ENCLOSED SPACE ENTRY PERMIT

General

Location and name of enclosed space: __________________________________________

Reason for entry: ____________________________________________________________

1. Pre-entry preparation (to be checked by Master or nominated person).

• Space thoroughly ventilated ð

• Space segregated by blanking off and safe from pipelines leak or electrical power ð

• Space cleaned (where necessary) ð

• The atmosphere tested and found safe ð

• Arrangements made for frequent atmosphere checks while the space is occupied ð

• Continual ventilation secured ð

• Illumination adequate ð

• Rescue & resuscitation equipment ready for use and emergency procedures agreed ð

• Constant attendant at entrance designated ð

• Officer of the watch on bridge /ER advised ð

• Communication and signals between parties agreed and tested ð

• Personnel properly dressed and equipped ð

2. Pre-entry checks (to be checked by the person entering the space).

• Instructions and permission for entry received ð

• Section 1 of this permit satisfactorily completed ð

• Communication procedures agreed and understood ð

• Reporting interval of _____ minutes agreed ð

• Emergency and evacuation procedures understood and agreed ð

• I will immediately vacate the space in case of ventilation failure/atmosphere change ð

3. Breathing apparatus and equipment (to be checked jointly by responsible person and the one who enters the space).

• Those entering the space are familiar with the breathing apparatus to be used ð

• The apparatus tested as follows:

- gauge and capacity of air supply

- low pressure audible alarm

- face mask (positive pressure, no leak) ð

• Means of communication tested, and emergency signals agreed ð

• All entering personnel provided with rescue harnesses and lifelines ð

see next page

This permit is valid

from: time ___________ , date ____________________.

to: time ___________ , date ____________________.

Signed upon completion by:

................................................................ time ___________ , date ____________________.

Master (or nominated person) for sections 1 and 3

................................................................ time ___________ , date ____________________.

Person supervising entry for sec. 1 and 3

................................................................ time ___________ , date ____________________.

Person entering the space for sec. 2 and 3

4. Personnel entry (to be completed by the responsible person supervising entry).

Names Time in Time out

________________________________ ______________ _____________

________________________________ ______________ _____________

5. Completion of job (to be completed by the responsible person supervising entry).

• Job completed time ___________ , date __________________.

• Space secured against entry time ___________ , date __________________.

• The officer of the watch duly informed time ___________ , date __________________.

Signed upon completion by (for section 4 and 5):

Responsible person supervising: _______________________________________

time ___________ , date __________________

Note: To be completed every time and filed in ship's file.

To retain for 5 years.

Issue date: 03.11.2003/Rev. 00 I-ED01-F01 Page: 2/2

ENTER ENCLOSED SPACES CHECK LIST

QSMS I-ED01-F01 Rev. No.00

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