Confined Spaces Rescue/Emergency Action Plan

This form is to be completed before first entry and whenever there is a rotation of duties
Site Permit No. Date
Maximum Number of People Allowed in Confined Space
Job Description
Emergency Co-ordinator
Contacts the Emergency Services. Name Tel
Controls the Rescue until the
Emergency Services arrive. Deputy Tel
Emergency Services
Telephone Number / Radio Contact
Location of nearest telephone
Location of Emergency Shower
Rescue Standby Man
Monitors the entry personnel. Name Tel
Dons BA/Harness/PPE in
preparation for entry, if required. Deputy Tel
Keeps a tally of entry
personnel Does not enter unless
instructed by co-ordinator

Rescue Team Site Rescue Team - Emergency Services (Tick)

Don BA/Harness/PPE and enter Name Tel
space for Rescue when instructed
by co-ordinator. Name Tel
First Aid Person
Resuscitation and First Aid Name Tel
treatment.

Rescue and Emergency Equipment

tick Qty tick Qty
Rescue Breathing Apparatus
Escape Breathing Apparatus
Air horn/means of raising alarm
Harness and Lanyard
Winch
Tripod or lifting point
Fire Extinguisher
Torch or Lights
Resuscitator
First Aid Kit

Ensure all equipment is available, tested and in working order before first entry