HomeMy WebLinkAboutHUR130-027 Confined Space EntryC.d
PiCKERiNG
Procedure
Procedure Title: Confined Space Entry
Procedure Number
HUR 130-027
Reference
Date Originated (m/dly)
Date Revised (m/dly)
Pages
Occupational Health & Safety
Act, R.S.O, 1990
June 1, 2007
January 10, 2013
June 2019
13
Regulations for Construction
Projects. (0. Reg. 213/91 as
amended to O. Reg. 628/05)
Confined Space Regulations (0.
Reg. 632/05)
HUR 130 — Occupational Health
& Safety Policy
i
Approval: Chief Ad rn stra Officer
Point of Contact
, )e f
Coordinator, Human Resources
Procedure Objective
To ensure that all employees who are required to enter confined spaces are protected from
hazards presented by and found in confined spaces.
To identify, eliminate or control all health and safety hazards in the workplace,
To prevent all work-related incidents that cause or have the potential to cause personal injury or
illness,
Application
This procedure and its associated guidelines apply to all City -owned or leased facilities. It also
applies to all City Departments, Divisions, employees and contractors engaged in confined
space entry at City of Pickering facilities.
Index
01 Definitions
02 Procedures
03 Confined Space Entry Coordination
04 Pre -Entry Preparation
05 Confined Space Entry
06 Rescue & Emergency
01 Definitions
01.01 Assessment - a review of the hazards with respect to one or more confined
spaces in the workplace.
01.02 Atmosphere - a combination of gases, biological/chemical agents, vapors
and/or fumes that occupy a space as `air'.
01.03 Atmospheric Hazard
• the accumulation of flammable, combustible or explosive agents
• an oxygen content in the atmosphere that is less than 19.5 percent or
more than 23 percent by volume, or
• the accumulation of atmospheric contaminants, including gases, vapors,
fumes, biological/chemical agents, dust or mist, that could;
i. result in acute health effects that pose an immediate threat to life;
ii. interfere with a person's ability to escape unaided from a confined
space.
01.04 Attendant - a City employee who has been assigned to perform the topside
stand by, monitoring, traffic control and rescue functions at a confined space
entry. The Attendant is the designated "Person in Charge" who leads and
coordinates the entry.
01.05 Cold Work - confined space entry where there are no ignition hazards.
01.06 Competent Person - a person who is qualified by way of training, knowledge
and experience to perform either traffic protection, a confined space entry or
the Attendant function.
01.07 Confined Space - a fully or partially enclosed space that is both,
• not designated and constructed for continuous human occupancy, and
• in which atmospheric hazards may occur because of its construction,
location or contents or because of work that is done in it.
01.08 Confined Space Entry - any human entry into a space that is identified as a
confined space by the Regulations and Definitions. For the purpose of this
program, a confined space entry is also deemed to be made as soon as an `at
grade' confined space covering, such as a manhole cover, is lifted.
Procedure Title: Confined Space Entry Page 2 of 13
Procedure Number: HUR 130-027
01.09 Confined Space Entry Permit - a document that is prepared at the time of a
specific confined space entry to record the specific conditions that exist at that
time and includes traffic control and rescue plans.
01.10 Confined Space Hazard Assessment - a form that is completed to document
a specific confined space. Includes:
• the address or location of the confined space
• type of work performed
• the identity of the assessor and the date of assessment
• determination of confined space, according to the legislated definition
• type of confined space
• potential hazards
• personal protective equipment requirements
• entry, fall arrest and traffic control equipment requirements
• rescue and first aid equipment requirements.
01.11 Confined Space Entry Program - This entails:
• methods for recognizing each confined space to which the legislation
applies (confined space inventory)
• methods for assessing the hazards for each confined space to which the
legislation applies (confined space hazard assessment)
• rescue measures for each confined space to which the legislation applies
• Personal Protection, Fall Arrest and Traffic Control Measures for each
confined space to which the legislation applies
• methods for coordinating site-specific confined space assessments with
contractors and/or property owners (coordination plan)
• an entry permit system that includes testing and continuous monitoring
• Confined Space Entry, Fall Arrest, and First Aid training
• provision and maintenance of equipment, tools and devices
• documentation and record keeping
• methods for communication and provision of documents and records, as
required.
01.12 Entrant - the individual who is entering the confined space.
01.13 Critical/Fatal Incident Response - is the action taken when responding to a
critical injury as defined by the Occupational Health & Safety Act and set out in
HUR 130-004.
