PERMIT TO WORK - WORK IN CONFINED SPACES

PERMIT N°:
form XXX-YYYY- rev 00 Comment : this form is designed to be filled manually, not electronically
Reminder: A Permit To Work shall be issued for any entry in a confined space.A confined space is a space or a structure that is large
enough that employees can bodily enter and perform work and is not designated for continuous occupancy and has limited openings
for entry and exit and restricted natural ventilation.

General information Initials :

Work in confined space, precise number of : GE empl. Contractor empl.
Type of lifting : Routine Non routine
DESCRIPTION

If contractor, Company name :

Description of the lift (attach drawing/sketch as necessary): Area where lift will occur::

Risk assessment (tick adequate risks) Initials :

Risk of asphyxia, anoxia Risk of toxic atmosphere Risk of flammable/explosive atmosphere
Other (describe)

Rescue plan (tick adequate actions) Initials :

Emergency situations identified Rescue needs identified
Hazardous atmosphere in the confined space Escape mask Inertia reel with rescue winch
PREPARATION & ASSESSMENT

Injured worker in a confined space Respirators for rescue team Rescue tripod + hoist / winch
Need of evacuation (fire, etc.) Extinguisher Other (describe)
Other (describe)

D. Precaution to be taken prior to commencement and during the work Initials :

Equipment Hazardous atmosphere prevention measures Confined space PPEs
□ Non metallic tools □ Continu air monitoring Full body harness attached to anchor point or lifeline
□ Other (describe) □ Ventilation system Respirator
□ Other (describe) Other (describe)

Other PPE
□ Safety shoes □ Safety glasses □ Chemical gloves □ Dust mask
□ Apron □ Welder mask □ Mechanical gloves □ Chemical mask
□ High visibility jacket □ Visor □ Manual handling gloves □ Fiber mask
□ Other, describe …………..

Other risks and precautions :

Checks to perform prior to start of work (white cases : before starting to work ; grey boxes inspection during
the work) To be completed by the permit issuer / closer Initials :
Start Exec. Start Exec.
- Suitable work equipement available - Work area clear and demarcated
- Suitable PPE worn by all concerned person - Pre-entry air monitoring performed (see at the back of PTW)
- Watcher nominated and present - Adequate training provided to all person involved
- Proper means of exit provided - Appropriate hazardous atmosphere prevention
Inspection

- Appropriate rescue means available measures implemented

- Suitable fire fighting facilities provided - Appropriate ventilation and lighting provided
- Equipment completely drained / depressurized - Nearby workers informed
After the work is completed … working location inspected and found in good condition
Inappropriate conditions to be reported in this section including actions taken to rectify the situation

People covered by the permit to work Initials :

Name (printed letters) Company Role Training OK? Signature

Employees

Guideline concerning the training required :

General confined spaces training … anyone going in a confine space
Air monitoring equipement trainingwho….performs
Anyone performing
air monitoring
the air monitoring
Rescue equipement training … anyone
involved
withinthe
rescue
rescuing
operation
responsability
Harness use training … anyone having
involved
to wear
in anone
operation in a confined space where an harness is required

Permit Issue & Closure (to be done by competent person authorized to issue permits to work (ref instruction on PTW) Initials :

Permission is given for the work to proceed subject to the conditions specified above.
Name (printed characters) Signature Date / time Validity period
PERMIT ISSUE & CLOSURE

Permit issuer From : To :

Permit requestor

Permit closer

As defined in the PTW instruction, in specific cases, permit issuer may be the same as the person covered by the permit (usually specific to Service
people doing a mission on a customer site). In this case, he has to communicate with his supervisor prior to start the work.
When required, Discussion held with the supervisor
Location description for air tests :
Location 1 :
Location 2 :
Location 3 :
Location 4 :
Gas to be tested :
Oxygen

Tests values :
Location 1 Location 2 Location 3 Location 4
Component Threshold values time Value time Value time Value time Value

Note : oxygen must be between 19.5 and 23.5