The version control will be maintained by the SHEQ team and is controlled via the Safety Equipment Inspections Document 2073838157-15.
Asset Overview
Asset name / Number / Location

Other permits eg permit to work, Hot work, FIFM, Working at heights.

Confined Space Risk Assessment
If the answer is YES to any of the questions bellow the controls must be coved on the site specific Risk Assessment

Is there the possibility of contact with electricity / Is LOTO in place?

Are there chemicals present in the confined space? Controls must be put in place to mitigate the hazard of these chemicals?

Trade Waste Flammable gas or substances pressent / Ventilate and use specialist gas tester

Restricted size of access / Is the hatch larger than 450mm x 550mm

Restricted size of chamber / Is the chamber greater than 750mm square / 900mmm for sewer?

Is the structural integrity of the confined space damage or suffers from deterioration?

Emergency Management

ERP - Please state below the Emergency response plan it must be documented below and rehearsed before entry.

Has all Mechanical or Electrical Isolation, handover from a competent person been completed

Reponsible person to sign
Select date
Protective and Safety equipment used - Visually check before use

Safety Harness


Fall Arrest

Safety Line

Air Supplied breathing apparatus

Additional Ventilation

Atmospheric Test Requirements - Undertake initial testing prior to entry and then monitor throughout work.
Gas Test Date and Time

Oxygen between 19.5 - 23.5% As per calibration on bottle? Record reading below.

Is Carbon Monoxide below 30ppm As per calibration on bottle? Record reading below.

Flammables under 5%LEL As per calibration on bottle? Record reading below.

Hydrogen Sulphide under 10ppm. As per calibration on bottle? Record reading below.

Gas Test Equipment / Serial Number

Responsible person to sign to validate.
Sign in at Entry & Exit
Site Induction completed prior to entry: Sign In and Out when working in a confined space. (Including all Visitors). If more people than five people are going to be signed in and out of the confined space a paper based sign in sheet is to be placed at the entry and exit point of the confined space and be managed by the responsible person.
Sign In
Sign Out
Sign In
Sign Out
Sign In
Sign Out
Sign In
Sign Out
Sign In
Sign Out
Completeing of work / Has all work been completed or suspended, equipment removed and persons vacated from the confined space.

Are all people accounted for and have safely exited the confined space

Stand by person to sign