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RISK ASSESSMENT RECORD

WI-5-02-75
USE OF SCAFFOLDING
RA No: 011 DATE: 2013.07.05

CONTRACTOR: Fibre-Wound LOCATION: Mine Waste Solution Stilfontein

BRIEF DESCRIPTION OF SCOPE OF WORK/ACTIVITY: Using of Scaffolding

RISK ASSESSMENT TEAM:

Title/Appointment
Contractors: Approved: Yes/ No
Initials & Surname
Signature
Chris Swart Project Coordinator Project Manager:
Name: ______________ Signature: ______________
Andrè Gerber Project Engineer

Anton van Zyl CR 6.(6) Safety Officer: Engineering Manager:

Name: _________________ Signature: ____________

Title/Appointment
Client representative
COMMENTS:
Vaughan Swart
Safety Coordinator

Discipline Coordinator

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REQUIRED AND EXISTING CONTROL MEASURES: (SUBMIT AND ATTACH TO RISK ASSESSMENT)
Available Adequate Changes Required Remarks
Yes No Yes No Yes No

Scope of work (Logical steps on how task

will be performed )
Procedures: (W I / SOP / Vendor spec's) X X X
Training (induction) / Competency certificates/ X X
X
Specific training identified / Other (Instructions)
Special Permits required (specify) X X X
Equipment /Tool registers / others (specify) X X X
Code of Practice: X X X
Other:

Frequency Scale Severity Scale: Probability Scale

Frequent Occurrence/ daily (3) Catastrophic (Many Fatalities />10 Million damage) (8)
Has happened before (3)
It has happened/ Monthly (2) Disaster (Fatal injury / >1 Million damage ) (7)
Quite possible (2)
Could occur/ Yearly (1) Very Serious (Reportable Accident/ >R 100,000 damage (6)

Serious ( Disability Injury (LTI) />R10000 damage (5) Unusual but possible (1)

Important (Non Disabling Injury/<R1000 damage) (4)

Of Concern (Minor Injury />R100 Damage) (3)

RISK RANKING / PRIORITY FACTOR

If score is 61 to 72 AA Potentially Disaster, action needed immediately
If score is 49 to 60 A Potentially Major, action to be taken within 8 hours – during the shift
If score is 37 to 48 B Potentially Serious, action to be taken within 16 hours – during the second shift
If score is 20 to 36 C Potentially Minor, action to be taken within 7 days
If score is 0 to 19 D Potentially Concern , action not to be taken during work

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RISK ASSESSMENT

N LIST TASK WITH ALL POTENTIAL AND EXISTING PROB SEV OF FREQ SCORE RISK PREVENTATIVE MEASURES PERSON RESPONSIBLE
O TASK STEPS HAZARDS OF OCCUR OF TOTAL RANK / AND CONTROLS RESPONSIBLE TO PERSON’S
(WHO WILL DO WHAT,  INJURY OCCUR 3/4/5/6/7/8 OCCUR PXSXF PRIORITY  ELIMINATE RISK ENSURE SIGNATURE ON
WHERE AND WHEN) 1/2/3 1/2/3 FACTOR PREVENTATIVE COMPLETION
 HEALTH  CONTROL AT SOURCE MEASURES AND DATE
 PROCESS  PUT/FOLLOW PROCEDURE CONTROLS ARE IN
 MATERIAL  PROVIDE PPE PLACE

 ENVIRONMENT
1. Responsible Sec  Tools and 3 8 3 72 AA All equipment that are
16.2 to ensure all equipment will not going to be used with Responsible
tools and be identified their registers shall be 16.2
equipment numbered and checked by the site’s DAN PRICE
(Personal inspected and responsible person and
protective couldn’t comply signed off before work
equipment etc) to with legal shall commence
be used are requirements/site (Electrical Machinery
identified standards which Reg.9+10 & driven
numbered can result in legal Machinery Reg 20
inspected and on liability claims. /General Safety Reg 14a
register (5)(b)

 People could be 3 8 3 72 AA Where any certification is Responsible

exposed to injury required this will form part 16.2
due to failure of of the register to ensure DAN PRICE
equipment. failure of equipment is
kept to a minimum
2. Responsible Sec  Personnel may be 3 8 3 72 AA Responsible 16.2 to Responsible
16.2 will ensure all exposed to ensure Works Instruction 16.2
his/her personnel hazards not WI – 19 – 04 – 2/1 is DAN PRICE
go through the known to him followed to the letter.
medical
surveillance and  Possible Health
attend induction related issues will
before work will not be identified
commence that could result
in injury

 Possible Health
related issues will not
be identified that
could result in injury
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N LIST TASK WITH ALL POTENTIAL AND EXISTING PROB SEV OF FREQ SCORE RISK PREVENTATIVE MEASURES PERSON RESPONSIBLE
O TASK STEPS HAZARDS OF OCCUR OF TOTAL RANK / AND CONTROLS RESPONSIBLE TO PERSON’S
(WHO WILL DO WHAT,  INJURY OCCUR 3/4/5/6/7/8 OCCUR PXSXF PRIORITY  ELIMINATE RISK ENSURE SIGNATURE ON
WHERE AND WHEN) 1/2/3 1/2/3 FACTOR PREVENTATIVE COMPLETION
 HEALTH  CONTROL AT SOURCE MEASURES AND DATE
 PROCESS  PUT/FOLLOW PROCEDURE CONTROLS ARE IN
 MATERIAL  PROVIDE PPE PLACE

