Confined Space Pre-Entry Checklist

Project : Jakarta - Bandung High Speed Railway

LOCATION OF CONFINED SPACE :
DESCRIPTION OF CONFINED SPACE :
PURPOSE OF ENTRY :
SUPERVISOR IN CHARGE :
AUTHORIZED ENTRANTS 1
2
3
4
WORK TO BE PERFORMED

STATUS
NO ITEM/DESCRIPTION REMARKS
YES NO N/A
I Hazards
Atmospheres (Defficient or enriched oxygen,
1
flammable, toxic
2 Harmful materials
Environmental hazards: dust, heat,cold, humidity,
3
noise, vibration
4 Poor visibility

5 Excessive depths and heights

6 6. Wet and slippery hazards, trips and falls.

Electrical/mechanical hazards due to failure to
7
lockout/tagout
8 Sharp and protruding objects and equipment
Personal failure such as: heart attack, claustrophobia,
9
etc
10 Lack of specialized equipment and training

11 Lack of communication

12 Others (Radiation, static electricity, Iron sulphide, etc)

II Preparation
Isolation (emptying space, blinding/blanking, line
1
breaking, double block and bleed)
2 Lockout/Tagout

3 Purged, flushed, ventilated

III Atmospheric/Gas Test

Person Taking Atmospheric/Gas Test :
1 LEL
2 O2
3 H2S
4 CO2
5 CO
 Confined Space Pre-Entry Checklist
Project : Jakarta - Bandung High Speed Railway

IV Equipment
1 Respirator (SCBA, SABA, APR, etc)
2 PPE :
- Hardhat
- Boots (Leather/Rubber)
- Safety Glasses/Goggles
- Coverall/Chemical Protection Suit
- Gloves (Leather/Rubber)
- SCBA/SABA/APR
- Full body harness+lifelines)
3 Rescue (harness, lifeline, tripod, etc)
4 First aid (resuscitator, stretcher, etc)
5 Lighting
6 Gas detectors
7 Exhaust/Blower
8 Radios
9 Fire extinguishers/fire water
10 Explosion proof flash light.
V Roles and responsibilities
1 HSE
2 Safety Standby
3 Entrants
4 Rescue team
5 Gas Tester
6 First Aider
VI Miscellaneous
1 Specific Procedures
2 Entry Permit
3 Rescue Plan
4 MSDS
 CONTINUOUS ATMOSPHERIC TEST
PTW NO :
Confined Space Location :
Date : Perform by:

GAS
NO TIME TEMP oC Remarks
LEL % O2 % H2S ppm CO2 ppm CO ppm
 Roles and responsibilities of confined space team

No Position Name Roles and responsibilities Comments

1 The entrants Understand the hazards and follow
the COPI procedures

2 The Entry Supervisor Originally authorized entry

3 HSE 1. Maintain the equipment required

such as: respirator, gas detectors,
rescue, etc
2. Perform pre-job meeting
3. Perform first gas test.

4 Safety Standby/ 1. Remain outside the confined space

Attendance during entry operations until reliefed
by another.
2. Call rescue or other needed resources
in case of emergency
3. Maintain adequate communication
with the entrants and rescue team.
4. Prepare fire extinguishers and extinguish
in case of fire

5 Gas tester Test the gas before entry and or continous

periodically measure if required

6 Rescue team 1. To remove the victims from a confined

space.
2. Prepare the rescue equipment required

7 First aider Prepare and maintain first aid equipment

Provide first aid treatment to IP
 CONFINED SPACE RESCUE PREPLAN
DATE :
SPACE DESIGNATION : SPACE LOCATION :
(Unit/Vessel Name/No)
STAGING AREA
SPACE CATEGORY SPACE TYPE (1-3):
Category I - Rescue Available (RA) Elevated :
Category II - Rescue Stand-by (RS) Congested:
MEANS TO SUMMONS RESCUE SERVICES:
Phone Pager Radio Audible Signal Intercom Other:

METHODS OF RESCUE Confirm that attendant has been trained in emergency response procedures
External (Retrieval): Internal: (Congested:Many Job )
Hauling System Required Victim-Lowering System Required/Lowering Area
Anchorage: Overhead: Pre-rigging Required? Yes No
Achorage: Beam Welded steel Handrail Suport Strut Other :
Stairwell Anchored Steel Pipe Support Column
SUGGESTED CSR RESCUE EQUIPMENT REQUIREMENTS: (Indicate Quantity Needed)
PREPLANNED Hauling System Carabiners Pulleys
TECHNIQUE: Ascenders Prusiks Shock Absorbers
CSR# Achor Straps Webbimg Rigging Bags
RESCUE ROPES NEEDED: (Indicate Quantity Needed)
Main Line(s) Hauling System Lowering Line(s)
Safety Line(s) Line-Transfer System(s)
MEDICAL & PACKAGING EQUIPMENT NEEDED: (Indicate Quantity Needed)
Spinal Immobilization Device: Stretcher Device:
C-Collar: Medical Kit:

ADDITIONAL PPE: (See Permit / MSDS)

DESIGNATION OF RESCUE PERSONNEL: (Last Name, First Initial)

First Responder(s): Rigger:
Team Leader: Attendant:
Safety Line(s): Air Watch:
Back-up Rescuer:
SPACE DESCRIPTION:
Incinerator.

SKETCH OR DIAGRAM OF SPACE: (Use Back of Page if needed)

ENTRY SUPERVISOR: PHONE DATE

REPORT COMPLETED BY:
 CO Personnel and tools / equipment entry record
PTW NO :
Confined Space Location :
Date : Perform by:

NO NAME Tools/ Equipment Time In Time Out