SWMS NO: ACTIVITY : REVIEW NO: DATE:
Authorised by: R Dusting © SafetyCulture All rights reserved Page 1- Version 7.0
Signature: Date:
SAFE WORK METHOD STATEMENT – Part 1
Company details
Company Name: VISCOUNT PROPERTY SOLUTIONS Contact Name, Position
and phone number:
Craig Kennedy Handyman/Operations
0422 276 266
ABN: 69 310 851 798
Address: 68-72 YORK ST SOUTH MELBOURNE 3205
Project details
Project: JLL 818 BOURKE Area: ALL AREAS
Job Address: 818 BOURKE ST DOCKLANDS
Job Description: SUPPLY TRADES AND HANDYMAN SERVICES
Activity:
Handyman Services
-
uilding
M
aintenance
-
general
This SWMS has been developed in consultation with: SWMS Approved by:
Name:
Signature:
Date:
Page 1 of 18
Name: Signature: Job Title: Date:
Craig Kennedy
Robert Dusting
Handyman/Operations
Senior manager OHS
27/7/2011
27/7/2011
Personnel responsible for monitoring and managing activity:
Craig Kennedy & Robert Dusting
Overall Risk Rating After
Controls
4 A
cute
3 H
igh
2 M
oderate
1 L
ow
ALL PERSONS INVOLVED IN TASK MUST HAVE THIS SWMS COMMUNICATED TO THEM PRIOR TO WORK COMMENCING
Regular inspections and observations will be conducted by Craig Kennedy to ensure SWMS is being complied with.
Daily Tool Box Talks will be undertaken to identify, control and communicate additional site hazards.
Work must cease immediately if incident or near miss occurs. SWMS must be amended in consultation with relevant persons.
Amendments must be approved by Robert Dusting and communicated to all affected workers before work resumes.
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Personal Protective Equipment
Green 204
Day Operations – Normal Requirements:
Safety footwear, hearing protection, high visibility shirt or vest, hard hat and sun protection if required eye/face protection (goggles) face
protection (shield), hand protection (gloves), overalls, breathing protection
Foot
Protection
Hearing
Protection
High
Visibility
Head
Protection
Eye
Protection
Face
Protection
Hand
Protection
Protective
Clothing
Breathing
Protection
Safety Notes
This SWMS deals with general hazards associated with building and property maintenance. Where tasks involve high risk work, such as
operation of machinery, falls risks of 2m or more, work in confined spaces, asbestos or lead paint removal, A/C gassing, etc, a site and task-
specific SWMS must be developed for that activity.
Main hazards:
- Exposure to hazardous atmosphere (asbestos, lead, chemicals)
- Exposure to biological contaminants
- Electric shock
- Manual handling
- Falls from height
- Fire/burns/welding flash
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Planning
Personal Injury:
- Exposure to
hazardous
atmosphere
- Fire /explosion
- Burns
- Exposure to
radiation
- Eye Injury
- Struck by moving
vehicle
- Manual Handling
- Electric shock
- Animal attack
- Physical or
verbal abuse/
violence
3H
Ensure all persons are qualified, licensed and adequately
trained to perform the tasks as required.
Ensure suitable lifting/transport equipment is provided.
Provide transport vehicle equipped with ramps/hydraulic
tailgate to allow safe removal of heavy materials as
required.
Ensure sufficient persons available for task.
Assess intended workplace. Gather information on the
following (if possible):
- Presence of potentially aggressive persons
- Dangerous animals
- Presence of asbestos
- Presence of lead/lead based paints
- Condition of electrical wiring
- Age of residence
- Maintenance condition
- Presence of biological contamination (waste, debris,
animal or human waste, syringes etc)
- Space to conduct work and access/egress points
- Existing lighting
- Disposal requirements for materials (example: lead
and asbestos containing materials)
If hazards are observed, ensure suitable risk controls are
implemented for type of hazard.
Ensure Material Safety Data Sheets are suitable (within 5
year issue date) and accessible for hazardous chemicals.
