CONFINED SPACE HAZARD ASSESSMENT FORM

Transcription

1 CONFINED SPACE HAZARD ASSESSMENT FORM Location: Date of Assessment: Description of Location: 1. CONFINED SPACE CLASSIFICATION This space is a: q Permit-Required Space q Non-Permit Required Space q Not a Confined Space q Inventory Number 2. CONFINED SPACE LOCATION/DESCRIPTION Building Name: Confined Space Description: Department Name/Location: Street Address: Space: q At Ground/Floor Level q Indoors q Below Ground/Floor Level q Outdoors q Elevated (If outdoors, give reference points and distance) Details: Dimensions: Volume (cubic feet): No. of Access Openings: Primary Access Point: Standard Drawings Available: q YES q NO If yes, Drawing Number: Means of Access Into Space: q Portable Ladder q Existing Ladder q Stairwell q Above Ground, Hand Railing provided q Horizontal q Elevated q Vertical q Other:

2 3. PROCESS/ WORK PERFORMED IN SPACE Identification of Process: Chemicals/Hazardous Materials in Use? q YES q NO Chemical/Material Name Supplier q If Yes: q q q Copy of MSDS required at worksite q YES q NO Waste Products/Sludge Present When Space is Emptied? q YES q NO 4. ENTRY INTO SPACE IS CARRIED OUT q Yes q No If YES: Primary q Preventative Maintenance q Inspection Reason for q Maintenance Repair q Cleaning Entry q Fire q Other: Frequency of Entry q Daily q Weekly q Monthly q Other: 5. NOTIFICATION q Notification to be given to the affected department of service interruption and entry work : Department = q Pre-Entry briefing on specific hazards and control measures to Confined Space Team 6. SITE CONTROL q Yes q No If YES: q Barricades/Guardrails q Rope/Warning Tape q Traffic Protection Plan q Warning Signs q Secure Access Doors q Other: 7. SPACE PREPARATION METHODS q Yes q No If YES: q Empty q Purge q Depressurize q q Clean q Cool q Cool q Ventilating Other: 8. LOCKOUT / TAGOUT q Yes q No If YES: q Electrical q Hydraulic q Pneumatic q Chemical q Thermal q Radiation q Gravity q Gases q Chemical/ Fluids q Blocking/ Cribbing q Other: q Reference established Lockout/Tagout written procedure. 9. PIPELINE ISOLATION q Yes q No If YES: q Broken q Blanked/ Blind q Capped q Vented q Double Valve & Bleed q Isolation Valve

3 10. HAZARD IDENTIFICATION A. Atmospheric Hazards q Yes q No C. Potential Energy Sources q Yes q No If YES complete Section A. If NO proceed to Section B. If YES complete Section C. If NO proceed to Section D. Y N Oxygen Content: Y N q q Deficiency < 19.5% q q Electrical q q Enrichment > 23.0% q q Hydraulic Toxic, Explosive & Gases: q q Pneumatic (LEL% UEL%) q q Mechanical q q Acetone ( ) q q Ammonia ( ) q q Steam q q Benzene ( ) q q Piping systems q q Carbon Dioxide ( 900 mg/m 3 ) q q Gravity q q Carbon Monoxide ( ) q q Other: q q Ethyl Alcohol ( ) q q Gasoline ( ) q q Hexane ( ) q q Hydrogen Sulphide ( ) D. Safety Hazards q Yes q No q q Methane ( ) If YES complete Section D. If NO proceed to Section E. q q Methyl Alcohol ( ) q q Entry/ Exit (access/egress) q q Nitrogen Dioxide (310 mg/m 3 ) q q Ventilation Systems q q Propane ( ) q q Machinery q q Sulphur Dioxide (13 mg/ m 3 ) q q Piping/ Distribution Systems q q Toluene ( ) q q Residual chemicals/ materials q q Xylene ( ) q q Visibility Fumes, Dusts & Smoke: q q Physical obstacles q q Fogs q q Temperature extremes q q Smoke q q Humidity Biological Agents: q q Noise q q Vibration B. Configuration Hazards q Yes q No q q Hazardous animals If YES complete Section B. If NO proceed to Section C. q q Other: q q Interior shape or slope q q Low overhead clearance q q Drop offs E. External Hazards q Yes q No q q Complex layout If YES complete Section E. If NO proceed to Section 10. q q Structural integrity q q Traffic q q Compartmentalized q q Machinery / equipment q q Elevated Work Surfaces q q Work in neighboring compartments q q Sharp surfaces q q Terrain q q Inwardly converging walls q q Processes q q Maneuverability q q Weather If yes, give examples: q q Others 11. HOT WORK

