Attachment XIX
ENCLOSED SPACE ENTRY PERMIT
1. Vessel’s Name: Date: Location:
* Permit No: Control measures as identified by : JHA
* Vsl Name /PTW/Year / Running Number: JHA Reference No:
WORK DESCRIPTION:
2. PERMIT VALIDITY (The permit will be valid for 12 hrs only. A new permit to be applied if the duration exceeds 24 hours)
Permit Start Date: Time: Permit Expires Date: Time:
The permit is automatically suspended whenever an emergency alarm is activated. Work must stop and site made safe and permit return
to source.
(Tick box as appropriate)
3. ENTRY CHECK LIST YES NO
1 Space drained and gas free (if applicable, gas free certificate to be attached)
2 Pre-entry atmosphere test is made, atmosphere is found safe for entry (readings as follows)
Oxygen ……….. % Vol Hydrocarbon (% LFL): ………….. Toxic Gases (ppm): ……….. H2S Gases (ppm) ………..
3 Space is adequately ventilated, ventilation is maintained throughout entry.
4 LOTO - Valves closed, pumps stopped, pipes blanked when required, tag procedure is enforced.
5 Adequate illumination and safe access to space is provided.
6 Emergency rescue equipment is ready for use at entrance.
7 Stand-by personnel is nominated, briefed and attending at entrance.
8 Communication procedures are agreed and tested.
9 Others (Please specify):
9. CLEARANCE APPROVAL
A. PERMIT APPLICANT B. APPROVAL FOR WORK SIGNATORY C. AUTHORIZING SIGNATURE
(Ch Officer or 2nd Engineer) (Master or Chief Engineer) (Master or Tech Superintendent)
I understand the precautions to be taken and I have inspected the worksite and satisfied I authorise work to commence
agree to fully comply with the Company that it has been properly prepared for the
instructions / requirements stated above. work as specified on this permit.
Sign: Date: Sign: Date: Sign: Date:
Name: Name: Name:
Rank: Rank: Rank:
Remark (if any): Remark (if any): Remark (if any):
I have stopped work. The area has been I have visited the worksite and satisfied
I am satisfied that the work has stopped
restored to a safe and operational condition. myself that the work has stopped. The area
and the area restored to a safe and
has been restored to a safe and operational
operational condition.
condition.
Signature: Date: Signature: Date: Signature: Date:
Name/Rank Name/Rank Name:
Remark (if any): Remark (if any): Remark (if any):
PERMIT DISTRIBUTION
ORIGINAL - To be displayed on the Bridge till completion and Master COPY – To be displayed at the worksite till completion.
to keep for record.