Working at height PPE Inspection

Inspection conducted by David Jalbert

• Document No.

• Conducted on

  Date
• Location
  Address

User Identification

• 

• Employee name?

  Select Bakker, Luke Balesdent, Dana Brinton, Daniel Burns, Cody Carpenter, Jim Daigneault, Eric De Lafontaine, Alain Dube, Kevin Duhaime, Pierre Fortier, Martin Garson, Kevin Gyorgy, Szilard Hooper, Nathan Hunt, Cohen Monteith, Wesley George Murray, William Roy Nadj, Robert Rauth, Jason Rider, Michael Rider, Eric Sproule, Ryan Yakaback, Drake Gilroy, John Glenn Drew Chenier, Zacharie Malouin, Pierre Drew, Glenn

  • Bakker, Luke
  • Balesdent, Dana
  • Brinton, Daniel
  • Burns, Cody
  • Carpenter, Jim
  • Daigneault, Eric
  • De Lafontaine, Alain
  • Dube, Kevin
  • Duhaime, Pierre
  • Fortier, Martin
  • Garson, Kevin
  • Gyorgy, Szilard
  • Hooper, Nathan
  • Hunt, Cohen
  • Monteith, Wesley George
  • Murray, William Roy
  • Nadj, Robert
  • Rauth, Jason
  • Rider, Michael
  • Rider, Eric
  • Sproule, Ryan
  • Yakaback, Drake
  • Gilroy, John
  • Glenn Drew
  • Chenier, Zacharie
  • Malouin, Pierre
  • Drew, Glenn

• Work location

  Chatham, On

  Ottawa, On

  Casselman, On

  Waterloo, On

• Known product history
  It is the responsibility of the PPE user to inform the inspector about any conditions of use or exceptional event during use (examples: falling or stopping a fall, use or storage at extreme temperatures, modification out of manufacturer's workshops, etc.).

• has your equipment been involved in a fall or do you have any other information to disclose that could affect the effective use of your working at height PPE?

  Yes

  No

• Please describe?

Harness

• 

• Is there a harness to inspect?

  Yes

  No

• Manufacturer

• Model #

• Serial #

• Year of Manufacture

• Date of first use

  Date

Legend: (G) Good working condition (M) To monitor (A) Action to take prior to use (R) Do not use, Remove (NA) Non applicable

• Manufacturer label, CSA logo and all readable

  (G)

  (M)

  (A)

  (R)

  (NA)

• Impact indicators (Z stitches, D-ring pad)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Chest D-Ring

  (G)

  (M)

  (A)

  (R)

  (NA)

• Dorsal D-Ring

  (G)

  (M)

  (A)

  (R)

  (NA)

• Shoulder D-Rings (left and right)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Waist D-Rings (left and right)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Chest buckle

  (G)

  (M)

  (A)

  (R)

  (NA)

• Waist buckle

  (G)

  (M)

  (A)

  (R)

  (NA)

• Leg tongue buckle (left and right)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Sit strap (holding both leg strap in the back)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Stitches

  (G)

  (M)

  (A)

  (R)

  (NA)

• Nylon straps, webbing

  (G)

  (M)

  (A)

  (R)

  (NA)

• General condition

  (G)

  (M)

  (A)

  (R)

  (NA)

• I declare that this harness is:

  Select Fit to stay in service Unfit and must be remove Need to have corrective measures before going back in service

  • Fit to stay in service
  • Unfit and must be remove
  • Need to have corrective measures before going back in service

Double leg landyard

• 

• Is there a double leg landyard to inspect?

