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/MECH 04/26/2017

General Description:
ISOLATION OF FIRE WATER LINE CONNECTING TO FIRE HYDRANT(PW-
FW-635, PW-FW-507)
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:

Approvals/Review Print Name KAUST Mobile Signature Date

ID# Number
Project Receiver.
MOH’D HILAAL 153408 0599033238
Contractor Project
Engineer. MOHAMMED 145671
0581023499
SAMEEUDDIN
RFI’s completed
/issued/attached.
Contractor
SHABBEER AHMED 157605 0582650202
Safety Rep.
E&PM Project
HARIS SIDDIQUE 100219 0544701257
Engineer.
E&PM Safety
GEYLORD MANGULAD 143544 0534182103
Specialist.

Page 1 of 8
To be filled by service provider / contractor
BADGE/ID
DEPARTMENT NAME POSITION DATE
NO.

CIVIL AHMED MOHSEN CIVIL ENGR 155983

MECHANICAL
MECHANICAL MOHAMMED SAMEEUDDIN 145671
ENGR
Supervisor Details:
Yrs. Of
BADGE /ID
Name Company Qualifications Experience
No.
in Role
AMR MOHAMMED
SUFRAAT 2343784571 FIRE FIGHTING
ANWAR 6
TAMMAYAZ SUPERVISOR
Operatives Details
Yrs. of
Name Company Badge/ID No. Trade/skills Experience
in Role
SUFRAAT FIREFIGHTING
MOHAMMED AHMED 2280611316 6
TAMMAYAZ TECHNICIAN
SUFRAAT FIREFIGHTING
MD.ISHTIAQ 2304494061 6
TAMMAYAZ TECHNICIAN
SUFRAAT FIREFIGHTING
ALI ABDULLAH 2052493471 6
TAMMAYAZ TECHNICIAN
SUFRAAT FIREFIGHTING
2309424790 6
FAROOQ KHAN TAMMAYAZ TECHNICIAN

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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.
Risk
Risk Score
Score
Please write details of work to be undertaken step by step Without
After
Controls
Controls
TASK 1: EXCAVATION FOR CHECKING THE PIPELINE LOCATION
WHICH CONNECTED TO EXISTING FIRE HYDRANT.(CONFINED 6 4
SPACE)

1. Mark the area as per drawing.

2. Use grinder to cut the concrete around
3. Use of jackhammer to break up the concrete for making excavation
of 1.2 meter depth and 1mX1.5m width in bottom level with slope to
become wider on top level width 2mX3m.
4. Shoring will be by fixing plywood to all sides of excavation and
provide access ladder then continue excavation by manual.
5. Connect the pipe line of fire hydrant with this pipeline go inside
direction and remove broken debris layer by bobcat then continue
by manual.

Hazard Identified:
 Cave-in hazard of excavation, Trip, Struck
 Fall of objects into excavation
 Falling of personnel
 Uncontrolled electric hand tools
 Vibration
 Dust
 Noise due to jackhammer

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  Ergonomics
Risk
 Circulation of blood due to vibration
 Body injury due to falling
 Hand injury
 Eye injury
 Hearing loss
 Electric shock & sparks
 Ergonomics practice
Control Measure

 Comply to Confined Space Work Permit System

 Barricading the area with signboards – EXCAVATION –
 Shoring and supporting the excavation sides
 Taking care while manual excavating to avoid damage to any
underground service that may by present.
 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 and Ear plugs.
 Safety Officer will discuss the hazards in the operation and advise
safe working procedures.
 Proper ventilation
 Proper access ladder with 3 ft above step off point
 Make sure stock pile away by 3 ft from excavation
 Preventive maintenance of power tools
 Power tools should be in good condition, No damage cords and parts
 Checklist for power tools & equipment
 TUV certificate for BOB CAT & operator.
 Proper shoring.

ENSURE YOU COLOR CODE THE RISK SCORES (refer to above matrix)

Page 5 of 8
 Risk Risk
Score Score
Please write details of work to be undertaken step by step
Without After
Controls Controls
TASK 2: ISOLATION ON THE FIRE FIGHTING PIPE LINE OF HARBOR
EAST SCHOOL 6 4
1. Isolation of the fire water line main valve which is located near
the Harbor east school
2. After isolation of main valve the main pipe of fire water will be
cut to make a tee connection by using pipe cement solvent
3. After tie-in connection to the main line the joint is allowed to
dry for minimum 6hours.
4. A new line will installed by using pipe cement solvent and
connecting to the riser system of firefighting system at harbor
east school
5. After the installation of new line the main valve will be opened
to check for any leakage in the installed fire water line
6. If no leak found the excavated area will be backfilled as per
standard.

Hazard Identified:

 Slip, trips, pinch,

 Fall, struck by, heat stress and over fatigue
 Dust, ergonomics
 Manual handling
Risk
 Hand injury, health illness due to installation of dust/fumes.
 Eye injury
 Body injury, severe headache, heat stroke
 Breathing irritation
 Minor injuries

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, hard hat, safety
shoes and, safety glasses, hand gloves, dust mask.
 Safety Officer will discuss the hazards in the operation and
advise safe working procedures.
 Proper ventilation
 Using handling aids , proper access for excavation
 Supervision of engineer or foreman, permit receiver and
supervisor
 Housekeeping after and before
 Authorised persons only in the working area, proper
communication to the involved persons
 Chemical handling safety procedure.

Page 6 of 8
PLANT AND EQUIPMENT

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

HAND TOOLS

EXTENSION
CORD

POWER TOOLS

LADDER

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

EAR PLUG

SAFETY
SHOES

DUST MASK

Page 7 of 8
 ACKNOWLEDGEMENT
I acknowledge receiving and understanding these instructions, I will fully comply with the assigned task
requirements

DEPARTMENT NAME POSITION BADGE/ID NO. SIGN

AHMED
CIVIL Civil Engineer 142064
MOHAMMED
MOHAMMED MECHANICAL
MECHANICAL 145671
SAMEEUDDIN ENGR
Supervisor Details:
Name Company Badge /ID No. Qualifications Sign
AMR MOHAMMED
SUFRAAT 2343784571 FIRE FIGHTING
ANWAR
TAMMAYAZ SUPERVISOR
OPERATIVES DETAILS
BADGE/ID Position / Trade
NAME COMPANY SIGNATURE
NO. / Skills
SUFRAAT FIREFIGHTING
MOHAMMED AHMED 2280611316 6
TAMMAYAZ TECHNICIAN
SUFRAAT FIREFIGHTING
MD.ISHTIAQ 2304494061 6
TAMMAYAZ TECHNICIAN
SUFRAAT FIREFIGHTING
ALI ABDULLAH 2052493471 6
TAMMAYAZ TECHNICIAN
SUFRAAT FIREFIGHTING
2309424790 6
FAROOQ KHAN TAMMAYAZ TECHNICIAN

(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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