CMSRA to be attached to permit and displayed at jobsite.

COMBINED METHOD STATEMENT and RISK ASSESSMENT

Task Planning
Permit/Work Order No: Name of Company: Dept: Date:

ABC CIVIL 04/01/2017

General Description:
CONCRETE POURING , RUBBER TILES & GRANITE TILES FIXING AND
LANDSCAPING IN EXTERIOR AREA OF HARBOR EAST SCHOOL
Emergency Action Plan (Risk Management)
Area / Unit / Building Name (please
HARBOR EAST SCHOOL
specify):

Emergency contact number/s: Nearest Evacuation Route:

Dial 911 (from a landline phone) ASSEMBLY AREA

Dial 8080911 (from a mobile phone)
Nearest Assembly Area: Safety shower / eye washer located  Yes  No
MAIN PARKING/ MATERIAL YARD

Communication
Stop work conditions (reminders)
Adjacent work hazards Chemical spills or releases Excessive noise Fires and explosions

Fire/Toxic Gas Evacuation

Change in conditions Extreme weather Unusual odours
alarm
Supervisor and worker comments / change in conditions:

KAUST Mobile Signature Date

Approvals/Review Print Name
ID# Number
Project Receiver.
MOH’D ALI IMAM 144138 0599033238
Contractor Project
Engineer. 142064 0581023540
AHMED EL-BEILY

RFI’s completed
/issued/attached.
Contractor
AMR OSAMA 146263 0581525855
Safety Rep.
E&PM Project
HARIS SIDDIQUE 100219 0544701257
Engineer.
E&PM Safety
REDENTOR ROBLES 139588 0501731516
Specialist.

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To be filled by service provider / contractor
BADGE/ID
DEPARTMENT NAME POSITION DATE
NO.

CIVIL AHMED EL_BEILY PROJECT ENGR 142064

RONILO GUADES
QA/QC QA/QC 146038
ESCUADRO
Supervisor Details:
Yrs. Of
BADGE /ID
Name Company Qualifications Experience
No.
in Role
IBRAHIM AL-SAYED
ABC 145918 CIVIL FOREMAN 20
MOHAMMED

Operatives Details
Yrs. of
Name Company Badge/ID No. Trade/skills Experience
in Role
CONCRETE POURING & LANDSCAPING
MUHAMMAD IKRAM ABC 144142 LABOR 2
QAMAR SHAHZAD ABC 144113 LABOR 1
SHAHBAZ AHMED ABC 144140 LABOR 2
MOHAMMED MAHBOB ABC 143482 TILE FIXER 10
TARAN SAH ABC 145791 MASON 5
ABOBAKAR HAGGAG ABC 2392866022 MASON 6
AYMAN HUSSAIN ABC 145817 MASON 4
AHMED MAHMOUND ABC 2392866204 MASON 5
RUBBER TILES FIXING
REYHOLD PINAS VENDOR 2290569892 TILE FIXER 2
BARUN SHARMA RAM VENDOR 2353921059 TILE FIXER 3
ROHALD RELEZ CUA VENDOR 4037171669 TILE FIXER 1
KINGDE JESUS CABAIS VENDOR 4037171644 TILE FIXER 4
WAFI MOHAMMAD VENDOR 2370088276 TILE FIXER 2
JOHN FELIX MARTE VENDOR 4037171636 TILE FIXER 1

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 RISK ASSESSMENT MATRIX
Damage Injury

4 4
Total Fatality 4 8 12 16
Failure

3 3
Major Major 3 6 9 12
OUTCOME

2 2
Minor Minor 2 4 6 8

1 1
Nil No Injury 1 2 3 4

1 2 3 4
Unlikely Possible Probable Definite

PROBABILITY

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 RISK = PROBABILITY x OUTCOME

Probability means the likelihood of something going wrong.

Outcome means the result when something goes wrong.
The simple Matrix below allows calculation of risk even for non-skilled operatives

METHOD STATEMENT

A Method Statement is an agreement between the workforces, Service Provider and the Person
or Organization requesting the work and that the work being undertaken is being managed and
any risk is mitigated to an acceptable level.
The method of work must be clearly communicated and understood by all parties involved.
Operatives undertaking the works the works supervisor and line managers must sign the
document as agreement with the method of works.

It must be noted that more than one method statement may be required for any sequence of
works.
Method statements and risk assessments go hand in hand, as the method of work is dictated
by the risks identified, and the risk is identified by the proposed method of work.

When conducting risk assessments in the first instance all built in safety experience must be
ignored. This will allow true identity of the risks associated with what work is proposed. Then
methods of work can be developed to reduce risk to an acceptable level.

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ENSURE YOU COLOR CODE THE RISK SCORES (refer to above matrix)
Risk Risk
Score Score
Please write details of work to be undertaken step by step
Without After
Controls Controls
TASK:
CONCRETE POURING IN EXTERIOR AREAS. 8 3
a) The sub base is compacted; the forms are set.
a) Using of JCB to transport
b) Crew will pour wet concrete into the forms using wheelbarrow
until they are full to the top edge.