Procedure Title: Confined Space Entry Page 3 of 13
Procedure Number: HUR 130-027
01.14 Escape Air Pack - a personal protective device comprised of a face mask and
air supply sufficient to provide a minimum of 10 minutes of air.
01.15 Fall Arrest - devices and equipment that are used to prevent a person from
falling or to arrest a fall.
01.16 First Aid - help given to a sick or injured person until emergency medical
treatment is available.
01.17 First Aid Kit - an approved first aid kit that is on site and immediately available
to the Attendant.
01.18 Hot Work - confined space entry where there are actual or potential ignition
hazards. See also 'Intrinsically Safe'.
01.19 Intrinsically Safe - equipment, devices and tools that will not produce an
ignition source such as high temperatures, flames, static electricity or sparks.
01.20 JHSC — Joint Health & Safety Committee.
01.21 Lead Party - a business, organization or individual that 'owns' the confined
space to be entered. The Lead Party is responsible for ensuring that both a
confined space hazard assessment and a confined space entry coordination
document have been completed, and that all other parties have received
copies of these documents before any work is performed.
01.22 Permit - a written entry permit prepared by a competent person in advance of
entering a specific confined space and that meet the requirements described in
the regulation.
01.23 Person in Charge - the person performing the Attendant functions is the
designated "Person in Charge" of the confined space entry. The Person in
Charge leads and coordinates the entry.
01.24 Plan - means a written plan (as described in regulation) for one or more
confined spaces in a workplace.
01.25 Purging — means displacing contaminants from a confined space, ("purge").
01.26 Rescue Measures - specific steps taken to remove a sick or injured person
from a hazardous situation before emergency responders arrive.
01.27 Rescue Team - all competent persons performing the confined space entry.
May also include emergency services.
01.28 Traffic Control - specific steps taken to protect the entry site and City
employees from traffic hazards.
Procedure Title: Confined Space Entry Page 4 of 13
Procedure Number: HUR 130-027
01.29 Unsafe Work Refusal - a worker's legislated right to refuse to perform a
particular task if he/she has reasonable grounds to believe that an immediate
threat to health and safety exists.
01.30 Unsafe Work Refusal — Exemption: Emergency Responders - employees
who have responsibilities to protect public safety cannot refuse unsafe work if
the danger in question is a normal part of their job or if the refusal would
endanger the life, health and safety of another person.
01.31 Ventilation Device - a device that forces air into a space and displaces
ambient air. The device shall be equipped with an alarm to warn of device
failure.
01.32 Workplace - for the purpose of this program, "workplace" means any confined
space that a City employee may be required to enter in the course of his/her
employment to perform assigned duties and tasks, whether on City property or
otherwise.
02 Procedures
02.01 Director or Non -Union delegate who occupy and/or are responsible for
maintaining their own facilities (including City properties) will ensure that:
• confined space work is performed in compliance with the Occupational
Health and Safety Act, applicable regulations, this policy and its
associated guidelines and industry standards;
• where there is multi-employer involvement in a confined space entry, a
coordination document is prepared by the lead employer;
• resources and funds are made available to ensure work can be carried
out in accordance with legislative requirements, this policy and its
associated guidelines and divisional safe work procedures;
• a process is developed for evaluating work operations to determine
where a confined space entry program and plans are required;
• a written confined space entry program is developed, implemented and
maintained, as required by the applicable regulation and this policy's
associated guidelines;
• adequate written confined space plans, including procedures for the
control of hazards, are developed and implemented by a competent
person for every confined space;
• identifying and providing appropriate personal protective equipment (refer
to recommended personal protective equipment in the associated
guideline);
• general and specific training are provided to workers involved in confined
space work every three years;
Procedure Title: Confined Space Entry Page 5 of 13
Procedure Number: HUR 130-027
• refresher training shall occur annually;
• an evaluation process is established for the purchase of new equipment
used in confined space work, in consultation with JHSC and Health and
Safety staff; and
• regular reviews of the confined space entry program and plans are
performed.
02.02 Staff who acquire (purchase/lease) and/or maintain facilities will ensure that:
• when purchasing or leasing facilities where City employees will be
located, an assessment is conducted to identify if there are any confined
spaces, and if there are, notify the occupying Divisions prior to
occupancy; and
• the requirements of the confined space legislation, this policy and its
associated guidelines are met as they apply to maintenance operations.