 ENVIRONMENT
or legal liability claims
3. Responsible Sec  Exposures to 3 8 3 72 AA Responsible 16.2. to
16.2 will ensure unknown hazards ensure no job will
that all relevant commence before all
permits and  Exposure to legal necessary permits are
clearance to work liability obtained and clearance to
will be obtained work has been given by
before the work  Possible process the responsible person of
will commence interruptions the section work is to be
performed (Occ H&S Act
Const Reg 7 )
4. Responsible 16.2 to Exposures to unknown 3 8 3 72 AA All workers to sign the Appointed 16.2
ensure risk hazards workman’ s declaration. L Engelbrecht
assessment is Working on wrong
discussed; equipment and
understood and machinery
signed prior to work
is commenced People can be exposed
to Injury
5. Establish user Inadequate/material 3 5 2 30 C Competent person
needs. used for specific scaffold establishing needs.
requirements. May lead Appointed certified
to scaffolding collapsing scaffold inspector erector.
which in turn may result
in serious injury,
damage to property and
possible fatalities.
6. Scaffold handing Hand and head injuries 3 6 2 36 C Scaffolding company Responsible 2.1
over can occur when falling must sign off completed SASHERN
from elevated height scaffold in scaffolding MOODLEY
register that gives the
area, date and type of
scaffold and that it is safe
to use.
7. PPE. Hand and head injuries 3 6 2 36 C The wear of PPE and Responsible 2.1
. can occur when falling safety harnesses are SASHERN
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N LIST TASK WITH ALL POTENTIAL AND EXISTING PROB SEV OF FREQ SCORE RISK PREVENTATIVE MEASURES PERSON RESPONSIBLE
O TASK STEPS HAZARDS OF OCCUR OF TOTAL RANK / AND CONTROLS RESPONSIBLE TO PERSON’S
(WHO WILL DO WHAT,  INJURY OCCUR 3/4/5/6/7/8 OCCUR PXSXF PRIORITY  ELIMINATE RISK ENSURE SIGNATURE ON
WHERE AND WHEN) 1/2/3 1/2/3 FACTOR PREVENTATIVE COMPLETION
 HEALTH  CONTROL AT SOURCE MEASURES AND DATE
 PROCESS  PUT/FOLLOW PROCEDURE CONTROLS ARE IN
 MATERIAL  PROVIDE PPE PLACE

 ENVIRONMENT
from elevated height compulsory. To be MOODLEY
checked by safety rep
and supervision.
8. Completed Head and hand injuries 2 5 2 20 C Use PPE correct / Responsible 2.1
erection , attach “ with potential falls. Supervision and SASHERN
SAFE TO USE” competent person to MOODLEY
(SGB type) board check at all times.
to the most
conspicuous place
9. Daily inspection and Damages to scaffolding. 2 7 3 42 B To be done daily by Responsible 2.1
after bad weather, Serious injuries to competent person and noted SASHERN
date and signature people/damages to in the daily inspection MOODLEY
when inspected property register.
must be brought on
to the back of the
“SAFE TO USE”
board
10. Climbing onto Falling from elevated 2 7 3 42 B The worker to ensure that Responsible 2.1
scaffolding level causing fractures the scaffolding hs a” SASHERN
and fatalities SAFE TO USE” board on MOODLEY
and that the inspection
date is the same as the
date that he is working on
the scaffolding.
No worker is allowed to
climb onto scaffolding
with any tools or
equipment in the hands.
All equipment and tools
will be hoisted onto the
working platform
11. Working on Falling from elevated When working on Responsible 2.1
scaffolding level causing fractures scaffolding the worker will SASHERN
and fatalities always be attached by MOODLEY
both safety lanyards and
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N LIST TASK WITH ALL POTENTIAL AND EXISTING PROB SEV OF FREQ SCORE RISK PREVENTATIVE MEASURES PERSON RESPONSIBLE
O TASK STEPS HAZARDS OF OCCUR OF TOTAL RANK / AND CONTROLS RESPONSIBLE TO PERSON’S
(WHO WILL DO WHAT,  INJURY OCCUR 3/4/5/6/7/8 OCCUR PXSXF PRIORITY  ELIMINATE RISK ENSURE SIGNATURE ON
WHERE AND WHEN) 1/2/3 1/2/3 FACTOR PREVENTATIVE COMPLETION
 HEALTH  CONTROL AT SOURCE MEASURES AND DATE
 PROCESS  PUT/FOLLOW PROCEDURE CONTROLS ARE IN
 MATERIAL  PROVIDE PPE PLACE

 ENVIRONMENT
when moving attached by
one at all time No worker
will be allowed to tamper
with scaffolding, if
scaffolding must be
modified the erector will
be asked to do so.
12. Before leaving Excessive material can 2 7 2 28 C Supervisor or competent Responsible 2.1
proper become a tripping person to do a final SASHERN
housekeeping hazard causing injuries inspection before leaving MOODLEY
must be done and damage to area to ensure it is clean
equipment
and free ob any
obstructions.

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I the undersigned Responsible person ________________________________hereby
(Print name in full)
declare that:

I have after consultation with my employees as far as reasonably practicable identified and recorded all the significant hazards and risks associated with the
task that I am to perform with regards to this Risk Assessment
I have determined all measures that needs to be in place for this task, including changing the organization of work and design of safe systems of work, necessary
to eliminate, control, minimise, or where the risk still remains provided the necessary personal protective equipment, and implemented them.
I undertake to periodically review the hazards identified and the risk assessed, to determine whether further elimination, control and minimization of risk is
possible
I have provided every employee as part of this risk assessment with the necessary training, information, instruction or supervision to enable them to perform
their work without risk to his/her Safety and Health.

Signed on the: _________/20… at ANGLOGOLD ASHANTI by: _______________________

(Date) (Responsible person)

Employed by: FIBRE – WOUND (Name of Company)

I / we the undersigned hereby declare that the Responsible person in charge has made us familiar with the work-related hazards and risk and the measures that
must be taken to eliminate, control and minimise those hazards and risks:

Print name in full Signature

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