

  Yes

  No

  N/A

• Hazardous deposits and sludges removed

  Yes

  No

  N/A

• All required lock-offs carried out, no source of ingress for dangerous material, gas or fumes

  Yes

  No

  N/A

• Gas purging completed satisfactorily and purged gas cleared

  Yes

  No

  N/A

• Satisfactory pre-entry atmosphere test

  Yes

  No

  N/A

• Continuous/ periodic atmospheric monitoring provided

  Yes

  No

  N/A

• Forced ventilation and extraction provided and correctly sited

  Yes

  No

  N/A

• All sources of ignition eliminated

  Yes

  No

  N/A

• Acceptable pipeline, trunking and cabling Management arrangements

  Yes

  No

  N/A

• All required notifications made, safety signs and barriers put in place

  Yes

  No

  N/A

• Adequate lighting

  Yes

  No

  N/A

• Communication link between operatives and attendants established and tested

  Yes

  No

  N/A

• Emergency telephone located and tested

  Yes

  No

  N/A

• I (Being the Authorised Person) hereby certify that I have inspected the work area, certify that it is safe and authorise entry into the confined space for the work described above to take place, subject to all required precautions being taken and maintained.