CONFINED SPACE ENTRY – PERMIT TO WORK

CONFINED SPACE ENTRY – PERMIT TO WORK (ACOP L101)
This confined space permit to work must be completed prior to entry into a confined space.
This permit is only valid when all sections of the permit have been completed.
The permit for work must then be signed and dated.
Location: / Project/Permit Number: / Date:
Time of Entry: / Time of Expiry:
1.DESCRIPTION OF WORK
2. GENERAL / Tick
Health and safety Plan/Method Statement in place
Risk Assessment Completed
3. AUTHORITY / Tick
Authorities/operators notified
Permits/documentation required in place
Permission to enter confined space obtained
Conflicting works/Activities identified/stopped
Electrical/Mechanical Shutdowns/Isolations in place.
4. WORK SITE/WORKING ENVIRONMENT / Tick
Air Quality Gas test required/complete
Gas Monitoring required/in place
Breathing apparatus required/Checked
Substances COSHH Assessment samples required/taken
Lighting Adequate lighting available
Sound Decibel check where appropriate
Barriers erected/warning sign in place at access point
Appropriate PPE available/worn
Suitable access equipment utilised
Topman identified – Roles and responsibilities understood.
5. RESCUE AND RECOVERY / Tick
Rescue and recovery system in place and tested
Personnel understand rules and responsibilities
Contact with authorities in place
6. COMMUNICATIONS / Tick
Line of sight maintainable
Radio Required/Range tested
Emergency evacuation communications in place and understood
7. EQUIPMENT REQUIRED / MEDICAL/FIRST AID REQIREMENTS
First Aid Kit
Tripod and Winch/Pulley system / Burns Kit
Gas Testing Meters / Medical Oxygen Kit
Escape Breathing Apparatus / Automated Emergency Defibrillator
Working Breathing Apparatus / Rescue Stretcher/ Spinal Board
Ventilation Equipment / Limb Splints
Fire Extinguisher / Spinal Immobilisation Collar
Confined Space Signage / PPE REQUIRED
2-way radios (Intrinsically Safe? Y/N) / Basic Kit (safety boots/ helmet/ hi-vis)
Headtorches (Intrinsically Safe? Y/N) / Gloves (types appropriate to task)
Task Lighting (Intrinsically safe? Y/N) / Waterproofs (Boots/ Waders/ Dry suit)
Rope Access Kit (inc. rescue pack) / CS Fall Arrest Harnesses
Safety Glasses/ Goggles
8. MANPOWER AND RESCUE REQUIRMENTS
(Enter number of each role required)
Topman / Working Party / Rescue Team
9.TRAINING REQUIRMENTS
  1. Designated Topman must hold at least confined space working certificate.
  2. Rescue Team personnel must hold confined space rescue with full working BA certificates.
  3. Rescue Team must have at least one member who is qualified 1st Aider.
  4. Working party members must all hold confined space with escape BA certificates AS A MINIMUM.

Please tick box to confirm all team members are qualified to at least the minimum standard as described above / Vc0s
10.GAS MONITORING RESULTS (To be taken at 15 min intervals)
Test No. / Time of Test / Results / Pass/ Fail
O2 (%) / H2S (ppm) / LEL (CH4 %) / Other (Specify)
1
2
3
4
5
Is atmosphere being continually monitored during works? Y/N
11.KNOWN HAZARDS AT THE SITE OF WORK (Contaminant sources, flooding, adverse weather, inundation etc.)
Hazard / Yes / No / Hazard / Yes / No
Flammables/ Oxygen Enrich / Free-Flowing solids
Toxic Gas, Fume, or Vapour / Presence of Excessive Heat
Oxygen Deficiency / Access/ Egress problems
Vermin/ Sharps/ Contamination / Layout/ Physical Dimensions
Ingress or presence of liquid / Trips/ Slips and Falls
Others (Give Details):
Is a written safe system of work available on site? / Y/N / Has this been briefed to the work party? / Y/N
12.EQUIPMENT CHECKS
Type of Equipment: / Cylinder ID / Contents of Cylinder / Signed: / Name
Working BA Sets / 1.
2.
3.
15 min Escape Sets / 1.
2.
3.
4.
5.
2-way radios / 1. / 2.
Gas Monitors
Make / 1. / 4.
2. / 5.
3. / 6.
Tripod and Winch / Serial No / Test Date
13.AUTHORISATION
I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the permit information has been explained to all workers involved. I accept responsibility for the work.

The area is a low risk confined space suitable for entry without breathing apparatus.

The area is a medium risk confined space and escape breathing apparatus should be available.

The area is a high risk confined space and working breathing apparatus should be employed.
Signed: / Name: / Date: / Time:
14. WORKING PARTY MEMBERS SIGN IN/ OUT
NAME / TIME IN / OUT / IN / OUT / IN / OUT / IN / TIME OUT
15.CLEARANCE
I confirm that the work has been completed/suspended, checked by myself, all entrants have left the confined space AND SIGNED OUT and the area has been left in a safe condition. This permit is now cancelled.
Signed: / Name: / Date: / Time:

Comments:

Confined Space Entry - Permit to Work V4 Feb 20171