FALL HAZARD ASSESSMENT

• Facility

  Select

• Workcenter

• Location
  Address

• Equipment Identification and/or Identification number

• Competent Person completing assessment

• Conducted on

  Date

PART II: HAZARD IDENTIFICATION

• Task or reason for accessing area?

  Select Inspection Maintenance Repair Testing

  • Inspection
  • Maintenance
  • Repair
  • Testing

• Brief Description of task being performed:

• Distance to Edge:

• What is the method of access

  Select Stairs Fixed Ladder Portable Ladder Portable Stairs Maintenance Stand Other (specify

  • Stairs
  • Fixed Ladder
  • Portable Ladder
  • Portable Stairs
  • Maintenance Stand
  • Other (specify

• Specify other means of access

• Is access point within 15’ of an unprotected edge?

  Yes

  No

  N/A

• Could the worker approach within 15’ foot of an unprotected edge?

  Yes

  No

  N/A

• Does the task expose workers to a fall 4’ or more feet?

  Yes

  No

  N/A

• Other Identified Hazards

  Select Low Light Slippery Surfaces Sloping Surfaces Trip Hazards Protruding Objects Unstable Surfaces/Footing Exposure to High Winds Floor Openings Skylights Other

  • Low Light
  • Slippery Surfaces
  • Sloping Surfaces
  • Trip Hazards
  • Protruding Objects
  • Unstable Surfaces/Footing
  • Exposure to High Winds
  • Floor Openings
  • Skylights
  • Other

• Specify Other Hazards

PART III: HEIRCHY OF CONTROL

• Select method to control fall Hazard

  Select Military Unique Operations Elimination: (Can the work be relocated to a non-fall hazard area?) Passive Measures: (Can engineering controls be put in place?) Fall Restraint Systems: (Can positioning systems be used to restrict range of movement to prevent fall?) Fall Restraint Systems: (Can personal fall arrest systems be used to stop a fall after it occurs?) Other (Supervisory, designated work area, ect.)

  • Military Unique Operations
  • Elimination: (Can the work be relocated to a non-fall hazard area?)
  • Passive Measures: (Can engineering controls be put in place?)
  • Fall Restraint Systems: (Can positioning systems be used to restrict range of movement to prevent fall?)
  • Fall Restraint Systems: (Can personal fall arrest systems be used to stop a fall after it occurs?)
  • Other (Supervisory, designated work area, ect.)

• Contact Wing Safety Office for assistance in mitigating the hazard(s)

• Comment/Description

• Comment/Description

• Comment/Description

• Comment/Description

• Comment/Description

• Fall Height:

• Fall Arrest Stopping Distance: *Stopping Distance must be less than Fall Height

PART IV: WORK AREA DIAGRAM

• *Facilities with certified roof anchors must maintain copies of the inspection report and certification documents

• Upload picture or diagram of work area, identify access point

  Media

• Risk Management Instructions: Use the above risk assessment Matrix to determine the Overall Risk. Use the additional information to determine the overall placement in the Fall Hazard Survey Report

  Yes

  No

  N/A

PART V: RISK ASSESSMENT:

• 

• Duration of the Task:

• Frequency of the Task:

• Number of personnel exposed to fall hazard:

• History of Mishaps:

  Yes

  No

  N/A

• Risk Level:

  Select Very Low Risk Low Risk Moderate Risk Substantial Risk High Risk Very High Risk

  • Very Low Risk
  • Low Risk
  • Moderate Risk
  • Substantial Risk
  • High Risk
  • Very High Risk

• Yes

  No

  N/A

• Occupational Safety:

  Sign

• Workcenter Supervisor:

  Sign