CONFINED SPACE ENTRY PERMIT

Project Name: ______________________Name of Contractor____________________ PERMIT Ref No. ________

Number of Employee Involve in the activities:_______
Starting from Date:____________ Time:__________ End of Completion:______________ Time:____________
Location of work:____________________________________________________________________________
Description of work:__________________________________________________________________________
Hand tools, Power tool, equipment to used:______________________________________________________

Precautionary measures require to make the work Safely.

Sr. # Conditions /Precautions Yes No N/A Remarks

01 Are the employees aware by the expected hazards?

02 Is the Electricity isolated & LO/TO?

03 Is the Mechanical part Isolated & LO/TO?

04 Are all energy sources isolated?

05 Is there good ventilation?

06 Is there a good lightening

07 Is the vessel cleaned or purged?

08 Is the firefighting equipment available on site?

09 Is the rescue equipment available on site?

10 Is there a special PPE required? (Respiratory/Hearing protection, Life vest, Safety Harness)

11 Is there a confined space attendant on site where worker work inside vessel?

12 Have the required tools and apparatus been inspected and adjusted?

13 Any other Requirements (Please write)

What Risk associated with the Confined space activities.

PLEASE TICK THE RISK ASSOCIATED

HOT BURN NOISE ELECTRIC SHOCK

ADVERSE WEATHER UNDER PRESSURE TOXIC MATERIALS FLAMMABLE CORROSIVE

FALLING OBJECT ELECTRICUTION ELECTRICAL SHOCK TRIPPING CABLE PROTRUDING OBJECT

OTHERS(SPECIFY)
DANGER OF FALLING GENERATING SPARK FLYING PARTICLES SLIPPING

Page 1 of 6
 CONFINED SPACE ENTRY PERMIT
Additional Document must be attached with this Confined space entry permit.

PLEASE TICK THE FOLLOWING DOCUMENTS

OTHERS(SPECIFY)
JOB HAZARD ANALYSIS METHOD STATEMENT RISK ASSESSMENT

Personal Protective Equipment Required for the Activity.

PLEASE TICK THE FOLLOWING PPE REQUIRED

SAFETY SHOES MECHANICAL GLOVES FACE SHIELD GUMBOOT

REFLECTIVE VEST SAFETY HARNESS EAR MUFF/PLUGS SAFETY CLOTHES

OTHERS(SPECIFY)
SAFETY HELMET SAFETY GLASSES GAS MASK

The following areas / Items have been Inspected by issuer and receiver.

PLEASE TICK THE FOLLOWING

ACCESS/EGRESS DANGER/ WARNING SIGN LIGHTING OTHERS(SPECIFY)

GAS DETECTOR LOG BOOK REGISTER CONFINED SPACE TRIPOD KIT

CONFINED SPACE ATTENDANT AIR VENTILATION SAFETY BARRIERS

TYPE FIRE EXTINGUISHER: QUANTITY SIZE KG:

Are emergency team available/contact number displayed at place?

Contact Number: 1. ___________________2. __________________3.____________________

4.____________________5.__________________6.____________________

ISSUE AND ACCEPTANCE BEFORE CONFINED SPACE ACTIVITY

Acceptance: I agree that the above-mentioned conditions/precautions shall be ensured by me before and during the work. The site will be left safe on completion of job.

PERMIT RECEIVER: (General work in charge- Name & Sign):________________________________________________Date:__________________________________

Authority to proceed by Authorized person Issuer: I reviewed the work permission checklist and checked the working conditions. I have reviewed all aspect of the task
/activity and am satisfied with the arrangement as detailed in the “Risk assessment, Job hazard analysis, Method Statement” have been put in place and certify that the
activity detailed above is authorized to proceed.

PERMIT ISSUER: (Person in charge- Name & Sign):_______________________________________________________ Date:__________________________________

I have reviewed the work permit and verified entire checklist corresponding to workplace all the necessary control measures has been taken according to “Risk assessment,
Job hazard analysis, Method Statement” and additional precautionary measure implemented.

ACKNOWLEDGE BY CONTRACTOR: (Name & Sign):____________________________________________________________Date:__________________________________

SAFETY ENGINEER/OFFICER
I confirm that all works is completed and the work site is in clean safe condition.

CLOSED OUT BY: (General work in charge- Name & Sign):_________________________________________________Date:__________________________________

Entry Conditions: Confined Space Permit must be in place/If you have adequate/appropriate PPE/If you fit for work (health fitness)

Page 2 of 6
 CONFINED SPACE ENTRY PERMIT

Supervisor Name Permit Ref No.

