Intertek AIM Fall Protection Inspection Form

• Competent Person Performing Inspection

  Gerald Killian

  Mike Lamb

  Jeff Ridlehoover

  Greg Szanyi

• Facility

  Select 3M Champion Houston Campion Midland Cargill Chevron Cedar Bayou Chevron E&P Chevron Port Arthur Citgo Dow ExxonMobil Odessa Office HESS Ineos Oligmers Linde Gas Marathon GBR Momentive Norco Motiva Convent Motiva Norco Motiva Port Arthur Nuevo Oxy Oxy Oxyvinals Praxair Shell Deer Park Shell Geismar Shell E&P Shell Westhollow SUGS Valero Houston Valero Texas City Texas City Office

  • 3M
  • Champion Houston
  • Campion Midland
  • Cargill
  • Chevron Cedar Bayou
  • Chevron E&P
  • Chevron Port Arthur
  • Citgo
  • Dow
  • ExxonMobil
  • Odessa Office
  • HESS
  • Ineos Oligmers
  • Linde Gas
  • Marathon GBR
  • Momentive Norco
  • Motiva Convent
  • Motiva Norco
  • Motiva Port Arthur
  • Nuevo
  • Oxy
  • Oxy
  • Oxyvinals
  • Praxair
  • Shell Deer Park
  • Shell Geismar
  • Shell E&P
  • Shell Westhollow
  • SUGS
  • Valero Houston
  • Valero Texas City
  • Texas City Office

• Conducted on

  Date

• Equipment Issued To:

1. Harness

• Was Harness Inspected?

  Yes

  No

• Enter serial number

• Enter manufacture date

• Webbing not cut?

  OK

  Not OK

• Webbing not frayed?

  OK

  Not OK

• Webbing has no abrasions?

  OK

  Not OK

• Webbing stitching not damaged?

  OK

  Not OK

• Webbing has no chemical exposure?

  OK

  Not OK

• Webbing has no sun damage?

  OK

  Not OK

• Hardware not deformed?

  OK

  Not OK

• Hardware has no corrosion or rust?

  OK

  Not OK

• Hardware has no chemical exposure?

  OK

  Not OK

2. Lanyard

• Was Lanyard Inspected?

  Yes

  No

• Enter serial number

• Enter manufacture date

• Webbing not cut?

  OK

  Not OK

• Webbing not frayed?

  OK

  Not OK

• Webbing has no abrasions?

  OK

  Not OK

• Webbing stitching not damaged?

  OK

  Not OK

• Webbing has no chemical exposure?

  OK

  Not OK

• Webbing has no sun damage?

  OK

  Not OK

• Hardware not deformed?

  OK

  Not OK

• Hardware has no corrosion or rust?

  OK

  Not OK

• Hardware has no chemical exposure?

  OK

  Not OK

• Double latch hook present?

  OK

  Not OK

• Gate operates correctly?

  OK

  Not OK

• Double lock operates correctly?

  OK

  Not OK

3. SRL

• Was SRL Inspected?

  Yes

  No

• Enter serial number

• Enter manufacture date

• Webbing not cut?

  OK

  Not OK

• Webbing not frayed?

  OK

  Not OK

• Webbing has no abrasions?

  OK

  Not OK

• Webbing stitching not damaged?

  OK

  Not OK

• Webbing has no chemical exposure?

  OK

  Not OK

• Webbing has no sun damage?

  OK

  Not OK

• Hardware not deformed?

  OK

  Not OK

• Hardware has no corrosion or rust?

  OK

  Not OK

• Hardware has no chemical exposure?

  OK

  Not OK

• Double latch hook present?

  OK

  Not OK

• Gate operates correctly?

  OK

  Not OK

• Double lock operates correctly?

  OK

  Not OK

4. Extension

• Was Extension Inspected?

  Yes

  No

• Enter serial number

• Enter manufacture date

• Extension is not deformed?

  OK

  Not OK

• Extension not frayed?

  OK

  Not OK

• Webbing stitching not damaged?

  OK

  Not OK

• Webbing has no chemical exposure?

  OK

  Not OK

• Webbing has no sun damage?

  OK

  Not OK

• Hardware has no corrosion or rust?

  OK

  Not OK

• Hardware has no chemical exposure?

  OK

  Not OK

5. Comments

• Enter comments