Smithsonian Institution
CONFINED SPACE PERMIT
2008-xxxxxx
SI IN-HOUSE
Rev 12/10/07 Page 1 of 3
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1 2
Service Work Order #:
NAME OF BUILDING AND CONTACT NUMBER:
Name of Building: Project Title:
CONTRACTOR
Permit Issued To: Requested by:
Phone: Phone:
3
EXACT LOCATION OF WORK AREA ( Specific Area Name & Room # and/or Exterior Location):
4
AREA COVERED:
5
REASON FOR ENTRY:
CONTRACTOR AND/OR SI WORK GROUP & TYPE OF GENERAL WORK
EMERGENCY PHONE #
Select Type of Work from Drop Downs. Select "blank" to write in additional comments. (Contracting Company Name, Employee’s Names and Emergency Phone Number)
I verify the above location has been examined, the precautions checked on the required precautions checklist have been taken to ensure safety. Proper procedures and personnel protective equipment will be used.
NAME SIGNATURE NAME/SIGNATURE (Confined Space Entry Supervisor) & Date PERMIT START DATE: PERMIT START TIME : PERMIT EXPIRE DATE: PERMIT EXPIRE TIME : NAME/SIGNATURE (Project Manager or COTR) (if applicable) & Date
July
18 5:00 AM
2008
CONFINED SPACE WORK MAY BEGIN AFTER IT HAS BEEN VERIFIED THAT ABOVE CONDITIONS HAVE BEEN MET, PERMIT SIGNED FOR APPROVAL AND POSTED. COPIES OF THIS PERMIT HAVE BEEN DISTRIBUTED TO OFFICE OF PROTECTION SERVICES (SECURITY MANAGER AND SECURITY CONTROL ROOM OPERATOR), BUILDING MANAGER, OFMR SAFETY MGR., AND SAFETY COORDINATOR.
July
18 7:00 AM
2008
CONFINED SPACE PERMIT IS ONLY GOOD FOR 8 HOURS FROM ISSUE DATE AND TIME UNLESS AREA HAS BEEN TESTED AGAIN. PERMIT MUST BE AUTHORIZED BY ZONE MANAGER OR DESIGNATED INDIVIDUAL PRIOR TO WORK WORK SUPERVISOR CHECK NOTIFICATIONS (AS APPROPRIATE) / ZONE MGR NOTIFY DIRECTOR & BLDG SAFETY COORDINATOR / PRECAUTIONS TAKEN 6 BUILDING SECURITY CONTROL OPER NOTIFIED * BUILDING MANAGER NOTIFIED * WMC (1560) NOTIFIED * MUSEUM DIRECTOR NOTIFIED BUILDING SAFETY COORDINATOR NOTIFIED * SI OFMR SAFETY NOTIFIED OEDC PROJECT MANAGER / COTR NOTIFIED ZONE PROJECT LIAISON NOTIFIED USRO / HVAC SHOP NOTIFIED SED BLDG SYSTEM ENG (BAS) NOTIFIED SED CTRL SAFETY/FIRE PUMP SHOP NOTIFIED NMZ CTRL SHOPS NOTIFIED HOT WORK ALLOWED HOT WORK PROHIBITED LOCK OUT TAG OUT REQUIRED FIRE SYSTEM PERMIT REQUIRED HAZARDOUS OPERATIONS STOPPED
*
REQUIRED COPIES
The above requestor has approval for confined space entry with the understanding that all safety codes and regulations will be followed. Additional Comments
7
Example: The facility experienced flooding in the chiller room due to overflow to main sump. The engineering branch is inspecting and making repairs to the sump pump. Fire Permit is not needed at this time nor expected. For Additional Information Contact: David Jones xxx xxx-xxxx
8
Confined Space Permits can only be authorized by the ZM or his/her designated person
Initial NAME / TITLE OF AUTHORIZING INDIVIDUAL
CONFINED WORK SUPERVISOR RETURN THE ORIGINAL PERMIT TO THE BUILDING / FACILITY MANAGER UPON COMPLETION OF WORK. CONFINED SPACE WORK PERMITS WILL BE FILED BY BUILDING MANAGEMENT DEPARTMENT.