02.03 Staff (including Supply & Services) who hire contractors whose work includes
confined space entry will ensure that:
• language in Request for Proposals (RFPs), contracts, etc. stipulate that
the contractor's employees are adequately trained in confined space
procedures, provide their own equipment and if requested provide a copy
of their confined space program; and
• language in RFPs, contracts, etc. include a requirement that contractors
will adhere to the coordination document prepared by the Division.
02.04 Managers (whose staff works in confined spaces) will ensure that:
• for each of their workplaces, a centralized listing of all confined spaces is
established. The listings will include a description of the confined space,
its location and its specific plan;
• a written confined space program and plans are developed (in
consultation with the JHSC or Health and Safety representative),
implemented and maintained;
• a process is developed and implemented to ensure that all confined
space equipment is adequate and is maintained in good working order;
and
• conduct periodic audits of the confined space entry program and plans,
and recommend changes, as needed.
02.05 Staff with supervisory duties will:
• be familiar with all aspects of the divisional confined space program and
specific confined space entry plans;
Procedure Title: Confined Space Entry Page 6 of 13
Procedure Number: HUR 130-027
• be familiar with the actual and potential hazards associated with confined
space work;
• develop written safe work procedures for specific tasks, particularly in
unusual or unique situations in consultation with work crews, managers,
and the JHSC and Health and Safety staff as necessary;
• ensure that all employees under their supervision who work in confined
spaces are competent to do assigned work and are provided with
instruction and training prior to work assignments;
• ensure that confined space assessments, control plans, on-site rescue
procedures and entry permits are completed prior to confined space work
assignments;
• ensure that air monitoring is conducted prior to entering, and
continuously throughout while in a confined space and that test results
are recorded onto the confined space entry permit;
• ensure that hot work permits are issued before hot work is performed in a
confined space;
• monitor staff to ensure procedures are followed and when violations
occur, take appropriate action;
• ensure that all staff use or wear required safety equipment when
performing assigned tasks; and
• ensure thatall equipment needed for confined space work is in good
working condition.
02.06 Workers will:
• work in accordance with legislative requirements and this procedure;
• attend all relevant confined space training before performing confined
space work and apply knowledge gained in the performance of their
work;
• use or wear all equipment required to safely perform workplace specific
activities;
• report any violations, hazards or deficiencies in equipment to immediate
supervisor without delay;
• assist supervisory staff in developing safe work procedures for specific
tasks; and
• follow established procedures in the event of an injury, accident or
emergency.
Procedure Title: Confined Space Entry Page 7 of 13
Procedure Number: HUR 130-027
02.07 JHSC will:
• actively assist management through consultation, in the development of
the confined space program and specific plans;
• assist management in a regular review of equipment status;
• make recommendations during the evaluation process of new confined
space equipment prior to purchase; and
• review this policy and relevant procedures annually and make
recommendations for changes if necessary.
02.08 Coordinator, Human Resources will:
• assist in the evaluation of work operations as necessary, to determine the
need for confined space entry programs;
• provide assistance in the development of confined space programs and
plans;
• provide assistance in the development and delivery of confined space
training;
• provide assistance during the evaluation process of new confined space
equipment prior to purchase; and
• advise divisions and JHSC of any changes to the relevant legislation,
standards and industry practices.
03 Confined Space Entry Coordination
03.01 The operating Department/Division will ensure that:
• an inventory of all confined space types (Appendix 1) and the
corresponding Confined Space Hazard Assessment Forms (Appendix 2)
are maintained and updated as required;
• a site specific Confined Space Hazard Assessment Form is prepared for
every confined space where work could be performed by City employees.
These assessments must be completed before assigning an entry task to
a City employee or a Contractor; and
• copies of the Confined Space Hazard Assessment Form and the
Confined Space Entry Coordination Form (Appendix 3) are retained in
the project file.
03.02 The Non -Union Supervisor will ensure that a copy of the site specific Confined
Space Hazard Assessment is available to employees who are required to
perform confined space entry in advance of a scheduled task.
Procedure Title: Confined Space Entry Page 8 of 13
Procedure Number: HUR 130-027
03.03 The employee having charge of the contract:
• shall provide the independent contractor where confined space entry on
City property is performed, a copy of the City's site specific Confined
Space Hazard Assessment in advance of the commencement of work;
• and the representative for the contractor shall jointly complete the
Confined Space Coordination Form in advance of the commencement of
work; and
• shall provide a copy of the completed Confined Space Coordination Form
to the contractor.
