APPENDIX
A - CONFINED SPACE AND PERMIT-REQUIRED CONFINED
SPACE RECOGNITION FORM
Part
I
Yes/No
1
Is
the space large enough so an employee can
bodily enter and perform work?
2
Does
the space have limited or restricted means
for entry and exit?
3
Is
the space designed for occupancy?
Note
to the Employer: Refer to Section II for
additional clarification and assistance.
If the answers to items 1 and 2 are yes
and item 3 is no, then the space is not
considered a confined space and no further
action is needed. If the answers to items
1,2 and 3 are yes, then you have identified
the space as a confined space. Continue
to Part II if a confined space has been
identified to determine if it is a permit-required
confined space.
Part
II
Yes/No
1
Does
the space contain or potentially contain
a hazardous atmosphere?
2
Does
the space contain any chemicals or chemical
residues?
3
Does
the space contain any flammable/combustible
substances?
4
Does
the space contain or potentially contain
any decomposing organic matter?
5
Does
the space have any pipes which bring chemicals
into it?
6
Does
the space have any materials that can trap
or potentially trap, engulf or drown an
entrant?
7
Is
vision obscured by dust at 5 feet or less?
8
Does
the space contain any mechanical equipment?
9
Does
the space have converging walls, sloped
floors or tapered floor to smaller cross-sections
which could trap or asphyxiate an entrant?
10
Does
the tank or vessel contain a rusted interior?
11
Does
the space contain thermal hazards (e.g.,
extreme hot or cold)?
12
Does
the space contain excessive noise levels
which could interfere with communication
with an attendant?
13
Does
the space present any slip, trip or fall
hazards?
14
Are
there any hazards from falling objects?
APPENDIX
A - CONFINED SPACE AND PERMIT-REQUIRED CONFINED
SPACE RECOGNITION FORM
Part
II
Yes/No
15
Are
there any operations conducted near the
space opening which could present a hazardto
entrants?
16
Are
there lines under pressure servicing the
space?
17
Are
cleaning solvents or paints going to be
used in the space?
18
Is
welding, cutting, brazing, riveting, scraping
or sanding going to be performed in the
space?
19
Is
electrical equipment located in or required
to be used in the space?
20
Does
the space have poor natural ventilation
which would allow an atmospheric hazard
to develop?
21
Are
there any conditions which could prevent
any entrant's self rescue from the space?
22
Are
there any corrosives which could irritate
the eyes in the space?
23
Are
there any substances used in the space which
have acute hazards?
24
Is
mechanical ventilation needed to maintain
a safe environment?
25
Is
air monitoring necessary to ensure the space
is safe for entry due to a potential hazardous
atmosphere?
26
Will
entry be made into a diked area where the
dike is 5 feet or more in height?
27
Are
residues going to be scraped off the interior
surfaces of the vessel?
28
Are
non-sparking tools required to remove residues?
29
Does
the space restrict mobility to the extent
that it could trap an entrant?
30
Is
respiratory protection required because
of a hazardous atmosphere?
31
Does
the space present a hazard other than those
noted above which would make it a permit
space?
Note
to the Employer: If any of the questions
in Part II have been checked Ayes@, the
confined space is a permit-required confined
space. As such, entry into these spaces
must be performed under the protection
of a full permit-required confined space
program. Note that in some situations,
alternative procedures or reclassifying
to a non-permit space may be possible
in lieu of a full permit-required confined
space program.
APPENDIX
B - ALTERNATIVE PROCEDURE WORK SHEET
Note
to the Employer: This worksheet is intended
to provide written certification that
the permit space qualifies for alternative
procedures and verifies that the space
is safe for entry. This checklist should
be augmented with any relevant information
for this certification process.
1)
a)
Permit Space Location
b)
What is the size (volume) and configuration
of the space?
2)
a)
Have employees received permit space training?
b)
Has the certifier received permit space
training?
Y
N
Y
N
3)
a)
What tasks are to be performed during
the entry operation?
b)
Is a hazardous atmosphere the only hazard
of concern? If no, alternative procedures
cannot be used.
