Fall Protection Plan

• Conducted on:

  Date

• Building Name:

• Building Address:
  Address

• City:

Description of tasks to be done:

• Task:

Fall Protection Plan

• Identify all existing & potential fall hazards associated with the task activity.

• Potential to fall from heights

  No

  Yes

  N/A

• Can materials be dropped from height into a high traffic area

  No

  Yes

  N/A

• Can ropes be sheared

  No

  Yes

  N/A

• Can ropes slide

  No

  Yes

  N/A

• Additional Fall Hazards

Hazard

• Hazards:

Identify the fall protection systems to be used at the work site to protect workers from the fall hazard (i.e. travel restraint, personal fall arrest system, safety net, control zone, etc)

• Fall Protection System to be Used:

• Anchors:

  Engineered

  Improvised

Clearance Distance(s) to be Confirmed

• L = Initial Length of lanyard, energy absorber and connecting hardware
  B = Height of D-ring measured from the worker’s feet
  C = Distance between anchor point and unguarded edge
  EAE = Energy absorber extension (typically 4 feet)
  DS = D-ring slippage (typically 1 foot)
  SM = Safety margin (typically 2 feet)

• Free Fall Distance (FFD = L + B - C):

• Total Fall Distance (TFD = FFD + DS + EAE):

• Clearance Distance (CD = TFD + B + SM)

• Clearance distance is ≤ to the obstruction below

  Yes

  No

  N/A

Describe the procedures that will be followed if a worker falls and needs to be rescued.

• Identify the Safe Work Practice and/or Safe Job Procedure developed for the task.

  Select 3.4 Rope Access - Safe Work Practice 3.5 Rope Access - Safe Job Procedure 3.17 Working Near Ungaurded Edges - Safe Working Practice 3.18 Working Near Ungaurded Edges - Safe Job Procedure 3.35 Eavestroughing - Safe Work Practice 3.36 Eavestroughing - Safe Job Procedure

  • 3.4 Rope Access - Safe Work Practice
  • 3.5 Rope Access - Safe Job Procedure
  • 3.17 Working Near Ungaurded Edges - Safe Working Practice
  • 3.18 Working Near Ungaurded Edges - Safe Job Procedure
  • 3.35 Eavestroughing - Safe Work Practice
  • 3.36 Eavestroughing - Safe Job Procedure

• Identify Emergency Response Procedures:

  Select 10.14.1 Ladder Rescue 10.14.2 Boom Lift Rescue Tower Rescue From Descent Tower Rescue From Lowering System

  • 10.14.1 Ladder Rescue
  • 10.14.2 Boom Lift Rescue
  • Tower Rescue From Descent
  • Tower Rescue From Lowering System

• I hereby certify that all information is accurate and that an actual inspection was conducted.

• Crew Manager's Printed Name & Signature

  Sign

• Worker's Printed Name & Signature

Worker

• Worker:

  Sign