CONFINED SPACE PERMIT
Form No:
APAOHS-10
Revision:
MAY 2013
Issue Date:
Page:
1 of 3
This form is for the purpose of obtaining permission to conduct works which involve entry into a confined space. A confined space is
defined under AS2865-2009 “Confined Space” as: “an enclosed or partially enclosed space that is not intended or designed primarily
for human occupancy, within which there is a risk of one or more of the following :
(a) An oxygen concentration outside the safe oxygen range;
(b) A concentration of airborne contaminant that may cause impairment, loss of consciousness or asphyxiation;
(c) A concentration of flammable airborne contaminant that may cause injury from fire or explosion;
(d) Engulfment in a stored free-flowing solid or a rising level of liquid that may cause suffocation or drowning.
Appropriate entry and exit points are important for safe access and egress or retrieval of personnel in an emergency, however
restricted entry/exit is not a consideration in identifying an enclosed or partially enclosed space as a confined space.
A JSA is required to be submitted with this application.
Section 1: Permit Dates
Date
Permit Valid From
Permit Valid To
Section 2: Applicant Detail’s
Name of Applicant
Contact No
Company
Description / Duration
of Works
Ship/Site Location of
Confined Space
Section 3: Please tick yes or no to the following
YES
1.
Has a JSA been completed and submitted (use APA form if you don’t have your own)?
2.
Do you have an emergency contact and rescue/evacuation procedure in place? (attach copy)
3.
Do you have the required training as specified in section 2.6 and appendix D of AS2865-2009 to
carry out work in a confined space?
4.
Do you have all applicable PPE as outlined in your JSA?
5.
Do you have appropriate first aiders and first aid kit on site?
6.
Is all of your equipment in good order and compliant with any applicable legislation and
standards?
7.
Will the task be carried out in accordance with AS2865-2009 Confined Spaces and any other
applicable Codes of Practice and Guidance Notes?
NO
Section 4: Applicant / Contractor Statement of Acknowledgement
I acknowledge the requirements of the Albany Port Authority to identify and control risks and work in a safe manner at all
times. I confirm the company has satisfactory documented safe systems of work in place and that all permits and licences
required are in order and understood.
Signature:
Position:
Name:
Date:
/
/
CONFINED SPACE PERMIT
Form No:
APAOHS-10
Revision:
MAY 2013
Issue Date:
Page:
2 of 3
Section 5: APA Representative Statement of Acknowledgement (APA Use Only)
I am satisfied that the contractor information provided to me is sufficient to show that the contractor has a system in place
to fulfil their legal obligations to conduct works in a safe manner. This Permit to Work is approved subject to any
conditions listed below.
APA Representative
Signature
Date / Time
Position
SPECIAL CONDITIONS FOR APPROVAL (IF ANY)
SPECIAL CONDITIONS
The APA may withdraw this permit at any time if unsafe work practices are seen
Section 6: Notifications
Engineer
Safety
Security
Maintenance
Environment
Pilots
CONFINED SPACE PERMIT
Form No:
APAOHS-10
Revision:
MAY 2013
Issue Date:
Page:
3 of 3
Identifying A Confined Space
Is space
enclosed or
partially
enclosed?
Yes
Is space not intended,
or designed primarily
for other than,
continuous human
occupancy?
Yes
Has space an
oxygen
concentration
outside the safe
oxygen range?
Yes
No
No
Has space an
airborne contaminant
that may cause
impairment, loss of
consciousness or
asphyxiation?
No
Not a
Confined
Space
Yes
No
Has space an
airborne
contaminant
that may cause
injury from fire
or explosion?
Yes
No
No
Confined
Space
Has space a stored free
flowing or a rising
level of liquid that may
cause suffocation or
drowning by
engulfment?
Yes