Test update 1020

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?:
Selected:
Yes
Available options were:
Yes No
Choose the controls for dropped objects and access to work area:
0 selecteds of 12 items
Tool tethers
Materials stored away from leading edge and fall hazards
Materials secured to structure
Small materials stored in buckets
Debris netting
Exclusion zones below &/or at access
Signage and locked doors (when possible) at all entry points to exclusion zone
Coordinate with Prime contractor
Spotter(s)
Hard hat tether
Mobile phone/ radio tether
Rope/ cable to secure large items
Other tool/ material controls:
N/A
Are there power lines near your work area?:
Selected:
Yes
Available options were:
Yes No
Warning LOA:
When there is potential for you to enter the limit of approach during the arresting of a fall and when there is potential for any of your tools or materials to enter the LOA - you will need an additional procedure created and followed.
Confirm Voltage and controls:
No selection made
Available options:
Limit of approach will be confirmed using 30M33 documents

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:
Selected:
Yes
Available options were:
Yes No
How will you control the fall hazard that is present while you access the work area?:
No selection made
Available options:
A procedure for 1st person up will be used Personal fall protection system will be connected to prior to access A tag line will be used to allow connection from lower surface Other
Are there floor openings that you could fall in?:
Selected:
Yes
Available options were:
Yes No
How will you control the floor/ roof openings?:
No selection made
Available options:
A suitable cover will be secured to floor opening Guardrails will be added around the floor opening Barrier tape will be added around floor opening with a buffer zone
Is the work surface a steep slope (8/12 +)?:
Selected:
Yes
Available options were:
Yes No
How will you control the steep slope hazard?:
No selection made
Available options:
Use roof strapping Use toe boards Use work positing line and fall protection line
Is the lower surface less than 18’ below anchor point?:
Selected:
Yes
Available options were:
Yes No
How will you control the low clearance?:
No selection made
Available options:
Personal fall protection system will be restraint only Fall arrest system will be a retractable device
Are there any other hazards?:
N/A

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

Are you working from a ladder?:
Selected:
Yes
Available options were:
Yes No
Ladder safety confirmation - check to confirm:
0 selecteds of 5 items
Pre-use inspection ladder
Short duration work
Access ladders secured
Tools/ materials hauled up or in bag/ pouch
Trained and will practice ladder safety
Are you working from a mobile elevated work platform?:
Selected:
Yes
Available options were:
Yes No
Mobile elevated work platform safety confirmation - check to confirm:
0 selecteds of 4 items
Pre-use inspection of equipment and work area
Competent operator
Fall restraint for boom lift – see site rules for scissor lift
If near leading edge a curb (25% of tire diameter) added
Are you working from a scaffold?:
Selected:
Yes
Available options were:
Yes No
Scaffold safety confirmation - check to confirm:
0 selecteds of 5 items
Pre-use inspection completed
All edges are controlled with guardrails (wall side up to 12” gap)
Erected by a competent person following manufacturers instructions
Safe access
Engineered when required
Are you working from a swing stage?:
Selected:
Yes
Available options were:
Yes No
Swing stage safety confirmation - check to confrim:
0 selecteds of 10 items
Workers will connect to an independent personal fall protection system prior to accessing stage
Lifelines will reach within 4’ of safe lower access point
Pre-use inspection of stage
Competent operators
If over 300' - need for engineered confirmation of meeting CSA
Check wind forecast - 40 KPH is suggested max.
Confirm max/ load and adhere to it
Roof plan
Rigging plan
Safe Job Procedure
Are you working from a bosuns chair?:
Selected:
Yes
Available options were:
Yes No
Bosun chair safety confirmation - check to confirm:
0 selecteds of 3 items
A Bosun chair workplan is available
Workers will connect to an independent personal fall protection system prior to accessing chair
Competent operator
Are you using rope access?:
Selected:
Yes
Available options were:
Yes No
Rope access safety confirmation - check to confirm:
0 selecteds of 2 items
A rope access plan is available
Workers are certified in rope access
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, I will also use other controls
Available options were:
Yes – 100% of time including access to the work area Yes, I will also use other controls No
Guardrails not 100% - why:
N/A
Are you able to work in fall restraint – a tight line stops you from falling over the edge?:
Selected:
Yes, but not all the time
Available options were:
Yes – 100% of the time restraint and/ or guardrails Yes, but not all the time No
Restraint not 100% - explain why:
N/A
Will you be working in fall arrest – a line stops you from hitting the ground?:
Selected:
Yes – and I will use administrative controls as well
Available options were:
Yes – and I will use administrative controls as well Yes, when I/we cannot work in fall restraint - I will not use administrative controls No
Swing Fall Hazard Warning:
When you use a fall arrest system consider the hazards of swinging when your system stops you. Look at what you could swing into - best practice is to limit swing fall to less than 25 degrees
Will you be using a procedure or administrative controls (raised warning line, barriers other than guardrails):
No selection made
Available options:
Yes - 100% of the time Yes - when I/we cannot work in fall arrest or fall restraint No

