Risk Assessment / Method Statement Form

Company Name Supervisor / Mgr Name

Assessment By Supervisor / Mgr Contact No.
Assessment Date 21/08/2014 Site / Location
Project / Task General Works / Hot Works / Working at Height Lifting Works / Electrical Works
(Please )
Excavation Works Chemical Confined Space Pressure Sys Others

ACTIVITY: _______Hack off slab for sub-structure works (pile cap, ground beam & ground slab)____________________

Persons at Risk (delete as applicable) Contractor Clients Personnel Visitor Others:

Probability Severity IM VUL UL L VL

IM 1 Improbable NFA 1 Near Miss / No First Aid NFA 1 2 3 4 5
VUL 2 Very Unlikely FA 2 First Aid Injury FA 2 4 6 8 10
UL 3 Unlikely MTC 3 Medical Treatment Case MTC 3 6 9 12 15
L 4 Likely LTA 4 Lost Time Accident LTA 4 8 12 16 20
VL 5 Very Likely MAJOR 5 Major Accident or Fatality MAJOR 5 10 15 20 25

With control measures in place no further action required

Requires Supervisor to review the method statement and control measures that are in place and approve them as safe
Immediate action required to reduce the risk
Reviewed and Agreed by :

Signature: Signature: Signature:

Name : Name : Name :
Date: Date: Date:
Designation : Designation : Designation :

Signature: Signature: Signature:

Name : Name : Name :
Date: Date: Date:
Designation Designation : Designation :
 Risk Assessment / Method Statement Form

Risk Analysis
NO JOB SEQUENCE HAZARDS Likelihood Severity Risk MITIGATION /RECOMMENDATION ACTION
(L) (S) (R) PARTY
1. Site survey and Slip and fall 2 2 4  Work with caution
marking the  Wear safety shoes with good sole Supervisor
existing RC slab

Cutting RC Slab
 Ensure all the hand tools must be in Supervisor
Marking point and Defective tools good order before start works
cut the existing RC  Daily pre-inspection of power tools/
slab by using Dusty equipment prior to start works.
diamond cutter  Spray water during hacking works to
Noise reduce the dust if necessary and
must ensure to wear dust mask all
the time.
 To comply with ear plug/ ear muff
and other relevant basic PPE
requirement.
 Barricade off and signage to be
posted to prevent access to
unauthorized.
2 Hacking
2 3 6  Ensure all the hand tools must be in Supervisor
Using backhoe Defective good order before start works &
breaker/excavator tools/plants  Daily pre-inspection of power tools/ Operator
breaker to hack equipment prior to start works.
existing slab after Dusty  Spray water during hacking works to
cutting works done reduce the dust if necessary and
Noise must ensure to wear dust mask all
the time.
 Unauthorized  To comply with ear plug/ ear muff
person not and other relevant basic PPE
allowed/ requirement.
trepassing  Barricade off and signage to be
posted to prevent access to
unauthorized.
 To clear unused and unwanted
materials from site daily basic.
 Assign a supervisor to closely
monitor
Hot Work
5 Unauthorized 2 3 6  Erect warning barricades all around Supervisor
The existing entry to warn others, especially hot work
ground RC slab location
rebar will cut using  A competent /experience personal
oxy cutter and Fire/spark will be handle the hot work activities
grinder (protruding  Station fire extinguisher around the
rebar) hot works area.
Physical Injury  Ensure the work area clear from
combustible materials
 Ensure cylinder properly secured in
upright position. Installed flash back
arrestor.
 Cylinder protected from direct fire,
spark and excessive heat.
 To assign a permanent trade
supervisor to closely monitor.
 Full PPE comply with safety glass,
safety shoe, high visible vest , hard
hat ,face shield, heavy duty glove/
laser glove for hot work
6. Use ladder every Ladder collapse / 2 2 4  Ladder should be in good condition Supervisor
for access and damage and check and tag.
egress  Individual ladder for each excavation
pit
 Access & Egress to be free from
obsruction

7 The Hit by site 2 3 6  Stay away from moving vehicle Supervisor

Backhoe/excavator machineries  Backhoe to be check using checklist &
is required to use prior to use Machine
for excavation Machinery hazard  No workers allowed to work operator
work to the surrounding work radius
Hydraulic hose
required depth  Make sure all site vehicles are
and dimension burst
properly maintained before
coordinated for occupied.
footings  No Loose materials from edge of of
Unauthorized
entry excavated are allow and have to be
removed by the worker work on top
Physical injury  To carry out daily pre use inspection
on the equipment’s
Falling hazard  Close supervision at all times
 To ensure only well trained and
experienced operator are engaged
for this work
 Cordon off and signage to be posted
to prevent access to unauthorized
 Use submersible pump or other type
of pump to pump out the stagnant
water inside excavated pit
 Full PPE comply with safety glass,
safety shoe, hard hat and gloves
  All the opennings and pits to be
cover up or hard barricade with
proper signage the surrounding area.

8 To remove unused Sharp object 2 2 4 Supervisor

and unwanted  Full PPE comply with safety glass,
Fall & trip
materials from safety shoe, hard hat and gloves
site.  Good housekeeping must be
maintained all the time.
 Proper materials arrangement