Port of Derby Diving Permit

This form is for the purpose of obtaining permission to conduct diving in Port limits and to ensure that hazards associated with this work activity are controlled. All diving operations are to be carried out in accordance with AS/NZS 2299.1 (2015) and any other relevant Authorities requirement – this permit will only be issued to divers who are conducting the work.

Note: All diving activities must be authorised by the KPA Harbourmaster or their delegate, prior to the Permit being authorised.

Comments

This field is for validation purposes and should be left unchanged.

Applicant Details

Dive Tender(Required)

Contact Number (Dive Tender)(Required)

Divers name (1)(Required)

Contact Number (Diver 1)(Required)

Divers name (Row 2)(Required)

Contact Number (Diver 2)(Required)

Company(Required)

Contact Number (Company)(Required)

Description of Location and Activity

Location and Vessel Name(Required)

Description of Works(Required)

Description of equipment to be used(Required)

Permit Dates

Permit Requested For
(to be filled out by permit applicant)

Start Date(Required)

DD slash MM slash YYYY

End Date(Required)

DD slash MM slash YYYY

Start Time(Required)

Hours

:

Minutes

AM PM AM/PM

End Time(Required)

Hours

:

Minutes

AM PM AM/PM

Permit Dates Authorised
(to be filled out by Permit Authoriser)

Start Date(Required)

DD slash MM slash YYYY

End Date(Required)

DD slash MM slash YYYY

Start Time(Required)

Hours

:

Minutes

AM PM AM/PM

End Time(Required)

Hours

:

Minutes

AM PM AM/PM

Permit Conditions

Permit Applicant must tick yes to all of the following

A copy of Dive Cert. AS/NZS 2815 and valid medical is attached to this permit(Required)

A copy of Dive Cert. AS/NZS 2815 and valid medical is attached to this permit

Has a JHA/Procedure or dive plan been prepared and is it available for the works?(Required)

Has a JHA/Procedure or dive plan been prepared and is it available for the works?

Will diving flags be displayed?(Required)

Will diving flags be displayed?

The Dive vessel will monitor VHF CH16 and UHF CH14(Required)

The Dive vessel will monitor VHF CH16 and UHF CH14

Ships clearance to dive procedure has been activated, including shutdown andpropeller immobilised if applicable – refer to ships shutdown procedures.(Required)

Ships clearance to dive procedure has been activated, including shutdown andpropeller immobilised if applicable – refer to ships shutdown procedures.

Is the person conducting the work suitably trained and competent?(Required)

Is the person conducting the work suitably trained and competent?

Has the required PPE been identified and will it be worn by all persons involved?(Required)

Has the required PPE been identified and will it be worn by all persons involved?

Is all the dive equipment serviceable, fit for purpose and in current certification as perAS/NZS 2299.1 (2015)?(Required)

Is all the dive equipment serviceable, fit for purpose and in current certification as perAS/NZS 2299.1 (2015)?

Is the Dive vessel is in survey (if applicable)?(Required)

Is the Dive vessel is in survey (if applicable)?

Are people trained in First Aid available?(Required)

Are people trained in First Aid available?

Permit Applicant to tick yes (Yes), no (No) or not applicable N/A to the following:

Will the diving work require jetty closure?(Required)

Yes

No

N/A

Has the wharf’s cathodic protection system been turned off?(Required)

Yes

No

N/A

Will the area be barricaded/cordoned off and warning signs displayed?(Required)

Yes

No

N/A

Will SCUBA equipment be used for the dive?(Required)

Yes

No

N/A

Will Surface Supplied Breathing Apparatus (SSBA) be used?(Required)

Yes

No

N/A

Will first aid equipment (including Oxygen) be carried?(Required)

Yes

No

N/A

Applicant Statement of Acknowledgement

Name(Required)

Position(Required)

Email(Required)

Date(Required)

Day

Month

Year

Signature(Required)

Notification to Vessel Master Prior to Activity Commencement (if applicable)

Prior to activation of the permit, the Permit Applicant must notify the Vessel Master who will sign below:

Vessel Master Name(Required)

Vessel Master Signature(Required)

Vessel Master to notify KPA on commencement and on completion of activity on Channel 17 orvia email to derbyoperations@kimberleyports.wa.gov.au, operations@kimberleyports.wa.gov.au

Vessel Master to notify KPA on commencement and on completion of activity on Channel 17 orvia email to derbyoperations@kimberleyports.wa.gov.au, operations@kimberleyports.wa.gov.au

Vessel Master to issue Security radio announcement on Channel 17

Vessel Master to issue Security radio announcement on Channel 17

Completion Sign Off. (Provide form to Gatehouse or KPA contact on departure)

Permit Applicant(Required)

Signature(Required)

Date(Required)

DD slash MM slash YYYY

Time(Required)

Hours

:

Minutes

AM PM AM/PM

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