DWM Equipment Fall Protection Checklist

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• Person(s) Conducting:

Full Body Harness Checklist/Log

• Full Body Harness Model: Manufacture/Lot Date: Serial Number: Purchase Date:

• Hardware:<br>(Includes D-rings, buckles, keepers, & back pads)<br>Inspect for damage, distortion, sharp edges, burrs, cracks, & corrosion

  Safe

  At Risk

  N/A

• Webbing:<br>Inspect for cuts, burns, tears, abrasion, frays, excessive soiling, & discoloration

  Safe

  At Risk

  N/A

• Stitching:<br>Inspect for pulled or cut stitches

  Safe

  At Risk

  N/A

• Labels:<br>Make certain all labels are securely held in place & legible

  Safe

  At Risk

  N/A

• Other:<br>Please describe below

  Safe

  At Risk

  N/A

• undefined

Lanyards Inspection Checklist/Log

• Lanyard Model: Manufacture/Lot Date: Serial Number: Purchase Date:

• Hardware:<br>(Includes D-rings, buckles, keepers, & back pads)<br>Inspect for damage, distortion, sharp edges, burrs, cracks, & corrosion

  Safe

  At Risk

  N/A

• Webbing:<br>Inspect for cuts, burns, tears, abrasion, frays, excessive soiling, & discoloration

  Safe

  At Risk

  N/A

• Stitching:<br>Inspect for pulled or cut stitches

  Safe

  At Risk

  N/A

• Synthetic Rope:<br>Inspect for pulled or cut yarns, burns, abrasion, knots, excessive soiling & discoloration

  Safe

  At Risk

  N/A

• Wire Rope:<br>Inspect for broken wires, corrosion, kinks, & separation of strands

  Safe

  At Risk

  N/A

• Energy Absorbing Component:<br>Inspect for elongation, tears, & excessive soiling

  Safe

  At Risk

  N/A

• Labels:<br>Make certain all labels are securely held in place & legible

  Safe

  At Risk

  N/A

• Other:<br>Please describe below

  Safe

  At Risk

  N/A

• undefined

Hooks/Carabiners Inspection Checklist/Log

• Hook/Carabiner Model: Manufacture/Lot Date: Serial Number: Purchase Date:

• Hardware:<br>(Includes D-rings, buckles, keepers, & back pads)<br>Inspect for damage, distortion, sharp edges, burrs, cracks, & corrosion

  Safe

  At Risk

  N/A

• Webbing:<br>Inspect for cuts, burns, tears, abrasion, frays, excessive soiling, & discoloration

  Safe

  At Risk

  N/A

• Stitching:<br>Inspect for pulled or cut stitches

  Safe

  At Risk

  N/A

• Labels:<br>Make certain all labels are securely held in place & legible

  Safe

  At Risk

  N/A

• Other:<br>Please describe below

  Safe

  At Risk

  N/A

• undefined

Tie-Off Adaptors/Anchorage Plates Inspection Checklist/Log

• Tie-Off Adaptor/Anchorage Plate Model: Manufacture/Lot Date: Serial Number: Purchase Date:

• Physical Damage:<br>Inspect for cracks, sharp edges, burns, deformities, & locking operation

  Safe

  At Risk

  N/A

• Excessive Corrosion:<br>Inspect for corrosion which effects the operation &/or strength

  Safe

  At Risk

  N/A

• Fasteners:<br>Inspect for corrosion, tightness damage & distortion. If welded, inspect weld for corrosion, cracks & damage

  Safe

  At Risk

  N/A

• Markings:<br>Make certain marking(s) are legible

  Safe

  At Risk

  N/A

• Other:<br>Please describe below

  Safe

  At Risk

  N/A

• undefined

Self Retracting Lifelines Inspection Checklist/Log

• Self Retracting Lifeline Model: Manufacture/Lot Date: Serial Number: Purchase Date:

• Impact Indicator:<br>Inspect indicator for activation (rupture of red stitching, elongated, etc.)

  Safe

  At Risk

  N/A

• Screws/Fasteners:<br>Inspect for damage & make certain all screws & fasteners are tight

  Safe

  At Risk

  N/A

• Housing:<br>Inspect for distortion, cracks & other damage. Inspect anchoring loop for distortion & damage

  Safe

  At Risk

  N/A

• Lifeline:<br>Inspect for cuts, burns, tears, abrasion, frays, excessive soiling & discoloration, broken wires

  Safe

  At Risk

  N/A

• Locking Action:<br>Inspect for proper lock-up of brake mechanism

  Safe

  At Risk

  N/A

• Retraction/Extension:<br>Inspect spring tension by pulling lifeline out fully and allowing it to retract fully (no slack)

  Safe

  At Risk

  N/A

• Hooks/Carabiners:<br>Inspect for physical damage, corrosion, proper operation markings (see separate checklist/log for hooks & carabiners)

  Safe

  At Risk

  N/A

• Reserve Lifeline: <br>Inspect reserve lifeline retention systems for deployment

  Safe

  At Risk

  N/A

• Labels:<br>Make certain all labels are securely held in place & legible

  Safe

  At Risk

  N/A

• If all that applies has been completed please sign:

  Sign