Pre-Task: Confined Space Checklist/Permit

• Job Title/Scope - Give a brief discription of the work to be undertaken.

• Document No.

• Conducted on

  Date

• Prepared by

  Darren Downing

  Dave Norton

  Andrea Burnham

  Ryan Scott

• Risk assessment completed and job specific.

  Yes

  No

• A full detailed risk assessment must be completed before any work commences.

  Yes

  No

• Location

  Waltham WPSI

  Waltham National office

• Sub Location

  Select Waltham Lodge - Zone 2 Hachiko - Zone 3 Endal - Zone 4 Lynx - Zone 5 Jaguar - Zone 6 Leopard - Zone 7 Betsy - Zone 8 Nursery - Zone 9 Lab Block - Zone 10 Apollo - Zone 11 WPSI Main Office Area - Zone 12 Car parks and Landscaping - Zone 13 Tiger - Zone 14 Togo - 15 Other - (Add in notes)

  • Waltham Lodge - Zone 2
  • Hachiko - Zone 3
  • Endal - Zone 4
  • Lynx - Zone 5
  • Jaguar - Zone 6
  • Leopard - Zone 7
  • Betsy - Zone 8
  • Nursery - Zone 9
  • Lab Block - Zone 10
  • Apollo - Zone 11
  • WPSI Main Office Area - Zone 12
  • Car parks and Landscaping - Zone 13
  • Tiger - Zone 14
  • Togo - 15
  • Other - (Add in notes)

Confined Space Details

• Project / Site Name

• A PERMIT REQUIRED CONFINED SPACE - means an enclosed or partially enclosed space that is not designed for continuous occupancy. A confined space requires a permit if the space may contain a hazardous atmosphere; contain material that has the potential to engulf an entrant; has walls that converge inward or floors that slope downward and taper into a smaller area which could trap or asphyxiate an entrant; or contains any other recognized health and safety hazard, such as unguarded machinery, exposed live wires, or exposure to heat or cold stress.

• Has a detailed risk assessment been completed and determined a permit is required for entering the space outlined in the job scope? (Permit required confined space)

  Yes

  No

• Has a permit to work been completed linked to this checklist?

  Yes

  No

• Permit to work must be completed before any work commences.

  Yes

  No

  N/A

• Permit issued to

• Permit to work number

• Identify potential hazards of this confined space? (select all that apply)

  Select Flammable Atmosphere Corrosive Reactive Toxic High Temperature Low Temperature Engulfment Other Hazards

  • Flammable Atmosphere
  • Corrosive
  • Reactive
  • Toxic
  • High Temperature
  • Low Temperature
  • Engulfment
  • Other Hazards

• Describe other hazard(s)

Preparation

• Space ventilated to full extent possible?

  Yes

  No

  N/A

• All people involved have completed confined space training?

  Yes

  No

  N/A

• Vehicles and plants removed from confined space to reduce fume hazard? If not, have precautions been put in place?

  Yes

  No

  N/A

• Correct confined space signage in place?

  Yes

  No

  N/A

• Space lighting in place and appropriate?

  Yes

  No

  N/A

• Access (both entry and exit) points have been identified and are clear of hazards for use?

  Yes

  No

  N/A

• Communications plan defined and understood by all involved?

  Yes

  No

  N/A

• Select methods of communication to be adopted (select all that apply)

  Select Mobile phone Two-way radio Rope signals Sounds Verbal communication Hand signals Other

  • Mobile phone
  • Two-way radio
  • Rope signals
  • Sounds
  • Verbal communication
  • Hand signals
  • Other

Air Monitoring

• Does the air of this confined space require monitoring?

  Yes

  No

  N/A

• Is the air of the confined space being continuously monitored? (as required)

  Yes

  No

  N/A

• Log air sample results

Air Sample

• Time of sample

  Date

• Sample result

• Is this sample within acceptable parameters? Should confined space work proceed?

  Yes

  No

• Has air monitoring equipment been calibrated?

  Yes

  No

  N/A

Safety Equipment & PPE

• Select equipment to be used in this confined space entry

  Select Warning signs, barricades Barricade tape, cones Ventilation fan or blower Fire equipment in place GFCI'S in place Lighting (rated for hazardous locations) Grounding and/or bonding Ladder Other

  • Warning signs, barricades
  • Barricade tape, cones
  • Ventilation fan or blower
  • Fire equipment in place
  • GFCI'S in place
  • Lighting (rated for hazardous locations)
  • Grounding and/or bonding
  • Ladder
  • Other

• Describe other equipment

• Select PPE to be used in this confined space entry

  Select Airline respirator Self-contained breathing apparatus Other respirator Gloves Rain gear Boots Hearing protection Safety glasses Fall protection/arresting equipment Chemical splash goggles Other

  • Airline respirator
  • Self-contained breathing apparatus
  • Other respirator
  • Gloves
  • Rain gear
  • Boots
  • Hearing protection
  • Safety glasses
  • Fall protection/arresting equipment
  • Chemical splash goggles
  • Other

• Describe other PPE

Rescue & Emergency Plan

• Emergency evacuation and rescue plan is complete, in place and understood by all involved?

  Yes

  No

  N/A

• Emergency Number

• Location of phone or radio

• Emergency actions to be taken

• Potential emergency situations

Team Sign Off

• Have all relevant personnel participated in pre-entry briefing?

  Yes

  No

  N/A

• Confined Space Entrants: We (I) have reviewed the potential emergency situations and actions to be taken. We (I) are familiar with all rescue equipment and communication methods. I have been formally trained in confined space entry.

Confined Space Entrant

• Name and Signature (entrant to sign)

  Sign

• Confined Space Entry Supervisor: I have properly evaluated this confined space and verified that acceptable entry conditions exist. All personnel have reviewed the conditions of the entry and are adequately trained to perform this task. I have been formally trained in confined space entry and rescue.

Confined Space Entry Supervisor

• Name and Signature (supervisor to sign)

  Sign