close
lumiform
Lumiform Mobile audits & inspections
Get App Get App

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

Downloaded 11 times

Rated 5/5 stars on Capterra

Say goodbye to paper checklists!

Lumiform enables you to conduct digital inspections via app easier than ever before
  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 5,000 expert-proofed templates

Digitalize this paper form now

Register for free on lumiformapp.com and conduct inspections via our mobile app

  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 4000 expert-proofed templates
Rated 5/5 stars on Capterra

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

Authorized Entry Points

Top
Side
Bottom

Hazards - Explosive Atmosphere

Source type
Quantity and quality (LEL)
Severity
Hazard abatement method

Hazards - Combustible Material

Source type
Quantity and quality
Severity
Hazard abatement method

Hazards - Electrical Circuits

Source type
Quantity and quality
Severity
Hazard abatement method

Hazards - Toxic Gases

Source type
Quantity and quality (PEL)
Severity
Hazard abatement method

Hazards -Toxic Material

Source type
Quantity and quality
Severity
Hazard abatement method

Hazards - Thermal Hazards

Source type (degrees Fahrenheit)
Quantity and quality
Severity
Hazard abatement method

Hazards - Machinery

Source type
Severity
Hazard abatement method

Hazards - Slip and Fall Hazards

Source type
Severity
Hazard abatement method

Hazards - Engulfment Hazards

Source type
Severity
Hazard abatement method

Hazards - Entrapment Hazards

Severity
Source type
Hazard abatement method

Hazards - Pneumatic/Kinetic Energy

Source type
Severity
Hazard abatement method

Personal Protective Equipment Required

Gloves
Coveralls
Hearing protection
Safety glasses
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
OV
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:
Share this template:

Similiar templates