03.04 The employee having charge of the work:
• where confined space entry is performed by City employees on property
other than City property, shall request a copy of the site owner's (or its
designated contractor) site specific Confined Space Hazard Assessment
Form in advance of the commencement of work; and
• and the representative for the site owner (or its designated contractor)
shall jointly complete the Confined Space Entry Coordination Form in
advance of the commencement of work.
A summary is outlined in Appendix 4 — Confined Space Entry Summary.
03.05 The site owner (or its designated contractor) shall provide the City
representative with a copy of the completed Confined Space Entry
Coordination Form.
03.06 No City employee shall undertake confined space entry on property other than
City property until and unless the site owner (or its designated contractor) has
provided the City with the site specific Confined Space Hazard Assessment
and Confined Space Entry Coordination Form.
04 Pre -Entry Preparation
04.01 The Non -Union Supervisor shall:
• appoint a competent employee to be the 'Person in Charge', and to
perform the Attendant functions; and
• provide the `Person in Charge' with a Confined Space Entry Permit
(Appendix 5), a copy of the site specific Confined Space Hazard
Assessment Form and a copy of the Confined Space Entry Coordination
Form (if applicable).
Procedure Title: Confined Space Entry Page 9 of 13
Procedure Number: HUR 130-027
04.02 The 'Person in Charge':
• shall check and/or calibrate as required ("bump test") all monitoring,
communication and safety equipment to ensure these are in good
working condition and functioning properly;
• shall report any piece of equipment that is faulty to his/her Non -Union
Supervisor and shall immediately take such equipment out of service;
• shall ensure (once onsite):
i. employees wear personal protective equipment, including but not
limited to, a hard hat, safety vest and safety footwear;
ii. traffic control measures are set up using the Traffic Protection Plan
Checklist (Appendix 6) including, but not limited to, warning devices
such as cones, delineators, flashers and vehicles, as set out in Book
7 — "Temporary conditions" of the Ontario Ministry of Transportation;
and
iii. oxygen levels are tested and the presence of combustible or toxic
gases is identified by inserting measuring sensors into the confined
space before removing any covers.
• may permit the employee to open the confined space cover and allow air
to vent, and then re -test the air quality. If the confined space is a sealed
manhole, the employee shall first test the manholes immediately
upstream (1) and immediately downstream (1) from the entry point;
• shall record the 'date of entry' test findings on the Confined Space Entry
Permit form;
• shall initiate mechanical ventilation (air blower) for at least 20 minutes,
and then re -test, in the case of oxygen deficiency or toxic gases that
cannot be corrected by natural ventilation;
• shall not permit entry into the confined space in the case of oxygen
deficiency or toxic gases that cannot be corrected after 20 minutes by
natural or mechanical ventilation;
• shall not permit entry for any reason if the atmospheric content is greater
than 5 percent of the Lower Explosive Limit;
• shall contact his/her Non -Union Supervisor immediately for further
instructions in the case of explosive atmosphere;
• shall permit the set up of tripods, hoists, fall arrest, lighting, ventilation
devices and any other required entry equipment if safe to do so; and
• shall test the employee's harness, life line, and respiratory protection and
communication devices and shall ensure the life line is secured to a
mechanical retrieval device.
Procedure Title: Confined Space Entry Page 10 of 13
Procedure Number: HUR 130-027
04.03 The employee performing the entry work shall wear a full body harness
secured to a self -retracting lifeline, which is fastened to a tripod capable of
withstanding 5,000 pounds of pull and flashlight.
05 Confined Space Entry
05.01 The employee shall conduct a final visual inspection of the confined space to
ensure there are no additional physical hazards such as loose ladder rungs,
cramped spaces, protrusions, condensation, slippery surfaces, pooled or
flowing water, etc.
05.02 The employee may proceed with the entry if safe to do so.
05.03 The Person in Charge shall stay at the point of entry, maintain continuous voice
contact with the employee performing the entry and shall monitor all conditions
continuously. The Person in Charge records monitored findings on the
Confined Space Entry Permit.
05.04 The employee performing the entry shall immediately leave the confined space
if the atmospheric monitors sound an alarm or if instructed to do so by the
Person in Charge.
05.05 The Person in Charge shall stand by to assist the employee to exit the confined
space rapidly and shall then notify his/her Non -Union Supervisor of the
hazardous condition(s).
06 Rescue and Emergency
06.01 Prior to any worker entry, written rescue plan that applies to the Confined
Space Entry Summary will be in place for immediate implementation.
