CONFINED SPACE PERMIT
The Applicant shall complete section 1 to 10 and sign section 11 and submit to PPA safety team for approval.
The Permit Checklist has been reviewed with the applicant prior to the commencement of work
PPA Use
Permit No.:
EDOC No.:
SECTION 1: GENERAL
Permit Valid From:
(Hrs)
Date:
To:
Date:
(Hrs)
SECTION 2: WORK DETAILS, PRECAUTIONS & CONDITIONS
2.1 Description of Work
Location:
Description of Work to be Performed:
2.2 Permit Checklist
Does the work involve:
1. Excavation, cutting, drilling, penetrating ground by more than 100mm, or drilling
into walls?
2. Work with potential to generate heat or spark, (e.g. welding, cutting, grinding,
abrasive blasting etc) result in fire associated with equipment, vessels, or
structures in vicinity incl fire associated with other operations eg bunkering?
3. Abrasive blasting?
4.
5.
6.
Y
N
If yes obtain:
Dig Permit
Hot Work Permit
DCW / DBLB /
General
Abrasive Blasting
Checklist
High Voltage (HV) incl entry to any signed HV space or cabinet. 240V electricity
which cannot be isolated. Sewer or sewage systems, gas or high pressure
water?
Height greater than 2.4m involving risk of an unrestrained fall or any work at a
height of less than 2.4m involving risk of a fall from one level to another?
Work within 3 m of road within Port and KBIE requiring decreased speed limits
or use of safety barriers or has the potential to impact traffic flow?
Services Permit
Working at
Heights Permit
Traffic Permit
Heavy Lift
Permit
7.
All lifts over 20t on DCW or more than 1.5t / m2 on DBLB?
8.
Handling dangerous goods (DG) incl DG transported onto or off PPA land,
transported onto DCW or DBLB, loaded onto or off vessels, or in transit on
vessels in Port?
Dangerous
Goods Permit
9.
Removal of native vegetation, work in or near a previously undisturbed area or
within a National Heritage Listed area?
Environment
and Heritage
Permit
10. Diving within 200m of PPA wharf facilities - DBLB, DCW, ALF, HLO, Barge
Ramp?
Diving Permit
Oversized Load
Permit
11. Loads greater than 4.3m high, 2.4m wide, 19m long or over 42.5t?
2.3 Permit Conditions
Y
1.
Fire Extinguisher is to be on standby at all times.
2.
If required, a fire watch has been organised, fire equipment laid out ready for use, or the
fire pump or fire brigade is on standby.
A180410
N
Page 1 of 6
N/A
CONFINED SPACE PERMIT
3.
Barricades and warning signage are to be in place at all times.
4.
Hoses, electrical leads and equipment have been tested/tagged in accordance with
Australian Standards.
The Company representative in charge of works / person in attendance agrees to advise
all team members of Permit Conditions.
5.
2.4 Required Permit Documentation
1.
Y
N
N/A
Y
N
N/A
JHA / JSA / JSEA / WMS / SWI.
2.5 Associated Permits/Forms
Isolation Handover?
(If yes, Form Number:
Hot Work? (If yes, Permit Number:
Evacuations?
Other?
)
)
(If yes, Permit Number:
(If yes, Form Number/Type:
)
)
2.6 Identified Asset Related Hazards
Gas / Fumes
Noise
Temperature extremes
Biological
Solids
Slipping
Moving Parts
Other
Liquids
Falling
Strains / Sprains
Vermin
Electrocution
Corrosive Material
2.7 Identified Asset Related Hazards
a) Is purging required?
Y
N
If Yes, state requirements:
b) Manholes to be opened?
Y
N
Minimum duration prior to entry:
c) Forced ventilation?
Y
N
Minimum duration prior to entry:
d) Is cleaning required?
Y
N
If Yes, Specify Type:
Chemical
Hydro jetting
Steam cleaning
Abrasive
Normal hose
e) Additional requirements:

By Whom:

By Whom:
2.8 Isolation Requirements
Isolations:
have been carried out
are required (responsible person to arrange)
Are not
required
Isolation descriptions:
OR
See attachment
A180410
Page 2 of 6
CONFINED SPACE PERMIT
SECTION 3: AUTHORISATION FOR CONFINED SPACE ENTRY
The entry may proceed with the above precautions and subject to a satisfactory pre-entry gas test recorded on this
permit.
Authorised
Person:
Date:
(Name)
Multiple Use Permit:
Y
N
(Signature)
Date:
If YES, Original Permit No:
I have read and understood the specific requirements detailed by the Authorised Person.
I understand the asset related hazards and agree to comply with all instructions listed above and shall ensure that all
other persons working under my supervision also comply with these instructions. I confirm that a Work Instruction or Job
Safety Analysis shall be conducted prior to the commencement of work (reviewed each day).
I also understand that if the work environment changes such that the original permit does not address the hazards, that
this permit will become invalid and a new permit will be required.
Responsible
Person:
Date:
(Name)
(Signature)
Nominated Persons:
Name:
Signature:
Date:
Name:
Signature:
Date:
Name:
Signature:
Date:
SECTION 4: ATMOSPHERIC TESTING REQUIREMENTS (completed by authorised gas test
panel member)
Pre-entry gas tests have been completed, are satisfactory and recorded over page
YES (Mandatory)
Further testing will be required (to be recorded over page)
Continuous, and recorded at
Minute intervals
Tested and recorded at
Minute intervals
No further testing
Name:
Signature:
Date:
SECTION 5: CHEMICALS AUTHORISED FOR USE IN CONFINED SPACE (no chemicals other
than those listed may be used – including cleaners)
The MSDS for each chemical must be available
Yes
Yes
a)
Qty
MSDS
c)
Qty
MSDS
b)
Qty
MSDS
d)
Qty
MSDS
A180410
Page 3 of 6
CONFINED SPACE PERMIT
SECTION 6: PRECAUTIONS CHECKED BY RESPONSIBLE PERSON
Yes
N/A
 Isolations have been carried out
 The space is adequately ventilated
 Lighting is adequate (or of approved type)
 Simultaneous activities have been considered
 Portable electrical equipment is connected to an RCD
 A JSA or Work Instruction is in place for the task, attached to Permit and been discussed with
the crew
 Hazards listed in Section 4 are being managed
 Cleaning/purging/ventilation requirements are met, as per Section 5
Equipment is Suitable and ready:
Yes
N/A
Yes
SCBA
N/A
Communications
Fall arrest
Retrieval
Fire Extinguisher

