Confined Space Entry
Planned Date of Work:
Permit No:
Planned Start Time:
Approval and Authority to Commence
Validity Period:
Remote site approval applies (PH signature required)
Task Description:
Area Authority (AA): I authorize this work permit and the work can proceed as planned.
Task Location:
Task Area:
Print Name:
Signature:
Time/Date:
Secondary Location:
Area Operator (AO): I have demonstrated zero energy to the Permit Holder (when required and not delegated). I believe it is safe to perform this work and the Permit
Holder is aware of the equipment to be worked on.
Task Description Details:
Zero Energy:
Demonstrated to the PH
Not Required
Delegated to the PH
Note: At times, the zero energy demonstration will be done with the assistance of other Isolating Authorities or delegated in the case of Personal Isolations or Remote
Field Operations (RFO).
Print Name:
Signature:
Time/Date:
Permit Holder (PH) Acceptance to Commence Work: I understand the precautions that must be taken and Zero Energy (when required) has been demonstrated to
me or delegated to me (Personal Isolations or RFO). The Permit Pack has been reviewed with the work team members and I will notify the Area Operator of the job status
when work is completed/ceased. The procedures and checklists included in this Permit Pack are correct for the task and are current. Individuals who will be using these
procedures and checklists are competent in their use.
Print Name:
Signature:
Time/Date:
Area Interface Authority (AIA): I have reviewed this work permit and the work can proceed as planned.
Print Name:
Signature:
Permit Shift Handover/Extension/Reissue*
Equipment ID/Tag Number:
Equipment Description:
Date/Time
Number of People:
Lead Discipline:
Isolations Required:
ICC
Time/Date:
RFIC
Personal
Is this a Handover,
Extension, or Reissue?
Area Authority
Area Operator
Permit Holder
Area Interface
Authority
None
Work Order Number:
Requested by:
Company:
Permit Pack Required Documents:
Cross Referenced Certificates:
Atmospheric Test Record
Lifting Plan
Rescue Plan
Temporary Defeat
MSDS
SWP Checklist
Isolation Certificate
P&ID/Drawing
SIMOP Deviation
JSA/THA
Procedure
Work Aid
Type
Certificate/Permit Number(s)
Isolation:
Temporary Defeat:
* 1. Any changes of AA, AO, PH, and AIA personnel on this permit must sign accepting their responsibility.
2. Shift extensions must be signed by the AA to a maximum of 4 hours.
3. Reissued permits must be signed each shift by the AA, AO, PH, and AIA.
Work Permit(s):
List Required Checklists:
Permit Close-Out
Work associated with this permit has been completed?
Yes
Other (describe):
PH: I confirm that all personnel have been accounted for and the worksite has been restored to a safe and tidy working condition.
Print Name:
Signature:
Time/Date:
Area Authority (AA) Reviewer: The task description accurately details the permit work activity. The required permit pack documentation has
Work Status comments:
been identified.
Print Name:
Signature:
Time/Date:
AO: I am satisified that the worksite has been restored to a safe and tidy condition. All isolations relevant to this permit must follow the de-isolation procedure prior to
reenergizing, or a long term isolation (LTI) must be applied.
Person In Charge (PIC): I have endorsed this work and it will not conflict with other
RFO - PIC notified:
Signature:
(Initial)
Have isolations been removed?
activities. It can commence when the permit conditions are fulfilled.
Print Name:
Yes
Time/Date:
Print Name:
Yes
No
PIC or the AA has been notified?
Signature:
Yes
No
Time/Date:
No
Work Management System Work Permit Requirements Matrix
Work/Job Activity
Work Team Declaration:
Work Pack Requirements
Isolation
Work
Permit
Confined Space Entry
LO/TO
Blinding
Defeat
Job
Safety
Analysis
M*
Safe Work
Practice
Checklist
Work
Procedure
Mandatory for permit pack
To be reviewed and considered
for permit pack by Permit Holder,
Area Authority, and PIC.
Atmospheric
Test Record
*Isolation requirements may not be needed
for certain entry types (such as excavation).
Positive isolation required for all entries
where hazardous energy exists.
Work team members must sign before commencing work for the first time to indicate that they have reviewed the Permit Pack with the Permit Holder.
Each person understands the scope of work, their responsibilities and is competent to execute their part of the Permit Pack (including JSA, Procedures,
and Checklists) to complete the work safely.
If any person observes an unsafe situation developing they must immediately stop work, inform their co-workers, make the worksite safe, and inform the
Permit Holder and the Area Operator.
Note: Workers reassigned, crew changing, or no longer working on this permit while the permit is valid must sign off.
Date
Name
Sign On
Date
(if different)
Sign Off
Work Management System Atmospheric Test Record
Area to be Tested:
Test Frequency:
Continuous gas testing required:
Prior to work commencing:
Yes
No
Every
Yes
No
Hour(s):
No
Yes
Required Tests:
O2
LEL
H 2S
CO
VOC
Benzene
SO2
CO2
Other
Calibration Date:
Detector used:
Comments/Special Precautions:
Confined Space Entry - Personnel Log-In/Log-Out Sheet
Name
Time In
Results (Pre Start + Work Period Tests)
CSE Class 1
Limits
CSE Class 2
Limits
19.5 to 23.5%
16% to 19.5%
or > 23.5%
Pre-Start
Test
Result
Result
Result
Result
Result
Result
Result
Date
Time
Oxygen (O2)
Lower Explosive Limit (LEL)
Flammability General Work
1% of LEL (HC)
< 10% of LEL (HC)
Flammability Hot Work/Critical Work
Spark Potential
0% of LEL
0% of LEL
Total Hydrocarbon Content (THC)
< 500 ppm
< 1000 ppm (IDLH)
Hydrogen Sulphide (H2S)
< 5 ppm
< 100 ppm (IDLH)
Carbon Monoxide (CO)
< 25 ppm
< 1200 ppm (IDLH)
Benzene
< 0.5 ppm
< 500 ppm (IDLH)
Sulphur Dioxide (SO2)
< 0.5 ppm
< 100 ppm (IDLH)
Other
Authorized Gas Tester (AGT) Initials:
Confined Space Entry Attendant
Name: (Print)
Time Out