06.02 Emergency response plans must always be developed considering the hazards
presented by the confined space and the work to be conducted within.
06.03 In developing rescue plans, the following should be considered:
• the confined space hazard assessment
• the space's geographic location
• the required and anticipated emergency response time
• the selection and provision of appropriate rescue equipment
• the entrant's ability to remain attached to a retrieval system at all times
• the on-site first aid capabilities.
Procedure Title: Confined Space Entry Page 11 of 13
Procedure Number: HUR 130-027
06.04 Self -rescue is the Entrant's self preservation actions that they initiate with little
or no help from the Attendant. Self -rescue can only be planned for a confined
space that displays the following:
• atmosphere is proven safe, stable and controlled with adequate
ventilation
• atmosphere is not likely to change during the course of entry
• atmosphere is not immediately dangerous to life or health
• all physical hazards identified are controlled prior to entry
• hazard assessment confirms that no hazard(s) are present that could
render the Entrant immobile (such as an electric shock, entanglement,
etc.)
• Entrant can remain in continual (unassisted) verbal or visual contact with
Attendant
• entrant can exit space unassisted.
06.05 Non -entry rescue is the aid provided by the Attendant or Rescue Team when
operating the retrieval system to remove the Entrant from the confined space.
The most important characteristic of the response is that no one enters the
confined space to remove the Entrant.
06.06 Non -entry rescue is the preferred method for rescue of personnel from any
confined space. It is unacceptable for any employee to enter a confined space
for rescue.
06.07 The Person in Charge:
• is responsible for removing an employee from the confined space as
quickly as possible in cases where a direct and unobstructed path can be
ensured between the attendant and the entrant utilizing the fall
protection/retrieval system;
• is responsible for wearing all approved personal protective equipment
when performing the rescue;
• shall remain topside and shall not enter the confined space under any
circumstances if an emergency exists;
• shall immediately initiate rescue measures if:
i. requested by the employee performing the entry
ii. voice communications are lost or the employee does not respond
iii. air monitoring or ventilator alarms are sounded
iv. a topside condition makes continued entry dangerous, e.g. turbulent
weather, sudden downpour or flash flooding, etc.;
• shall assess the employee's condition and determine whether a medical
emergency exists;
Procedure Title: Confined Space Entry Page 12 of 13
Procedure Number: HUR 130-027
• shall immediately call 9-1-1 and ask for medical assistance if the
employee shows signs of distress, physical injury, difficulty breathing or
loss of consciousness;
• shall initiate first aid measures until Emergency Responders arrive on
site;
• shall contact his/her Non -Union Supervisor immediately once care of the
employee is taken over by Emergency Responders; and
• shall complete a detailed Incident Report as soon as possible and
provide this to his/her Non -Union Supervisor.
06.07 The Non -Union Supervisor shall initiate the City's Critical/Fatal Incident
Response procedure in the event of a confined space entry critical injury or
fatality (as defined by the Occupational Health & Safety Act).
NOTE: 9-1-1 Emergency Responders (Police, Fire, and EMS) will provide medical
assistance but will not enter a confined space to perform the rescue function.
Appendices
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Confined Space Types
Confined Space Hazard Assessment Form
Confined Space Entry Coordination Form
Confined Space Entry Summary
Confined Space Entry Permit Form
Traffic Protection Plan Checklist
Procedure Title: Confined Space Entry Page 13 of 13
Procedure Number: HUR 130-027
U.v �C
DICKERING
Confined Space Types
Appendix 1
Department
Type
Location
City Development
Department
P-101 Pre -cast Maintenance Hole
Various
P-102 Pre -cast Maintenance Hole
Various
P-103 Pre -cast Maintenance Hole
Various
P-104 Pre -cast Maintenance Hole
Various
P-105 Pre -cast Maintenance Hole
Various
P-106 Pre -cast Maintenance Hole
Various
P-107 Pre -cast Maintenance Hole
Various
P-110 Pre -cast Maintenance Hole
Various
P-111 Pre -cast Maintenance Hole
Various
P-200 Catch Basin
Various
P-201 Catch Basin
Various
P-220 Catch Basin
- Various
P-221 Catch Basin
Various
P-300 Headwalls & Outfalls
Various
P-301 Headwalls & Outfalls
Various
Corrugated Steel Pipe Culverts
Various
Pre -cast Concrete Box Culverts
Various
Stormwater Quality Control Devices - Stormceptor,
CDS, Vortechnics, etc.
