Fall Protection Plan

Work Site

Job Number*

Describe work to be done

Fall Hazards - Identify all existing and potential fall hazards associated with the work site (i.e. edges, openings, guardrails, slips and trips, doors, stairways, scaffolds, roof, other equipment, ground conditions)

Fall Protection Systems to be used - Identify the fall protection systems to be used at the work site to protect workers from fall hazards (i.e. travel restraint, personal fall arrest systems, safety net, control zone, guardrails)

Anchors to be used during work - Identify the anchors, both engineered and improvised, that workers are to use (i.e. manufacturer identified anchor points, point on roof)

Procedures - Identify detailed procedures to assemble, inspect, use, maintain, and dismantle fall protection systems identified above (i.e. manufacturer's information, inspection checklists, PSI's, work site conditions, travel area)

Rescue Plan - Describe the procedures that will be followed if a worker falls and needs to be rescued (i.e. location of rescue equipment, suspension of trauma straps, other manlifts/zoom boom, communication available, 911)

Fall Protection Plan Acknowledgement

Workers must be trained in the safe use of fall protection equipment and the procedures they must follow to ensure their personal safety while using this equipment. This training must include procedures to assemble, maintain, inspect, use, and dissassemble the fall protection systems in use. Workers expected to rescue a workers who has fallen and is suspended by a fall protection system must be trained in rescue procedures.

Reference OHS Legislation Code Part 9

Workers signing this form acknowledge that they have reviewed and understand this fall protection plan.

Name

First NameLast Name

Date

MonthDayYear

Signature

Name

First NameLast Name

Signature

Name

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Signature

Name

First NameLast Name

Signature

Name

First NameLast Name

Signature

Workers Trained and Informed:

Have all workers been trained in the safe use of the fall protection equipment?

YesNo

Have all workers been made aware of this plan?

YesNo

Supervisor Name

First NameLast Name

Date

MonthDayYear

Supervisor Signature

Clearance Distances to be Confirmed - Clearance distance must be sufficient to prevent a worker from striking the ground, an objects, or level below the area.

L = Initial length or lanyard, energy absorber, and connecting hardware

B = Height of D-ring measured from the workers feet

C = Distance between anchor point and unguarded edge

EAE Energy Absorber Extension

DS = D-ring slippage (typically 1 foot)

SM = Safety margin (typically 3 feet)

Step 1 - Free Fall Distance (FFD) / FFD = L + B(5) - C

Step 2 - Total Fall Distance (TFD) / TFD = FFD + DS(1) + SAE(4)

Step 3 - Clearance Distance (CD) / CD = TFD + B(5) + SM(3)

Distance to lower level or any other obstruction below

Is clearance distance sufficient

YesNo

Free Fall Distance (FFD)
The free fall distance (FFD) equals the distances between the heights of the D-ring before the fall begins to the point where the fall protection equipment begins to arrest fall.

Total Fall Distance (TFD)
Total fall distance (TFD) is defined as the vertical distance from the point at which a worker falls, to the point where the fall stops after all falls, to the point where the fall stops after all fall arresting system components have extended.

Fall Clearance Distance (CD)
The minimum fall clearance is a total of the TFD plus the distance from the surface to the D-ring (D-ring to the workers feet) before the fall, plus a safety margin of at least 0.6m (2') or 0.9m (3').

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