Confined Space Checklist - Brentwood Services, Inc.
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Writing Your Program To help you think through your confined space program and implement safety precautions, the following is a suggested method to survey your spaces and document your program. Please feel free to copy any pages in this section, carry them to the space in question. Document your findings and retain them for review by safety compliance inspections. Space is available under each entry for you to document your particular space information in full. General Information Identify the space_________________________________________________________________ _______________________________________________________________________________ Date of initial survey: ________________ Name of Person making Survey:_____________________________________________________ Is this a confined space? ____ Yes ____ No If you answer all of the following questions with “yes” the space is considered to be a confined space. Does the size and shape allow a person to bodily enter to perform work? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Are there limited or restricted openings making entry and exits difficult? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Is the space designed for continuous human occupancy? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Permit Required Confined Spaces If you answer “yes” to at least one of the next four questions, this is a permit-required space. 1. Does it contain or have the potential to contain a hazardous atmosphere? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Brentwood Services Loss Control 2. Does it contain a liquid or finely-divided solid material such as a sand or sawdust that could surround or engulf and entrance? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ 3. Does it have an internal shape—Such as a (Page3 top) converging walls or a floor that slopes downward and tapers to a smaller cross section—that could cause an entrant to be trapped or asphyxiated? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ 4. Does it have any other characteristics that is recognized as a serious safety or health hazard? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Will your own employees enter this confined space? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Will contractor employees or visitors enter the confined space? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Is it feasible to seal off this space to prevent space? ____ Yes ____ No Possible Methods: ___ Locks ___ Covers ___ Guardrails ___ Fences ___ Others Explain: _______________________________________________________ _______________________________________________________ If you cannot completely prevent entry, you must decide how to inform employees and others about hazards of the space Possible Methods: ___ Signs ___ Training ___ Visitor training ___ Covers ___ Barriers ___ Other How will you determine that these methods are in place? ___ Regular surveys ___ Inspections ___ Training ___ Other Explain: _______________________________________________________ _______________________________________________________ Brentwood Services Loss Control Reclassifying the Space Could this be a non-permit required space? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Is it possible to eliminate all its hazards without anyone entering the space? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ It is possible to certify that the space has no actual or potential atmosphere hazards and all other hazards within the permit space have been eliminated? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Certification of reclassification: Date of the determination Location of the space Signature of the person making the determination. This certification becomes a permanent part of the employer’s written permit space program and must be made available to each employee entering the space. Could this space qualify for alternate entry procedure? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Do testing and monitoring results show a controllable hazardous atmosphere as the only hazard? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Monitoring and inspection data demonstrate both of the following: First, actual or potential hazardous atmosphere is the only hazard poised by the permit-required confined space. Second, continuous forced air ventilation alone is sufficient to maintain the permit space safe for entry. Since these determinations must be made in writing and supported with actual testing and monitoring results, the person making the determination must complete the paper documentation and sign it. Brentwood Services Loss Control Developing Safe Permit Entry Procedures The following can help you to develop and implement the means, procedures and practices necessary for safe permit space entry operations. Does the space contain and immediate or delayed threat to life? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Does this space contain a threat that would cause irreversible adverse health effects? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Does the space contain a threat that would interfere with an individual’s ability to escape unaided from a permit space? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Does this space contain atmospheric hazard? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Is it a flammable gas, vapor or mist in excess of 10 percent of its lowest flammable limit (LFL)? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Is it an airborne combustible dust at a concentration that meets or exceeds its LFL (approximated as a condition in which the dust obscures vision at a distance of 5 feet (1.52 m) or less)? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Is it an atmospheric oxygen concentration below 19.5 percent (oxygen-deficient)? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Is it an atmospheric oxygen concentration above 23.5 percent (oxygen-deficient)? ____ Yes ____ No Explain: _______________________________________________________ Brentwood Services Loss Control _______________________________________________________ Is it an atmospheric concentration of any substance that could result in employee exposure to toxic air contaminates in excess of permissible exposure limits? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Is it any other atmospheric condition that is immediately dangerous to life or health? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Would periodic atmospheric testing or continuous monitoring control the above hazards? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ If you answered “yes” to this question, develop a testing and/or monitoring program for this space. Developing Safe Atmospheric Testing/Monitoring Is it necessary to test periodically for oxygen content? ____ Yes ____ No If yes, how often? _____________________ Instrument to use: ___________________________ Is it necessary to test periodically for flammables? ____ Yes ____ No If yes, how often? _____________________ Instrument to use: ___________________________ Is it necessary to test periodically for toxics? ____ Yes ____ No If yes, how often? _____________________ Instrument to use: ___________________________ Would continuous monitoring be better? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Add monitoring needs, what monitor to use and describe how: _______________________________________________________________________________ _______________________________________________________________________________ Brentwood Services Loss Control Identifying Other Hazards Does this space contain thermal burn hazards? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Does this space contain chemical burn hazards? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Does this space contain mechanical force hazards? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Does this space contain engulfment in liquids or finely-divided solid particle hazards? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Does this space contain noise hazards? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Does this space contain heat stress hazards? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Are there other hazards not listed here which are potentially present in this space? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Developing Hazard Control Now you are ready to develop procedures to eliminate or control the hazards listed above. Can the space be cleaned, purged or inerted? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Brentwood Services Loss Control Can the space be isolated from hazardous energy and materials? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Can lockout/____ prevent unexpected operation of equipment inside the space? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Can blanking or blinding prevent accidental entry of hazardous materials? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Would mechanical ventilation conceal toxic or flammable gases and vapors? ____ Yes ____ No Explain: _______________________________________________________ _______________________________________________________ Would mechanical ventilation ensure adequate oxygen supply? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Is there a need for back work permits and procedures? