Safe Work Plan
Project: R-206
Scope: 325 SWP No.:
Date Created: 20/10/2 Revision Number: Review Date:
Workers Involved in Developing this Lifting Plan
Print Name: Signature: Print Name: Signature:
Hazard Identification:
Fall Hazards ,trip slip hazards
Health & Safety Related Training
(If Required):
Emergency Response:
(Contracts; Phone Numbers, Etc)
Project Site Contacts:
Hot Work Permit ☐ Yes Confined Space Permit ☐ Yes Scissor Lift / Boom Lift ☐ Yes Other Permit ☐ Yes
Applicable Permit(s):
PPE
Required:
Safe Work Method Statement
Step 1
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Consequences
5 – Severe Potential to be fatal. Permanent disability. Destruction of property or plant.
4 – Major Serious injury. Long term disability. Major damage to plant, property or environment.
3 – Moderate Potential for injury resulting in medical attention. Damage to plant, property or environment.
2 – Minor Injury requiring First Aid treatment and / or short term discomfort.
1 – Negligible Cause a near miss, needs to be reported
Step 2
Potential (Likelihood)
A – Almost Certain This event is expected to occur in most circumstances
B – Likely The event will probably occur in most circumstances
C – Possible The event might occur at some time
D – Unlikely The event could occur at some time
E - Rare The event may occur only in exceptional circumstances
Step 3
Matrix Consequences
Potential 1 – Negligible 2 – Minor 3 – Moderate 4 – Major 5 – Severe
A – Almost Certain M (9) S (15) S (19) H (24) H (25)
B – Likely L (7) M (11) S (18) S (21) H (23)
C – Possible L (5) L (6) M (13) S (17) H (22)
D – Unlikely L (3) L (4) M (10) M (14) S (20)
E - Rare VL (1) L (2) M (8) M (12) S (16)
Legend
Risk Rating
Activity to be re-planned and/or re-designed. If this is not possible, an independent Hazard Assessment of the activity is to be completed by the Project
High Manager prior to completing the SWMS
Significant Activity Must be reviewed by Senior Site Management Representative and have identified risk controls built into the SWMS and work procedure
Medium Site Supervisor must review method of task.
Low Some action may be required, Supervisor to determine and monitor
Very Low Minimal risk, monitor where work changes
Safe Work Method Statement
Risk Person Responsible
Job Step Potential Hazard Rating
Control
for Controls
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Have you considered the site specific hazards? e.g. IN PREPARING A SAFE WORK PlAN YOU MUST:
- Layout of the work area 1. Consider any site specific potential hazards and include any identified risks in Safe Work Plan (SWP)
- Obstacles (buildings, workers,equipment) 2. Assess the risk
- Changes to site conditions 3. Insert controls using the hierarchy of controls for the hazards identified i.e. Elimination, Substitution (materials,
- Other contractors’ work in progress equipment, and chemicals), Isolation, Engineering (guarding), Administration (training) or PPE
Have you considered work area conditions? Eg. 4. Review the residual risk to ensure controls are adequate to safely perform the work
- wind 5 Ensure that all workers involved in the job task have read, understood and signed off on the SWP
- rain 8. Ensure that work is carried out in a safe manner in accordance with the SWP
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- heat
- cold etc
Safe Work Plan
WORKERS INVOLVED IN JOB TASK
We, the undersigned, confirm that we have been consulted regarding the above SWP and that its content is clearly understood. We also confirm that our required qualification(s) etc. to
undertake this activity, is\are current and that we are competent to complete the work safely and without risk to our own health or the health and safety of others. We clearly understand
that the control(s) in this SWP must be applied as documented, otherwise work is to cease immediately, and we will ensure that the work area is made safe, as far as reasonably
practicable.
Name: Company: Signature: Date:
I, the undersigned Supervisor, confirm that I have checked all qualifications provided and verify that they are applicable and current. I have also ensured that all
inductions have taken place and that all tools and equipment are properly maintained and safe to use. I have issued all relevant permits and have ensured to the
best of my ability that the work area is safe and that the work will not damage any property or injure any persons.
Supervisor Name Supervisor Signature Date _______________
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