Y
N
4)
Does
the atmospheric hazard in the space have
the potential to create high temperatures
or high pressures? If yes, take appropriate
action before removing cover.
Y
N
5)
Are
conditions safe to remove cover? If no,
cover removal is prohibited.
Y
N
6)
After cover removal, is opening properly
guarded?
List guarding methods:
Y
N
7)
a)
Continuous forced air ventilation provided?
If no, explain why :
If yes, explain capacity (CFM) air exchange
rate.
b)
Minimum ventilation duration prior to
allowing entry
Note:
Refer to Section III for information on
ventilation systems and appropriate calculations.
Conduct pre-entry atmospheric testing
and continue to ventilate the space during
the entire entry operation.
Y
N
8)
Is
atmospheric testing equipment calibrated?
Date
of calibration:
Y
N
APPENDIX
B - ALTERNATIVE PROCEDURE WORKSHEET
9) Atmospheric Testing Record:
Substance
Acceptable
Level
Readings
Oxygen
19.5%
- 23.5%
Explosive
(Gas/Vapor)
<10%
LFL
Explosive
Dust
<LFL
(5 ft. Visibility)
Carbon
Monoxide
50
PPM
Hydrogen
Sulfide
10
PPM
10)
Does
inspection of interior have to be conducted
to see if other hazards exist?
If yes, full entry program is required.
Y
N
11)
a)
Is frequent or periodic testing performed?
If no, explain why
b)
Who is to perform frequent or periodic
monitoring?
Y
N
12)
a)
If a hazardous atmosphere is detected
during entry, have employees been instructed
to evacuate immediately?
b)
Is there a procedure to reevaluate the
space if a hazardous atmosphere does develop?
Describe Procedure:
c)
Have steps been taken to prevent employees
from re-entering the space until it is
proven to be safe?
List steps :
Y
N
Y
N
Y
N
13)
Have
employees had the opportunity to review
the data to support use of alternative procedures?
Y
N
Signature
of Certifying Head
Date
APPENDIX
C - RECLASSIFYING PERMIT SPACE WORK SHEET
1)
Permit
Space Location
2)
Have
employees received permit space training?
Y
N
3)
A.
Are any hazardous atmospheres present
or potentially present?
B.
Is continuous forced air ventilation needed
to maintain acceptable levels?
C.
Is air monitoring required? If yes, record
test results.
Y
N
Y
N
Y
N
ATMOSPHERIC
TESTING RECORD
Substance
Acceptable
Level
Readings
Oxygen
19.5%
- 23.5%
Explosive
(Gas/Vapor)
<10%
LFL
Explosive
Dust
<LFL
(5 ft. Visibility)
Carbon
Monoxide
50
PPM
Hydrogen
Sulfide
10
PPM
D.
Is
atmospheric testing equipment calibrated?
Date
of calibration :
Y
N
Note
to the Employer #1: If hazardous atmospheres
are present or ventilation is needed to
control levels, then reclassifying the
space is not possible. It is necessary
to eliminate the atmospheric hazard to
reclassify (see Note to the Employer #2).
4)
Is
an engulfment hazard present?
If
yes, what control measure is used to eliminate
the engulfment hazard?
Y
N
5)
Is
there an entrapment hazard?
If
yes, then list the steps to be taken to
eliminate the hazard.
Y
N
APPENDIX
C - RECLASSIFYING PERMIT SPACE WORK SHEET
6)
Have
all hazardous energy sources (including
chemical and physical hazards) been eliminated?
Y
N
Check
isolating methods used to eliminate the
hazard(s).
deenergize equipment
locking out electrical circuits and related
training provided
tagging out electrical circuits and related
training provided
physically block machinery so it can not
move
blank or blinds
double block and bleed
locking and/or tagging valves
disconnecting lines
other procedures, be specific:
Note
to the Employer: The above listed isolation
techniques are generally used in combination
to ensure elimination of the hazard(s).
Is
it necessary to enter the permit space
to determine if the hazard has been eliminated?