4 Hot Work Permit Is Required q Yes q No If YES: Special Precautions for Welding / Cutting: Space must be re-evaluated for hazards and appropriate measures and precautions must be taken. q NO SMOKING PERMITTED IN SPACE AT ANY TIME q Yes q No Portable Fire Extinguisher If YES: (type) Size: 12. ELECTRICAL EQUIPMENT (TO TAKE INTO SPACE) q Yes q No If YES: q Double Insulated Tools q Battery Operated q Low Voltage q Ground Fault Circuit Interrupter (GFCI) q Generator q Positively Grounded Tool / Equipment q Explosion Proof Equipment q Other 13. ILLUMINATION (TO TAKE INTO SPACE) q Yes q No If YES: q Portable Electric Safety Lamp q Low Voltage q Battery Operated Lighting (ex. Flashlights) q Light Stations q Light Sticks q Explosion Proof Equipment q Lighting Provided within space q String of Lights q Others 14. PRE-ENTRY AND ENTRY ATMOSPHERIC TESTING (ALWAYS REQUIRED) * Oxygen q Continuous q Periodic Frequency * Combustible Gas q Continuous q Periodic Frequency * Toxic q H 2 S q CO q Continuous q Periodic Frequency Other: PEL: H 2 S = 10 ppm, CO = 35 ppm INSTRUMENTATION: q 3-Gas Meter q 4-Gas Meter q Draeger Tubes q Accessories q Other: 3-Gas meter = % oxygen / % LEL / Toxic. 4-gas meter = % oxygen / % LEL / Toxic / Toxic 15. RESPIRATORY PROTECTION q Yes q No If YES: q Half Mask Air Purifying Respirator for: q Powered Air Purifying Respirator for: q Full Mask Air Purifying Respirator for: q Air-Line Supplied with 5 minute escape cylinder q Self-Contained Breathing Apparatus (SCBA): 16. PERSONAL PROTECTIVE EQUIPMENT q Yes q No If YES: q Safety Glasses q Welding Helmet q Protective Clothing (type) q Impact Goggles q Hard Hat q Protective Footwear q Chemical Goggles q Face shield q Gloves (type) q Cutting Goggles q Hearing Protection q Double Hearing Protection q Traffic Vest *PPE requirements must be determined from the activity being performed within the Confined Space. *

5 17. FALL PROTECTION AND RESCUE DEVICES q Yes q No If YES: q Davit System / Tripod System q Personal Alert and Distress Device q Full Body Harness with D Ring q Lifeline with Safety Hooks (type) q Escape SCBA q Material Handling Winch Length: q q Barricades/ Guard Rails Special Attachment/ Anchor Requirements: 18. COMMUNICATION EQUIPMENT q Yes q No If YES: Attendant Required? q YES q NO Between Attendant and Entrant(s): q Verbal (voice) q Radio q Personal Communication Device q Other: Emergency Notification: q Portable Radio q Telephone q Walkie-talkie Emergency Telephone Number: Location of Nearest Working Telephone: 19. RESCUE TEAM q Emergency Services (Fire Dept.) q Notify Stand-By Personnel: 20. SPECIAL HAZARDS / REQUIREMENTS / NOTES 21. PERFORMED BY: Name Signature Date JHSC Worker Member JHSC Management Member Department Representative Health and Safety Services Rep

