Site Specific Fall Protection Plan - DUPLICATE - Instance 753

Filled for Category: Site Specific Fall Protection Plan version 3 (Form)
Site: Form Creator | Employer: We the Safe Inc.
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Template Updated about 1 month ago

Creation details

Disclaimer:
This QRsafety.com Smart Form is a series of questions that should be answered prior to working at heights. The questions may not identify every hazard for your task and location. The form is to be completed by a qualified person that can identify all hazards and add any that are missing.
This Smart Form has fields that will be hidden if they are not relevant to the work, as determined by your hazard assessment answers.
The completed Site Specific Fall Protection plan may be a part of the total solution however is not to be the only part of it. Users use it at their own risk.
Date:
N/A
Creators contact info - add additional rows if needed:
No data entered

Workplace location/ contact details

Location:
No data entered
Location cont.:
No data entered
Supervisor info - add additional rows if needed:
No data entered

Work area details

What type of structure/ work area? :
N/A
What location is the work taking place (level/ side etc.)?:
N/A
What type of work (ex. window washing)?:
N/A

Hazards (basic) with standard controls

Definition Hazard:
Anything that could harm a worker or the public. Think of your work and location - what could happen to hurt workers or public
Definition Control:
Steps/ actions taken to eliminate or decrease the risk of the hazards identified above. NOTE - best practice and regulations require controls to be chosen following a hierarchy with elimination being the first.
Can a worker fall to lower surface from leading edges, roof, shafts, openings, doorways etc..?:
No selection made
Available options:
Yes No
Is it possible to drop tools/ materials or have workers/ public enter your work area and be exposed to a fall hazard?:
No selection made
Available options:
Yes No
Are there power lines near your work area?:
No selection made
Available options:
Yes No

Hazards (task Specific) with control checklist added when chosen

Is there a fall hazard during access to the work area? - example: needing to climb a roof to connect to anchor:
No selection made
Available options:
Yes No
Are there floor openings that you could fall in?:
No selection made
Available options:
Yes No
Is the work surface a steep slope (8/12 +)?:
No selection made
Available options:
Yes No
Is the lower surface less than 18’ below anchor point?:
No selection made
Available options:
Yes No
Are there any other hazards?:
N/A

Hazards (ladders and work platforms) with control checklist when chosen

Are you working from a ladder?:
No selection made
Available options:
Yes No
Are you working from a mobile elevated work platform?:
No selection made
Available options:
Yes No
Are you working from a scaffold?:
No selection made
Available options:
Yes No
Are you working from a swing stage?:
No selection made
Available options:
Yes No
Are you working from a bosuns chair?:
No selection made
Available options:
Yes No
Are you using rope access?:
No selection made
Available options:
Yes No
Are there any other work platforms you are using?:
N/A

Controls - Personal Fall Protection system and administrative

Are you to able work in an area with guardrails controlling fall hazards? note - swing stage guardrails require a back up fall arrest system :
Selected:
Yes – 100% of time including access to the work area
Available options were:
Yes – 100% of time including access to the work area Yes, I will also use other controls No

Equipment list and system step by step set up- will be empty when not applicable

Step by step:
Do not proceed until you have reviewed and understand the manufacturer instructions. These step by step are in additional to them.

Photos - add photos that will help users understand the hazards and controls

Do you want to add any photos:
No selection made
Available options:
Yes No

Drawings - add any that will help users understand the hazards and controls

Do you want to upload any files:
No selection made
Available options:
Yes No

Inspections

Pre-use and routine inspections:
The checked items will be inspected following the manufacturer instructions and at intervals checked to confirm set up is correct.
Guardrail inspections - before use 2:
0 selecteds of 5 items
No gaps large enough to pass through
Top rail 40-44
Posts securing rails on narrow side
125 pounds strength horizontally - does not pass over edge with force
If manufactured system - consult instructions