Smithsonian Institution
CONFINED SPACE PERMIT
2008-xxxxxx
0 0
OXYGEN DEFICIENCY TOXIC CONTAMINANTS COMBUSTIBLE GAS MECHANICAL PHYSICAL HAZARDS: CHEMICAL/BIOLOGICAL HEAT
Rev 12/10/2007 Page 2 of 3
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Service Work Order #:
NAME OF BUILDING AND CONTACT NUMBER:
Parent Building: Project Title:
9
ATMOSPHERIC HAZARDS:
ELECTRICAL NOISE
AUTHORIZED ENTRANTS
DATE TRAINED SOURCE ISOLATION (NO ENTRY) Pump or Lines Blinded VENTILATION MODIFICATION Mechanical Natural Ventilation Only
ATTENDANTS' Misc:
Disconnected or Blocked
Required Precautions Checklist - Precautions have been taken by the Supervisor 10
Check ( X ) Nearest phone and fire alarm box identified Respiratory equipment in good repair
YES
NO
N/A
Personal Protective Equipment Required
Entrants: Type of Gas Monitor Calibrated
Communication Procedures to Contact / Emergency Service
Gas Free Technician and found safe to enter Mandatory Pre-Entry Briefing Conducted by Supervisor
Safety Watch: ACCEPTABLE ENTRY CONDITIONS
TEST 11 OXYGEN (O2) EXPLOSIVE GAS HYDROGEN SULFIDE (H2S) CARBON MONOXIDE (CO) SULFUR DIOXIDE (SO2) AROMATIC HYDROCARBON AIRBORNE COMBUSTIBLE DUST AMMONIA
1st
2nd
3rd
4th
5th
6th
7th
8th
INITIAL OF TESTER
19.5 to 23.5 % < 10% LEL < 10 PPM * 15 PPM < 35 PPM < 2 PPM * 5 PPM < 1 PPM * 5 PPM Meets or Exceeds LFL * 35 PPM TIME
SPECIAL TRAINING
Traffic Control
YES Barricades Flags Signs NO N/A
* Short term exposure. Limit up to 15 minutes + 8 hr. Time Weighted Avg. for 8 hrs. (longer with appropriate respiratory protection)
12
Make note of any special training by providing type, trainer and date trained: SPECIAL REQUIREMENTS AND PERMITS Check ( X ) YES NO N/A
13
LockOut / TagOut Required - Proper procedures will be used and noted in the LOTO Log Utility Impairment Notification Form Required - Notification Form SI-OFMR001 Attached Hot Work Permit Form Required - Permit Form SI-OFMR003 Attached
REQUIREMENTS: WORK SUPERVISOR AREA MONITORING & GAS FREE TECHNICIAN / CONFINED SPACE SUPERVISOR'S FINAL INSPECTION (COMPLETED AFTER CONFINED SPACE WORK)
WORK SUPERVISOR
14
GAS FREE TECH
PERFORMED WORK IN A SAFE MANNER MONITOR WORK IN PROGRESS AREA CLEANED & EQUIPMENT STOWED AWAY NO PERSONNEL INJURIES REPORTED
CONFINED SPACE PERMIT POSTED & TURNED INTO API FIRE SYSTEM IMPAIRMENT PERMIT REQUIRED (ATTACHED) LOCKOUT / TAGOUT REQUIRED AND USED NOTIFIED SECURITY CONTROL ROOM OPERATOR (WORK COMPLETED) INSPECTED AREA AFTER WORK (BACK TO NORMAL) NOTIFIED TENANT / DEPT HEAD (WORK COMPLETED) PROPER PROCEDURES & PPE USED (NO WORK STOPPAGE)
Comments: Initial
Initial
Confined Space Supervisor, Project Manager and/or COTR Comments (Prior to turning in Permit to Building Management)
15
Example: The confined space area was tested and monitor as required. The inspection and repairs were successful and completed on time. For Additional Information Contact: David Jones xxx xxx-xxxx.
