Appendix – Example of an Enclosed Space Entry Permit ^footnote

This permit relates to entry into any enclosed space and should be completed by the master or responsible person.

General
Location/name of enclosed space
Reason for entry ...........................................................................................................................................................................................................................................................................
This permit is valid		from:________________________ hrs	Date .........................
		to:__________________________ hrs	Date .........................
			(See note 1)
Section 1 – Pre-entry Preparation
(To be checked by the master or nominated responsible person)
		Yes	No
Has the space been thoroughly ventilated by mechanical means?		“	“
Has the space been segregated by blanking off or isolating all connecting pipelines or valves and electrical power/equipment?		“	“
Has the space been cleaned where necessary?		“	“
Has the space been tested and found safe for entry? (See note 2)		“	“
Pre-entry atmosphere test readings:		“	“
	oxygen ................... % vol (21%)^footnote	By:
	- hydrocarbon ........... % LFL (less than 1%)
	- toxic gases ............. ppm (less than 50% OEL of the specific gas)	Time:
(See note 3)
Have arrangements been made for frequent atmosphere checks to be made while the space is occupied and after work breaks?		“	“
Have arrangements been made for the space to be continuously ventilated throughout the period of occupation and during work breaks?		“	“
Are access and illumination adequate?		“	“
Is rescue and resuscitation equipment available for immediate use by the entrance to the space?		“	“
Has an attendant been designated to be in constant attendance at the entrance to the space?		“	“
Has the officer of the watch (bridge, engine-room, cargo control room) been advised of the planned entry?		“	“
Has a system of communication between all parties been tested and emergency signals agreed?		“	“
Are emergency and evacuation procedures established and understood by all personnel involved with the enclosed space entry?		“	“
Is all equipment used in good working condition and inspected prior to entry?		“	“
Are personnel properly clothed and equipped?		“	“
Section 2 – Pre-entry Checks
(To be checked by each person entering the space)
		Yes	No
I have received instructions or permission from the master or nominated responsible person to enter the enclosed space		“	“
Section 1 of this permit has been satisfactorily completed by the master or nominated responsible person		“	“
I have agreed and understand the communication procedures		“	“
I have agreed upon a reporting interval of ............. minutes		“	“
Emergency and evacuation procedures have been agreed and are understood		“	“
I am aware that the space must be vacated immediately in the event of ventilation failure or if atmosphere tests show a change from agreed safe criteria		“	“
Section 3 – Breathing Apparatus and Other Equipment
(To be checked jointly by the master or nominated responsible person and the person who is to enter the space)
Those entering the space are familiar with any breathing apparatus to be used		Yes	No
The breathing apparatus has been tested as follows:		“	“
	- gauge and capacity of air supply
	- low pressure audible alarm if fitted
	- face mask – under positive pressure and not leaking
The means of communication has been tested and emergency signals agreed		“	“
All personnel entering the space have been provided with rescue harnesses and, where practicable, lifelines		“	“
Signed upon completion of sections 1, 2 and 3 by:
Master or nominated responsible person	.....................................................................	Date ............................................................	Time ............................................................
Attendant...............................................................................................................................		Date ............................................................	Time ...........................................................
Person entering the space..................................................................................................		Date ............................................................	Time .........................................................
Section 4 – Personnel Entry
(To be completed by the responsible person supervising entry)
Names
Time in		Time out
Section 5 – Completion of Job
(To be completed by the responsible person supervising entry)
Job completed:		Date ............................................................	Time .........................................................
Space secured against entry		Date ............................................................	Time .........................................................
The officer of the watch has been duly informed		Date ............................................................	Time .........................................................
Signed upon completion of sections 4 and 5 by:
Responsible person supervising entry:................................................................................		Date ............................................................	Time .........................................................
THIS PERMIT IS RENDERED INVALID SHOULD VENTILATION OF THE SPACE STOP OR IF ANY OF THE CONDITIONS NOTED IN THE CHECKLIST CHANGE
Notes
1	The permit should contain a clear indication as to its maximum period of validity.
2	In order to obtain a representative cross-section of the space's atmosphere, samples should be taken from several levels and through as many openings as possible. Ventilation should be stopped for about 10 minutes before the pre-entry atmosphere tests are taken.
3	Tests for specific toxic contaminants, such as benzene or hydrogen sulphide, should be undertaken depending on the nature of the previous contents of the space.

Appendix – Example of an Enclosed Space Entry Permit footnote

Appendix – Example of an Enclosed Space Entry Permit ^footnote