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Confined Space Hazard Assessment Template

Download and use this confined space risk assessment to identify and isolate hazards. There are different risks associated with the different types of confined space work, so it’s essential you walk through every checkpoint, as some have more than one hazard. Below, are a couple of examples of the types of checkpoints you’ll encounter in this template:

• Authorized entry points
• Permit to work
• Explosive atmosphere
• Combustible materials
• Electrical circuits
• Toxic gasses
• Toxic material
• Thermal hazards
• Dangerous machinery

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Confined Space Hazard Assessment Template

Audit

Space ID Number

Date of last assessment

Confined Space - must meet all of the criteria below

Is large enough or so configured that an employee can bodily enter and perform work and

Has limited or restricted means for entry and exit and

Is not designed for continuous employee occupancy

Permit Required Confined Space -must be a confined space and meets any of the criteria below

Contains or has the potential to contain a hazardous atmosphere or

Contains a material that has the potential for engulfing an entrant

Has an internal configuration such that an entrant could be trapped or asphyxiated by inwardly converging walls or by a floor that slopes downward and tapers to a smaller cross-section or

Contains any other recognized serious safety or health hazard

Hard hat

Goggles

Air supplied respirator

SCBA

Line fed

Ventilation Requirements

Space volume in cubic feet

Natural circulation - no atmospheric hazards in place. Additional ventilation may be required for worker comfort, hot work, grinding, or other operations that would produce airborne fumes, mist or dust. Entry Supervisor must assess additional ventilation requirements based on tasks to be performed in the space prior to time of entry.

Mechanical ventilation

Supply

Volume, in cubic feet per minute

Point

Exhaust

Volume, in cubic feet per minute

Point

Local

Volume, in cubic feet per minute

Point

Ventilation Formulas and Requirements

20 Air Changes per Hour. (ACH) required for duration of entry. 20 ACH = space volume x 20

Adequate Blower Capacity (ABC). ABC = space volume x 20 ACH, divided by 60 minutes.

Initial Purge Time. 7.5 x space volume, divided by effective blower capacity.

Required Rescue and Safety Equipment (check if required)

Lifeline

Body harness

Floor level opening barrier

Tripod

Powered communication

Portable lighting

Atmosphere make and model

Electrical equipment

Monitor

Man winch

Fall arrest unit

Emergency retrieval line

Blower

Vent saddle

Vent truck

Ladder

Emergency escape respirators

APR Respirator Cartidges

Acid/gas

DMF

N-95

R-95

P100

Acceptable Entry Conditions

Confined space entry permit closed

Oxygen 19.5-23.5%

Lower explosive level 10%

Toxic fumes/vapors less than PEL

No engulfing materials in space

Continuous air monitoring

Space drained, flushed

Training verified for Supervisor, entrants and attendants

LOTO electrical components in use

LOTO mechanical components in use

LOTO all pipes to and from space

Forced mechanical ventilation established and maintained

No hazardous chemicals or materials

Rescue team available

Pre-entry brief completed

Training verified for rescue team

Maximum internal temperature

Minimal internal temperature

Communication Procedures (between attendant and entrants)

Wireless radio

Line radios

Verbal from access

Line of sight

Rescue Procedures

Self rescue

Non-entry rescue

Rescue team entry

Notes

Notes

Determination

This space has been determined to be a:

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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.

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