If
yes, then the entry must be performed
in accordance with a full PRCS program,
paragraphs (d) through (k).
Y
N
Note
to the Employer #2: Permit spaces that
contain or have the potential to contain
hazardous atmospheres may also be reclassified
as non-permit spaces if the source of
the hazardous atmosphere can be eliminated
during the entire entry operation. After
the space is isolated, purged and ventilated
from outside, it must be entered to test
the atmosphere and inspect conditions
within the space in order to ensure that
the hazards have been eliminated. This
entry must be conducted in accordance
with the full permit space program requirements
given in paragraphs (d) through (k). Once
again, control of a hazardous atmosphere
is not the same as its elimination. This
reclassification would also be valid only
as long as the hazards remain eliminated.
7)
Have
all employees who will enter the declassified
space been instructed to immediately evacuate
the space if a hazard is detected?
If
no, instruct employees of this safety
precaution measure.
Y
N
8)
Has
a procedure been instituted to re-evaluate
the space and reclassify it back to a
permit space if the need arises?
If no, then institute steps to properly
re-evaluate the space, prohibit entry
and if necessary reclassify it back to
a permit space.
If
yes, describe procedure:
Y
N
APPENDIX
C - RECLASSIFYING PERMIT SPACE WORK SHEET
9)
Have
all employees participating in the entry
operation had and opportunity to review
this safe entry certification form?
Y
N
Signature
of Certifying Head
Date
APPENDIX
D - PERMIT-REQUIRED CONFINED SPACE (PRCS) PROGRAM
WORK SHEET
Permit
Space Location:
Hazards
Acceptable Entry Conditions
Equipment
Required
Yes/No
Type
Air
testing monitor
Forced
air ventilation
Communication
Personal
Protective Equipment
Lighting
Barriers
Entry/Egress
Rescue
Equipment
Respirator
Other
Equipment
Methods
to prevent Unauthorized Entry:
Specific
Space Entry Procedures:
APPENDIX
D - PERMIT-REQUIRED CONFINED SPACE (PRCS) PROGRAM
WORK SHEET
Designated
Required Personnel:
Authorized
Entrant's
Name(s):
Duties:
Attendant's
Name(s):
Duties:
Is
one attendant monitoring multi-spaces at
the same time?
Y
N
If
yes, 1) list method(s) to monitor multi-spaces:
2)
Provide procedure(s) to respond to an emergency
and still be able to ensure the safety of
the other spaces:
Entry
Supervisor's
Name:
Duties:
Air
Monitor's Name:
Duties:
APPENDIX
D - PERMIT-REQUIRED CONFINED SPACE (PRCS) PROGRAM
WORK SHEET
Entry
Permit: (company representative's name)
will provide entry permits for PRCS operations.
All entry permits will be completed by the entry
supervisor authorizing entry. Upon cancellation
of the entry permit by the entry supervisor,
the entry permit will be returned.
Procedures
for Summoning Rescue and Emergency Services:
Multi-Employer
Permit Space Operation? Y
N
If
yes, develop procedures to coordinate entry
operations.
List
measures taken to close entry portal and return
the space to normal operating conditions.
(Company
Representative's Name)
will review entry operations if measures taken
did not fully protect employees [see 1910.146
(d)(13)].
(Company
Representative's Name)
will conduct a review of the permit program
at least annually utilizing canceled entry permits.
Any inadequacies will be corrected.