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Are line breaking procedures required? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Are there other isolating methods necessary for this space? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ During entry and work does the space require barriers such as covers, guardrails, fences or locks to keep unauthorized personal out? ____ Yes ____ No Explain: ________________________________________________________________________ _______________________________________________________________________________ Brentwood Services Loss Control Identifying Equipment Needs Now you are ready to decide which equipment is necessary for safe entry work and exit. You will also need to decide how to maintain this equipment, how it is to be inspected and who is responsible for the equipment program. List atmospheric testing instruments: _______________________________________________________________________________ _______________________________________________________________________________ How maintained? ________________________________________________________________________ ________________________________________________________________________ How inspected? ________________________________________________________________________ ________________________________________________________________________ Person(s) responsible? ________________________________________________________________________ ________________________________________________________________________ List monitoring instruments: _______________________________________________________________________________ _______________________________________________________________________________ How maintained? ________________________________________________________________________ ________________________________________________________________________ How inspected? ________________________________________________________________________ ________________________________________________________________________ Brentwood Services Loss Control Person(s) responsible? ________________________________________________________________________ ________________________________________________________________________ List ventilation equipment: _______________________________________________________________________________ _______________________________________________________________________________ How maintained? ________________________________________________________________________ ________________________________________________________________________ How inspected? ________________________________________________________________________ ________________________________________________________________________ Person(s) responsible? ________________________________________________________________________ ________________________________________________________________________ List necessary communication equipment: _______________________________________________________________________________ _______________________________________________________________________________ How maintained? ________________________________________________________________________ ________________________________________________________________________ How inspected? ________________________________________________________________________ ________________________________________________________________________ Person(s) responsible? ________________________________________________________________________ Brentwood Services Loss Control ________________________________________________________________________ List special lighting equipment required: _______________________________________________________________________________ _______________________________________________________________________________ How maintained? ________________________________________________________________________ ________________________________________________________________________ How inspected? ________________________________________________________________________ ________________________________________________________________________ Person(s) responsible? ________________________________________________________________________ ________________________________________________________________________ List PPE: Eye protection: ________________________________________________________________________ Head protection: ________________________________________________________________________ Hearing protection: ________________________________________________________________________ Respirator: ________________________________________________________________________ Egress bottle: ________________________________________________________________________ Special tool requirements: ________________________________________________________________________ Brentwood Services Loss Control Barriers and signs: ________________________________________________________________________ Entry and exit equipment: ________________________________________________________________________ Rescue equipment: ________________________________________________________________________ Any other equipment required for safe entry, work and exit: ________________________________________________________________________ ________________________________________________________________________ Assuring Proper Equipment Use How will you ensure that the above equipment is used properly? _______________________________________________________________________________ _______________________________________________________________________________ Training: ________________________________________________________________________ How Often: ________________________________________________________________________ Trainer: ________________________________________________________________________ Practice: ________________________________________________________________________ Inspection: ________________________________________________________________________ Brentwood Services Loss Control If any of the previous equipment is not available or serviceable, how will you prevent entry? _______________________________________________________________________________ _______________________________________________________________________________ Procedure: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Assigning Entry Team Personnel How will entrances be assigned? _______________________________________________________________________________ _______________________________________________________________________________ Training: ________________________________________________________________________ Listing can permit: ________________________________________________________________________ How will attendants be assigned? _______________________________________________________________________________ _______________________________________________________________________________ Training: ________________________________________________________________________ Listing can permit: ________________________________________________________________________ How will entry supervisor be assigned? _______________________________________________________________________________ _______________________________________________________________________________ Brentwood Services Loss Control Previous experience: ________________________________________________________________________ Training: ________________________________________________________________________ Listing can permit: ________________________________________________________________________ Establishing Rescue Plans Should conditions become unacceptable, what are rescue plans? _______________________________________________________________________________ _______________________________________________________________________________ Elements of self-rescue: ________________________________________________________________________ Calling for help: ________________________________________________________________________ Service assigned to rescue: ________________________________________________________________________ How is emergency team trained? _______________________________________________________________________________ _______________________________________________________________________________ How will emergency team know special space conditions? _______________________________________________________________________________ _______________________________________________________________________________ How will emergency team know special space hazards? _______________________________________________________________________________ _______________________________________________________________________________ Brentwood Services Loss Control Will there be first-aid and CPR training? _______________________________________________________________________________ _______________________________________________________________________________ How will untrained would-be rescuers be kept out of the space in an emergency? _______________________________________________________________________________ _______________________________________________________________________________ Establishing Contractor Safety You are now ready to think about contractor/host relationship How will you