WTSFP102125

Filled for Category: Site Specific Fall Protection Plan version 3 (Form)
Site: Form Creator | Employer: We the Safe Inc.
Form Completed
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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:

2025-10-21

Creators contact info - add additional rows if needed:
This plan creators name Email Phone
Mr. Class — —

Workplace location/ contact details

Location:
Project/ Building name Prime Contactor/ Owner
BldA ABC Inc
Location cont.:
Address of work
6969-666 Salem
Supervisor info - add additional rows if needed:
Supervisor(s) name - add rows for each Supervisor phone #
Hank the Tank —

Work area details

What type of structure/ work area? :

High rise residential building

What location is the work taking place (level/ side etc.)?:

Bld A SW corner 8th floor to 12 floor.

What type of work (ex. window washing)?:

refer to SWP k9 666

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..?:
Selected:
Yes
Available options were:
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:
7 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:
No
Available options were:
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:
Selected:
No
Available options were:
Yes No
Are there floor openings that you could fall in?:
Selected:
No
Available options were:
Yes No
Is the work surface a steep slope (8/12 +)?:
Selected:
No
Available options were:
Yes No
Is the lower surface less than 18’ below anchor point?:
Selected:
Yes
Available options were:
Yes No
How will you control the low clearance?:
Selected:
Fall arrest system will be a retractable device
Available options were:
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:
No
Available options were:
Yes No
Are you working from a mobile elevated work platform?:
Selected:
No
Available options were:
Yes No
Are you working from a scaffold?:
Selected:
No
Available options were:
Yes No
Are you working from a swing stage?:
Selected:
No
Available options were:
Yes No
Are you working from a bosuns chair?:
Selected:
No
Available options were:
Yes No
Are you using rope access?:
Selected:
No
Available options were:
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:
No
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:

leading edge work

Are you able to work in fall restraint – a tight line stops you from falling over the edge?:
Selected:
Yes – 100% of the time restraint and/ or guardrails
Available options were:
Yes – 100% of the time restraint and/ or guardrails Yes, but not all the time 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:
6 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:
6 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:
1 selected 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?:
Selected:
No
Available options were:
Yes No
Harness options needed:
1 selected 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:
No
Available options were:
Yes No
Will you be using a vertical lifeline?:
Selected:
No
Available options were:
Yes No
Will you be using an energy absorbing lanyard?:
Selected:
No
Available options were:
Yes No
Will you be using a horizontal lifeline?:
Selected:
No
Available options were:
Yes No
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:
9 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:
No
Available options were:
Yes No

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

Do you want to upload any files:
Selected:
No
Available options were:
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.
These components will be inspected before use:
5 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.:
4 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:
2 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:
No
Available options were:
Yes No
We will use a rope rescue system - only choose if there is a system available:
Selected:
No
Available options were:
Yes No
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:
Supervisor signs to confirm it has been reviewed by workers - attach an additional sign off sheet if needed
Signature:
Signature for Signature