Form : Entry into Enclosed Space CBPL 062

Vessel’s: ____________________________________________ Date: ____________________

GENERAL (This Checklist must be completed by pen)

Location/ Name of Enclosed space …………………………………………….………………………………….

Reason for entry ………………………………………………………………………….………………………..

This permit is valid from ……………….. hrs Date …………………. (See Note 1)
To ……………….. hrs Date ………………….

Section 1 - Pre-Entry Preparations

(To be checked by Master or the nominated Responsible Person)

 Has the space been segregated by blanking off or Yes No NA

isolating all connecting pipelines ? ………………………………………………….

 Have valves on all pipelines serving the space been

secured to prevent their opening ? Yes No NA
………………………………………………….

 Has the space been washed/cleaned? Yes No NA

………………………………………………….

 Has the space been thoroughly ventilated by Yes No NA

………………………………………………….
Mechanical Means?
 Pre-entry atmosphere tests: (See Note 2)
Readings Oxygen ………………….. % vol (21%)
Hydrocarbon …………….. % LEF (Less than 1%)
Toxic Gases :- (See Note 3)
Name of Gas TLV in ppm Reading in ppm

 Have arrangements been made for frequent atmosphere

checks to be made while the space is occupied and after
work breaks ? Yes No NA
…………………………………………………
 A valid risk assessment is applicable to this job ………………………………………………….
Yes No NA
 Have arrangements been made for the space to be
continuously ventilated throughout the period of Yes
Yes No
No NA
NA
occupied and during work breaks ? …………………………………………………

 Is adequate illumination provided? …………………………………………………

Yes No NA
 Is rescue and resuscitation equipment available for
immediate use by the entrance to the space ? Yes No NA
…………………………………………………

 Has a responsible person been designated to stand by

the entrance to the space ? Yes No NA
………………………………………………...

 Has the Officer of the Watch (bridge, engine room,

cargo control room) been advised of the planned
entry? Yes No NA
…………………………………………………
 Has a system of communication between the person at
the entrance and those entering the space been agreed
and tested ? Yes No NA
………………………………………………….

 Are emergency and evacuation procedures established

Controlled Revision: 2
Yes No
Issue Date: 01 Dec 2019
NA 1 of 3
 Form : Entry into Enclosed Space CBPL 062

and understood ? ………………………………………………….

 Is there a system for recording who is in the space? Yes No NA

………………………………………………….

 Is all equipment used of an approved type? Yes No NA

………………………………………………….

 Have the persons entering the space been briefed on the

Yes No NA
configuration and any other dangerous aspects of the space?………………………………………………….

Section 2 - Pre-Entry Checks

(To be checked by the person authorised as leader of the team entering the space)

 Section 1 of the permit has been completed fully. Yes …………………………………………………

No NA
 I am aware that the space must be vacated immediately
in the event of ventilation failure or if atmosphere tests
change from agreed safe criteria.
Yes
…………………………………………………
No NA

 I have agreed the communication procedures. …………………………………………………

Yes No NA
 Yes No NA
I have agreed upon a reporting interval of …….. minutes. …………………………………………………

 Emergency and evacuation procedures have been agreed

and are understood. Yes No NA
…………………………………………………
To be signed by: Signature Date Time

Responsible Officer …………………… ..………………… ……………..

Master …………………… ..………………… ……………..

Person entering enclosed space …………………… …………………. ……………..

Section 3

The work has been completed and all persons under my supervision, materials and equipment have been withdrawn.

Authorised person incharge: ………………………………. Time: ………………… Date: ……………………

Notes:

1. The entry Permit should contain a clear indication as its maximum period within normal working day. In case, work to be carried out beyond a
normal working day, risk assessment to be reviewed and additional controls must be put in place. For the purpose of this permit, Normal
Working Day is defined from 8AM to 5PM.
2. In order to obtain a representative cross-section of the compartment’s atmosphere, samples should be taken from several depths and through as
many opening as possible. Ventilation should be stopped for about 10 minutes before the pre-entry atmosphere tests are taken.
3. Tests for specific toxic contaminants, such as benzene and hydrogen sulphide, should be undertaken depending on the nature of the previous
cargo, for details refer to MSDS.
4. One copy shall be displaced at the entrance of the Space.
Initial
OOW

THIS PERMIT IS
RENDERED
PERMIT NO:

Time
Out

Controlled Revision: 2 Issue Date: 01 Dec 2019 2 of 3

 PERSONNEL ENTRY RECORD (To be completed by
responsible person supervising entry) & REPETITIVE CHECK

Controlled
Ventilation
Date Name of Person Continuous LEL H2S Bnz Other
O2 Time In
/Time Entering since Last (%) (ppm) (ppm) (ppm)
Entry (%)
Form : Entry into Enclosed Space

Revision: 2
Yes
No
NA

Issue Date: 01 Dec 2019

CBPL 062

INVALID AND MUST BE RENEWED IF THE VENTILATION STOPS OR IF ANY OF THE CONDITIONS NOTED IN

3 of 3
THE CHECKLIST CHANGE