FORM FM0910
Application for a Petroleum Safety Zone
Part 1 – Details of person making the application
Name:
Date:
Position:
Email:
Australian Address:
Phone:
On behalf of:
 (Name of titleholder or registered facility operator)
Being the:
Holder of title:
or Registered Operator of facility:
Part 2 – Details of well(s), Structure(s) and/or Equipment
Equipment
Title area
Structure
Description
Well
Name
(what protection is being sought for, see also note 2)
Distance
sought
Latitude
(hh:mm:ss.ss)
Longitude
(hh:mm:ss.ss)
GDA94 Datum
GDA94 Datum
(<=500m)
Part 3 – Justification
(on what basis is protection being sought)
Key factors
Proximity to shipping lanes (Nm):
Proximity to commercial fisheries (Nm):
Water Depth (m):
Activities at, or in connection with the well, structure
and / or equipment:
Other factors
(narrative)
Part 4 – Timing
(when is protection being sought)
Commencement date:
Termination date (where applicable):
Part 5 – Scope
All vessels other than:
(vessels to be prohibited, edit/remove as appropriate)
e.g. vessels under the control of the applicant
e.g. vessels under the control of the operator of the [NAME] facility OR holder of [title] title(s)
e.g. vessels that are [specify a class of vessels]
e.g. [provide names of vessels]
Part 6 – Consultation (outstanding issues)
Party consulted with:
(insert additional rows if required)
Outstanding issue
Proposed response:
Part 7 – Application Checklist
Yes 
1
Submission is being made by a titleholder or the registered operator for the facility (or their agent)
2
A consultation summary [see note 3] report is attached and referenced in Part 9
3
For complex safety zones (multiple items) [see note 2] a line drawing is attached and referenced in Part 9
4
All coordinates provided use the GDA94 Datum
Revision: 2
Revision Date: 18 March 2014
Page 1 of 2
National Offshore Petroleum Safety and Environmental Management Authority
Reference: N-04800-FM0910
Objective ID: A197959
FORM FM0910
Application for a Petroleum Safety Zone
Part 8 – Sign-off
person making application
Signed:
Date:
Name:
Part 9 - Attachments
(edit as appropriate)
No.
Title
Document Id
1
[Consultation summary report]
2
[Line drawing of complex safety zone]
Revision
Dated
Instructions for use:
1
This form is intended for use by titleholders and operators of facilities applying to NOPSEMA for the establishment of a petroleum safety zone.
2
Applicants should complete Parts 1 to 6 and use Part 7 as a checklist to ensure all items have been address/included as part of the application before
signing Part 8. Attachments should be clearly listed in Part 9.
3
The completed form, consultation summary report and, where applicable, line diagram of the petroleum safety zone should be emailed to
safetyzones@nopsema.gov.au.
Notes:
1
Petroleum safety zones are provided for in Part 6.6 of the Offshore Petroleum and Greenhouse Gas Storage Act 2006
2
From NOPSEMA Policy N-04800-0886:
Where an applicant is requesting the establishment of a petroleum safety zone that encompasses a combination of one or more wells, structures or items
of equipment the application shall include:
(1)
(2)
3
a black and white line drawing of the proposed safety zone that includes:
(a)
a graphical representation of boundaries of the proposed petroleum safety zone including latitudes and longitudes sufficient to clearly
delineate the area;
(b)
graphical representations of items of significant infrastructure including but not limited to: wells, production facilities, moorings, flowlines and manifolds.
a tabulation of the latitude and longitude of all wells, facilities (structures and vessels), manifolds or other significant items of subsurface
infrastructure.
From NOPSEMA Policy N-04800-0886:
(1)
(2)
An application for establishment of petroleum safety zone must include a report that describes consultation the applicant has undertaken with:
(a)
relevant Commonwealth and State/NT agencies; and
(b)
any users of the ocean commons (person or organisation) likely to be especially affected by the establishment of the petroleum safety
zone.
The report on consultation undertaken must include:
(a)
a summary of each response made by an agency, person or organisation that has been consulted by the applicant;
(b)
an assessment by the applicant of the legitimacy of any objection or claim of adverse impact; and
(c)
a statement of the manner (if any) in which the applicant has responded or proposes to respond to each objection or claim.
Privacy Notice
NOPSEMA collects your personal information so that it can administer the Offshore Petroleum and Greenhouse Gas Storage Act 2006 and associated regulations. If
you do not provide your personal information, NOPSEMA may not be able to process your application.
NOPSEMA will not use or disclose your personal information for any other purpose without your consent, unless it is required or authorised by law, or relates to
NOPSEMA’s enforcement activities. Your personal information may be disclosed to the following organisations, entities or individuals:

individuals who make a request under the Freedom of Information Act 1982

the Australian National Audit Office and other privately-appointed auditors

other law enforcement bodies (for example, the police or the Coroner)

NOPSEMA’s legal advisors.
NOPSEMA may occasionally be required to disclose information to overseas recipients in order to discharge its functions or exercise its powers, or to perform its
necessary business activities.
Information about how you can access, or seek correction to, your personal information is contained in NOPSEMA’s APP Privacy Policy at
www.nopsema.gov.au/privacy. If you have an enquiry or a complaint about your privacy, please contact NOPSEMA’s Privacy Contact Officer on 08 6188 8700 or by
email at privacy@nopsema.gov.au.
Revision: 2
Revision Date: 18 March 2014
Page 2 of 2
National Offshore Petroleum Safety and Environmental Management Authority
Reference: N-04800-FM0910
Objective ID: A197959