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  • Permit CS

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    surya adi wijaya
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    This confined space permit outlines safety procedures for entry into a confined space. It requires identification of hazards, safety controls, personal protective equipment, and authorization signatures. The permit specifies the location, activities, potential hazards like flammable gases, toxic vapors, and physical dangers. It also lists safety measures such as ventilation, energy isolation, gas testing, safe entry/exit, lighting, fall protection, and tools inspection. Workers must be trained and wear respirators, eye protection, gloves, and other PPE. An attendant is assigned to monitor entry/exit and provide rescue if needed. The permit must be completed and signed by the contractor, employer OHSE, supervisor and manager to authorize the work.

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    This confined space permit outlines safety procedures for entry into a confined space. It requires identification of hazards, safety controls, personal protective equipment, and authorization signatures. The permit specifies the location, activities, potential hazards like flammable gases, toxic vapors, and physical dangers. It also lists safety measures such as ventilation, energy isolation, gas testing, safe entry/exit, lighting, fall protection, and tools inspection. Workers must be trained and wear respirators, eye protection, gloves, and other PPE. An attendant is assigned to monitor entry/exit and provide rescue if needed. The permit must be completed and signed by the contractor, employer OHSE, supervisor and manager to authorize the work.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    11 views1 page

    Permit CS

    Uploaded by

    surya adi wijaya
    This confined space permit outlines safety procedures for entry into a confined space. It requires identification of hazards, safety controls, personal protective equipment, and authorization signatures. The permit specifies the location, activities, potential hazards like flammable gases, toxic vapors, and physical dangers. It also lists safety measures such as ventilation, energy isolation, gas testing, safe entry/exit, lighting, fall protection, and tools inspection. Workers must be trained and wear respirators, eye protection, gloves, and other PPE. An attendant is assigned to monitor entry/exit and provide rescue if needed. The permit must be completed and signed by the contractor, employer OHSE, supervisor and manager to authorize the work.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    No : FORM-03-HSE-11
    Revision : 00
    Confined Space Permit Date : 1 Nov 2017
    Page : 1 of 1
    In case of emergency the permit will be considered invalid.
    A. Time Schedule
    Start Date: Finish Date:
    From (hh:mm): To (hh:mm):
    B. Location and Activities:

    [ ] Storage Vessel [ ] Silo


    Confined Space Entry Type [ ] Ruang di bawah Atap
    [ ] Ruang Electrical
    [ ] Lainnya (specify):___________________
    [ ] Tangga Shortcut
    C. Periksa Semua Hazards yang Berpotensi (Bahaya yang ada di area/di dalam/ confined space)

    Hazardous Atmoshperic Physical Hazards


    [ ] Flammable [ ] Temperature [ ] Spark-producing Hazards Lainnya (sebutkan)
    [ ] Toxic [ ] Chemical Absorption Operations
    _______________________
    [ ] Irritant [ ] Spilled liquids
    [ ] Corrosive [ ] Noise
    [ ] Engulfment _______________________
    [ ] Oxygent-Deficient [ ] Entrapment
    [ ] Oxygent-Enrich [ ] Vibration [ ] Radiation ________________________

    D. Safety Controls (assess together between the permit issuer and the permit holder)
    D1. Risk Assessment(Name, doc.no., revision, date):
    Job Safety Analysis (Name, doc.no., revision, date):
    Other (Name, doc.no., revision, date):
    D2. Additional Safety Controls - Prior commence and during work Comments & Definitions
    [ ] Depressurising, draining, venting, cleaning, purging
    [ ] Ventilation (suction or blowing)
    [ ] Energy Isolation (electrical and/or mechanical) Energy Control Permit Ref. No.:
    [ ] Gas Test & record
    [ ] Provision of safe entrance and egress
    [ ] Assign manhole watch Name:
    [ ] Additional lighting ( …... V) [ ] Warning notices at entry points
    [ ] Safety Line is available during work
    [ ] Tools have been inspected before used inside
    [ ] Periodic gas measurement every .… minutes
    [ ] Continuous ventilation (suction or blowing)
    [ ] Record entry/exit in entry logbook
    Apakah sebelum memasuki confined space, ruang confined space perlu dibersihkan? [ ] YA [ ] TDK
    Jika YA, Pembersihan menggunakan apa? List __________________________________________
    Apakah sisa gas yang ada dalam confined space harus dikosongkan dan confined space bebas gas
    Apakah prosedur ini sudah dilaksanakan? [ ] YA [ ] TDK

    E. Personal Protective Equipment


    E1. Respiratoty Protection 2. Eyes Protection 3. Routine Protection
    [ ] Self Contained Breathing [ ] Safety Glasses [ ] Gloves [ ] Overall
    [ ] Air purifying respirator
    [ ] Goggles [ ] Chemical Suit [ ] Earplug/muffs
    [ ] Air line
    [ ] Hard Hat [ ] Safety Boot
    E2. Rescue or Access Equipment
    [ ] Escape Set [ ] Fire Extinguisher [ ] Lainnya (sebutkan)
    [ ] Communication (2 Way Radio) [ ] First Aid Kits
    [ ] Lifeline [ ] Torch
    F. Work Authorisation (All signatures must be completed or else the permit is invalid)
    Contractor/ Permit Requestor: Employer OHSE:
    Employer Supervisor: Construction Manager:
    G. Nama Pekerja yang Bekerja di Lokasi Kerja Sesuai Ijin Kerja
    1 3 5
    2 4 6
    H. Confirmation of work completion (Pekerjaan selesai, area dikembalikan ke kondisi awal & aman).
    Permit Requestor : Employer OHSE:
    Employer Supervisor: Construction Manager:
    Date/ Time :

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