With entrants

Off site
Other:
First Aid Kit
SECTION 7: SAFETY EQUIPMENT AND PPE TO BE WITH ENTRANTS (worn when applicable)
Harness
ELSA Equipment
Lanyard/safety line
Full/half face respirator
Gas detector
Overalls
Personal gas monitor
Torch
Gloves
Head protection
Hearing protection
Safety Footwear
Eyewear
(type)
Other
(define)
SECTION 8: ADDITIONAL PRECAUTIONS TO BE FOLLOWED FOR ENTRY
Means Of Communicating With Entrants:
Contact Intervals:
Other:
SECTION 9: STANDBY/FIREWATCH PERSON/FIRST AIDER & RESCUE ARRANGEMENTS
Trained and suitably equipped persons must be located at the entrance to the Confined Space, be in control of the
entry/exit point at all times and capable of being in continuous communication with and if practical, to observe those
inside. In addition, where necessary, initiate emergency response procedures and operate and monitor equipment used
to ensure safety during entry and work in the confined space. Fire/Safety watch must be trained in the use of
extinguishers and fire hoses and must know how to sound the alarm as appropriate. AS/NAS 2865: 2009
Names of Standby, Firewatch/First Aider and Rescue Personnel to be printed below:
A180410
Page 4 of 6
CONFINED SPACE PERMIT
Person
Duties
SECTION 10: EMERGENCY SERVICES CONTACT DETAILS
(a) Nearest Medical
Support
No:
(b) Fire/Rescue/SES
No:
(c) Other
No:
Rescue Plan Summary:
SECTION 11: CHECKLIST FOR PERSONNEL ENTERING & WORKING IN THE CONFINED SPACE
Ensure that the following questions are read and understood prior to signing below.
Do not sign unless satisfied that all issues have been addressed.
(a) I understand my responsibilities and safety precautions to be compiled with
(b) I understand and will comply with the Job Safety Analysis (or Work Instruction) for this entry
(c) I have been briefed on the hazards associated with this Confined Space
(d) I understand and will comply with the arrangements for communication
(e) I am aware of and understand action/s to be taken in the event of an Emergency
(f) I will report immediately to the Responsible Person all incidents and accidents
(g) I have participated in a training course and am competent to enter a Confined Space
(h) I consider myself fit for the tasks I have been allocated
Read
Checklist
A180410
Name (Print)
Duties
Signature
Date
Page 5 of 6
CONFINED SPACE PERMIT
SECTION 12: PPA RECEIPT, PERMIT APPROVAL & PERMIT ACCEPTANCE
If the Applicant is the Company which will carry out the work, by applying for this permit it makes the following
warranties, undertakings and acknowledgements:
1. The Applicant warrants that it understands the nature of the work permitted by the permit and risks
associated with it, has sufficient competence to carry out the work and accepts responsibility (including
occupational health and safety responsibility) for the work.
2. The Applicant undertakes to notify PPA as soon as possible after it identifies any issue which would
prevent the work from being carried out safely, and to liaise with PPA to allow the work to be carried out
safely.
3. The Applicant acknowledges that the issuing of this permit does not constitute approval by the PPA of the
work or occupational health and safety procedures in relation to the carrying out of the work.
4. The Applicant warrants that, where it has particular expertise or technical knowledge with respect to the
work permitted by the permit, it accepts that it, and not PPA, exercises control over that work and is
responsible for any occupational health and safety obligations arising from that work.
If the Applicant is not the Company which will carry out the work, by applying for this permit it makes the following
warranties, undertakings and acknowledgements:
1. The Applicant warrants that it understands the nature of the work and risks associated with it.
2. The Applicant undertakes to take whatever steps are required to ensure that the Company which will carry
out the work understands the nature of the work and risks associated with it.
3. The Applicant warrants that the Company which will carry out the work has sufficient competence to carry
out the work and accepts responsibility (including occupational health and safety responsibility for the work.
4. The Applicant undertakes to take whatever steps are required to ensure the Company which will carry out
the work notifies the PPA as soon as possible after it identifies any issue which would prevent the work
from being carried out safely and liaises with the PPA to allow the work to be carried out safely.
5. The Applicant undertakes to take whatever steps are required to ensure the Company which will carry out
the work understands that the issuing of this permit does not constitute approval by the PPA of the work or
occupational health and safety procedures in relation to the carrying out of the work.
Applicant’s Authorised Representative:
(Name)
(Signature)
(Date)
(Signature)
(Date)
(Title)
Permit Authoriser:
(Name)
Notifications:
Wharf Manager Y
N
Environment Y
N
Safety Y
N
Maintenance Y
N
Engineering Y
N
Security Y
N
Other:
SECTION 13: Completion
The work has been completed and all persons who had a role in carrying out the work, materials and equipment have
been withdrawn.
Authorised Representative of Applicant Signed
(Name)
OR
Company in Charge of Works Signed
(Signature)
(Date)
(Signature)
(Date)
Permit Authoriser:
A180410
Page 6 of 6