6 CONFINED SPACE ENTRY PERMIT Issued (date/time): Expired (date/time): Confined Space Location: Description of Work: Attendant: Supervisor: List of team members: Name: Training: Signature(s): Attendant(s) Entrant(s) Communications/Scribes Labourer(s) Description of Confined Space Hazard(s) Lock-out Locked Initial Removed Initial Atmospheric Testing Air Monitoring Equipment Identification No. Calibration Date Calibrated By Bump Testers Signature to Confirm Test Confirmation of O₂, LEL, CO and H₂S Sensors Pre-test Top/Opening Middle/ 1.0m Middle/ 2.0m Bottom O₂ (19.5% to 23%) LEL (Alarm 25%) CO (Alarm 25ppm) H₂S (Alarm 10ppm)

7 Ventilate then Test Top/Opening Middle/ 1.0m Middle/ 2.0m Bottom Supervisor Sign-off O₂ (19.5% to 23%) LEL (Alarm 25%) Date: Time: Signature: CO (Alarm 25ppm) H₂S (Alarm 10ppm) Entrant Personal Protective Equipment Entrant Equipment List Inspected By Date Rescue Equipment Inspected By Date Entrant/Attendant Accountability Entrant Name Attendant PPE Checked Training Checked Time in: Time out:

8 Time: Location in Space O₂ (19.5% to 23%) Monitoring LEL (Alarm 25%) CO (Alarm 25ppm) H₂S (Alarm 10ppm) Signature of Competent Supervisor Closing Permit: Date/Time:

9 HOT WORK PERMIT Permit No.: Type of Operation: q Welding q Cutting q Open Flame q Burning q Other: Permit issued to (name of person): Representing: Telephone Number: ( ) Supervisor: Telephone Number: ( ) Start Date: Permits are valid from until on the date of issue only Work done by: q City Staff q HVAC q Plumbing q Gen Maintenance q Contractor q Other Location where work will be performed [be specific about the location of work Bldg. Floor, Column and approximate distance from column (s)]: Brief Description of work (be specific when describing the work to be performed): Fire Watch (identify who will provide the fire watch): THIS PERMIT IS TO BE ACCOMPANIED BY A JOB WRITE-UP WHEN HOT WORK IS TO BE PERFORMED ON LINES, AIR DUCTS OR BESSEL NORMAL CONTAINING COMBUSTIBLE MATERIALS SUCH AS OIL, DOWTHERM OR ADIPIC ACID. VERIFY ALL OF THE FOLLOWING: Y N q q Hot work equipment will be inspected and determined to be good repair prior to the start of work q q No sprinklers will be taken out of service while this work is being done q q The potential for smoke, heat, airborne dust, etc. to trigger a fire alarm has been evaluated q q There are no combustible fibers, dusts, vapours, gases or liquids in the area. There are no tanks or equipment that previously contained flammable liquids in this area or they will be purged and the absence of explosive gases developing in nearby piping, equipment, or tanks containing flammable liquids or gases, the area will be continuously monitored for hazardous conditions with appropriate instruments. q q All combustibles will be relocated 20 feet from the operation and the remainder protected with metal guards or flame-proofed curtains or covers (no ordinary tarpaulins). q q Fire alarms will not be taken out of service or a suitable fire watch will be arranged q q Surrounding floors will be swept clean and, if combustible, wet down q q Ample portable fire extinguishers and trained personnel to use them will be available at the job site. At a minimum, a 5 lb ABC rated extinguisher must be present in addition to the normal compliment of building extinguishers. q q Prior to starting work, workers will determine the location of the nearest: building fire extinguisher and telephone (accessible) and verify a clear escape route from the wok area SAFETY PRECAUTIONS Y N Y N q q Special Job write-up attached q q Rope off area q q Post warning sign q q Remove Combustible Material q q Shield Arc Welding q q Protect Critical Surfaces from heat q q Fire Watch q q Special Ventilation q q Protect electrical and instrumentation conduits, cables and tubing from heat and spark damage q q Minimum size, 5 lb dry chemical or equivalent fire extinguisher on hand q q Protect ceiling and floor opening from welding g spark and slag q q Other: IMPORTANT: All fires, even those of a minor nature are to be reported in writing to the fire hall immediately following the incident

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