METHOD STATEMENT TEMPLATE

Project: DB6X

Project No.: 1206

Method Statement Insert Number

Number:
Scope of Works: Insert brief scope of works

Insert revision
Status: For approval Rev. No. number

Main Contractor: Winthrop Technologies Ltd.

Subcontractor: Insert Name Insert Logo

Approved By: Insert Name of Authorized Supervisor

Date: dd / mm / yyyy

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 1. METHOD STATEMENT REVIEW/ACCEPTANCE

Insert name 1206

Name of Contractor Project Number
Insert title Insert no
Method Statement Title Method Statement No
Insert date Insert rev. no
Date issued to Winthrop Revision No
Package Manager to determine reviewer, distribute Proposed date work Insert date or TBC
and return to contractor to start on site
Comments
1. .
2. .
3. .
4. .
5. .
6. .
7. .
8. .
9. .
10.

ACCEPTABLE (Tick appropriate box)

CONTENT YES NO IN PART N/A
Description of Work
Sequence of Operations
Name of Supervisor
Allocation of responsibilities
Controls and Monitoring e.g. permits
Plant inspection, Certification & Operator Training
Controls re. live Services
Risk assessment including High Risk Activities (HRA)
Material Handling, Hazardous Materials, Driving, Work
at Heights (WAH), Lifting Operations, Confined
Spaces, Energy Isolation, Electricity, Ground
Disturbance, Mobile Equipment
Safety of Adjacent Operations
Environmental Controls
Emergency Arrangements and Personal Protective
Equipment (PPE).
Lifting Operations/Plan
Other: COVID-19 Control Measures

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 Overall Approval Status Yes No Date
CAT A - Accepted for implementation. Work may
proceed as planned
CAT B - Accepted subject to comments above being
implemented.(Note: Method Statement to be
resubmitted within 7 days for approval, otherwise
works will be suspended).
CAT C - Not accepted for implementation.
Resubmission required
Date returned to contractor
Print Name Sign Date
Insert name Insert Signature Insert Date
Prepared by:
Insert name Insert Signature Insert Date
Reviewed by: (Site
Management)
Reviewed By: (EHS) Insert name Insert Signature Insert Date

Reviewed By: Insert name Insert Signature Insert Date

(Environmental
Manager)

Additional Signature
where required
Note: Clearance to proceed with this Method Statement does not relieve the Subcontractor of their
contractual or legal obligations, including safety, environmental, structural integrity or any
implications to permanent works arising from these proposals

IMS Document No:1.04.02 IFHS_03 Page 3 of 13 Revision 06

 Table of Contents

On completion of document, right click table of content, update field, update entire table,
and click ok

1. Method Statement Review/Acceptance.............................................................................2

2. Scope of works.....................................................................................................................5
3. Methodology /Programming/Schedule of Works...............................................................5
4. Works Phasing/ Drawing’S..................................................................................................5
5. Resources Required Prior to commencing the Works........................................................5
5.1 Labour & Personnel......................................................................................................5
5.2 Client/Main Contractor Attendances...........................................................................5
5.3 Plant & Equipment.......................................................................................................6
5.4 Personal Protective & Emergency Equipment.............................................................6
6. Subcontractors Proposed....................................................................................................6
7. Emergency Arrangements...................................................................................................6
8. Risk Assessment Matrix.......................................................................................................7
9. Risk Assessment & Controls................................................................................................8
10. ENVIRONMENTAL IMPACTS ASSESSMENT........................................................................10
11. Employee Consultation......................................................................................................13

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 2. SCOPE OF WORKS
Overall description of the work that needs to be executed, and the duration

3. METHODOLOGY /PROGRAMMING/SCHEDULE OF WORKS

All contractors should review and sign-off on the “Method Statement” and if
there are any issues with it they should highlight it to their supervisor and
Safety, such that they can review and resolve the issue, update the Method
Statement or the Safe Plan of Action (SPA) and then the contractor can sign-off
on the Method Statement.

Insert detailed description (in chronological order) of the work that needs to be
executed. Describe how these activities are to be executed (step by step) and the
type of equipment that is to be used. All these activities need also to be part of
the chart in 8. Risk assessment and controls. In this chart you show
comprehensively how you organize risk controls to address the identified hazards
(including environmental).

If the work cannot be completed as per the approved Method Statement, stop
work immediately, contact your supervisor and Safety/Environmental function.
Review the issue and put a solution in place, update the Method Statement or
SPA as required.

4. WORKS PHASING/ DRAWING’S

Insert as applicable

5. RESOURCES REQUIRED PRIOR TO COMMENCING THE WORKS

5.1 Labour & Personnel

Which employees will carry out the work? Detail the roles of those personnel
particularly if there are Construction Skills Certification Scheme (CSCS) trained
operatives, Site supervisors etc.

5.2 Client/Main Contractor Attendances

Detail any expectations or attendances requested from the main contractor.
Note- these attendances must be agreed with Winthrop as part of discussions
with senior management

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 5.3 Plant & Equipment
Add an overview of the equipment that is to be used to carry out the work,
including inspection dates/expiration dates. Copies of test certificates must be
present at the workplace.
(Calibration records for the testers to be used)

5.4 Personal Protective & Emergency Equipment

Detail any specialist equipment or PPE that is required. Do not include the
standard site PPE of Safety helmet, safety boots, safety glasses, gloves, high
visibility vest.

