Mid West Ports Authority

Permit Number:

F4.1q Permission to Immobilise

APPLICANT DETAILS
Full Name: / Company:
Email Address: / 24 hr Contact No.:
Start Date/Time: / Completion Date/Time:
VESSEL DETAILS
Vessel Name: / Berth No:
Vessel Master Name: / Vessel Master Contact No.:
Start Date/Time: / Completion Date/Time:
Nature Of Immobilisation:
Please confirm, through the Master, that following completion of the immobilisation of the main engine, the vessels manoeuvring abilities for the arrival/departure, will not in any way be affected. / Yes / No
If yes please advise (e.g. Limited M/E rpm)
Estimate of time to mobilise in an emergency
(Note: immobilisation must be completed at least 6 hours prior to scheduled departure time) / hours
REQUIREMENTS CHECKLIST
I will ensure that the following requirements are met by advising the Duty Pilot via email:
The actual time immobilisation commences
The expected duration
Any changes to the expected time of completion
The actual time that immobilisation is completed
ACCEPTANCE OF CONDITIONS/REQUIREMENTS
By signing this document, the undersigned has read, understood and accepted the terms and conditions of this application and declares that all information is true and accurate.
Applicant name / Signature / Date:
APPROVAL ISSUED ONLY WHEN SIGNED BELOW, BY AUTHORISED MWPA REPRESENTATIVE
AND PROCESSED BY THE DUTY WHARF SUPERVISOR
I the accept the below additional mandatory requirements set by the Harbourmaster
MWPA ASSESSMENT
As appropriate
Harbour Master Check / Name: / Signature: / Date:
Rejected – Revise and Resubmit / Approved / Additional Mandatory Conditions
Comments:
MWPA FINAL ASSESSMENT
Processed by
Wharf Supervisor /
Signature /
Date:
OFFICE USE ONLY
Recorded in Work Permits Register / Date:
Completion notified / Date:
Application closed / Date:
MWPA TERMS AND CONDITIONS
1. / Engine immobilisation must be conducted strictly in accordance the above conditions and requirements.
2. / Applicants are responsible for ensuring they have a BHF Authority to Work Permit which can be obtained through the Operations Supervisor or 0407 797 311 when working on or under Berths 4 or 5.
3 / To ensure timely approval, this application must be lodged a minimum of 2 working days prior to commencement of the work.
4 / No work can commence until a signed approval from MWPA has been received (in hard copy or via email) and any additional conditions/requirements have been accepted.
5 / Any safety or environmental incidents, or damage, during works must be reported to the MWPA immediately. After hours, please call (08) 9964 0510. With regard to such incidents, you are responsible to make good the site and any other affected areas to the satisfaction of the MWPA.
6 / All personnel accessing MWPA sites are required to have completed a MWPA induction. Within the secure zone, individuals are also required to carry their own Maritime Security identification Card (MSIC) at all times. A visitor’s pass may be obtained but all visitors must be escorted at all times by a holder of a current MSIC.
7 / Any failure to gain approval for work, or failure to comply with MWPAs Requirements of Contractors document or Permit Procedures may result in a penalty or permission to enter MWPA sites being withdrawn until al MWPA requirements are met.
8 / This permit to be held on site at all times during the works.
Should you have any queries, please contact MWPA Duty Wharf Supervisor on (08) 9964 0510.
Completed permits should be emailed to

Custodian: Harbour Master

Uncontrolled when printed or in hard copy

V3 – 18 January 2018 Page 2 of 2