16
NAME/TITLE CONFINED SPACE SUPERVISOR AND/OR PM/COTR
Initial
Rev 12/10/2007 Page 3 of 3
CONFINED SPACE PERMIT FORM
GENERAL INSTRUCTION
Summary: The Confined Space Permit Form is to be used for all maintenance, repairs, modifications and upgrades when confined space requirements exist. All work must be authorized and approved through the appropriate zone management and/or designated persons. Using this form should help prevent miss communication and assure continuity of work among various shops and departments within the Office of Facility Engineering and Operation (OFEO).
Purpose: This permit is to be used for all maintenance, repairs, modification and/or upgrades in order to minimize communication failures and work disruptions. It also helps to ensure all appropriate shops and departments are contacted while confined work is being performed. This forms helps ensure that codes and regulation are followed while maintaining historical records of work. Instructions: 1. Tracking Control # / Control Number SWO# – Select the appropriate control number and enter the tracking number. The OFMR group will use an SWO for the tracking number. The tracking number will be used for a reference to work which allows us to pull historical records for labor and material cost. All individuals in the Office of Facility Maintenance & Reliability (OFMR) working on this permit should use the same number. SI In-House and Contractor – check either or both if work involves in-house and outside contract work.
2. Name of Building – select from the drop down list the location of work. If unable to find a proper location use the blank and type in the building name. Project Title – show project title if applicable. Permit Issued To and Requested By - Permit Issued to specify the individual who will be responsible for coordinating all shops in order to accomplish work.. The requested by identified who is asking to have the work done. Provide a phone numbers (xxx xxx-xxxx.). Requester and Phone – use this block for the requester’s name that work is being requested. Example: Work request may come from Building Management, Safety Office and / or the Office of Engineering, Design and Construction.
3. Exact Location of the Valve/Zone – enter the valve location and identification number. Copy of this permit will be posted at the valve location at a visible site. 4. Area Covered - provide some detail of the zones and/or areas affected by this work.
5. Reason for Entry - select from the drop downs and provide an emergency phone number ( xxx xxx-xxxx ). the Confined Space Entry Supervisor and / or Project Manager / Contracting Offers Technical Representative (COTR) shall print first, last name and sign requesting confined space entry work. Provide the permit start date and time, permit expire date and time by using the drop downs. 6. Notification - Precautions Taken (check as appropriate) – use the list and check those that are appropriate. The Work Supervisor / Leader will provide notification to the Building Security Control Operator, Building Management, and Work Management Center (WMC) by providing a copy of the permit prior to any work other than extreme emergencies. Other precautions are noted whether or not hot work is allowed or prohibited, lockout & tagout and / or other permits required. 7. Additional Comments – use this block to provide more specific information. 8. Authorized By – The Confined Space Permit must be authorized by the Zone Manager or designated person. Provide the first, last name and title (print) and initial. 9. Atmospheric Hazards – identify by checking box. Enter names of authorized entrants and attendants. Use drop downs to select (yes, no, or n/a) for source isolation and ventilation modifications. 10. Personal Protective Equipment – selected by using drop downs or entering equipment. Answer communication questions and show type of Gas Monitor Used. The gas monitor must be in calibration – answer by selecting drop down. 11. Test and Acceptable Entry Conditions – monitor the confine space hourly for conditions, indicate n/a if not appropriate, show time and initial. Traffic Controls – answer by checking what measures have been taken. 12. Special Training – make note of any special training. 13. Special Requirements and Permits – Check ( yes, no, or n/a ) whether or not other permits are required. 14. Work Supervisor and Gas Free Tech – provide following up on confined space work and initial. 15. Confined Space Entry Supervisor – use this block to make additional comments if needed. 16. Confined Space Entry Supervisor, Project Manager and / or COTR - authorized by first, last name ( print ) and initial.