Hazard Identified:

 Portable hand tools

 Protruding objects
 Spinning of drum on the back of truck (ready mix)
 Uncontrolled electric hand tools
 Manual handling
Risk
 Hand injury
 Eye injury
 Entanglements
 Puncture hazard
 Ergonomics practice

Control Measure
 Comply to Work Permit System
 Machine guard
 Standby fire extinguisher
 Ensure that tools and equipment are in good condition and
shall be daily inspected
 All workers shall wear proper PPE such as, safety shoes and
concrete boots, safety glasses, hand gloves, dust mask.
 Safety Officer will discuss the hazards in the operation and
advise safe working procedures.
 Preventive maintenance of power tools
 Sufficient light in concrete area

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 Risk Risk
Score Score
Please write details of work to be undertaken step by step
Without After
Controls Controls
TASK:
RUBBER TILES AND LANDSCAPING IN EXTERIOR 8 3
AREAS.

b) Measure & Adjust size of tiles and area where to be fixed.

c) Using of hand tools to cut rubber tiles to be fixed
d) Crew will put white gravels and white sand in specific exterior
area by wheelbarrow.

Hazard Identified:

 Portable hand tools

 Protruding objects
 Manual handling
Risk
 Hand injury
 Eye injury
 Ergonomics practice

Control Measure
 Comply to Work Permit System
 Ensure that tools and equipment are in good condition and
shall be daily inspected
 All workers shall wear proper PPE such as, safety shoes, safety
glasses, hand gloves, dust mask.
 Safety Officer will discuss the hazards in the operation and
advise safe working procedures.

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 Risk Risk
Score Score
Please write details of work to be undertaken step by step
Without After
Controls Controls
TASK:
GRANITE TILES AND LANDSCAPING IN EXTERIOR 8 3
AREAS.

c) Measure size of tiles and area where to be fixed.

e) Using of grinder to cut the tiles to be fixed in specific areas.
f) Crew will put white gravels and white sand in specific exterior
area by wheelbarrow.

Hazard Identified:

 Cutting of tiles
 Tool equipment are source of ignition
 Extension cable over heating
 Dust
 Tile sharp edge.
 Breakage of cutting disk
 Uncontrolled electric hand tools
Risk
 Damage to property
 Overheating of cables
 Breakage of cutting disk
 Hand injury
 Cut wounds
 Eye injury
 Heat transfer
 Ergonomics practice

Control Measure
 Comply to Work Permit System
 Ensure that tools and equipment are in good condition and
shall be daily inspected
 Safety Officer will discuss the hazards in the operation and
advise safe working procedures.
 Competent personnel supervised by a qualified and
experienced supervisor shall only carry out the works.
 Daily hazard analysis shall be done.
 Preventive maintenance of power tools
 Power tool guard.
 All workers shall wear proper PPE such as, safety shoes, safety
glasses, hand gloves and dust mask.

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PLANT AND EQUIPMENT

TEST
SERIAL DATE OF LAST
ITEM NAME CERTIFICATE REMARKS
NUMBER MAINTENANCE
ATTACHED

HAND TOOLS

BOBCAT

Wheelbarrow

GRINDER

LIST OF SAFETY EQUIPMENT and PPE

TEST
SERIAL DATE OF LAST
ITEM NAME CERTIFICATE REMARKS
NUMBER MAINTENANCE
ATTACHED
SAFETY
HELMET

SAFETY GLASS

HAND GLOVES

SAFETY
SHOES/LONG
BOOTS

DUST MASK

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 ACKNOWLEDGEMENT
I acknowledge receiving and understanding these instructions, I will fully comply with the assigned task
requirements

DEPARTMENT NAME POSITION BADGE/ID NO. SIGN

CIVIL Ahmed El-Biely Civil Engineer 142064
RONILO GUADES
QA/QC ESCUADRO
QA/QC 146038
Supervisor Details:
Name Company Badge /ID No. Qualifications Sign
IBRAHIM AL-SAYED
ABC 145918 CIVIL FOREMAN 20
MOHAMMED
OPERATIVES DETAILS
BADGE/ID Position / Trade
NAME COMPANY SIGNATURE
NO. / Skills
CONCRETE POURING &
LANDSCAPING
MUHAMMAD IKRAM ABC 144142 LABOR
QAMAR SHAHZAD ABC 144113 LABOR
SHAHBAZ AHMED ABC 144140 LABOR
MOHAMMED MAHBOB ABC 143482 TILE FIXER
TARAN SAH ABC 145791 MASON
ABOBAKAR HAGGAG ABC 2392866022 MASON
AYMAN HUSSAIN ABC 145817 MASON
AHMED MAHMOUND ABC 2392866204 MASON
RUBBER TILES FIXING
REYHOLD PINAS VENDOR 2290569892 TILE FIXER
BARUN SHARMA RAM VENDOR 2353921059 TILE FIXER
ROHALD RELEZ CUA VENDOR 4037171669 TILE FIXER
KINGDE JESUS CABAIS VENDOR 4037171644 TILE FIXER
WAFI MOHAMMAD VENDOR 2370088276 TILE FIXER
JOHN FELIX MARTE VENDOR 4037171636 TILE FIXER

(Supervisor will ensure completed combined Method Statement and Risk Assessment forms are forwarded to the Area /Bldg. Manager and
PTW Office)

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