Appendix E

Facility NameConfined Space Program

Pre-Entry Hazard Assessment

This form is to be used to identify the hazards associated with a specific confined space and to determine the procedures and safety precautions that are required to enter the space. If during the course of work in the confined space new hazards evolve, the entrants must stop and contact the CSES for a re-assessment.

The form must be completed by a designated Confined Space Entry Supervisor (CSES) in compliance with the Facility Name Confined Space Standard.

Date: Location:______CS Inventory #

Description of work to be performed:

______

______

______

CSES name (print): ______Phone: ______

CSES signature: ______

Atmospheric Hazards Checklist
Hazard / Does the hazard exist or have the potential to evolve due to work performed in the space? / Level Measured / Equipment used for Test - model and serial number / Calibration current?
if "Yes" - proceed
if "No" - STOP! / Can the Hazard be eliminated or controlled by ventilation?
Oxygen Deficient<19.5%
Oxygen Enriched>23.5%
LEL>10%
Carbon monoxide>25 ppm
Carbon dioxide>500 ppm
H2S>2 ppm
other - ______
TLV- IDLH -
other - ______
TLV- IDLH -
other - ______
TLV- IDLH -
other - ______
TLV- IDLH -
Section 2 - Hazards Evaluation Checklist
Check those items that are a significant hazard either because of the potential risk if the hazard is not controlled and the need to ensure that controls are present or because the hazard is present to a degree that may cause injury, illness or loss of life.
Hazard Description / Does the hazard exist or have the potential to evolve during work in the confined space? / Can the hazard be eliminated or controlled? Describe the adequate method of control.
Process hazard
Entrapment
Entanglement
Feed-line (steam, chemical, water)
Chemical reaction possible
Chemical cleaning planned
surface scaling / abrasion planned
Hydraulic pressure
Pneumatic pressure
Mechanical pressure
Sludge
Steam
Engulfment or immersion
Electrical (above 50v?)
Fire or explosion
Explosive / implosive
Hot surface, material or air
Cold surface, material or air
Fall, Slip or Trip hazards
hazardous walking/ working surfaces
Structural integrity
inadequate ventilation
sloping, narrowing or tapering floor
Radiations
Illumination extremes (too dark or too bright)
Noise
Vibration
Low / High frequency noise
Infrared Radiation
Ultraviolet Radiation
Microwave radiation
Ionizing Radiation
Biological Agents (list)
Chemical Hazards:
Inhalation hazards
Ingestion hazards
Skin Contact hazards
Skin absorption hazards
Eye Contact hazards
Mucous membrane Contact
Mechanical Hazards:
rotating equipment
sharp edges
automatic start / stop
pinch points
in-running gears or belts
falling objects
shear hazards
inward converging wall(s)
Other Hazards:
Blocked / difficult entry or exit
Poor communications likely
Attendant view obstructed
work performed after normal hours / on holiday
Section 3 - Decision Tree
Q / Y / N
1 / Are there any serious safety or health hazards identified in Sections 1 or 2? If "Yes", go to Question 2
If "No", the CSES may reclassify the space as a Non-permitted Space for no more than 1 shift.
2 / Does the Space present an actual or potential atmospheric hazard? If "Yes" go to question 3. If "No" go to question 4.
3 / Is the only hazard in the space an atmospheric hazard that can be controlled by ventilation? If "Yes" you may follow the Alternate Entry Procedures. If "No" you must follow the Permit Required Procedures.
4 / Can all hazards be eliminated without entry into the space? If "Yes" the hazards can be controlled and the space reclassified as a non-permit space. If "No" you must follow the Permit Required Procedures.
Section 4 - Reclassification to Non-Permit Space Certification
I certify that the space identified in this form has been assessed and does not contain or have the potential to contain an atmospheric hazard for the duration of the job and that all other hazards identified have been eliminated by use of controls noted above. The space reclassification as a non-permit space is only for the duration of this job or 1 shift (which ever occurs first) or for the continued time that the noted controls are installed and effective. The entry must be made using all general safety precautions for the works tasks and those noted in this form.
CSES signature: ______date & time:______