Ventia Safety Confined Space Entry to Work Permit

• The version control will be maintained by the SHEQ team and is controlled via the Safety Equipment Inspections Document 2073838157-15.

• Document No.

• Maximo Work Order Number

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel.

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
  Address

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

  Safe

  At Risk

  N/A

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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Emergency Management

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Reponsible person to sign

  Sign

• Select date

  Date

Protective and Safety equipment used - Visually check before use

• Safety Harness

  Yes

  No

  N/A

• Tripod

  Yes

  No

  N/A

• Fall Arrest

  Yes

  No

  N/A

• Safety Line

  Yes

  No

  N/A

• Air Supplied breathing apparatus

  Yes

  No

  N/A

• Additional Ventilation

  Yes

  No

  N/A

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

• Gas Test Date and Time

  Date

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Gas Test Equipment / Serial Number

  Yes

  No

  N/A

• Responsible person to sign to validate.

  Date

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

• Sign Out

  Sign

• Sign In

  Sign

• Sign Out

  Sign

• Sign In

  Sign

• Sign Out

  Sign

• Sign In

  Sign

• Sign Out

  Sign

• Sign In

  Sign

• Sign Out

  Sign

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

  Yes

  No

  N/A

• Stand by person to sign

  Sign