Information
-
Audit Title
-
Document No.
-
Client / Site
-
Conducted on
-
Prepared by
-
Location
-
Personnel
-
THIS CHECKLIST IS TO BE COMPLETED PRIOR TO ALL CONFINED SPACE ENTRIES AND RETAINED FOR AT LEAST ONE MONTH . Checklist must be completed by a Reilly Competent Person.
1. IDENTIFICATION
-
Date and Time of Entry
-
Entry/Access Permit Number
-
Confined Space Location
-
Description of Works
-
Manhole No
-
Category of manhole entry
- 1
- 2
- 3
-
Have consent from your Supervisor.
Read and sign onto appropriate SWMS and JHA's.
Have a working 2-way radio on hand.
Have a Personal Gas Detector and conduct all required tests.
Chambers 1.5m or deeper, ladder entry must be by ladder. -
Have consent from your Supervisor.
Read and sign onto appropriate SWMS and JHA's.
Have a working 2-way radio on hand.
Have a Personal Gas Detector and conduct all required tests.
Chambers 1.5m or deeper, ladder entry must be by ladder.
Chambers 1.5m or deeper, personnel must also wear a harness. -
Have consent from your Supervisor.
Read and sign onto appropriate SWMS and JHA's.
Have a working 2-way radio on hand.
Have a Personal Gas Detector and conduct all required tests.
Chambers 1.5m or deeper, ladder entry must be by ladder.
Chambers 1.5m or deeper, personnel must also wear a harness.
Chambers 3m or deeper, a full tripod and winch system must be used in addition to all previous. A spotter is required to man the winch at all times.
6. REVIEW CONDITIONS THAT MAY CHANGE STATUS OF CSE
5. VENTILATION
5. VENTILATION
4. ATMOSPHERIC TESTING
3.ISOLATION
-
Site Photo
2. PERSONNEL
-
Enter the names of Entry Personnel and Expiry Date of CSE Ticket
-
Enter the names of Surface Personnel and Expiry Date of CSE Ticket
-
Relevant Emergency contact numbers are accessible on site ?
-
Electrical Isolation Required
-
Mechanical Isolation Required
-
Contact with System Operator Required
-
Required Isolation in Place - Checked by
-
Signature
-
Gas Detector Calibration Date
-
Record Peak Test Readings Prior To Entry
-
Recommended Levels
-
Oxygen b/w 19.5% to 23.5% : Explosive Gas <5% LEL : Hydrogen Sulphide <10ppm : Carbon Monoxide <30ppm
-
Oxygen (%)
-
Explosive Gas (LEL%)
-
Hydrogen Sulphide (ppm)
-
Carbon Monoxide (ppm)
-
Other Gases Tested
-
Record any
-
Natural
-
Forced
-
Wash Down
4. ATMOSPHERIC TESTING
3.ISOLATION
-
Site Photo
2. PERSONNEL
-
Enter the names of Entry Personnel and Expiry Date of CSE Ticket
-
Enter the names of Surface Personnel and Expiry Date of CSE Ticket
-
Relevant Emergency contact numbers are accessible on site ?
-
Electrical Isolation Required
-
Mechanical Isolation Required
-
Contact with System Operator Required
-
Required Isolation in Place - Checked by
-
Signature
-
Gas Detector Calibration Date
-
Record Peak Test Readings Prior To Entry
-
Recommended Levels
-
Oxygen b/w 19.5% to 23.5% : Explosive Gas <5% LEL : Hydrogen Sulphide <10ppm : Carbon Monoxide <30ppm
-
Oxygen (%)
-
Explosive Gas (LEL%)
-
Hydrogen Sulphide (ppm)
-
Carbon Monoxide (ppm)
-
Other Gases Tested
-
Record any
-
Natural
-
Forced
-
Wash Down
-
Select any of the following that will be taken into consideration before entry into the Confined Space
-
Weather
-
Traffic
-
Noise
-
Catchment
-
Flow Volume
-
Trade Waste Discharge
-
Industrial/Commercial Discharge
-
Domestic Discharge
7. PERSONAL PROTECTION EQUIPMENT
-
Select relevant PPE to be worn or carried by persons entering the Confined Space.
-
First Aid Kit
-
Helmet, Boots, Safety Vest
-
Gloves
-
Eye Protection
-
Hearing Protection
-
Overalls, Chemical Suite
-
Waders
-
2 Way Radio
-
Gas Detector
-
Self Rescue Respirator
-
Fall Arrest Device
-
Lifeline
-
Harness
-
Airline
-
Road Signage
-
Platforms
-
Barricades
-
Lighting
-
Bosun
-
Ladders
-
Man Cage
-
Fire Extinguisher
8. HOT WORK
-
Has the area been cleared of combustible materials for 15m ?
-
Have all drains within 15m been covered with a wet fireproof blanket ?
-
Will hot work be performed in the Confined Space ?
-
Are appropriate fire extinguishes on site ?<br>List the type of Extinguishers .
-
Is a water hose available & tested on site ?<br>If no, list precautions taken to substitute a water hose.
-
Is extra ventilation required ?<br>If "YES" what type and where will it be located.
-
All power leads clear of pipelines ?
-
All power leads clear of access way ?
-
Will the Hot works release toxic vapours ?<br>If "YES", describe the controls to be implemented to enable Hot Works to be performed safely.
8.1. Welders
-
Are welding machines/gas bottles at least 8m from the manhole/pit entry ?
-
Are electric welders earthed ?
-
Are welders serviced to manufacturers specifications ?
-
Welders Name & Signature
8.2. Authority to perform "HOT WORKS" works
-
I have checked the above conditions and consider it safe to carry out this work.
-
Name & Signiture
-
Select date
9. Reilly ENTRY
-
CONTACT Reilly FOR ENTRY TIME
-
Time phoned IN (Entry)
-
Time of intended EXIT
-
CWW Operator Name
10. APPROVAL TO ENTER
-
The Confined Space described in this Entry Checklist is in my opinion safe to enter using precautions listed above and all persons are properly trained to perform this work.
-
Name and Signature
-
Select date
11. JOB COMPLETION
-
All persons have left the Confined Space. No further Entries Permitted without New Permit
-
Name and Signature
-
Select date
12. CITY WEST WATER EXIT
-
CONTACT CITY WEST WATER FOR EXIT TIME - 9313 8499
-
Time of EXIT
-
CWW Operator Name
