Safe Work Method Statement / Rev.A

• Audit Title

Work Details

• Date of job:

  Date

• Work site name:

• Location:
  Address

• What are the current weather conditions:

  Select Sunny Fog Cloudy Overcast Rain Hail Lightening Sleet

  • Sunny
  • Fog
  • Cloudy
  • Overcast
  • Rain
  • Hail
  • Lightening
  • Sleet

• Other weather conditions:

• Name of level 2 first Aider on site:

• Name of staff member completing this record:

• The document is designed to be used to ANTICIPATE - IDENTIFY - ASSESS - EVALUATE & CONTROL hazards on the worksite. and must be completed in consultation with the employees working at the site BEFORE work begins. In the case of an 'Incident', follow the Incident Reporting Procedure O.35.12.

Training

• List the qualifications, permits, licences or certificates held.

• List Staff members on site:

Employee

• Name:

• Washington Flagger card

• Other training, please specify:

Personal Protective Equipment

• PPE Required for this job:

  Select Hi Vis Reflective Vest Long work pants Safety boots Hard Hat Eye protection Ear Protection

  • Hi Vis Reflective Vest
  • Long work pants
  • Safety boots
  • Hard Hat
  • Eye protection
  • Ear Protection

• Other, please specify:

Equipment

• Equipment required for this job:

  Select Utility Stop/Slow Paddles 2 way (UHF) radio Whistle Traffic Cones Traffic signs & legs Sign weights

  • Utility
  • Stop/Slow Paddles
  • 2 way (UHF) radio
  • Whistle
  • Traffic Cones
  • Traffic signs & legs
  • Sign weights

• Other please specify:

• The Safe Work Method Statement has been developed in consultation with the Safety Manager, L&I and OH&S Area Representatives. And has been developed in response to relevant requirements of the Safety Acts, including Road Management Act 2004 & Code of Practice Work Site Safety - Traffic Management.

Risk Rating Scale I.35.03.02

• When completing the following you must refer to the Risk Rating Scale I.35.03.02 information sheet.

SITE ARRIVAL

• 1. Does the job site involve parking a vehicle on the side of the road?

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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Potential Hazard

• Muscular/Skeletal injury from impact with worker/vehicle

• Risk Rating Scale = 25 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• USE: flashing lights on vehicle, exit vehicle from the non traffic side, wear hi-vis vest, pants, and hardhat

• Risk Rating Scale = MED 11

• Responsible for implementation: ALL STAFF

• 2. Did you conduct a Site Safety Induction?

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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• Site Safety Inductions are a requirement and must be completed!

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Potential Hazard

• Injury from not being aware of the hazards on site, daily changes to possible hazards.

• Risk Rating Scale = 25 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Conduct safety induction and ensure daily refresh occurs.

• Risk Rating Scale = 16 HIGH

• Responsible for implementation: SUPERVISOR

• 3. Are there over head hazards ?

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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Potential Hazard

• Muscular/Skeletal injury from impact with worker

• Risk Rating Scale = 20 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Inspect worksite at the beginning of every day and relocate away from the obstruction

• Risk Rating Scale =16 HIGH

• Responsible for implementation: ALL STAFF

• 4. Have you reviewed the Traffic Management Plan?

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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Potential Hazard

• Injury from team not knowing the work plan to follow

• Risk Rating Scale = 25 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Conduct a review with all staff on site

• Risk Rating Scale = 16 HIGH

• Responsible for implementation : SUPERVISOR

SITE SET UP

• 5. Are you installing and removing traffic control devices in advance of the work site?

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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Potential Hazard

• Muscular/Skeletal injury from back strain

• Risk Rating Scale = 22 UNACCEPTABLE RISK - you must take preventative action

Safety Control

• Use correct manual handling

• Risk Rating Scale = 4 LOW

• Responsible for implementation : ALL STAFF

Potential Hazard

• Muscular/Skeletal injury from impact with worker / vehicle

• Risk Rating Scale = 23 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Follow Traffic Management Plan, hold correct qualifications, wear hi-vis vest

• Risk Rating Scale = 11 MED

• Responsible for implementation : ALL STAFF

• 6. Are you installing and removing channelization/delineation devices in the work site?

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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Potential Hazard

• Muscular/Skeletal injury from impact with worker / vehicle

• Risk Rating Scale = 22 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Follow the Traffic Management Plan and wear a hi-vis vest

• Risk Rating Scale = 14 MED

• Responsible for implementation : ALL STAFF

Potential Hazard

• Fall/Trip/Slip on road surface

• Risk Rating Scale = 22 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Wear safety boots and observe work area

• Risk Rating Scale = 14 MED

• Responsible for implementation : ALL STAFF

OPERATIONS

• 7. Are staff crossing the road?

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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Potential Hazard

• Muscular/Skeletal injury from impact with worker / vehicle

• Risk Rating Scale = 23 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Use flashing lights on the vehicle and spotter for employee crossing roadway, wear hi-vis vest

• Risk Rating Scale = 16 HIGH

• Responsible for implementation : ALL STAFF

Potential Hazard

• Fall/Trip/Slip on road surface

• Risk Rating Scale = 22 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Wear safety boots & observe work area

• Risk Rating Scale = 14 MED

• Responsible for implementation : ALL STAFF

• 8. Have you established a correct traffic control position?

