"Confined Space Risk Assessment and Permit Form"

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Confined Space Risk Assessment and Permit
This risk assessment and permit must be used when entry into a confined space is required.
Section 1
Assessor Print Name:
Date of Assessment:
Time of Assessment
Assessor Sign Name:
Location being assessed:
Section 2
The first question you have to ask yourself is do you understand the risks & hazards involved in a confined space entry.
Yes No
Have you received confined space awareness training or confined space entry training.
Yes No
Are you familiar with the space-access-egress-escape routes etc
Yes No
Have you checked the asbestos survey for the area you will be working in
Yes No
If the answer is no to any of the questions above do not proceed and consult your supervisor or line manager.
Section 3
Do any of the risks-hazards identified below exist within the confined space
Risks-Hazard
Yes
No
Risk
Remarks-Control measures
Risk
Before
After
H M
L
H
M L
1
Toxic gases or vapours
2
Explosive or flammable
substances
3
Does the space have poor
ventilation
4
Is there a potential for
Oxygen deficiency or
enrichment
5
Are there any risks from
ingress of gas-vapour-fluids
from other areas? (work
vehicles-generators etc
dumping fumes in to the
space)
6
Will proposed work
affect/change the conditions
within the space and change
its classification
7
Are chemicals stored within
area?
8
Are there problems with
access/egress?
9
Are the entry -exits-and
escape routs more than 200m
apart?
10 Is access within the space
restricted? (pipes-cable tray-
conduits etc)
11 Have fixed ladders been
inspected in accordance with
annual PPM?
12 Is there drainage or sewer
runs within the space. (H²S-
methan-flooding)
13 Excessive heat
14 Other:
If the answer is yes to any of the questions above then the confined space entry permit overleaf must be used/ implemented
GM/H/Permits/2010
Confined Space Risk Assessment and Permit
This risk assessment and permit must be used when entry into a confined space is required.
Section 1
Assessor Print Name:
Date of Assessment:
Time of Assessment
Assessor Sign Name:
Location being assessed:
Section 2
The first question you have to ask yourself is do you understand the risks & hazards involved in a confined space entry.
Yes No
Have you received confined space awareness training or confined space entry training.
Yes No
Are you familiar with the space-access-egress-escape routes etc
Yes No
Have you checked the asbestos survey for the area you will be working in
Yes No
If the answer is no to any of the questions above do not proceed and consult your supervisor or line manager.
Section 3
Do any of the risks-hazards identified below exist within the confined space
Risks-Hazard
Yes
No
Risk
Remarks-Control measures
Risk
Before
After
H M
L
H
M L
1
Toxic gases or vapours
2
Explosive or flammable
substances
3
Does the space have poor
ventilation
4
Is there a potential for
Oxygen deficiency or
enrichment
5
Are there any risks from
ingress of gas-vapour-fluids
from other areas? (work
vehicles-generators etc
dumping fumes in to the
space)
6
Will proposed work
affect/change the conditions
within the space and change
its classification
7
Are chemicals stored within
area?
8
Are there problems with
access/egress?
9
Are the entry -exits-and
escape routs more than 200m
apart?
10 Is access within the space
restricted? (pipes-cable tray-
conduits etc)
11 Have fixed ladders been
inspected in accordance with
annual PPM?
12 Is there drainage or sewer
runs within the space. (H²S-
methan-flooding)
13 Excessive heat
14 Other:
If the answer is yes to any of the questions above then the confined space entry permit overleaf must be used/ implemented
GM/H/Permits/2010
Confined Space Risk Assessment and Permit
This risk assessment and permit must be used when entry into a confined space is required.
Important: This permit may only be issued for a maximum of 1 day, the person responsible for issuing this permit must monitor its use to ensure the controls are being implemented this
permit may not be extended, in the event that an extension is required a new permit must be issued. The person receiving the permit must agree to abide by the conditions of the permit
Details of person requesting the permit
Section 3
Yes
No
N/A
Controls cont’d
Section 1
Permit to Work Procedure
6. Man riding winch to be used
Print Name
This permit must only be issued by ESS employees
authorised to do so, please ensure all necessary details
7. Life Line to be worn
are completed
Specific location req’d
Start Date
Start Time
Finish Time
Location of
8. Breathing Apparatus Required
Work
1. Access the ESS Health and Safety Web Pages and
…./…./……
……………..
………………
locate the permit required.
9. Rescue Team Required
2. Download the form and complete it electronically
before printing one copy off so it can be signed.
10. Two way communications required
 1 x copy of the permit (signed) is given to the
11. Ongoing gas monitoring required
Description
person requesting the permit to work and must
of Work
available at the work location.
 1 x copy of the permit (electronic) must be emailed
Details of person issuing the permit
13. Intrinsically safe tools required
Section 2 a
to the Customer Services and Administration (CSA)
Sign
Date
Print
name
………/………/………
on permittowork@ncl.ac.uk who will enter the
14. Forced ventilation required
details from the permit on to the Permit to Work
Details of person receiving the permit
Section 2 b
data base. CSA will also advise you of any other
15. Other Controls Required
permits operating in the area.
Sign
Date
Print
name
………/………/………
Name
List other controls here:
3. Once work is complete the signed copy of the
permit must be returned to the ESS person
Company
responsible for the work who will then request
Name
Controls
Yes
No
N/A
CSA to remove details of the permit from the
Section 3
data base. The signed copy of the permit must
then be forwarded to CSA where it will be held
1. Equipment in the vicinity has been isolated and locked off.
on file.
2. Plant and equipment is drained and vented
3. Hazardous materials and substances have been removed
Useful Numbers
from the working area
Security Emergency
0191 2226666
Gas Meter Readings complete
5. Atmosphere test details
Fire Safety Officer
0191 2228127
below
Health and Safety
0191 2226847
H
S
Section 4 This section must be completed when
Gas Meter Serial
2
Estate Support Service
0191 2227171
cancelling or closing a permit. All copies of the permit
No
must be returned to the person that issued it
In the event of fire raise the alarm by activating the
CO
Print Name (person
Gas Meter
nearest live call point and leave the building by the
closing/cancelling the permit)
Calibration Date
nearest exit, once safe telephone the fire brigade and
the Emergency Security number above
/
/20
O
Signature
Date of Test
2
:
am/pm
Date
Time of test
Print Name:
Time
Details of person
Testing
Sign Name:
atmosphere
GM/H/Permits/2010
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