Working at Height / Over the Side Permit

The following Permit is required for tasks that include working at heights, working over the side, crane workbox, forklift workbox and includes rescue plan details. Note: for KPA employees undertaking forklift workbox work for cargo operations or using the personnel / rescue workbox a permit is not required.

Section 1: Applicant Details
Name of Permit Applicant (person undertaking work onsite)
Company representative/contact filling out permit (if different to permit applicant)
Section 2: Description of Location and Activity
Tick which activities you will be undertaking*

Operators - Names of operators who are involved in the work
Section 3: Rescue Plan

To be filled out by the permit holder if they have enough people in their team to enable their own rescue team. If left blank, Operations are to allocate a rescue team based on the next day’s rostering.

Rescue Team on CH4

Rescue Checklist – ensure rescue plan has considered the following

Ensure you have a way to communicate both within your team and externally in the event of an emergency:

Direct voice/ communication*
Hand signals*
Two-way Radios*
Safety Equipment

Confirm what equipment you will have available with you to assist with the emergency response:

Life Ring*
Harness and lanyard*

What other equipment may be required in the event of an emergency:

Small boat or Tender*
Work Box*
Milan winch*
Other HSE Considerations
Section 4: Permit Dates
Permit Requested For (to be filled out by permit applicant)
Section 5: Permit Conditions
Permit Applicant to confirm the following will be in place:
Will a pre-start discussion take place?*
JHA/SWMS includes a safe means of access/egress to the work location, PPE requirements and fall restraint/arrest equipment requirements?*
Has a pre start inspection been carried out and recorded?*
Are secure and rated anchor points available?*
Has the spotter/sentry been nominated?*
Has the method of communication been confirmed?*
Is the equipment you are using fit for purpose and has been inspected, tagged and in date?
Is the person/s conducting the work suitably trained and competent?*
Will the area be barricaded/cordoned off and warning signs displayed?*
Section 6: Applicant Statement of Acknowledgement
By ticking this box, the Applicant:*
  • Agrees that they are responsible for the works being undertaken and that they will work in a safe manner at all times and ensure that their contractors work in a safe manner;
  • Confirms that the company they represent and contractors they use at the Port of Broome will:
    1. have safe systems of work in place;
    2. use equipment that is certified (when required) and fit for purpose;
    3. be competent in the type of work being undertaken; and
    4. hold all required permits and licences.
Security Check*