TDE HS Form 17.0 Confined Space Entry Permit

• Document No.

• Client

• Site Location
  Address

• Created On

  Date

• Prepared by

CONDITIONS OF ENTRY

• ATMOSPHERIC CONDITIONS
  You must not enter a confined space if the levels are -
  WITHOUT breathing apparatus:
  Oxygen levels below 20.9%
  Flammable vapors over LEL 0
  Hydrogen Sulphide above the PEL of 0ppm
  Carbon Monoxide above 0ppm
  WITH breathing apparatus:
  Oxygen levels below 19.5%
  Flammable vapors over LEL 6
  Hydrogen Sulphide above the PEL of 6ppm
  Carbon Monoxide above 30ppm

• Atmospheric conditions of entry acknowledged and understood

• Area is cleared of all flammable and combustible materials

• Suitable and safe means of entry and exit established

• Ventilation is adequate

• Are any warning notices or barricades required?

  Yes

  No

  N/A

• Barricades and/or warning signage in place

EMERGENCY RESPONSE PROCEDURES

• STOP
  The spontaneous reaction in an emergency is often to immediately enter and attempt to rescue your colleague from the confined space.
  This must NOT happen as this may lead to the death or serious injury of those attempting the rescue.

• STOP procedure acknowledged and understood

• RETRIEVAL OF INJURED / UNRESPONSIVE PERSON
  If a person within the confined space is injured, unresponsive or otherwise unable to remove themselves from a dangerous situation, the stand-over person must use the harness and lifeline to hoist them as safely and quickly as possible.

• RETRIEVAL procedure acknowledged and understood

• CONTACT
  The stand-over person in charge should always remain at their post.
  In an emergency, call for assistance by dialing 111.
  Clearly state the nature of the emergency, the exactly location and your phone number.
  If no direct communication is possible, send the first available person to call for emergency assistance.
  If the emergency is within the confined space, ensure this is made clear to the operator and the fire service is to respond with rescue breathing apparatus.

• CONTACT procedure acknowledged and understood

• GAS ALERT
  If any gas detector signals an alarm, everyone must immediately evacuate from the confined space. This must be documented and gas levels testes before a re-entry can be approved. Do NOT erase the memory of the detector.

• GAS ALERT procedure acknowledged and understood

• FIRST AID
  A first-aider must attend to any person that is injured. If medical treatment is required the injured person must be taken to the closest emergency medical facility, or call 111 for an ambulance.

• FIRST AID procedure acknowledged and understood

• FIRE
  In the event of a fire, everyone must immediately evacuate from the confined space. Only attempt to extinguish the fire if it is safe to do so. Move well away from the fire and the direction of the smoke and dial 111 for the fire service.

• FIRE procedure acknowledged and understood

EMERGENCY RESPONSE CHECKS

• Emergency procedures rehearsed

• All equipment required for emergency response is available

• Location of Confined Space Work
  Address

• Description of Work

• Person in Charge

  Select

• Contact Phone Number of Person in Charge

• Other Permits / Documents Required

  Select Hot Work Permit T/A or SWMS None

  • Hot Work Permit
  • T/A or SWMS
  • None

• Hot work permit issued

• T/A or SWMS completed

• Site Photo

  Media

Entry Personnel

• Entry Personnel

Person

• Name

  Sign

• Confined Space Entry (CSE) ID

• Expiry Date of CSE Ticket

Surface Personnel

• Surface Personnel

Person

• Name

  Sign

• Confined Space Entry (CSE) ID

• Expiry Date of CSE Ticket

Confined space to be isolated from

• Water / Gas / Steam / Chemicals

• Mechanical / Electrical drives

• Hydraulic / Electric / Gas / Power

• Sludge/ Deposits / Wastes

• Locks and/or tags have been affixed to isolation points

  Yes

  No

  N/A

• Relevant items of Personal Protective Equipment (PPE) and other equipment required by persons entering the Confined Space

• Safety footwear

• Hearing protection

• High visibility

• Safety helmet

• Eye protection

• Face protection

• Hand protection

• Respiratory protection

• Protective clothing

• Other

• Other Personal Protective Equipment

PPE Equipment

• Method of communcation

• Continuous communication has been tested and established prior to entry

• Entry/Access Permit Number (if required)

• Permit valid FROM

  Date

• Permit valid UNTIL

  Date

• The below signed workers understand the conditions of this permit and agree that the control measures and precautions appropriate for the safe entry and execution of work in the confined space have been / will be implemented, and al workers involved with the confined space work have been advised of and understand the requirements.

• Permit issuer

  AJ Cahill

• Permit Holder

  Sign

• Stand-over Person

  Sign

• Notify AJ of CSE Permit Issued

  Notify AJ of CSE Permit Issue

Atmospheric Testing Record

• Time Monitored (Prior to entry)

  Date

• Oxygen (%)

• Explosive Gas - Lower explosive limit (LEL%)

• Hydrogen sulphide (ppm)

• Carbon monoxide concentrations (ppm)

• Is continuous atmospheric monitoring required for the duration of confined space work?

  Yes

  No

  N/A

• How often to levels need to be documented? (interval in minutes)

• Levels

Monitored Levels

• Time Monitored (During Entry)

  Date

• Hydrogen sulphide (ppm)

• Oxygen (%)

• Explosive Gas - Lower explosive limit (LEL%)

• Carbon monoxide concentrations (ppm)

• Entry / Exit Log

Entry/Exit

• Name of entry personnel

• Date & Time In

  Date

• Date & Time Out

  Date

• All persons have left the confined space. No further entries permitted without new permit.

  Yes

  No

  N/A

• All equipment has been removed from site?

  Yes

  No

  N/A

• All isolations have been restored?

  Yes

  No

  N/A

• Person responsible to sign to indicate the permitted work is completed and the permit is now withdrawn.

  Sign

• Ad photos of the work area at completion (optional)

  Media