Various
Rear Yard Catch Basin
Various
Storm sewer pipe — 250mm to 2400mm diameter
Various
Bridge Abutments
Various
Sewer, Foundation and Utility excavations
Various
Stormwater Management Facility
Various
Public Works
Section
1200 mm precast concrete manhole
Various
1200 mm semi - precast concrete manhole
Various -
1500 mm precast concrete manhole
Various
1800 mm precast concrete manhole
Various
2400 mm precast concrete manhole
Various
Concrete box culverts
Dixie Road
Kitley Avenue
Glenanna Road
Kingston Road
Fairport Road
Alyssum Street
Reytan Boulevard
Sandy Beach Road
Dunbarton Road
Large CSP Culverts
Radom Street
Twyn Rivers Drive
Appleview Road
Morden Lane
Storm Water Management Pond Inlets/Outlets
Various
Facilities
Maintenance
Section
Pool filter room sump pump pits 1 and 2
Recreation Complex
Sump pump pits 1 and 2
Civic Complex
Electrical sub -station pit
Civic Complex
School house crawl space to reach oil tank and boiler
Pickering Museum
DICKERING
Part 1 - Identification Data
Confined Space Hazard Assessment Form
Appendix 2
Address or Location
Type of Work Performed
Assessed By
Name/Title
Signature
Department
Division
Date
Time
Confined Space
Determination
0 Fully enclosed
0 Partially enclosed
0 Not designed and constructed for continuous human occupancy
❑ Potential Atmospheric Hazards
Type - Exterior
Description
Pre -cast Maintenance Hole
0 P-101
0 P-106
❑ P-102
0 P-107
❑ P-103
0 P-110
0P-104
0P-111
❑ P-105
0 Other (specify)
Catch Basin
0 P-200
0 P-220
❑ P-201
0 P-221
Headwalls & Outfalls
0 P-300
0 P-301
Corrugated Steel Pipe Culvert
Pre -cast Concrete Box Culvert
Rear Yard Catch Basin
Storm Sewer Pipe
250 mm to 2400 mm diameter
Sewer Excavation
Foundation Excavation
Utility Excavation
Stormwater Management Facility
Stormwater Control Devices
Storm Sewer Manhole
0 1200 mm pre -cast concrete
0 1200 mm semi -pre -cast concrete
❑ 1500 mm pre -cast concrete
0 1800 mm pre -cast concrete
❑ 2400 mm pre -cast concrete
0 Other semi -pre -cast concrete
Type - Interior (Facilities)
Description •
Recreation Complex
Sump Pump Pit - Pool Filter Room
0 Sump Pump Pit 1
0 Sump Pump Pit 2
Civic Complex
Sump Pump Pit - Basement
0 Sump Pump Pit 1
0 Sump Pump Pit 2
Electrical Substation
0 Substation Pit
Fire Hall #6
Containment Tank
0 3500 litre Pre -cast Tank
East Shore CC
Museum Village
School House Oil Tank & Boiler
0 Crawl Space access to oil tank & boiler
Type - Other (Specify)
Description
Trench (Trench Number)
c44
DICKERING
Part 2 - Potential Hazards
Confined Space Hazard Assessment Form
Appendix 2
Hazard Type
✓
Source/Description
Control Measures for Each Hazard
Oxygen deficiency
❑
Coveralls/Safety Vest
0
Oxygen enrichment
0
Attendant (First Aid Cert)
❑
Toxic Atmosphere
❑
Powered Equipment
0
Explosive Atmosphere
0
Eye Protection
0
Ventilation Hazard
0
Fire Extinguisher
0
Hazardous Chemicals
0
Ground Fault Circuit
Interrupters
0
Narrow Access/Egress
0
Hard Hat
0
Constricted Space
0
Backup SCBA
❑
Electrical Hazard
0
Traffic Warning Signs
0
Stored Energy Hazard
❑
Self Contained Breathing Apparatus
0
Moving Machinery
0
Wireless radio/phone
❑
Falling Hazard (person)
❑
Fall Shock Absorber
0
Falling Hazard (object)
❑
Escape Air Pack
0
Slip Hazards
❑
Continuous Contact
0
Water/Flow Hazard
❑
Exhaust Blower
0
Engulfment Hazard
❑
Full Body Harness
I D#
0
Entrapment Hazard
0
Retractable Life Line
0
Poor Light/Visibility Hazard
❑
Stop/Slow Sign
❑
Thermal Hazard
0
Copy of winch certification on site
0
Work Activity Hazard
0
Traffic Hazard
0
Other (specify)
0
Surface Condition Hazard
❑
Other (specify)
0
0
Part 3 - Personal Protection, Equipment & Rescue Requirements
Personal Protection
✓
Equipment
✓
Rescue
✓
Coveralls/Safety Vest
0
Safety Lighting
0
Attendant (First Aid Cert)
❑
Hearing Protection
0
Powered Equipment
0
First Aid Kit
0
Eye Protection
0
Spark Resistant Tools
0
Fire Extinguisher
0
Safety Boots
0
Ground Fault Circuit
Interrupters
0
Tripod/Hoist w
mechanical winch
ID#
0
Hard Hat
0
Barricades
0
Backup SCBA
❑
Gloves
❑ .
