The permit is automatically suspended on activation of the General Alarm or Instruction via Notification Alarm
CONFINED SPACE WORK PERMIT
WORK PERMIT NUMBER CSWP - PERMIT ISSUED TO SUBCONTRACTOR Yes □ No □
DIVISION / SUBCONTRACTOR NAME MANPOWER
1 A TASK DESCRIPTION
Task/Work Description
Location/Area
Validity Period
Work Shift □ Day Shift □ Night Shift
Days Date From To From To
(Working Duration)
Time From To From To
Description of Equipment: Equipment ID/Tag No.: Attachment □ Certificate □ Operator Qualifications
B HAZARD IDENTIFICATION & RISK ASSESSMENT
Description of Possible Hazards □ Access □ Isolations □ Stored Energy □ Flamable Gas □ Toxic Gas □ Inadequate Lighting
□ Entry / Exit □ Trap □ Power Tools □ Oxygen Defeciency □ Oxygen Enrichment □ Ventilation
□ Unauthorized Entry □ High Noise □ Equipment Hazard □ Communication □ High Pressure □ High Temperature
□ Others
Attachment required □ HEMP □ Risk Assessment □ Method Statement(MS) □ Drawings □others ______________
C CONTROLS
ORIGINATOR / PERFORMING AUTHORITY
Required Control measures: Yes No N/A Other Control Measures: Yes No N/A
Safe Access / Work Platform available □ □ □ Safety Signage Displayed "Confined Space Entry/Authorized Person" □ □ □
Positive Isolation by blinding /disconnecting & tag □ □ □ Emergency Rescue Plan in Place □ □ □
LOTO, if 'Yes' check Isolation work permit □ □ □ Use of SCBA □ □ □
Release of Stored Energy / Verification of Zero Energy □ □ □ Use of Tripod □ □ □
Gas Test (if "Yes" go to D) □ □ □ Communication for Hole Watch [ Attendant] & Entrant Established □ □ □
Are persons trained and have valid card for confined space Entry? □ □ □ Temp/Humidity/Wind Speed within Safe limits □ □ □
Hole Watch [Attendant] assigned with Entry / Exit Log register □ □ □ Repeated or continuous gas monitoring □ □ □
Adequate lighting (Lighting Lines < 24 V:) □ □ □ Equipments used are proprely grounded □ □ □
Forced ventilation (Air-blower with duct) in place □ □ □ Override of HSE Critical devices (if "Yes" go to F) □ □ □
Explosion Proof light, tools, equipment required in place □ □ □ Clean area and make safe: □ □ □
Safety Signage Displayed "Confined Space Entry/Authorized Person" □ □ □ Others (________________________________) □ □ □
PPE Required (Check the box if required) ;
Safety Helmet □ □ □ Face shields □ □ □
Safety Goggles □ □ □ Cartridge Respirator □ □ □
Safety Shoe □ □ □ Hood (□ Welding, □ Blasting, □ Others) □ □ □
Glove s(□Cotton, □Leather, □Nitrile,□IR) □ □ □ Chemical/Fire Resistant/ Other Clothing □ □ □
Full Body Safety Harness and Double lanyard □ □ □ Ear Plug / Ear Muff □ □ □
Actions & Other Precautions:
D GAS TEST (If additional gas tests are required, use the Additional Gas Tests Form)
Toxic
Gas Test Parameter Flammable Oxygen
Date Time Name H2S CO Ammonia SO2 Others Remarks
Safe Limits < 1% LEL 23.5%<O2> 19.5% < 10 ppm < 35 ppm < 25 ppm < 2 ppm
Test Results
Test Results
Test Results
2
E CROSS REFERENCES & ACKNOWLEDGMENT F PERMITS & CERTIFICATES REQUIRED
ORIGINATOR/AREA
SUPERVISOR
Other permits in area that Yes □ No □ Details: Other Permits or Certificates Required Yes □ No □
could interfere: [SIMOPS] Electrical Work Permit Number
Acknowledgement from Isolation Certificate Number
Affected Parties [SIMOPS]
3 DESCRIPTION PERFORMING AUTHORITY AREA SUPERVISOR ISSUING AUTHORITY HSE TEAM (AOTC)
I understand and accept the above conditions and precautions and I declare that all hazards have been identified and all specified control The Permit and any supplementary certificates have been completed. The For check, Compliance and Record
Acknowledgement accept responsibility for the work and ensure the persons under my measures are in place and it safe to carry out the work defined control measures defined are in place.
control understand and comply with these conditions and precautions
ISSUE
Name
Sign
Date/Time
CANCELATION
CHECK
PERFORMING AUTHORITY AREA SUPERVISOR ISSUING AUTHORITY HSE TEAM (AOTC)
EXTENSION
4
DATE TIME
D NAME SIGN NAME SIGN Name SIGN NAME SIGN
EXTENSION OR CANCELLATION
□ □
□ □
□ □
□ □
□ □
□ □
5 DESCRIPTION PERFORMING AUTHORITY AREA SUPERVISOR ISSUING AUTHORITY HSE TEAM (AOTC)
I declare that the work has been properly performed and that the I have inspected the equipment/work area and declare that the work All copies of Permit & any supplementary certificates collected. The control For check, Compliance and Record
Acknowledgement
equipment, plant and apparatus affected by the work have been left in a defined in this permit is complete and that the area is clean and safe. measures put in place for this permit have been removed.
COMPLETION
safe, clean condition
Name
Sign
Date/Time
Document Tag: AOTC-IMS-L4-301-F-003 | Rev:01 | Date: 10-01-2021