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Planning
-
continued
Personal Injury:
- Exposure to
hazardous
atmosphere
- Fire /explosion
- Burns
- Exposure to
radiation
- Eye Injury
- Struck by moving
vehicle
- Manual Handling
- Electric shock
- Animal attack
- Physical or
verbal abuse/
violence
3H
Liaise with client to determine whether:
- Excess clutter can be removed (if applicable)
- Any machinery is kept in a safe condition (not able to
be accidentally turned on, safety guards in place)
- Electrical devices, power-points, switchboards etc
are in a safe condition and RCD protected.
- Building security available when working alone,
especially at night.
Ensure equipment is suitable for task. Examples:
- Light weight vacuums (back pack or hip-mounted)
- Low-noise power equipment (hearing protection may
be required)
- Light-weight bucket/mops (with adjustable handle)
- Small sized equipment carts, well-maintained
- Small rubbish bins and bags
- Long handled tools with swiveling heads
- Step-ladders/ladders are industrial, sturdy and in
good condition
In consultation with employees,:
- Identify potentially hazardous manual handling tasks
- Conduct risk assessments for identified tasks, taking
into account postures, task duration, forces exerted,
environmental conditions and any previous injuries
reported from that task.
- Implement suitable controls
Ensure suitable communication procedures and equipment
provided (especially when working alone).
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Planning
-
continued
Personal Injury:
- Exposure to
hazardous
atmosphere
- Fire /explosion
- Burns
- Exposure to
radiation
- Eye Injury
- Struck by moving
vehicle
- Manual Handling
- Electric shock
- Animal attack
- Physical or
verbal abuse/
violence
3H
Develop and implement Hot Works Permit system. Include,
at least:
- Exact details of job
- Exact location
- Valid time/date
- Permit for each day required
- Equipment to be used
- Fire protection equipment available
- Responsible persons (including sign-off by suitably
trained persons)
- Work environment assessment
- Ventilation requirements
- Spotters (names, training etc) if required
- Name of all workers
- Gas testing equipment (if required)
- All safety precautions required
- A system to audit/monitor permits for completion.
Ensure:
- Appropriate equipment:
o Welding gear
o PPE (shield and/or respiratory protection)
o Screens
o Gas testing equipment (if required)
o Mechanical ventilation (if required)
o Flameproof/explosion proof rated electrical
equipment
o Communication equipment
o Non-synthetic barricading equipment and
signage (if required)
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Preparation
Personal Injury:
- Exposure to
hazardous
atmosphere
- Fire /explosion
- Burns
- Exposure to
radiation
- Eye Injury
- Struck by moving
vehicle
- Manual Handling
- Electric shock
- Animal attack
- Falls
3H
Ensure:
- Sufficient room for delivery of any materials
- Located away from traffic/vehicles/pedestrians
(develop appropriate traffic management plan if
required – include physical barriers, caution signs,
etc)
Ensure workers have access to:
- First aid kit/supplies
- Communication devices (check mobile phones will
have service in area)
- MSDS onsite (glues, paints, welding gases etc)
- Drinking water, clean-up and toilet facilities
- PPE as required
- Adequate lighting
- Sufficient clean air/ventilation.
Ensure water, gas, electricity is turned off to the property as
required and Lock Out /Tag Out procedures are followed.
Discuss with owner/resident beforehand so they are aware
of the duration of time required without utilities.
Ensure area is free of non-essential persons, pets and items
that may obstruct work or create hazards.
Assess suitable travel pathway to enter/exit residence when
carrying materials, ladders and other equipment.
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Preparation
-
continued
Personal Injury:
- Exposure to
hazardous
atmosphere
- Fire /explosion
- Burns
- Exposure to
radiation
- Eye Injury
- Struck by moving
vehicle
- Manual Handling
- Electric shock
- Animal attack
- Falls
3H
Ensure suitable equipment for job. Examples:
- Work at heights:
o Ensure scissor-lift or step platforms are used.
If ladders are only option, ensure they are
industrial, good condition, set-up correctly
and secured both top and bottom.
o Where a roof pitch exceeds 35 degrees, do
not stand on the roof. Work from a cherry
picker, scaffold or travel restraint system.
o If using travel restraint or fall arrestors,
ensure harness and clips are compatible,
anchor points have been assessed by
qualified persons, training undertaken and
emergency plan in place for rescue.