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

Components needed:
Based on the controls - the following components/ permits and/or tools will be part of your fall protection systems.
Step by step:
Do not proceed until you have reviewed and understand the manufacturer instructions. These step by step are in additional to them.
Exclusion zone items needed:
0 selecteds of 8 items
Calculation for size of drop cone
Coordination with Prime Contractor
QRsafety.com leading edge permit
Signs
Barricade tape or rope
Procedure for training spotters
Effective communication (radio/ whistle)
Flashlight
Exclusion zone step by step:
0 selecteds of 7 items
Post sign at entrance to fall hazard areas – “Authorized Personnel” only or similar
Lock access door, remove access ladder or block accesses
Review this plan with anyone who enters the area that has the fall hazard
Post this plan for anyone to see
Add a sketch to this plan that shows the outline of work area, fall hazard(s), path to work area and distance to maintain between from hazard(s)
Erect a highly visible raised warning line or barriers with a minimum 6.5’ buffer zone
Confirm with anyone who uses this plan that they are not to get within 6.5’ of any leading edge unless using personal fall protection
Fall Protection anchor item(s) needed:
0 selecteds of 6 items
Cast in web anchor strap
Choked around structure web or cable anchor strap
Bolt down anchor
Beam slider
Door/window jamb anchor
Re-usable concrete anchor
Are there any other anchors you will be using?:
No selection made
Available options:
Yes No
Harness options needed:
0 selecteds of 6 items
Basic single D ring - class A
Side D rings for work positioning - class P
Shoulder D rings for confined space - class E
Site saddle for extended work positioning
Sternum D ring - class L
Arc resistant - class R
Will you be using a rope grab?:
Selected:
Yes
Available options were:
Yes No
Warning for Rope Grabs:
To be in compliance, you will need to either have a rope grab with integral (permanently attached) 30" lanyard (CSA) or a separate lanyard max. 36" (ANSI)
Will you be using a vertical lifeline?:
Selected:
Yes
Available options were:
Yes No
Vertical lifeline step by step:
0 selecteds of 7 items
Inspect equipment
Don your harness
Connect lifeline to anchor then lower lifeline down work area - add and secure softener if required
In a safe zone, connect rope grab to lifeline, ensure arrow is pointed up towards the anchor, connect lanyard to rope grab – complete tug test
Complete buddy system check
Test equipment to ensure that it is in good working order
Always maintain rope grab above your back D ring and avoid swing fall hazard
Will you be using an energy absorbing lanyard?:
Selected:
Yes
Available options were:
Yes No
Will you be using a horizontal lifeline?:
Selected:
Yes
Available options were:
Yes No
Horizontal lifeline step by step:
0 selecteds of 5 items
Have engineering or have manufacturers system with instructions
Confirm total fall clearance stops worker to before hitting lower surface
Confirm anchorage is strong enough and allows a horizontal force
Confirm connecting components are accepted by mfg. or engineer
Follow mfg. instructions and/ or engineering
Will you be using work positioning?:
Selected:
No
Available options were:
Yes No
Will you be using a self retracting device (SRL/ SRD/ YOYO)?:
Selected:
Yes
Available options were:
Yes No
SRD step by step:
0 selecteds of 9 items
Inspect equipment
Don your harness
Connect device to the back D-Ring on the harness. Complete tug test.
Select an anchorage location with minimal free fall and swing fall hazards.
Select an appropriate anchorage point
Connect connecting device to anchorage
Complete buddy system check
Tug test system to confirm it is all connected and locking
If for restraint - edge is further away then SRD max length

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

Do you want to add any photos:
Selected:
Yes
Available options were:
Yes No
File Upload:
N/A
File Upload:
N/A
File Upload:
N/A

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

Do you want to upload any files:
Selected:
Yes
Available options were:
Yes No
File Upload:
N/A
File Upload:
N/A
File Upload:
N/A

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:
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
These components will be inspected before use:
0 selecteds of 8 items
Anchorage (the structure)
Anchor (connects to structure)
Lifeline
Self retracting device
Rope Grab
Lanyard
Carabiners/ connectors
Tool tethers
Also - After a break these components will be inspected.:
0 selecteds of 8 items
Anchorage connection to anchor
Lifeline connection to anchorage
Self retracting device connection to anchorage
Rope grab connection to lifeline
Buddy check on harness
Lanyard connection
Exclusion zone set up
Guardrail system
SRD - Type 2 or 3 self retracting devices will have routine inspections:
0 selecteds of 2 items
CSA authorized person within date range
Manufacturer required within date range

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.
We will use Worker self rescue first:
Selected:
Yes
Available options were:
Yes No
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
We will use Worker assisted rescue when self rescue cannot be used:
Selected:
Yes
Available options were:
Yes No
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
We will use DEP box rescue - only choose if a DEP box and crane is on site - when self or assisted rescue are not possible:
Selected:
Yes
Available options were:
Yes No
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
We will use MEWP (scissor or boom) rescue when one is available and worker is conscious:
Selected:
Yes
Available options were:
Yes No
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
We will use a rope rescue system - only choose if there is a system available:
Selected:
Yes
Available options were:
Yes No
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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