  Yes

  No

• Manufacturer

• Model #

• Serial #

• Year of Manufacture

• Date of first use

  Date

Legend: (G) Good working condition (M) To monitor (A) Action to take prior to use (R) Do not use, Remove (NA) Non applicable

• Manufacturer label, CSA logo and all readable

  (G)

  (M)

  (A)

  (R)

  (NA)

• Shock absorber

  (G)

  (M)

  (A)

  (R)

  (NA)

• Lenght (size to be compare to size on label)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Connectors (Self closing & locking) *verify closing gap

  (G)

  (M)

  (A)

  (R)

  (NA)

• Connectors (Corrosion, rivets, if any distortion)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Stitches

  (G)

  (M)

  (A)

  (R)

  (NA)

• Nylon straps

  (G)

  (M)

  (A)

  (R)

  (NA)

• General condition

  (G)

  (M)

  (A)

  (R)

  (NA)

• I declare that this double leg land yard is:

  Select Fit to stay in service Unfit and must be remove Need to have corrective measures before going back in service

  • Fit to stay in service
  • Unfit and must be remove
  • Need to have corrective measures before going back in service

Rail Slider

• 

• Is there a rail slider to inspect?

  Yes

  No

• Manufacturer

• Model #

• Serial #

• Year of Manufacture

• Date of first use

  Date

Legend: (G) Good working condition (M) To monitor (A) Action to take prior to use (R) Do not use, Remove (NA) Non applicable

• Manufacturer label, CSA logo and all readable

  (G)

  (M)

  (A)

  (R)

  (NA)

• Body (Corrosion, bolt, if any distortion)

  (G)

  (M)

  (A)

  (R)

  (NA)

• General condition

  (G)

  (M)

  (A)

  (R)

  (NA)

• I declare that this rail slider is:

  Select Fit to stay in service Unfit and must be remove Need to have corrective measures before going back in service

  • Fit to stay in service
  • Unfit and must be remove
  • Need to have corrective measures before going back in service

Personal fall limiter (PFL)

• 

• Is there a PFL to inspect?

  Yes

  No

• Manufacturer

• Model #

• Serial #

• Year of Manufacture

• Date of first use

  Date

Legend: (G) Good working condition (M) To monitor (A) Action to take prior to use (R) Do not use, Remove (NA) Non applicable

• Manufacturer label, CSA logo and all readable

  (G)

  (M)

  (A)

  (R)

  (NA)

• Carabiner (Self closing & locking)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Attachment point

  (G)

  (M)

  (A)

  (R)

  (NA)

• Housing (evidence of any damage, nuts/bolts/rivets/screws (if any))

  (G)

  (M)

  (A)

  (R)

  (NA)

• Lifeline (locking when pulled)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Lifeline (Cuts, fraying, broken stitches)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Shock pack (Shrink tube, Damage, fraying, stitches or any sign of deployment)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Connectors (Self closing & locking) *verify closing gap

  (G)

  (M)

  (A)

  (R)

  (NA)

• Connectors (Corrosion, rivets, if any distortion)

  (G)

  (M)

  (A)

  (R)

  (NA)

• General condition

  (G)

  (M)

  (A)

  (R)

  (NA)

• I declare that this PFL is:

  Select Fit to stay in service Unfit and must be remove Need to have corrective measures before going back in service

  • Fit to stay in service
  • Unfit and must be remove
  • Need to have corrective measures before going back in service

Pole climber Rope positioning

• 

• Is there a Pole climber to inspect?

  Yes

  No

• Manufacturer

• Model #

• Serial #

• Year of Manufacture

• Date of first use

  Date

Legend: (G) Good working condition (M) To monitor (A) Action to take prior to use (R) Do not use, Remove (NA) Non applicable

• Manufacturer label, CSA logo and all readable

  (G)

  (M)

  (A)

  (R)

  (NA)

• Carabiner at end (Self closing & locking)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Carabiner on slider (Self closing & locking)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Stitched rope end on carabiner (stitch, splice or swage)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Stitched rope end at other end (stitch, splice or swage)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Rope adjuster (CSA logo, direction arrow, evidence of any damage, nuts/bolts/rivets/screws (if any))

  (G)

  (M)

  (A)

  (R)

  (NA)

• Rope adjuster (locking as intended)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Rope (General condition and cleanliness)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Rope (Check for bump, soft or hard spot, cuts, burn, discoloration)

  (G)

  (M)

  (A)

  (R)

  (NA)

• Abrasion resistant sleeve (General condition)

  (G)

  (M)

  (A)

  (R)

  (NA)

• I declare that this rope positioning is:

  Select Fit to stay in service Unfit and must be remove Need to have corrective measures before going back in service

  • Fit to stay in service
  • Unfit and must be remove
  • Need to have corrective measures before going back in service

Sure climb slider

• 

• Is there a Sure climb slider to inspect?

