Combined Method Statement and Risk Assessment for

Infrastructure Work

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Document history

Revision code Description of changes Purpose of issue Date

01 26.06.2022

Document approval

Prepared by Reviewed by Approved by

Name TASAWAR Chadi ElJamal

Job Title QC Project Manager

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 PUBLIC WORKS & INITIATIVES EXECUTION (PW&IE)
COMBINED METHOD STATEMENT and RISK ASSESSMENT

Task Planning
Permit/Work Order Name of Company: Department: Date:
No: WAJDI Contracting Construction Engineering 26 June 2022
& Design
Task Description:

Excavation and preparation for Infrastructure

Emergency Action Plan (Risk Management)
Area / Unit / Building Name (please Exact Work Location:
specify): Oxagon – Opposite side Swimming Pool and New Dining
Tent
Emergency contact number/s: Nearest Evacuation Route:
Dial 8888 (from a landline phone) Tamimi Market
Dial 014-434888 (from a mobile
phone)
Nearest Assembly Area: Tamimi Market

Nearest Evacuation Route: Tamimi Market

COMMUNICATION
Stop work conditions (reminders)
Chemical spills or
Adjacent work hazards Excessive noise Fires and explosions
releases
Fire/Toxic Gas
Change in conditions Extreme weather Unusual odors
Evacuation alarm
Supervisor and worker comments / change in conditions:

Approvals/Review Print Name NEOM ID# Mobile Signature Date

Number
Project PTW
Receiver
Contractor
Chadi ElJamal 0553059118 26 June 22
Project Manager
Contractor Safety
Mohamed Irfan 0590102331 26 June 22
Representative

PWIE Project Mohamed

0598290919 26 June 22
Engineer Abuhantash

Gaylord
PWIESafety 0508337893 26 June 22
Mangulad
Proponent

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

EXACT WORK LOCATION:

Oxagon – Opposite side Swimming Pool and New Dining Tent

Supervisor Details:

BADGE/ Yrs.Of Experience

Name Company Qualifications
NEOM ID No. in Role

Operatives Details
BADGE / Yrs. of Experience
Name Company Trade/skills
NEOM ID No. in Role

RISK ASSESSMENT MATRIX

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 Damage Injury

4 4
Total Failure Fatality 4 8 12 16

3 3
Major Major 3 6 9 12

2 2
OUTCOME

Minor Minor 2 4 6 8

1 1
Nil No Injury 1 2 3 4

1 2 3 4
Unlikely Possible Probable Definite

PROBABILITY

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 identity of the risks associated with what work is proposed. Then
methods of work can be developed to reduce risk to an acceptable level.

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

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 Please write details of work to be undertaken step by step
Separate work permit for shutdown and termination.

 Steps To take prior to work:

 Ensure the requirement of Work Permit Process (HSE-OHS&FS-SOP-13) shall be applied for in
advance of the activity. (Confined space entry PTW)
 Ensure that signatures are obtained from all relevant PWIE personnel, HSE and Proponent.
 Notify PWIE fire service & obtain approval prior of start work.
 PPE, tools, and equipment will be checked by supervisor.
 Barricade to working area and providing warning signs.

 Task 1:Site Planning and Preparation

 Check the approved drawings.
 Check the existing situation or site survey and identify the location of unloading.
 Secure Permit before start of work.

RISK
RISK
SCORES
SCORES
Hazard RISK PROPOSED CONTROLS WITHOUT
WITH
CONTOR
CONTROLS
LS

 Ensure the drawing approved from

 Slips, trips,  Minor
PWIE QA.
falls. injuries
 Conduct good housekeeping
 Obtain approved permit to work. 4 2
 Muscle  Frequent drinking of water
 Heat Stress
Cramps

 Task 2: Excavation & Preparation for Infrastructure

 Determine the manholes and connection points and study the way we will connection it.
 Determine the location, area, and the path we need to excavate, as per approved drawings.
 Surveyor will determine the level of the excavation ( max dept 65cm and wd 30cm up to 50cm )
 We will use the JCB to excavate the tranches for infrastructure.
 Removal of excavated material will be done by Jcb and dump truck.
 Compact with compactor to obtain a levelled surface in the trench.
 Surveyor will verify the level of the excavation.
 Provide Sweet sand for bedding and compact it properly by water.
 Lay the pipe or the cable.
 Surveyor will verify the slope for the gravity drainage pipe.
 Provide sweet sand as a first layer of backfill
 Compact the first layer of backfill with water.
 Install concrete tiles for the medium voltage cable.
 Install warning tape.
 Backfill by layers of 30 cm by jcb.
 Compact each layer of backfill small compactor.
 Compaction shall be carried out with special care by means to avoid damages.
 FDT Test by Third Party.
 Finish the top as existing layer.

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 RISK RISK
PROPOSED SCORES SCORES
Hazard RISK
CONTROLS WITHOUT WITH
CONTROLS CONTORLS
 Conduct
Toolbox prior
to start the
activity with
supervisor
1. Slip, trip, and safety
and fall &  Minor officer in 6 4
Pinch injuries charge.
point.
 Close
monitoring of
engineer or
safety officer
until the task
is finish.
 Wet methods
should be
used to
minimize dust
generation
 Always wear
personal
protective
equipment
 Breathing dusk mask
problem (N95), safety
vest, safety
 Chest and
shoes, gloves,
throat
hard hat,
infection
 Hazards safety
from dust  Skin burning goggles etc.
or allergy
 Working area
 Eye’s should be
infection barricaded
and signage is
mounted to
prevent entry
of
unauthorized
person
 Keep worker
away from
direct
exposure to
dust.
 Ergonomi  Back pain  Use the
cs/manual ergonomics
Handling  Fatigue system such
as mechanical

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 equipment or
buddy system
 Frequent 15
minutes
break.
 Wear
 Noise appropriate
 Hearing loss
ear plug and
muff.
 Assigned
flagman to
 Traffic  Vehicle
control the
collision
moving
vehicles.
 Competent
operator shall
have a 3rd
party
certificate to
operate the
 Unauthori  Crush designated
zed  Bump equipment’s.
operator 8 3
heavy  Mechanical  Valid vehicle
equipmen failure certificates
t’s and
 Fatality documents
available on
site.
 Vehicular
inspection
checklist

 Task 3: Housekeeping after each work

RISK
PROPOSED SCORES RISK SCORES
Hazard RISK
CONTROLS WITHOUT WITH CONTORLS
CONTROLS
4 2
 Poor  Good
housekeeping housekeeping
 Back and
. routine orderly
shoulder
prior to
 Dust pains.
respective area
inhalation. of work.
 Minor
 Slips and injuries.
 Wear
trips. appropriate
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 PPE.
 Proper
segregation of
materials,
chemicals, and
tools.
 Provide waste
trash or
garbage
plastic.

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PLANT AND EQUIPMENT

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

Hand tools

Bobcat

Dump truck

Roller
compactor 25
ton

Grader

Bulldozer

Water tanker

LIST OF SAFETY EQUIPMENT and PPE

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

Safety Helmet

Safety Goggles

Safety Gloves

Ear plugs

Visibility Vest

Safety Shoes

Warning Tape

Warning Cone

Safety Signage

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All Personnel Should Read, Agree & Sign on this sheet before starting the Activity
Acknowledgement
OPERATIVES SIGN OFF SHEET
I acknowledge receiving and understanding these instructions, I will fully comply with the assigned task
requirements
NAME COMPANY Position / Trade / BADGE/ NEOM SIGNATURE
Skills ID NO.

(Supervisor will ensure completed combined Method Statement and Risk Assessment forms are forwarded to the Neom QA and HSE.

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