- Manual handling
o Use hand trucks, cable trolleys to move
materials (such as a/c units)
o Use smaller sized cable drums
- Hazardous Materials
o If cutting/drilling into structures, determine
material type. Provide suitable personal
protective equipment for short term works –
example:
o Non-Friable Asbestos: Protective clothing, P1
or P2 half face (can be either disposable or
cartridge)
o Silica: P1 or 2 half face with particle cartridge
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Preparation
-
continued
Personal Injury:
- Exposure to
hazardous
atmosphere
- Fire /explosion
- Burns
- Exposure to
radiation
- Eye Injury
- Struck by moving
vehicle
- Manual Handling
- Electric shock
- Animal attack
- Falls
3H
For Hot Works: Check:
- Confined Space (Note: Do not undertake Hot Works
in confined spaces unless Confined Space Entry
Permit and SWMS is followed)
- Ventilation requirements (indoor or outdoor). Provide
mechanical ventilation if required.
- Ensure not within 15m of:
o Grass/vegetation/timber and other
combustibles (if not practicable, grass can be
wetted sufficiently).
o Flammables storages
o Gas maintenance access points
o Storm water drains
o Rivers or sensitive environmental areas
o Pressure vessels and tanks (including
pipelines, flanges, vents and valves)
Check weather requirements. Do not conduct Hot Works in
high temperatures, high winds or on days of Total Fire Bans.
Ensure cylinders are fitted with correct flashback arresters.
Example:
- For hoses 3m or less, flashback arrestors fitted to
each gas line at the regulator outlet
- Hoses longer than 3m, two flashback arrestors fitted to
each gas line; one at the blowpipe connection and
one at the regulator outlet
Note: Incorrect flashback arresters can reduce flow
capacity, cause flame instability and increase risk of
flashback
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Preparation
-
continued
Personal Injury:
- Exposure to
hazardous
atmosphere
- Fire /explosion
- Burns
- Exposure to
radiation
- Eye Injury
- Struck by moving
vehicle
- Manual Handling
- Electric shock
- Animal attack
- Falls
3H
Ensure fire protection equipment provided and accessible:
- Dry Chemical or CO2 fire extinguishers in immediate
vicinity of cylinders (ensure fire extinguishers tested
and tagged).
Ensure appropriate PPE (cotton clothing, leather or welding
type gloves, goggles with side shields or welding mask with
filter lens as required for voltage used). Ensure Operator
does not have matches or a lighter on them
Note: PPE may include respirators depending on the type of
ventilation provided and materials to be welded. Some
alloys and coatings produce harmful fumes – ensure
Material Safety Data Sheets (MSDS) are obtained for fumes
and suitable PPE selected using MSDS.
Ensure all flammable materials (including waste, rags,
solvents, empty drums etc) are removed from area.
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Preparation
-
continued
Personal Injury:
- Exposure to
hazardous
atmosphere
- Fire /explosion
- Burns
- Exposure to
radiation
- Eye Injury
- Struck by moving
vehicle
- Manual Handling
- Electric shock
- Animal attack
- Falls
3H
Set up of portable ladders: Ensure:
- A set-up angle no greater than 4 in 1
- Flat ground (check manufacturer’s limits for side and
back slopes).
- Solid, stable base (free of oil, mess, leaf litter or
loose materials).
- Top of ladder projects 1m or more from landing point
- Secure/Tie top and bottom (ties should be attached
to stiles, not rungs. If ladder is used on a pole,
ensure strap or chain at top. Ensure 2
nd
person holds
ladder during tie-down process)
- If unable to tie, ensure 2
nd
person foots ladder.
- Not set-up within No Go zones of power lines
- Close to work area to prevent overreach
- No persons working underneath
- Not in doorways, or other areas where it could be
knocked over (if necessary, secure doors in open
position, and barricade/place signage)
- Not in close proximity to unprotected stairs, voids etc
A spreader board is used across top of stiles to
distribute load if ladder resting against weak, brittle
or plastic surfaces.
- Sufficient height to ensure person can reach working
area whilst remaining 900mm from top, or 2
nd
tread
or below from top plate of step ladder.
- No make-shift foundations (such as drums, boxes,
pallets, blocks etc) are used to gain height
- Step ladders and trestles are spread to fullest extent
– if in place, ensure locking mechanisms engaged
- Ladder is not close to live electrical wiring or against
operational piping (steam, sprinkler etc)
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Pre
-
Operational
Inspection
Personal Injury:
- Electric shock
- Falls
- Laceration
- Entanglement
- Fire / explosion
3H
Inspect all equipment.