APPENDIX
D-1 - SAMPLE COPY OF A PERMIT-REQUIRED SPACE
PROGRAM WORK SHEET
Permit
Space Location: Reactor Vessel #1, Production
Department, Main Building
Hazards:
Acceptable
Entry Conditions:
Oxygen
Deficiency
Flammable
Substances
-Toluene
-Acetone
19.5-23.5%
Toluene
(LEL 1.3%)<10%
Cleaning
Solvent (Acetone)
(LEL
2.6%)<10%
Toxic
Substances
-Toluene
-Acetone
<150
ppm-15 min. STEL
<100
ppm-8 hour PEL
<1000
ppm-15 min. STEL
<750
ppm-8 hour PEL
Mechanical/Engulfment-Mixer
Raw
Product Line
Toluene
-Isolate
Space
-Isolate Space
-Isolate Space
Lockout/Tagout/Block
Disconnect
Lines
Purge,
Clean, Ventilate
Required
Equipment:
Equipment
Required
Yes/No
Type
Air
testing monitor
Yes
O2
and combustible gas meter; detector tubes
for toluene and acetone
Forced
air ventilation
Yes
Explosion-proof
fan; adequate length of hose for ventilation
Retrieval
system (full body harness, tripod, winch)
Self-contained
breathing apparatus
Respirator
Yes
Air-purifying
respirator with organic vapor cartridges
Other
Equipment
Yes
High-pressure
steam cleaner
Yes
Isolation
equipment (locks, tags)
APPENDIX
D-1 - SAMPLE COPY OF A PERMIT-REQUIRED SPACE
PROGRAM WORK SHEET
Specific
Space Entry Procedures:
1)Have
entry supervisor obtain and complete entry permit
items as necessary. Refer to this written entry
program for procedures to follow. Have entry
supervisor contact on site rescue service to
notify them of confined space entry operation
in progress.
2)Isolation
Procedures-
(a) Raw Product Line - Have employees wear
chemical protective clothing, gloves, splash-proof
goggles, air-purifying respirators with organic
vapor cartridges. Close, lock and tag upstream/downstream
valves to the vessel. Bleed raw product residue
from between valve. Misalign or remove section
of pipe and cap. Use calibrated air-monitoring
equipment to test valve or cap for any leaks.
(b)
Mixer - Lockout/Tagout mixer's electrical
source at the control box number one, switch
number two. Verify that all stored energy
has been dissipated from the mixer and it
is disengaged by attempting to activate mixer.
(c) Drain residual material from vessel.
3)Rinse
space with acetone-containing solvent applied
from grounded and bonded low-pressure steam
cleaner then allow material to drain from the
vessel. Make sure affluent line is open.
4)Allow
vessel to cool, then rinse vessel with grounded
and bonded high-pressure steam cleaner using
soap and water solution. Allow material to drain
from the vessel and allow it to cool.
5)Make
sure it is safe to remove entrance cover, and
use only spark-proof tools.
6)Have
attendant conduct air monitoring using calibrated
equipment. Test vessel after opening for:
a. Oxygen
b. LFL
c.
Toluene
d.
Acetone
7)
Purge vessel with forced air ventilation for
30 minutes.
8)Retest
atmospheric conditions. If hazardous atmosphere
exists, repeat cleaning and purging procedures.
9)Perform
continuous forced air ventilation for duration
of entry operation
10)Check
and set up equipment. Have authorized entrant
wear personal protective equipment and full-body
harness with retrieval line attached.
11)Have
entry supervisor inspect operation and provide
authorization for entry. Post completed and
signed entry permit near entrance for employees
to review.
12)Conduct
additional pre-entry test and have attendant
conduct continuous monitoring for duration of
entry operation.
APPENDIX
D-1 - SAMPLE COPY OF A PERMIT-REQUIRED SPACE
PROGRAM WORK SHEET
13)Complete work inside the vessel and ensure
all authorized entrants have exited from the
space.
14)Notify
entry supervisor for cancellation of the entry
permit.
15)Return
space to normal operation.
16)Return
canceled permit to Safety Manager.
Designated
Required Personnel:
Authorized Entrant's Name(s): Individual's Name
Duties:
Know hazards, use equipment properly, communicate
with attendant, and alert attendant of any hazards,
exit quickly if ordered to do so.
Attendant's
Name(s):
Duties:
Know hazards of space, behavioral effects of
hazards, keep track of number of entrants, remain
outside of space during entry, communicate with
entrants, monitor activities outside space,
summon rescue and emergency medical services,
take actions to keep unauthorized entrants away
from space, perform non-entry rescues, and do
no other duties while monitoring entrants.
