CSTR-HSE-FM-002 (REV.

0)
Confined Space Checklist
(To be completed by a competent person)
Work Site Location Operation/Safety Checks Permit to Work Number
(indicate Y or N in each box)

Period 1 Yes Period 2 Yes Period 3 Yes Period 4 Yes Period 5 Yes Period 6
/ No / No / No / No / No Yes / No

Procedure for incapacitated person in place

Oxygen content 19.5% - 21%
Hydrocarbon test found to be nil
Carbon Monoxide found to be nil
H2S gas test found to be nil
Work checked by person in charge
Precautions against gas ingress
All sludge/combustibles removed
Drains, vents, pipework isolated
Barriers / warning signs erected
Continuous ventilation required
Ventilation equipment earthed
Adequate access / egress
Trapping Hazards identified
Guards against fall/collapse
Portable lighting required
Safety watch to be in position
Continuous Gas Monitoring

Has the gas detection equipment been checked prior to use

Is the gas detection equipment calibrated and in date?

Safety Equipment Required:

Resuscitator
Rescue ropes pulley etc.
Safety Harness & Line
Protective clothing
Respiratory protection
Eye protection
Hearing protection
Isolate unattended equipment
Rescue Plan (state ‘step by step’ how you will achieve rescue, list the rescue team, the equipment to be used and references to external
emergency services, ie Fire & Medical together with relevant telephone numbers and named points of contact)

Checks carried out by: Date: Title: Competent Person

Verified by: Date: Title: SSS/SHO

Note. The Person In Charge confirms that the checks have been completed properly by signing the PTW form. They have been reviewed
and discussed with the Nominated Responsible Person

CSTR-HSE-FM-002 Rev.0