Traffic Warning Signs
0
Escape Air Pack
0
Self Contained Breathing Apparatus
0
Ladders
0
Wireless radio/phone
❑
Air Line Respirator w Escape Pack
0
Fall Shock Absorber
0
Line radio/phone
0
Escape Air Pack
0
Forced Air Ventilation
❑
Continuous Contact
0
Air Purifying Respirator
0
Exhaust Blower
0
Full Body Harness
ID#
❑
Full Body Harness
I D#
0
Traffic Pylons
0
Retractable Life Line
0
Retractable Life Line
❑
Stop/Slow Sign
❑
Copy of winch certification on site
0
Maintenance Hole Opener/Pick
0
Other (specify)
0
Other (specify)
0
Other (specify)
❑
C4
DICKERING
Part 1 - Description
Confined Space Entry Coordination Form
Appendix 3
Contractor/Firm:
• Yes (attach copy of City's Confined Space Entry Permit)
• No (attach copy of Contractor's Confined Space Entry Permit)
Contract #:
• Yes (attach copy)
I•No
Work To Be Performed:
■
■
Monitoring & Equipment
■
■
Entry Location:
■
■
Rescue & Equipment
■
■
Entry Date(s):
Other: (specify)
■
■
Confined Space Type(s):
■
■
Contract Supervisor (city
Official):
Position/Title:
Department:
Division:
Phone:
Part 2 - Lead Part
Is this entry coordinated by the City of Pickering?
• Yes (attach copy of City's Confined Space Entry Permit)
• No (attach copy of Contractor's Confined Space Entry Permit)
Is a City of Pickering Confined Space Hazard Assessment Report available for this site?
• Yes (attach copy)
I•No
Part 3 - Resaonsibilities
Part 4 - Verification
Contractor Representative: (print)
Signature:
City Representative: (print)
Signature
Date:
Date
City
Contractor
Entrant
■
■
Attendant
■
■
Monitoring & Equipment
■
■
Personal Protective Equipment
■
■
Rescue & Equipment
■
■
Other: (specify)
■
■
■
■
Part 4 - Verification
Contractor Representative: (print)
Signature:
City Representative: (print)
Signature
Date:
Date
Gfy
DICKERING
Confined Space Entry Summary
Appendix 4
Department/Division
1. Identify all workplace confined spaces.
2. Complete Confined Space Hazard Assessments.
3. Maintain Completed Hazard Assessments in Department/Division Inventory Files.
Confined Space Entry By Employee
Confined Space Entry By Contractor
City Property
Not City Property
City Property
Not City Property
Obtain copy of
Confined Space
Hazard Assessment
form
Obtain copy of
Property Owner's
(or designate's)
Confined Space
Hazard
Assessment form
and Coordination
form
Provide copy of
Confined Space
Hazard
Assessment
form and
Coordination
form
Prepare specific
measures to control
site hazards
Prepare specific
measures to control
site hazards
Obtain Entry Permit
for specific entry
Obtain Entry Permit
for specific entry
Complete date of
entry Permit and
Traffic Control Plan
Complete date of
entry Permit and
Traffic Control Plan
File all completed
documents in project
file
File all completed
documents in
project file
File all
completed
documents in
project file
Obtain copy of
Property Owner's (or
designate's) Confined
Space Hazard
Assessment form and
Coordination form
0
P1CKE R1 NG
Confined Space Entry Permit
Appendix 5
Date of Issue:
Expiration Date:
Time:
Location of Space:
Description of Space:
Purpose of Entry:
Hazard Assessment:
Names of Attendant(s):
Names of Rescue Personnel:
Signature of Employees to Enter:
Safety Equipment
Y
N
PPE
Y .