Entry
Supervisor's Name:
Duties:
Know hazards of the space, verify that acceptable
entry conditions exist, terminate entry operations,
verify that rescue service is available, remove
unauthorized persons from area and ensure acceptable
entry conditions are maintained at appropriate
intervals.
Air
Monitor's Name:
Duties:
Know hazards of the space, know acceptable entry
conditions, know how to properly calibrate,
use, maintain and understand limitations of
the air sampling device, know how to properly
interpret the results obtained from the device.
Entry
Permit: (company representatives name)
will provide entry permits for PRCS operations.
All entry permits will be completed by the entry
supervisor authorizing entry. Upon cancellation
of the entry permit by the entry supervisor,
the entry permit will be returned.
Procedures
for Summoning Rescue and Emergency Services:
Rescue
services will be onsite for the duration of
the entry operation. Attendant will use walkie-talkie
radio to contact security officer, who will
contact onsite emergency services at
.
Multi-Employer
Permit Space Operation? Y
N
APPENDIX
D-1 - SAMPLE COPY OF A PERMIT-REQUIRED SPACE
PROGRAM WORK SHEET
List
measures taken to close entry portal and return
the space to normal operating conditions.
Attendant
will ensure all entrants have vacated the space
by checking their names off the entry permit.
The entry supervisor will verify that the entry
operation is complete and terminate the entry
permit. The entry supervisor will also check
to ensure that the entry portal is replaced
properly and that the vessel is returned to
normal operating conditions. The entry supervisor
will notify the onsite rescue services that
the confined space entry operation has been
completed
The
safety manager will review entry operations
if measures taken did not fully protect employees.
The safety manager will conduct a review of
the permit space at least annually utilizing
canceled entry permits. Any inadequacies will
be corrected.
Note
to the Employer: This sample copy of a
completed PRCS worksheet is intended to
give employers an idea of what types of
information is helpful in completing this
form. The procedures outlined are merely
examples and should not be expected to
be the correct protocol for each permit
space entry operation. The employer is
reminded that the information provided
in their program should be as specific
as possible to be beneficial to entry
team members. For example, more specific
list of duties for PRCS team members is
likely needed to be appropriate.
APPENDIX
E - HOST EMPLOYER=S RESPONSIBILITIES WITH CONTRACTOR
WORK SHEET
In
accordance with the requirements of the OSHA
Permit-Required Confined Space Standard 1910.146,
this information is being made available to
(Name of Contracting Company)
so they can take appropriate precautions to
protect their employees during a PRCS operation.
The following is a list of permit space locations,
their identified hazards and any precautions
taken by our firm.
Location
Hazard
Precautions
Taken
Other
applicable information concerning the permit
space which may be of assistance:
Note
to the Employer: A PRCS program is required
for these spaces, unless alternative procedures
or reclassification procedures can be
utilized and certified to allow safe entry.
During
the contractor's PRCS operation, our employees
(will) (will not) be involved in entry or work
near the permit space.
If
our employees will be involved with entry into
or near the permit space, then (Host Employer
Representative's Name)
will coordinate the entry operations with the
contractor.
List
whose permit space program will be used for
entry into the space: (Host Employer's)
OR (Contractor's)
APPENDIX
E - HOST EMPLOYER'S RESPONSIBILITIES
WITH CONTRACTOR WORK SHEET
Note
to the Employer: This coordination should
include a determination of whose permit
program is to be used. The standard does
not prohibit the host employer from requiring
a contractor to use the host employer's
permit program, nor does it require the
contractor to use the host's program.
The employer may choose to condition its
contract on the contractor's compliance
with the host's program.
Debriefing
conference will be held with, (Host Employers
representative)
and (Contractors Representative)
at the completion of the entry operation. At
a minimum, the following items must be covered:
Was
the PRCS program adequate?
Y
N
If
no, what deficiencies were noted?
Were
there any hazards confronted or created
by the entry operation (e.g.; hazardous
atmosphere, ventilation or testing equipment
failure, unauthorized entry, etc.)?
Y
N
If
yes, list circumstances and actions to be
taken to prevent reoccurrence.
