Permit to Work - Confined Space Entry

• Audit Category

  Select

• Audit Title

  Select

• Conducted on

  Date

• undefined

• Confined Space Name

• Location of Confined Space

• Confined Space ID

• Description of Work

• Date of Work

  Date

• Expected duration of Work

• Last Known Substance in Confined Space

• Name

• Name

• Confined Space Isolation

  Yes

  N/A

• CIP

  Yes

  N/A

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Chemical Dosing

  Yes

  N/A

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Product

  Yes

  N/A

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Direct Expansion Refrigeration

  Yes

  N/A

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Agitator

  Yes

  N/A

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Electrical

  Yes

  N/A

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Please Read SOP

• SOP Available

  Yes

  No

• Please Fill JSEA

  Yes

  No

• Job Details

• Location of Work

• JSEA Developed by

  Sign

• Date

  Date

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Common Hazards

  Yes

  No

• Work Environment/Site Layout

• Working from Height

• Ground Surface

• Stability

• Security

• Vibration

• Confined Spaces

• Site Access/Egress

• Underground Hazards

• Lighting

• Mobil Plant/Pedestrians

• House Keeping

• Asbestos

• Thermal Comfort

• Slips & Trips

• Overhead Hazards

• Site induction

• Chemical

• Biological

• Fire/Flammability

• Corrosive

• Compatibility

• Labelling

• MSDS Available

• Absorption

• Inhalation/Ingestion

• Signage

• Spill Control

• Storage

• PPE Available

• Manual Handling

• Repetitive Actions

• Cold/Hot

• Lifting/Carrying

• Bending/Reaching

• Excessive Distances

• Awkward Postures

• High Forces- Heavy Load

• Pushing/Pulling

• Restraining/Supporting

• Stability/Size of Load

• Plant

• Crushing

• Cutting/Stabbing

• Electrical

• Entanglement

• Falling

• High Pressure

• Hot Surfaces

• Isolation

• Maintenance

• Noise

• Pre-start Checks

• Striking

• Signage

• Safe Work Procedures

RISK MATRIX

• HSW RISK MATRIX

JOB SAFETY ANALYSIS

• Job Safety Analysis

  Yes

  No

  N/A

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Department Supervisor notified of entry

  Yes

  No

• Name of Supervisor

• Suspend Permit, Please check with Permit Issuer/ Manager

• Electrical Isolation Completed and Tested

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Confined Space has been Purged

  Yes

  No

• Suspend Permit, Please check with Permit Issuer/ Manager

• Barricades/ Signage in Place to prevent Pedestrian Access

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Mechanical Isolations Completed and Tested

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Ventilation Fixed

  Yes

  No

  N/A

• Circle

• Natural

• Mechanical

• Suspend Permit, Please check with Permit Issuer/ Manager

• PPE is Available and in Good Condition

  Yes

  No

• Suspend Permit, Please check with Permit Issuer/ Manager

• Harness/ Retrieval Equipment Inspected and In Date

  Yes

  No

• Suspend Permit, Please check with Permit Issuer/ Manager

• Pre-Entry Atmospheric Test has been Documented

  Yes

  No

• Level Must be Recorded Every 30 Minutes

• Pre -Entry Test

  Date

• Oxygen (O2) 19.5% - 23.5%

• Flammability <5% LEL

• Hydrogen Sulphide (H2S) <10ppm

• Carbon Monoxide (CO) <30ppm

• Suspend Permit, Please check with Permit Issuer/ Manager

• Retest 1

  Yes

  No

  N/A

• Pre -Entry Test

  Date

• Oxygen (O2) 19.5% - 23.5%

• Flammability <5% LEL

• Hydrogen Sulphide (H2S) <10ppm

• Carbon Monoxide (CO) <30ppm

• Suspend Permit, Please check with Permit Issuer/ Manager

• Tools and Equipment

  Yes

  No

• Rescue Plan Required

  Yes

  No

• Rescue Type

  Assisted Rescue

  Emergency Services

  Self Rescue

• Name of stand by First Aider

• Communication Arrangements

• Description of Plan

• Emergency Equipment

  Yes

  No

  N/A

• Fall Arrest

  Yes

  No

  N/A

• Torch

  Yes

  No

  N/A

• Fire Extinguisher

  Yes

  No

  N/A

• First Aid kit

  Yes

  No

  N/A

• Mobilephone/Telephone

  Yes

  No

  N/A

• Lifeline and retrieval system

  Yes

  No

  N/A

• Communication Arrangements

EMERGENCY EQUIPMENT

• Mobilephone

  Yes

  No

  N/A

• First Aid Kit

  Yes

  No

  N/A

• Torch

  Yes

  No

  N/A

• Communication Arrangements

  Yes

  No

  N/A

• Mobile phone

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Walkie talkie

  Yes

  No

  N/A

• I have reviewed the hazards and control measures documented in the relevant JSEA/SOP for this task. I believe that the work can be completed safely provided all the above-mentioned precautions and the relevant JSEA/SOP are complied with

• Permit Issuer

  Sign

• Permit User

  Sign

• Permit User

  Sign

• Safety Observer

  Yes

  No

  N/A

• Name and Signature

  Sign

• The permit has been suspended due to work not being completed. The following precautions have been completed in the work area

• Equipment Secured

• Area access restricted

• Isolation retested

• Signage in place

• Area Manager notified

• This Permit has been revalidated to allow suspended work to be recommenced. The following precautions have been completed

  Yes

  No

  N/A

• Area Inspected

• Environmental conditions safe

• Pre-start checks completed

• Area Manager notified

• Permit Issuer

  Sign

• Permit User

  Sign

• I have inspected the work area and certify that all personnel, tools and equipment have been removed from the area, all guards and covers have been replaced, all LOTO devices have been removed and all barriers and notices removed. I confirm that the area is safe for normal operations to resumes.

• Permit Issuer

  Sign