  Yes

  No

• Manufacturer

• Model #

• Serial #

• Year of manifacture

• Date of first use

  Date

Legend: (G) Good working condition (M) To monitor (A) Action to take prior to use (R) Do not use, Remove (NA) Non applicable

• Identification, CSA logo and all readable

  (G)

  (M)

  (A)

  (R)

  (NA)

• locking mecanism

  (G)

  (M)

  (A)

  (R)

  (NA)

• Body (Corrosion, bolt, if any distortion)

  (G)

  (M)

  (A)

  (R)

  (NA)

• General working order and condition

  (G)

  (M)

  (A)

  (R)

  (NA)

• I declare that this sure climb slider is:

  Select Fit to stay in service Unfit and must be remove Need to have corrective measures before going back in service

  • Fit to stay in service
  • Unfit and must be remove
  • Need to have corrective measures before going back in service

Other equipment not listed

• Is there any other equipment to inspect?

  Yes

  No

• Any equipment that is not listed before to be added here

Working at height equipment

• What type of equipment

• Manufacturer

• Model #

• Serial #

• Year of Manufacture

• Date of first use

  Date

Legend: (G) Good working condition (M) To monitor (A) Action to take prior to use (R) Do not use, Remove (NA) Non applicable

• Add inspection details

Inspection details

• undefined

• (G)

  (M)

  (A)

  (R)

  (NA)

• I declare that this equipment is:

  Select Fit to stay in service Unfit and must be remove Need to have corrective measures before going back in service

  • Fit to stay in service
  • Unfit and must be remove
  • Need to have corrective measures before going back in service

Acknowledgment

Corrective action (If any corrective action is to be taken, add here)

• Equipment and model #

• What are the corrective measure to be taken

• Employee to ensure corrective measure are taken

  Select Bakker, Luke Balesdent, Dana Brinton, Daniel Burns, Cody Carpenter, Jim Daigneault, Eric De Lafontaine, Alain Dube, Kevin Duhaime, Pierre Fortier, Martin Garson, Kevin Gyorgy, Szilard Hooper, Nathan Hunt, Cohen Monteith, Wesley George Murray, William Roy Nadj, Robert Rauth, Jason Rider, Michael Rider, Eric Sproule, Ryan Yakaback, Drake Gilroy, John Glenn Drew Chenier, Zacharie Malouin, Pierre Drew, Glenn

  • Bakker, Luke
  • Balesdent, Dana
  • Brinton, Daniel
  • Burns, Cody
  • Carpenter, Jim
  • Daigneault, Eric
  • De Lafontaine, Alain
  • Dube, Kevin
  • Duhaime, Pierre
  • Fortier, Martin
  • Garson, Kevin
  • Gyorgy, Szilard
  • Hooper, Nathan
  • Hunt, Cohen
  • Monteith, Wesley George
  • Murray, William Roy
  • Nadj, Robert
  • Rauth, Jason
  • Rider, Michael
  • Rider, Eric
  • Sproule, Ryan
  • Yakaback, Drake
  • Gilroy, John
  • Glenn Drew
  • Chenier, Zacharie
  • Malouin, Pierre
  • Drew, Glenn

• By when?

  Date

• Does the equipment need another inspection prior to be use?

  Yes

  No

• I, undersigned, certify that the inspection was done in accordance with CSA standard Z25910-12.

• David Jalbert

  Sign

• I, undersigned, declare that I will not use any equipment that are to be remove from service following this inspection result.

• Add signature

  Sign