PC HS 25 - Permit to Enter a Confined Space

• Project

  Select

• Person Completing Permit

• Permit Number

• Exact Location of Confined Space
  Address

• Nature of Work

• Date of Issue

  Date

• Validity of Permit (Max 1 Day)

Gas Tests

• Gas Tests : Carried out prior to entry by lowering gas detection equipment into confined space.

  Select Oxygen Hydrogen Sulphide Explosivity Carbon Monoxide Others

  • Oxygen
  • Hydrogen Sulphide
  • Explosivity
  • Carbon Monoxide
  • Others

• What were the results

• Type of Gas detection equipment

• Date of last calibration

  Date

The Confined Space is in line with the Safe System of Work

• Free from Noxious Substances/Sludge

  Confirmed

  N/A

• Free from Gas and Fume

  Confirmed

  N/A

• Isolated and locked off from every source of Electricity, Gas, Fume or Liquid

  Confirmed

  N/A

The following Precautions must be taken in line with the Safe System of Work

• Workforce competent and briefed on safe system of work including testing equipment.

  Confirmed

• Control of Access arrangements in place

  Confirmed

• Emergency Procedure and Rescue facilities in place

  Confirmed

• Effective means of communication to be provided between all parties

  Confirmed

• Stand By/Communications/Top Man available

  Confirmed

• First Aid equipment available

  Confirmed

• No smoking or naked lights

  Confirmed

  N/A

• Openings to have barrier and suitably signed

  Confirmed

  N/A

• Protective clothing to be provided (boots/suits/gloves/helmets)

  Confirmed

• Intrinsically Safe tools

  Confirmed

  N/A

• Adequate Lighting available

  Confirmed

• Tripod, winch, lifeline and harness to be used (certificates in place & inspected prior to each use)

  Confirmed

• Adequate ventilation

  Confirmed

• Escape set breathing apparatus to be worn (ready for use)

  Confirmed

  N/A

• Continuous gas monitoring at point of work after initial negative 10 minute test prior to entry

  Confirmed

  N/A

Before Work : The recipient is competent and conversant with the safe systems of work:

• Signature of Supervisor

  Sign

After Work: All persons have been withdrawn and the workplace has been left safe and this permit is cancelled

• Signature of Supervisor

  Sign

Confined space Pre Entry Briefing

• I confirm that I am medically fit and have proof of training to the correct category of confined space training and in the safety system of work for this operation

• Confined Space Entry Team Signatures

  Sign

• Confined Space Entry Team Signatures

  Sign

• Confined Space Entry Team Signatures

  Sign

• Confined Space Entry Team Signatures

  Sign

• Confined Space Entry Team Signatures

  Sign

• Confined Space Entry Team Signatures

  Sign

• Confined Space Entry Team Signatures

  Sign

• Confined Space Entry Team Signatures

  Sign

• Confined Space Entry Team Signatures

  Sign

• Confined Space Entry Team Signatures

  Sign