INFORMATION:

1- Fill in sheet 2-Checks only.

2- Sheet (Final L3 Report) is formulated and protected.

3- Critical (Go-No-Go) requirements are highlighted in

4- In tab "2- Checks" Hover over column cells to see reference

YELLOW
is made available, for more references refer back to relevant
Specification/Procedure.

5- Result of L3 assurance is auto assessed following this Risk

assessment matrix (RAM)"
 Inspection Date:
Inspection Location:
Contractor Name:
Contractor Number:
Area Supervisor: Name & Ref. Ind.

Sr No. Assurance on How / What to check

Check (From daily plan) which activity involves work in confined
space & ensure:

Personnel Supervising and working Interact with Working crew & verify their awarness on
1 in confined space are formally made controls
aware & Fit to work
Working crew involved have valid FTW?

Visit ongoing confined space activity to verify:

All entries in confined space is controlled by valid PTW or
2 Controlled entry in confined space Task SOP

Confined space entry certificate is authorized & Valid.

Visit ongoing confined space activity to:

Physically verify required safety precautions from

Controls from PTW & Confined confined space certificate are in place as applicable.
3
space certificate are operationalized (Physically check)

Signboards/barricading in place to prevent unauthorized

entry

Visit ongoing confined space activity to:

Check if gas testing equipment's calibration is valid ?

Confined space Gas testing & Check gas test record to verify test conducted as required
4 by PTW
entry/exit requirements met
Latest Gas test result is withing allowable limit

Validate personal entry/exit record form is accurate/up to

date.

Standby person appointed and in his position each time

crew inside confined space?

5 Confined space rescue plan in place Confined space Rescue plan from in place.

Rescue equipment available at work site as per rescue

plan
 Inspector (Lead): Name & Ref. Ind.
Name & Ref. Ind.
Inspection Team: Name & Ref. Ind.
Name & Ref. Ind.

YES/NO STATUS Comments

lves work in confined

Not checked

ify:

Not checked

Not checked

Not checked

Not checked
 HSE Tracker

Inspection Title: Confined Space Inspector (Lead): Name & Ref. Ind.

Related Document: PR-1418 , PR-1172

To check: Compliance to minimum confined

Inspection Date: 0 Scope:
space requriments are per PR-1148

Inspection Location: 0

Contractor Name: 0 Name & Ref. Ind.

Contractor Number: 0 Inspection Team: Name & Ref. Ind.
Area Supervisor: Name & Ref. Ind. Name & Ref. Ind.

* Verification of compliance to requirements and procedures in processes.

No. Requriment Status Comments Mandatory action

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