Title Page
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Fall Protection equipment shall be visually inspected before each use. This form is intended for the additional Semi-Annual inspections
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Conducted on
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Conducted by
Project: i5 North Coast Corridor Job #: 3179
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Fall Arrest Systems Inspecting
Equipment
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Select Equipment Type
HARDWARE (D-rings, buckles, keepers, connections) INSPECT FOR: damage, distortion, sharp edges, burrs, cracks & corrosion
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The D-ring shall pivot freely in the back pad, and plastic back pad shall be free of any cracks or other damage. Check for distortion, cracks, rust, corrosion, weld splatter, and sharp edges.
Tongue / Grommet Buckles - Buckle tongues shall be free of distortion in shape and motion and be free of sharp edges. Tongues shall overlap the buckle frame and move freely on the frame. Inspect for loose, distorted, or broken grommets. The webbing shall not have any additional holes made in it.
Friction and Matting Buckles - Inspect the buckle for distortion paying close attention to corners and attachment points of the center bar. The outer bars and center bars shall be straight. -
Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
WEBBING INSPECT FOR: burns, damage, distortion, sharp edges, burrs, cracks & corrosion
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Inspect webbing for damaged fibers or cuts. Heat damage will appear as brownish smears or smudges and chemical damage will result in a change of color and a loss of elasticity. If webbing strands are fused together or have hard shiny spots the webbing integrity has been compromised Paint or solvents can cause chemical damage that restricts fiber movement.
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
STITCHING INSPECT FOR: damage, distortion, sharp edges, burrs, cracks & Corrosion
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
LABELS INSPECT FOR: damage, distortion, sharp edges, burrs and legibility
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
OTHER WEAR INSPECT FOR: Sun rot, epoxy and oil splash
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
MANUFACTURE DATE: INSPECT FOR: Harness must be less than 5 years old
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
HARDWARE: (Snaphooks, carabiners, adjusters, keepers, thimbles, and D-rings) INSPECT FOR: damage, distortion, sharp edges, burrs, cracks, corrosion, proper orientation and locking
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
WEBBING INSPECT FOR: cuts, burns, tears, abrasions, frays, excessive soiling, and discoloration
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
STITCHING INSPECT FOR: pulled or cut stitches
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
SYNTHETIC ROPE INSPECT FOR: pulled or cut yarns, burns, abrasions, knots, excessive soiling, and discoloration
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
ENERGY ABSORBING COMPONENT INSPECT FOR: elongation, tears, cuts, burns, frays, excessive soiling, and discoloration
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
LABELS INSPECT FOR: all labels are securely held in place and are legible, verify activation tag is intact
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
OTHER WEAR INSPECT FOR: Sun rot, epoxy and oil splash
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
MANUFACTURED DATE: INSPECT FOR: Lanyards to be less than 5 years old
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
IMPACT INDICATOR INSPECT FOR: activation (rupture of red stitching, elongated indicator, etc.)
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
SCREWS/FASTENERS INSPECT FOR: damage and make certain all screws and fasteners are tight
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
HOUSING INSPECT FOR: distortion, cracks and other damage. Inspect anchoring loop for distortion or damage
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
LANYARD/LIFELINE INSPECT FOR: birdcages, broken wires, bent cables, cuts, burns, tears, abrasion, frays, excessive soiling and discoloration (See impact indicator section)
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
LOCKING ACTION: INSPECT FOR: proper lock-up of brake mechanism
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
RETRACTION/EXTENSION INSPECT FOR: spring tension by pulling lanyard out fully and allowing to retract fully (lifeline must be taut with no slack)
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
HOOKS/CARABINERS INSPECT FOR: twisting, physical damage, corrosion, proper orientation, markings, and proper locking.
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
LABELS INSPECT FOR: all labels are securely held in place and are legible
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
HARDWARE: (D-rings and pins) INSPECT FOR: damage, distortion, burrs, cracks, and corrosion
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
BOOM SLIDE INSPECT FOR: cracks, distortion, damage, corrosion, and twisting
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
ADJUSTABLE BEAM INSPECT FOR: cracks, twisting, corrosion, and damage
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
TAGS INSPECT FOR: Legibility
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
MANUFACTURED DATE: INSPECT FOR: Beam Walkers to be less than 5 years old
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Accepted / Rejected. (If Rejected, remove from Service)
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Supportive Detail/Comments
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Model / Name:
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Serial Number:
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Lot Number:
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Name of User
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Date of Manufacture
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Date of Purchase:
Certification
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Accepted / Rejected. (If Rejected, remove from Service)
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Add signature