Ensure:
- Power tools are in good condition and power cords
are not damaged or have exposed wires
- Guards in place
- Blades sharp and free of damage
-
Ladders:
If using ladders, ensure:
- Suitable type and height for task
- Footing is firm, stable and surrounding floor is free of
obstacles
- Ladder is undamaged, in good condition and rates
as industrial
- 3 points of contact
- Aluminium/metal ladders are not used for electrical
works
Ensure all electrical leads and equipment are
- Undamaged (inspect entire length of lead and plug)
- Tested and Tagged
- Safety switches (RCD’s) used
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Pre
-
Operational
Inspection -
continued
Personal Injury:
- Electric shock
- Falls
- Laceration
- Entanglement
- Fire / explosion
3H
Welder and equipment:
- Ensure cylinders are securely strapped to trolley
- Check for gas leaks (use bubble test) – apply soapy
water to valves and if bubbles appear – there is a
leak.
- Ensure no oil/grease on fittings.
- Suitable pressure, pressure valves functional
- Regulator maintained as required
- Correct colour and type of hoses. (Do not use
copper on acetylene lines – explosion risk)
- Hoses are free of damage and secured
- MSDS obtained for gas and possible contaminants
- Welding masks have suitable lens rating
- Gas detecting equipment (if used) calibrated,
working and batteries fully charged
- Fire protection equipment is within test date,
functional and accessible to intended location.
- Ensure screens are undamaged, sufficient size and
placed in a correct manner to prevent persons being
exposed to welding flash, hot sparks, slag etc.
If any equipment is damaged or unsuitable for the task do
not use. Take out of service immediately and apply LOTE
(Lock-Out / Tag-Out) procedures.
2M
Operation
Conduct work as required.
Ensure specific SWMS are developed for dealing with other
hazards (such as mould, lead and biological contaminants).
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Operation
-
continued
Personal Injury:
- Exposure to
hazardous
atmosphere
- Fire /explosion
- Burns
- Exposure to
radiation
- Manual Handling
- Electric shock
3H
Repair walls, wiring and plumbing as needed. Ensure
appropriate license (electrician or plumber) obtained as
required for relevant work activities.
Follow manufacturers’ instructions for installation of new
cabinets, flooring, windows, appliances etc.
Make use of power points in area. Use caution to avoid
tripping over extension cords.
Use power equipment as per manufacturer’s instructions
Ensure adequate ventilation for glues, silicon or welding and
painting.
Check for Reconnect services as required.
Clean area upon completion. Dispose of waste as agreed.
Ensure tasks are undertaken following manual handling risk
controls and using the equipment provided.
Ensure regular breaks are taken where employees can
stand up/stretch (especially if working in awkward/cramped
positions).
Position work between shoulder and knee height wherever
possible. Limit time spent on knees – use knee-pads.
Allow sufficient time for tasks.
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Operation
-
continued
Personal Injury:
- Exposure to
hazardous
atmosphere
- Fire /explosion
- Burns
- Exposure to
radiation
- Manual Handling
- Electric shock
3H
When using team lifts, they must be coordinated and
practiced. Ensure adequate communication and continue to
check for obstacles during lift. Move slowly.
Ensure employees are not required to work in awkward
positions when exerting force, or for more than 30 minutes
at a time, or 2 hours over entire shift. Implement controls,
such as job rotation for long duration tasks.
Ensure completed Hot Work Permit is available at site.
Ensure safe entry/exit is maintained. Barricade area as
needed. Ensure signage/barricading is positioned to prevent
persons entering area.
Follow safety precautions on Hot Work Permit.
Note: Do not conduct work that is not listed on Hot Work
Permit. If other Hot Works are required, obtain Hot Work
Permit for that task before commencement.
Monitor atmosphere if required – insufficient ventilation (stop
work immediately if gas levels reach 5% of UEL or LEL).
Note: UEL = Upper Explosive Limit. LEL = Lower Explosive
Limit).
Do not weld on coated materials, such as galvanized, lead,
or cadmium plated steel unless using airline respirators.
