Work in Confined Spaces - Take 5

Part 1 Prior to work commencing the Supervisor will ensure:

Permit Number: Individual task No. (Work Order Card):

High Risk Space

The confined space has been classified in accordance
Medium Risk Space
with OP-207-0200-062
Low Risk Space

YES N/A
Initial Initial
The specific Risk Assessment for this task has been communicated to the work party?
The specific Risk Assessment has been Peer Reviewed?
All clearly understand the contents of the Permit?
All necessary controls identified are in place?
Client specific controls identified for this task are in place?
The Method Statement for this task has been communicated to the work party?
Arrangements for emergency procedures and rescue including measures to protect rescuers are in place
and have been tested?
The work party members have all completed Confined Space Training, including the use of full body
harnesses for rescue arrangements??
The work party members have all completed Confined Space Critical Task standards and expectations
awareness Training?
Standby attendants have completed training?
The process drawings have been identified and checked?
The equipment to be worked on has been positively identified and tagged?
The COSHH assessment for the previous contents has been communicated to the work party?
All Personal Protective Equipment for this task has been identified and is available for the work party?
The Pre-Task Brief has been completed satisfactorily?
All those entering the space are fit for the task and have undergone the necessary medical assessments?
All equipment for the task is within statutory inspection and calibration dates e.g. air monitoring equipment,
safety harnesses and breathing apparatus?

WHEN PART 1 IS COMPLETE THE TAKE 5 TO BE TRANSFERRED TO THE WORK PARTY

Ref: SIN3/T5 - CT Confined Space Rev C Page 1 of 2

 Work in Confined Spaces - Take 5

Part 2 Prior to work commencing the Work Party will confirm: Yes N/A
Pre-job briefing has been conducted by supervisor?

Do you fully understand the safety documentation e.g. Risk Assessment, Method Statement and Permit to
Work?
All understand the scope of work to be carried out?
All are in no doubt as to what is required to complete this task in a safe manner?
Have you been briefed on and do you fully understand the site Tagging/Identification Procedure?
Confirm the Supervisor has positively identified the correct plant by “Touching the Tag”?
Identify that you have the correct PPE and RPE as per risk assessment for the scope of work?
Are you trained to use specific named PPE and RPE?
Appropriate warning notices are displayed at entry points?
The appointed Standby Attendant is in place and controlling entry?
Pre-entry atmospheric checks have been carried out by the appointed person?
Natural or Forced Ventilation equipment is in place and operating as required?
Communication methods for those inside and outside the space is in place?
The necessary arrangements are in place for emergency rescue and evacuation?
All those entering the space are in no doubt what to do in the event of an emergency?
There is adequate lighting for the task and arrangements for emergency lighting?
Pre-inspections check for all equipment to be used has been carried out?
Background and personal air monitoring equipment alarms and how they operate are familiar to all those?
entering the space?
All those entering the space are aware of the purpose for air monitoring equipment e.g. oxygen
deficiency/enrichment or detection of hazardous gases and vapours?

IF YOU HAVE NOT TICKED ANY OF THE Yes or N/A BOXES IN PART 2 YOU MUST STOP AND CONTACT
THE SUPERVISOR

The work party comprising the undersigned persons undertaking this task acknowledges their
Part 3 understanding of the safety precautions contained in the safety brief.
Title Man No. Print Name Signature Date / Time
Team Member
Team Member
Team Member
Team Member
Team Member
Team Member
Team Member
Team Member
Team Member

Task Supervisor

Ref: SIN3/T5 - CT Confined Space Rev C Page 2 of 2