N
Pipe lines purges or flushed
❑
❑
Air purifying respirator - type
■
❑
Area secure signs posted
❑
❑
Safety glasses or goggles
■
❑
Tripod/retrieval system
❑
❑
Hard hat
❑
❑
Communication equipment
❑
❑
Chemical resistant clothing
❑
❑
Gas detector
❑
❑
Protective boots and/or gloves
❑
❑
Fire extinguisher
❑
❑
Hearing protection
❑
■
Ground fault circuit interrupt
❑
❑
Chest harness and life line
❑
❑
Lighting
❑
❑
Other
❑
❑
Lockout/tagout
❑
❑
Air monitor #
Pipe lines capped or blanked
❑
❑
Air monitor calibration date:
Mechanical ventilation
❑
❑
Time/Date
Percent LEL
(10%)
Percent 02
(19.5-23.5%)
H2S
10ppm
CO
35ppm
Initials
Instrument
Cs, 4
PICKERING
Confined Space Entry Permit
Appendix 5
Time/Date
Percent LEL
(10%)
Percent 02
(19.5-23.5%)
H2S
10ppm
CO
35ppm
Initials
Instrument
❑ Body harnesses
❑ Rigging plates
❑Safety lines
❑Main lines
❑Wrist/ankle harnesses
❑ Fire extinguisher
❑ First aid kit
Supervisor authorizing entry (print):
Signature:
Rescue Plan
Communication:
Attendant to Rescue Personnel: ❑Phone ❑Audible Signal ❑Radio ❑Intercom
Attendant to Workers: El Phone ❑Audible Signal ❑Radio ❑Intercom
El Visual Hand Signal
Rescue Equipment Present and Inspected:
El Rope Signal
❑Hauling systems
❑Carabiners
❑Pulleys
❑Shock absorbers/lanyards
❑Anchor straps
❑Webbing
❑Ascenders
❑ Body harnesses
❑ Rigging plates
❑Safety lines
❑Main lines
❑Wrist/ankle harnesses
❑ Fire extinguisher
❑ First aid kit
Method of Rescue:
❑External retrieval
❑Self -retracting restraining system (winch)
c4
PICKERiNG Traffic Protection Plan Checklist
Appendix 6
Traffic Protection Plan
Date:
Time:
Location (be specific):
Work to be performed:
Supervisor:
Crew:
Person(s) setting up traffic protection:
Name:
Name:
Name:
Person(s) controlling traffic:
Name:
Name:
Name:
Competent Person
Competent Person
Competent Person
Competent Person
Competent Person
Competent Person
Emergency Services Notified for Road
Closure:
Police Ambulance
Fire
School Bus
Transit
Notice of Project (if applicable) #
Conditions Used to Determine Traffic
Control Plan
Traffic Control Requirements
Speed Limit
KM
Lane Closure Required
Two Lane
Both Directions
Sidewalk Closure Required
Same Direction
Traffic Control Person(s) Required
Multi -Lane
Both Directions
Road Work Sign
Same Direction
Lane Closure Sign
Long Duration
More than one day
TC Person Ahead Sign
Short Duration
Less than one day
Stop/Slow Sign(s)
Very Short Dur.
Less than 30 min
Other Signs (specify)
Moving Operation
Police Req.
Barricades
Traffic Volume
300 x # of cars in
(High volume = 3000
High Volume
Low Volume
3 minutes =
Delineators
Cones
+ cars daily)
Blocker Truck
Speed Control Devices
Hard Hat, Safety Boots, Vest
Based on the above site conditions and a review
Temporary Conditions, the Typical Layout required
Additional control requirements or deviations
detailed on the reverse side.
of the Ontario Traffic Manual, Book
is TL# .
7,
be
from the above typical layout are to
Additional control measures or deviations from the Typical Layout indicated on
the other side (written or illustrated)
Set up and removal of Traffic Control Area
❑ plan your set up
El place vehicles upstream for protection
❑ assemble devices away from road
❑ minimize exposure to traffic
❑ ensure workers are visible and conspicuous
❑ start setting up upstream
❑ always face traffic
❑ plan escape route
❑ be careful of curves
❑ cover signs installed before needed
❑ maintain 3 -metre lane width
❑ ensure traffic lane is all paved or all gravel
❑ remove in reverse order of set up on closed
side (move upstream)
❑ remove in same order as set up on open
side (move downstream)
❑ do not point work vehicles upstream
Emergency vehicles must be allowed to pass through traffic control zones as
quickly as possible.
Supervisor Name Supervisor Signature Date