Health, Safety and Environmental Management Procedures Manual

Title: HS&EP23 Issue No. 02 Revision: 00

Controlled Copy Page: 5 of 10

Confined Space Entry Permit

Permit No: BCL/
A. Job Details Department: Supervisor:
1. Area/Equipment covered by this permit: 2. Work to be done:

B. Isolations (specify where necessary) ON OFF

1. Circuit breaker locked out/fuses withdrawn/isolator locked off The competent person must
2. Circuit tested and found to be dead initial the appropriate section.
3. Mechanical/physical isolation
4. Valves closed/locked off/spades inserted “Section F” can not be
5. Pipelines drained/purged/disconnected/vented to atmosphere completed until isolations have
6. Other isolation signed off.
C. Precautions (to be taken as indicated)
YES NO
1. Hot Work Permit Permit No.____________________________________________
2. Protective clothing Type:________________________________________________
3. Respiratory equipment Type:________________________________________________
4. Non sparking tools Type:________________________________________________
5. Protected electrical equip. Type:________________________________________________
6. Safety harness Type:________________________________________________
7. Lifting tackle Type:________________________________________________
8. Special ventilation Type:________________________________________________
9. Additional precautions (if none state none)_____________________________________________
10. Atmosphere tests are/are not required at intervals of ______________and results must be recorded overleaf.

D. Personal controls and Signatures required before work starts

1. Maximum number of people allowed in at one

5. In my opinion the engineering precautions are adequate
time___________________________________

2. Maximum time in at one Signed

stretch_________________________________ (Engineer)___________________Date_____________

3. Length of rest pauses between 6. In my opinion the precautions taken against chemical/gas
stretches_______________________________ hazards are adequate

4. Number of watchers Signed

required_______________________________ (Tech)________________________Date____________

E. Issue and acceptance before work

1. Issue 2. Acceptance
I have examined the area specified and permission I have read, understand and accept the conditions of
is given for the work to start under the control of this permit
________________________________________
subject to the conditions above.

Signed_________________ Date:_______________
Signed _______________________Date___________

3. This permit is valid from_____Hours to ____Hours
(max one shift)
F. Clearance/Cancellation of permit
1. Clearance
All men under my charge have been withdrawn.
The permitted work is/is not complete
4. This permit is extended from____Hours to ____Hours
2. Cancellation
This permit is cancelled. The work is/is not complete.
The area/equipment is/is not safe to use.

Signed _________________Date ______Time_____ Signed_________________Date_______Time_____

See Overleaf for Atmosphere Test Record

13 September 2004 OP 07 Briggs Commercial Limited

Form No. F023B
 Health, Safety and Environmental Management Procedures Manual
Title: HS&EP23 Issue No. 02 Revision: 00
Controlled Copy Page: 6 of 10

Notes for the competent person supervising work being carried out under the
permit system.
1.Compliance with the conditions of this permit and associated permits is the responsibility of the
competent person in charge of the work. He must personally satisfy himself that all conditions
are being observed, that the work is performed safely at all times and that assistance is obtained
when necessary to ensure safety.

2.This permit and any associated permits shall be explained to those doing the work and then be
displayed in the work area.

3.The departmental supervisor shall be notified of the intention to start work in the area and the
workmen must leave the area if he so instructs. The departmental supervisor shall be notified
of the completion of the work and of the condition of the area/equipment at that time.

4.This permit shall be returned to the authorised person for cancellation.

5.Advice on the completion and use of the permit is contained in the Health Safety and Environmental
Management Procedures Manual (HS&EP 26).

6.In cases of doubt or if problems arise consult the senior authorised person.

ATMOSPHERE TEST RECORD

Initial Pre-entry Samples
Location Date Time Sludge O² % Toxic Gas Safe Sampler
yes no Type PPM yes no

I have carried out the above sampling and have found the area to be safe for:

Entry Only Entry and Hot Work Entry and Cold Work Only
(Hot work permit required) (General permit required)

Signed______________________ Date__________ Name (print)___________________

Atmosphere samples required by section C. 10 of permit

Location Date Time Sludge O² % Toxic Gas Safe Sampler

yes no Type PPM yes no

13 September 2004 OP 07 Briggs Commercial Limited

Form No. F023B