Whsmp · OPW16/0021

                                                                                  Confined Space Entry Permit
                                                                                                                  HB-HSEQ-F-075
                                                                                                                      Version: 4




Personal Protective Equipment (PPE) Requirements & Other Precautions
Minimum PPE / other items required: Yes     No Provide Clarifying Details as Required:
Supplied air breathing apparatus
Air purifying respirator
Particulate mask
Safety harness and lanyard / lifeline
Head protection
Face shield / goggles / safety glasses
Ear muffs / plugs
Gloves
Warning notices / barricades required
Specific lighting provisions required
Specific hot work controls required
Other:
Attachments (other documents/plans
prepared)
Permit Request:
This acknowledgement signifies a formal request to commence confined space entry / works. As the person requesting this
permit, I hereby certify that:
 •    I am competent to coordinate this confined space entry / work in accordance with the Risk Assessment & Entry Permit
     details;
 •    I shall undertake to implement all planned and necessary controls to ensure safe entry / work; and
 •    I shall monitor confined space hazards and control methods throughout the entry / work.
Name:                                         Signature:                                   Date:                Time:
Hutchinson Builders Authorisation:
This Hutchinson Builders Authorisation signifies that the planning component of the Risk Assessment & Entry Permit has been
completed and that confined space entry / work is authorised to commence in accordance with the Permit Request.
Name:                                         Signature:                                   Date:                Time:

Section 3 – Implementation
Atmospheric Testing / Monitoring Guide:
Atmospheric Issue Safe Level                         Caution (Entry during Emergency Response / With Additional Controls
                                                     Only)
Oxygen             > 19.5 % and up to 23.5%          < 19.5% need positive pressure supplied air breathing apparatus.
Contaminants:
CO                 < 30 ppm                          Generally, positive pressure supplied air breathing apparatus may be
H2S                < 10 ppm                          worn at levels approaching and slightly over the exposure standard as
CO 2               < 5000 ppm                        determined as part of Risk Assessment and control measure
NH 3               < 25 ppm                          implementation.
Other              As per specific exposure
                   standards
LEL                < 5%                               > 5% and up to 10 %
                                                      Entry permitted in emergency response. However, if during work the
                                                      level rises to above 5% and up to 10%, personnel are to evacuate,
                                                      unless a suitably calibrated combustible substance detector is used at
                                                      all times while personnel are in the space.
 For other contaminants not listed, specific monitoring devices and pre-work planning will be required to ensure safe entry /
                                                              work.
Atmospheric Test Results:
     When                          Atmospheric Test Results                                      Verification
 Date    Time          O2        CO     H2S      LEL                                Meter         Entry            Name
                                                                                   Number       Permitted
                                                                                                (Yes / No)




The atmosphere in the space is safe to enter:
      Without respiratory protection              With an air purifying device           With a supplied-air device




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