as best employer inform the oncoming contractor that your workspace has permit spaces that are to be entered only under a permit space program? _______________________________________________________________________________ _______________________________________________________________________________ How will you apprise the contractor of hazards associated with the permit space? _______________________________________________________________________________ _______________________________________________________________________________ How can you include in this pre-entry briefing information about your experience with the space? _______________________________________________________________________________ _______________________________________________________________________________ How will you apprise the contractor of any permit space procedures you have in place? _______________________________________________________________________________ _______________________________________________________________________________ Are there other topics you should cover with the contractor to assure safety for your employees and the contractor employees as well? _______________________________________________________________________________ _______________________________________________________________________________ How will you coordinate entry, work, and exit with the contractor? _______________________________________________________________________________ _______________________________________________________________________________ Brentwood Services Loss Control How will you debrief the contractor when permit-required confined space entry is complete? _______________________________________________________________________________ _______________________________________________________________________________ The contractor has certain requirements under 1910.146. You are ready to plan to assure he is in compliance How can you be assured that the contractor will obtain any available information concerning permit space hazards and entry procedures from you? _______________________________________________________________________________ _______________________________________________________________________________ How can you enforce the cooperation of joint permit space entry operations between host and contactor? _______________________________________________________________________________ _______________________________________________________________________________ How can you be assured that your permit-required confined space program and the contractor’s program are suited to the entry and work planned? _______________________________________________________________________________ _______________________________________________________________________________ How do you plan to gather information from the contractor about hazards encountered or created by contractor employees in your space? _______________________________________________________________________________ _______________________________________________________________________________ What control do you have over the contractor to ensure a complete debrief when entry and work are completed? _______________________________________________________________________________ _______________________________________________________________________________ Concluding Entry What systematic measures are in place to safely conclude confined space work entry? _______________________________________________________________________________ _______________________________________________________________________________ Brentwood Services Loss Control What is to be done about ensuring that all elements are out of the space at the termination of the permit? _______________________________________________________________________________ _______________________________________________________________________________ What is the procedure to shut down the space? _______________________________________________________________________________ _______________________________________________________________________________ Espcially when there has been work in the space what provisions are made so control fire or explosions after work is ended? _______________________________________________________________________________ _______________________________________________________________________________ How is the entry portal to be closed? _______________________________________________________________________________ _______________________________________________________________________________ Does the entry supervisor have a list of the procedures necessary for safe cancellation of the permit? _______________________________________________________________________________ _______________________________________________________________________________ What provisions are made for returning the space to normal operating conditions? _______________________________________________________________________________ _______________________________________________________________________________ Are there special worker safety provisions related to restoring normal work? _______________________________________________________________________________ _______________________________________________________________________________ Are there other considerations needed to provided an orderly transition between periods when entry is authorized and when it is not? _______________________________________________________________________________ _______________________________________________________________________________ Reviewing the Program You are now ready to decide what form the permit space program review and revision will take. Brentwood Services Loss Control How will you be notified when conditions at the workplace indicate that existing permit space procedures provide inadequate protection? _______________________________________________________________________________ _______________________________________________________________________________ Who reports near misses? _______________________________________________________________________________ _______________________________________________________________________________ How are they reported? _______________________________________________________________________________ _______________________________________________________________________________ How will you find out that a hazard not addressed in the entry permit was present? _______________________________________________________________________________ _______________________________________________________________________________ How will you find out that a condition not allowed by the permit was part of entry, work or exit? _______________________________________________________________________________ _______________________________________________________________________________ How will you know when a change in the use or shape of the space has affected entry team safety? _______________________________________________________________________________ _______________________________________________________________________________ Is there a method to receive employee complaints about permit program effectiveness? _______________________________________________________________________________ _______________________________________________________________________________ In all the above data collection is this a non-accusatory method, designed to gather information rather than to blame? _______________________________________________________________________________ _______________________________________________________________________________ How will you prevent additional entries before the above information is collected, reviewed and reflected in your permit program? _______________________________________________________________________________ _______________________________________________________________________________ The above are condition or situation-driven indicators that permit program needs revision. OSHO requires that you review each entry permit at lead annually to ensure entry team safety. Brentwood Services Loss Control How do you plan to keep completed permit? _______________________________________________________________________________ _______________________________________________________________________________ What will be done to notify you that the annual review is due? _______________________________________________________________________________ _______________________________________________________________________________ Who is responsible for analyzing the permit and reporting necessary changes? _______________________________________________________________________________ _______________________________________________________________________________ How will you correct permit program inadequacies? _______________________________________________________________________________ _______________________________________________________________________________ Is there a procedure developed to ensure that all affected entries benefit from the analysis of each permit space? _______________________________________________________________________________ _______________________________________________________________________________ Brentwood Services Loss Control
