V-HSF038 Confined Space Permit

• Site Conducted

  Select

• Date Conducted

  Date

• Contractor

• Contractor's Supervisor

• Permit Date

  Date

• Permit Start Time

  Date

• Permit Finish Time

  Date

• Confined space location and description, including any plant or processes

Hazards - the following processes within the confined spaces have been withdrawn from service:

• Electrical Power

  Yes

  No

  N/A

• Pressure Systems

  Yes

  No

  N/A

• Mechanical Power

  Yes

  No

  N/A

• Liquids/Flowing Substances

  Yes

  No

  N/A

• Relevant isolation permit no.

There exists the potential for the following hazards to be present:

• Flammable substances

  Yes

  No

  N/A

• Ingress/Presence of Liquids

  Yes

  No

  N/A

• Oxygen Enrichment

  Yes

  No

  N/A

• Oxygen Deficiency

  Yes

  No

  N/A

• Solids That Can Flow

  Yes

  No

  N/A

• Toxic Gases, Fumes or Vapours

  Yes

  No

  N/A

• Excessive Heat

  Yes

  No

  N/A

• Excessive Cold

  Yes

  No

  N/A

• Activities within the confined space

Safe Systems - A suitable and sufficient written safe system of work must be produced for this activity

• Risk Assessment document no.

• Risk Assessment author

• Method Statement document no.

• Method Statement author

The confined space has been assessed and the following control measures, identified within the written safe system of work, are to be implemented (tick all that apply)

• Removal of Residues

• Full Breathing Apparatus (BA)

• Escape BA only

• Use of Intrinsically Safe Tools

• Purge Atmosphere Before Entry

• First Aid/Emergency Procedures

• Forced Ventilation/Extraction

• Tools and Equipment Checked for Safe Use

• Leptospirosis (Weil's Disease) Cards Issued

• System of Communication in Place (e.g. radios/mobiles)

• Team Lead Only/Rescue Team

• Warning Signs/Barriers in Place

• Safety Harnesses/Lifelines

• Competency of Work Team Checked

• Continued atmospheric testing - record unit type/serial no.

Authorisation

• Permission is granted to work within the confined space according to the safe system

  Sign

• A recorded briefing has been delivered to the workforce on this safe system of work

  Yes

  No

  N/A

• As the supervisor, I am familiar with the scope of work and safe systems to be implemented

  Sign

• The activities authorised by this permit have finished and the confined space fully vacated

  Sign

• The confined space and any plant within it have been returned to service

  Yes

  No

  N/A

• The activities authorised by this permit have now ceased. The cancellation of this permit now precludes any further work taking place in this confined space

  Sign