2. Fall Protection Equipment Inspection

• Fall Protection Equipment being Inspected

• Conducted on

  Date

• Department/Location

• Prepared by

• Serial #

• Model #

• Manufacturer

• Equipment Owner

• DOM:

• In Service Date

• Photo of Equipment

  Media

Labels

• Attached and Readable

  Yes

  No

  N/A

• Damaged

  No

  Yes

  N/A

Impact Indicator

• Damaged

  No

  Yes

  N/A

• Deployed

  No

  Yes

  N/A

Shock Absorber

• Cuts, Tears, Adration

  No

  Yes

  N/A

• Deployed, Stretched, Elongated

  No

  Yes

  N/A

• Plastic cover missing

  No

  Yes

  N/A

• Holes, burns

  No

  Yes

  N/A

• UV Damage, fading

  No

  Yes

  N/A

• Excessive soiling

  No

  Yes

  N/A

Stitching

• Cuts

  No

  Yes

  N/A

• Broken

  No

  Yes

  N/A

• Burned

  No

  Yes

  N/A

• Missing stitch patterns

  No

  Yes

  N/A

Webbing

• Frayed

  No

  Yes

  N/A

• Cuts, Tearing, holes

  No

  Yes

  N/A

• Burns

  No

  Yes

  N/A

• Knots

  No

  Yes

  N/A

• UV Damage

  No

  Yes

  N/A

• Discoloration

  No

  Yes

  N/A

• Paint

  No

  Yes

  N/A

• Grease/Grime

  No

  Yes

  N/A

• Missing/Damaged stitch pattern

  No

  Yes

  N/A

• Abrasion

  No

  Yes

  N/A

• Heat damage/glazing

  No

  Yes

  N/A

• Mold

  No

  Yes

  N/A

Connectors/Snap Hooks

• Labelled/Marked

  Yes

  No

  N/A

• Sharp edges

  No

  Yes

  N/A

• Missing parts

  No

  Yes

  N/A

• Cracked

  No

  Yes

  N/A

• Welded

  No

  Yes

  N/A

• Corroded

  No

  Yes

  N/A

• Sticky gates

  No

  Yes

  N/A

• Stays open, won’t lock

  No

  Yes

  N/A

• Excessive dirt, grease

  No

  Yes

  N/A

• Close but don’t lock

  No

  Yes

  N/A

• Bent

  No

  Yes

  N/A

• Single action (no locking gate)

  No

  Yes

  N/A

Wire rope

• Kinked

  No

  Yes

  N/A

• Heat damaged

  No

  Yes

  N/A

• Missing, damaged thimble

  No

  Yes

  N/A

• Corrosion

  No

  Yes

  N/A

• Broken wire strands

  No

  Yes

  N/A

• Seperation of strands

  No

  Yes

  N/A

• Distorted

  No

  Yes

  N/A

• Abraded wires

  No

  Yes

  N/A

• Bird caging

  No

  Yes

  N/A

Rope

• Spliced, loose, coming out

  No

  Yes

  N/A

• Thimble loose/missing

  No

  Yes

  N/A

• Inner core damage

  No

  Yes

  N/A

• Fraying

  No

  Yes

  N/A

• Cuts, pulls on fibers

  No

  Yes

  N/A

• Burns

  No

  Yes

  N/A

• Knots

  No

  Yes

  N/A

• Heat damage/Glazing

  No

  Yes

  N/A

• Bird caging

  No

  Yes

  N/A

• Discoloration

  No

  Yes

  N/A

• Dirt, grease

  No

  Yes

  N/A

• Stretched, kinked

  No

  Yes

  N/A

• 5 Pull tucks on rope splice

  No

  Yes

  N/A

• Paint, rust, stain

  No

  Yes

  N/A

Final Appraisal

• Fall Protection Status PASS/FAIL

  PASS

  FAIL

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