6. SUBCONTRACTORS PROPOSED
Detail any specialist or third party contractor you propose. Please note the use of
third party contractors must be agreed in advance with Winthrop management.

7. EMERGENCY ARRANGEMENTS
Detail any emergency arrangements relevant to works that you will be carrying
out- i.e. spill response, fire, work at heights rescue etc.
(in case of a spill response – spill response training)

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 8. RISK ASSESSMENT MATRIX

Likelihood Severity

So unlikely that probability 1 Minor injury/illness/first aid resulting in 1

is close to zero lost time of three days or less. No residual
damage or health effect

Unlikely to occur, though 2 Injury illness causing lost time more than 2
conceivable three days, some residual damage

Likely to occur sometime 3 Major illness/injury to one or more 3

persons not causing permanent disability

Occurrence not surprising. 4 Major illness/injury causing permanent 4

May occur more than disability, long lasting residual effect
once

Occurrence very likely 5 Fatality 5

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 9. RISK ASSESSMENT & CONTROLS

Note: If Designated High Risk Activities (HRA) and the associated risks are included in the works
task, these should have a specific line-item reference in the risk assessment;
Please tick as appropriate the relevant hazards that will arise in the course of your works.

HAZARD HAZARD
YES/NO YES/NO
Materials/Manual Hazardous
handling Materials
Driving Work at heights

Lifting Operations Confined Spaces

Energy Isolation Electricity

Ground Disturbance Mobile Equipment

Hot Works Leak potential

Noise/Dust/Hygiene Cutting Operations

Works Scope Change Adjacent Services

Housekeeping Access/Egress

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 Task – Activity – Risk/possible At Risk Risk assessment Preventive measurements (controls) Risk assessment
Location- Hazard Effects (no controls) (with controls)

Lik Sev RR Lik Sev RR

(Insert new lines as appropriate)

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 10. ENVIRONMENTAL IMPACTS ASSESSMENT

Example of what the completed Environmental Aspects should possibly contain.

Prior to Controls After Controls
Probability Severity Probability Severity
Aspect Impact Risk Rating Company Controls / Comment Risk Rating
P(1-4) S(1-4) P(1-4) S(1-4)
(PxS) (PxS)
Increase in landfill sites due to increase Waste controls are dependent on site
in waste. This therefore leads to the requirements and space (i.e. not enough
takeover of land and reduced available space on all sites to segregate waste).
General Waste 4 2 8 2 2 4
living or farming availability. Only certified waste contractors are used
Inappropriate disposal may lead to to transport general waste
legislative non-compliance
Hazardous Ground & water contamination as a Waste controls are dependent on site
result of incorrect hazardous waste 4 3 12 requirements. 1 3 3
Waste &

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 disposal. Inappropriate disposal may Hazardous waste is stored safely and
lead to legislative non-compliance securely prior to collection (i.e.
fluorescent tubes are handled carefully
COSHH to ensure that they don't break and are
placed into a coffin prior to collection by
an approved, specialized contractor for
removal from site and disposal)
Contamination caused from leaks and Survey carried out to identify areas of
spillages that are allowed / left to soak concern, competent contractors used if
into the ground/water removal is required
Uncontrolled sediment release in the
Soil & Water
watercourses could affect the water 4 4 16 Preventative sediment traps etc. to be 1 4 4
pollution
quality used. Water to be treated prior to
released back into the river. Water
monitoring is to be carried. Spill control
measures are to be utilized.
Vehicle & Plant Ground / water / air pollution as a result Designated areas to park vehicles
use of spillages and releases from poorly identified by the client. Regularly inspect
maintained vehicles. Inappropriately and maintain vehicle(s) to prevent
parked vehicles may lead to restricted leakages. Reduce air emissions,
access for emergency services or wherever possible by encouraging
evacuation. Increased mileage and 4 4 16 telephone conference calls for meetings 1 4 4
driving resulting in increased fuel as opposed to travelling. The Irish
consumption and reduced air quality Government offer a 'Cycle To Work
Scheme' to all staff to encourage the
reduction of carbon emissions (air
pollution)
Disturbance to Disturbance of flora & fauna during 3 3 9 Identified primarily by client and survey 1 3 3
Flora & Fauna project activities. carried out if an issue arises during
Potential spillages of chemicals / fuel project. Competent contractors used if
from tools / plant used. Potential removal required
interaction with non-indigenous species

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 (such as Japanese Knotweed)
Air & Noise Degradation of local air quality from use 4 3 12 All plant and equipment is maintained or 1 3
Emissions of diesel plant hired with
Dust control – POM pollution issues appropriate certification, Local Exhaust
Ventilation (LEV) used as required

Noise – impacts on wildlife and Measures taken to prevent the dust

residents. Complaints. (watering grounds).

"Due to the environment in which the

3
organisation
operates, noise control is typically
limited to Personal Protective Equipment
(PPE), control of operation hours
(i.e. during daylight hours), acoustic
barriers if required, and the most up-to-
date tooling is used and regularly
inspected / maintained on site to ensure
they are operating safely and efficiently"

11. EMPLOYEE CONSULTATION

If the task cannot be completed as per the Method Statement, stop work immediately and contact your Supervisor and
Safety/Environmental person.  The task should be reviewed in an effort to find a resolution, and the method statement
should be reviewed, and SPA’s updated.

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 Instruction by Date of
Name Signature Company
(name) instruction

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