Title Page
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Site conducted
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Date and time
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Task
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Conducted on
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Prepared by
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Location
Fall Protection System / Equipment
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1. Has the working at heights permit been issued i.e. all persons have read<br>and signed onto permit?
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2. Is the team’s fall protection equipment safe for use? E.g. harness,<br>lanyards, connectors, safety latches, shock absorbers, retractable lanyards<br>etc
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3. Is the team’s fall protection equipment appropriate for the task? E.g.<br>inspected, type, load rating, fitment.
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4. Is the anchor point safe for use and appropriate for the task? E.g. load<br>rated, certified, inspected.
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5. Can the rescue plan be executed in a timely manner? i.e. team<br>understand their role, communication devices working, rescue equipment<br>available.
Open Edge Protection
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6. Is there appropriate edge protection in place to prevent falls? E.g.<br>railings, hard barricading, horizontal life lines, rat lines, windrows and berms<br>(pit environments only)
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7. Are edge protection devices safe for use? E.g. maintained and inspected
Platforms, Ladders & Scaffolding
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8. Is the platform/ladder/scaffold appropriate for the task? E.g. load rated,<br>certified, inspected, tagged.
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9. Is the platform/ladder/scaffold safe for use? E.g. no missing / loose floor<br>or grating panels, secured handrails, midrails and toe boards, self closing<br>gates etc.
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10. Is the platform/ladder/scaffold positioned in a safe location? E.g. on<br>stable ground, suitable foundations, secure to prevent movement and<br>protected from impact by moving equipment?
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11. Is the team using platforms and ladders appropriately?
Mobile Work Platforms (MWPs)
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12. Is the mobile work platform (MWP) appropriate for the task?
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13. Are all those in the basket correctly secured to the approved anchor<br>point?
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14. Are team members within the basket at all times? i.e. not leaning over<br>handrails or stepping on midrails or accessing the structure from the basket.
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15. Is the MWP safe for use? i.e. inspected with no defects.
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16. Are weather conditions suitable for safe use? E.g. lightening, wind speed<br>taken into consideration.
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17. Has the work environment in all areas of use (including travel) been<br>inspected for hazards? E.g. overhead and underground hazards, uneven<br>terrain.
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18. Is there a competent operator (e.g. spotter) on the ground to provide<br>emergency action if required?<br>
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19. Is an entrapment protection device fitted? E.g. secondary guarding or<br>pressure sensing device?
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20. Is the team protected from being hit by moving vehicles/equipment?<br>E.g. positioning, clear area, barricading, signage.
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