Check continuously for sparks or fire outbreak. Use Spotter
if required.
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Procedure
(in steps):
Possible Safety or
Environmental
Hazards
RB
Control Measures to Reduce risk
RA
Responsible
Officer
NOTE: RB
= Risk Rating
before
controls implemented -
RA
= Risk Rating
after
controls are implemented.
Clean
-
up and
Maintenance
Personal Injury:
- Exposure to
hazardous
atmosphere
- Fire /explosion
- Burns
- Exposure to
radiation
- Manual Handling
- Electric shock
3H
When complete:
- Shut off all equipment
- Check for sparks/smouldering
- Remove all scrap metal (use gloves), waste or
debris
Ensure all power to plant and equipment is isolated before
cleaning or repairs/maintenance.
Inspect all equipment for damage. If damage is detected,
follow Lock Out/Tag Out procedure and remove from
service.
If electrical components / fittings were damaged, do not turn
on power. Seek advice from qualified persons, such as a
licensed electrician.
Ensure all equipment is serviced/maintained as per
manufacturer’s instructions.
1L
Emergency
Procedures
Personal Injury:
- Fire /explosion
- Burns
- Manual Handling
- Electric shock
3H
Develop and implement an emergency response plan for
the site.
Include:
- Assembly points
- Communication
- Responsible persons
- Emergency contacts (including nearest medical
facility)
- Use of fire protection equipment
2M
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
References:
OHS Legislation in all States
WorkSafe Victoria Code of Practice for Manual Handling
AS/NZS 1716:2003 Respiratory protective device
WorkSafe Victoria – Compliance Code – Removing Asbestos in Workplaces
NOHSC:2018 (2005) – Code of Practice for Management and Control of Asbestos in Workplaces
Worksafe WA Department of Commerce (2008). Manual Handling and Plumbers (Water, Drainage, Gas, Sanitary and Maintenance).
AS/NZS 1892.1 – 1996 Portable ladders Part 1: Metal
AS 1892.2 – 1992 Portable ladders Part 2: Timber,
AS/NZS 1892.3 – 1996 Portable ladders Part 3: Reinforced plastic
AS/NZS 1892.5 – 2000 Portable ladders Part 5: Selection, safe use and care.
WorkSafe Victoria (2005). Prevention of Falls - Ladders
HSE (2005). Safe Use of Ladders and Step Ladders – An Employers Guide
ACT WorkCover (2007). Portable Ladders
WorkSafe Victoria – Prevention of falls – Working on roofs 2005
Safe Work Australia - National Code of Practice for the Prevention of Musculoskeletal Disorders Caused From Performing Manual Tasks
(2007)
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
SAFE WORK METHOD STATEMENT – Part 2
Personal Qualifications and Experience
required for the job:
Duties and Responsibilities of those
employees undertaking the task:
Training Required to Complete the Work:
(All employees must be trained in relevant procedures.)
No license required generally, however
operators must demonstrate competency.
Licenses may be required for particular
tasks. Example: Licensed plumber required
for plumbing work as defined by Plumbing
Regulations 2008.
Include:Task specific SWMS
- Traffic Management
- MSDS Instructions
- Emergency Procedures
- First Aid
- Dealing with potentially aggressive
people
- Use of Fire Protection Equipment
- Site induction
Details of regulatory permits/licenses
required:
Engineering Details/Certificates/WorkCover
Approvals:
Codes of Practice, Legislation:
Plant to comply with RTA requirements
PPE to comply with relevant Australian
Standards
Occupational Health and Safety Act
Occupational Health and Safety Regulations
Codes of practice
Plant/Tools/Equipment:
(List plant and equipment to be used on the job.)
Maintenance Details:
(Include maintenance on cranes, forklifts, electrical
equipment etc.)
SWMS NO: ACTIVITY : REVIEW NO: DATE:
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Signature: Date:
Employee Sign-off
This SWMS has been developed through consultation with employees. I have read the above SWMS and I understand its contents. I confirm that I
have the skills and training, including relevant certification to conduct the task as described. I agree to comply with safety requirements within this
SWMS including safe work instructions and Personal Protective Equipment described.
Name
Qualifications
Signature
Date
Time
Emp
loyer
Review No.
1
2
3
4
5
6
7
8
9
Name and
initials
Date