Rescue

Rescue types:
The following rescue techniques will be used in a hierarchy approach with self rescue being the first choice.
Fall Restraint rescue:
In a fall restraint system you cannot fall therefore rescue will not require work at heights. Follow standard injury/ first aid procedures.
Administrative controls - rescue:
Administrative controls do not allow a worker to get within 6.5' of a fall hazard. Rescue will be standard injury/ first aid procedures.
Rescue types:
By choosing a scenario, the step by step instructions will be added to this plan.
Choose as many as needed.
They are listed in a hierarchy or difficulty.
Self Step by step:
a. Stay calm – let everyone know the system has worked and you are safe.
b. Look at yourself – are you injured. If so wait for help
c. Look at your system – has it been damaged? If so wait for help
d. If you can pull yourself back onto a work platform, floor, roof, structure without risking another fall – do so
e. Once back on the surface adjust your rope grab or your retractable device to remove any slack
f. Travel to a safe area
g. Disconnect system and notify your supervisor
h. Remove your entire fall protection system from service/ tag it
i. Notify owner of the anchor, if not your employer, and have it tagged/ removed from service
j. Participate in the incident investigation
Assisted Step by step:
a. Stay calm – let everyone know the system has worked and they are safe.
b. Notify your supervisor
c. Look at the fallen worker – are they injured. If so call first aid.
d. Look at the fallen workers fall protection system. Is it damaged from arresting the fall. If so, gather and deploy a back up fall protection system.
e. Make a note of the time the worker fell
f. If at anytime the worker gets groggy or becomes unconscious call your supervisor and 911
g. Prior to helping the fallen worker set yourself up in a fall protection system – restraint if possible
h. If you can reach out and grasp the fallen workers hand or harness, do so. Pull the worker into the structure
i. If needed have a rope and toss it to the fallen worker while the rescuer holds the other end – pull worker close when possible
j. In some cases you will need a short ladder or work platform for the worker to stand on and allow them to get slack on their rope grab or to reset their retractable. If this is required ensure the ladder/ work platform is tethered to structure, is held stable by the rescuer and the rescuer maintains hold of the fallen worker until they are able to stand on the surface.
k. Travel to a safe area
l. Disconnect system and notify your supervisor
m. Remove your entire fall protection system from service/ tag it
DEP Step by step:
a. Stay calm – let everyone know the system has worked and they are safe.
b. Notify your supervisor and with their direction notify the Prime Contractor.
c. Look at the fallen worker – are they injured. If so call first aid.
d. Look at the fallen workers fall protection system. Is it damaged from arresting the fall. If so, gather and deploy a back up fall protection system.
e. Make a note of the time the worker fell
f. If at anytime the worker gets groggy or becomes unconscious call your supervisor and 911
g. Follow the direction of the Prime Contractor – or if you are the Prime Contractor follow your procedure for DEP box rescue.
h. Remove your entire fall protection system from service/ tag it
i. Notify owner of the anchor, if not your employer, and have it tagged/ removed from service
j. Participate in the incident investigation
MEWP Step by step - for conscious workers:
NOTE - This plan requires a safe place to operate the MEWP that provides save access to the worker.
a. Stay calm – let everyone know the system has worked and they are safe.
b. Notify your supervisor and with their direction notify the Prime Contractor.
c. Look at the fallen worker – are they injured. If so call first aid.
d. Look at the fallen workers fall protection system. Is it damaged from arresting the fall. If so, gather and deploy a back up fall protection system.
e. Make a note of the time the worker fell
f. If at anytime the worker gets groggy or becomes unconscious call your supervisor and 911
g. Have qualified operator complete pre-use inspeciton of machine
h. Confirm the maximum load of the MEWP. Default to operator and the patient if you cannot confirm.
I. Place lift close to suspended worker. Using a second lanyard, connect to the workers back D ring.
J. Adjust MEWP location as required. When in best location connect the other end of fallen workers new lanyard onto the identified anchor of the MEWP.
K. Help worker gain access to the lift
L. When worker is in MEWP and connected to the MEWP - disconnect the fall pro system that stopped the fall.
M. Lower worker to safe area
h. Remove used fall protection system from service/ tag it
i. Notify owner of the anchor, if not your employer, and have it tagged/ removed from service
j. Participate in the incident investigation
Kit step by step:
a. Stay calm – let everyone know the system has worked and they are safe.
b. Notify your supervisor and with their direction notify the Prime Contractor.
c. Look at the fallen worker – are they injured. If so call first aid.
d. Look at the fallen workers fall protection system. Is it damaged from arresting the fall. If so, gather and deploy a back up fall protection system.
e. Make a note of the time the worker fell
f. If at anytime the worker gets groggy or becomes unconscious call your supervisor and 911
g. Follow your procedure for rescue using the specific rescue system
Notice - WSBC and emergency services:
NOTE 1– prior to considering emergency services your only rescue provider an assessment following requirements in WSBC Guidelines 14.3(1) must be completed and emergency services notified.
Note 2 - When doing short duration suspended work you should also consider the “Notice of Rescue Service for Short-term Work” found in section 4.13 of the WSBC guidelines - https://www.worksafebc.com/en/law-policy/occupational-health-safety/searchable-ohs-regulation/ohs-guidelines/guidelines-part-04#SectionNumber:G4.13_1

Notes from any section

Add any additional notes in this area:
N/A

Workers sign off

Signatures:
Choose the workers who will review this Site Specific Fall Protection Plan. A copy of this completed from will be added to each workers profile for future reference.
Worker Sign-offs:

No workers assigned to this form.

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