Date Location

DETAILS OF ENTRANTS

ID No. Entrant Name Time In Time Out Designation /Job Sign

10

11

12

DETAILS OF ATTENDANTS

ID No. Attendant Name Designation /Job Sign

PLANNED COMMUNICATION METHOD BETWEEN ATTENDANT AND ENTRANTS

PHONES (TYPE/MAKE/MODEL) RADIO (TYPE/MAKE/MODEL) OTHERS(SPECIFY)
VOICE /VISUAL/ROPE

CONTRACTOR

1. Permit Verified at (Date &Time) ______________________ by (HSE-Officer) sign

2. Permit cancelled at (Date &Time):_____________________ by (HSE Dep’t) sign

3. Permit will be extended at (Date & Time):_______________by (HSE Dep’t) sign

Page 3 of 6
 CONFINED SPACE ENTRY PERMIT

SCBA (Self Contained Breathing Apparatus) Checklist

PARTS INSPECTION CONDITION

YES NO
Check for crack, tears, deformed rubber, hole
Face mask Distortion/Clean/No scratch
FACE MASK ASSEMBLY Loose Lenses /face shield
Alcohol swab for cleaning after used

HEAD STRAPS Rubber straps no Breaks or Tears

No Broken buckles

No Cracks
BACK FRAME AND HARNESS Webbing straps in good condition
ASSEMBLY No missing parts
No presence of corrosion
Broken buckles

Valve/Gauges/Regulators Gasket/O-rings
1st and 2nd stage regulator No signs of cracks/Damages on regulators/gauges
Main Gauge and Remote gauge No missing parts on regulators/gauges
No Cracks or dent in housing

Cylinder/Tank No dent/deformation
No corrosion

Air Pressure full (must be in green level)

Breathing air quality / grade
Air Supply System Condition of supply hose
Hose Connection
Proper settings of regulators and valves
Oxygen certificate (Grade D)/air filling certificate
Inspected by: (Trained SCBA personnel)

Remarks

Page 4 of 6
 CONFINED SPACE ENTRY PERMIT
GAS TESTING/ MONITORING FORM
ONLY CERTIFIED GAS TESTER PERFORM GAS TESTS

Time LEL (%) H2S (ppm) O2 (%) Other gases ID No. Signature of
(Name/Value) Gas tester

Whenever testing of the atmosphere results in a gas monitor alarm condition work shall be stopped until proper controls are implemented which may
include establishing appropriate work procedure and providing suitable personal protective equipment to the work crew.

PORTABLE GAS MONITOR ALARM SET POINTS GAS TEST INFORMATION TABLE

Any reading No hot work allowed

GASES ALARM SET POINT above 0% LEL
Oxygen (O2) Low Alarm: 20.0% Combustible Gases/Vapors 5% LEL – 10% LEL Breathing apparatus must
High Alarm 23.5% be used
Lower Explosive Limit (LEL) 5% 10% LEL or No work (or confined
above space entry) allowed.
Hydrogen Sulfide (H2S) 10 ppm 10 ppm or above Breathing apparatus must
be used
Carbon Monoxide (CO) 35 ppm Hydrogen Sulfide (H2S) 10 ppm – 100 Division Head must sign
ppm the permit
Sulfur Dioxide (SO2) 2 ppm 100 ppm or No work (or confined
above space entry) allowed
Chlorine (Cl2) 0.5 ppm Less than 20.0% Breathing apparatus must
Oxygen (O2) be used & Division Head
must sign the permit
Ammonia (NH3) 25 ppm Above 23.5% No work allowed

Page 5 of 6
 CONFINED SPACE ENTRY PERMIT

ACKNOWLEDGEMENT OF STANDBY MAN’S RESPONSIBILITY

THE STANDBY MAN WILL BE RESPONSIBLE FOR:

1. MAINTAINING COMMUNICATION WITH EMPLOYEES IN THE CONFINED SPACE

2. ACCOUNTING FOR PERSONNELWORKING IN THE CONFINED SPACE
3. PREVENTING FOULING OR AIRLINE OR LIFELINES.
4. PROVIDING ASSISTANCE IN HANDLING MATERIALS, TOOLS, MESSAGES, ETC
5. BEING ALERT FOR POTENTIAL HAZARDS BOTH INSIDE AND OUTSIDE THE CONFINED SPACE
6. CALLING FOR ASSISTANCE IF AN EMERGENCY DEVELOPS
7. EVACUATING PERSONNEL IF NECESSARY
8. ENSURING THE CONFINED SPACE RNTRY LOG IS MAINTAINED
9. BEING KNOWLEDGEABLE IN THE OPERATION AND USE OF THE REQUIRED SAFETY AND RESCUE
EQUIPMENT
10. THE STANDBY MAN MUST NEVER LEAVE HIS POSITION WHILE PERSONNEL ARE IN THE CONFINE
SPACE.

ACKNOWLEDGEMENT

I_________________ACKNOWLEDGE THAT I HAVE READ THE STANDBY MAN’S RESPONSIBILITIES AS SET

FOR ABOVE. I ALSO UNDERSTAND THAT I HAVE BEEN DESIGNATED AS THE STABD BBY MAN AND
ACCEPT THESE RESPONSIBILITIES UNTIL MY SUPERVISOR HAS RELIEVED ME OF MY DUTIES.

EMPLOYER’S SIGNATURE: __________________________________________________________

EMPLOYEE NUMBER : __________________________________________________________
DATE : __________________________________________________________
TIME THAT DUTY BEGINS: __________________________________________________________

SUPERVISOR SIGNATURE: __________________________________________________________

EMPLOYEE NUMBER : __________________________________________________________

Page 6 of 6