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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Potential Hazard

• Muscular/Skeletal injury from impact with worker / vehicle

• Risk Rating Scale = 25 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Hold relevant qualifications, stand on shoulder of road, stand in well lit position, wear hi-vis vest

• Risk Rating Scale = 20 HIGH

• Responsible for implementation : ALL TRAFFIC CONTROLLERS

Potential Hazard

• Fall/Trip/Slip on road surface

• Risk Rating Scale = 22 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Wear safety boots & observe work area

• Risk Rating Scale = 14 MED

• Responsible for implementation : ALL STAFF

• 9. Slowing the traffic

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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Potential Hazard

• Muscular/Skeletal injury to the worker / vehicle from impact with motorists

• Risk Rating Scale = 25 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Follow the Traffic Management Plan & place signage in the correct position, clearly use slow bat, hold required qualifications, wear hi - vis vest

• Risk Rating Scale = 20 HIGH

• Responsible for implementation : ALL TRAFFIC CONTROLLERS

Potential Hazard

• Sunburn and or Fatigue

• Risk Rating Scale = 19 HIGH

Safety Control

• Wear sun hat and use sunscreen, take required breaks and ensure drinking water is available

• Risk Rating Scale = 3 LOW

• Responsible for implementation : ALL STAFF

• 10. Stopping traffic

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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Potential Hazard

• Vehicle collisions

• Risk Rating Scale = 25 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Clearly display the stop bat, hold required qualifications, wear hi - vis vest

• Risk Rating Scale = 20 HIGH

• Responsible for implementation : ALL TRAFFIC CONTROLLERS

Potential Hazard

• Muscular/Skeletal injury from impact with worker / vehicle

• Risk Rating Scale = 25 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Hold required qualifications, wear hi - vis vest

• Risk Rating Scale = 20 HIGH

• Responsible for implementation : ALL TRAFFIC CONTROLLERS

Potential Hazard

• Sunburn and or Fatigue

• Risk Rating Scale = 19 HIGH

Safety Control

• Wear sun hat and use sunscreen, take required breaks and ensure drinking water is available

• Risk Rating Scale = 3 LOW

• Responsible for implementation : ALL STAFF

• 11. Weather Conditions

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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Potential Hazard

• Change in weather conditions. E.G. Extreme heat, Fog, Rain, Lightning, Hail, etc.

• Risk Rating Scale = 24 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Site Supervisor is to monitor and discuss with other site employees

• Risk Rating Scale = 12 MED

• Responsible for implementation : SITE SUPERVISOR

ELECTRICAL SPOTTING JOBS

• 12. Spotting and Plant Operation

  Assessed as Safe to proceed

  Action taken to Address Hazard

  Not Applicable for this job
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Potential Hazard

• Death due to contact with overhead wires

• Risk Rating Scale = 25 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Hold required qualifications, always maintain 2 forms of contact with operator, remain alert, have whistle around neck, assess clearance,

• Do Not Leave Spotting Position Unless Told To Do So By Plant Operator!

• Risk Rating Scale = 20 HIGH

Potential Hazard

• Sunburn and or Fatigue

• Risk Rating Scale = 25 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Wear sun hat and use sunscreen, take required breaks and ensure that drinking water is available.

• Risk Rating Scale = 8 MED

• Responsible for implementation : ALL SPOTTERS

Potential Hazard

• Muscular / Skeletal injury from strain

• Risk Rating Scale = 21 UNACCEPTABLE RISK - preventative action must be taken

Safety Control

• Staff must take regular breaks to ensure they do not suffer any body/muscle fatigue.

• Risk Rating Scale = 8 MED

• Responsible for implementation : ALL SPOTTERS

• As you assess the work site, if you identify any other hazards, please record them below.

• 13. Additional Hazards

Hazard

• What potential hazard did you identify?

• Risk Rating Scale =

• What safety controls are needed to reduce the risk?

• Risk Rating Scale after safety measures are applied =

• Who is responsible for implementation:

Staff On Site

• Listed personnel below have been made aware of and understand the procedure, hazards and control measures outlined in this SAFE WORK METHOD STATEMENT ABOVE. All staff will abide by the measures outlined with the Safe Work Method Statement to ensure the safety of all employees.

• All employees on site must read and sign

Employee

• Name/Signature:

  Sign

• Position:

Amendments Required

• ANY CHANGES, ADDITIONS OR DELETIONS TO THE SAFE WORK METHOD STATEMENT ARE TO BE DISCUSSED WITH THE ABOVE PERSONNEL AND THE SITE SUPERVISOR. CHANGES SHOULD ONLY BE MADE BY AUTHORISED PERSONNEL.

• Are there any amendments required to the original SWMS completed?

  Yes

  No
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• Amendments discussed with all personnel on

  Date

Declaration

• Are there any Special Comments required for this job?

  Yes

  No
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• Special Comments:

• Form completed by Name/Signature:

  Sign

• Once the job has been completed this form must be forwarded back to your Depot Manager.
  Depot Managers are required to review the form to ensure its correctly completed and file as per the GAME O.20.04 Records Maintenance Procedure.