Free Fall Protection Plan Template

Fall Protection Work Plan
1
Company Name: _________________________________________________________________________
Jobsite Name & Address: __________________________________________________________________
Job Task: _______________________________________________________________________________
Supervisors Ensure: Workers must review and sign this fall protection work plan prior to starting work in an
area where a hazard of falling exists. Workers must understand this plan and be trained in fall protection and the
systems and equipment that will be used. This plan must be posted at the worksite for the duration of the work
activities. This plan must be used in conjunction with a comprehensive and effective Fall Protection Program. Add
additional pages as necessary.
Effective period for plan:

(dd/mm/yy) ________________________________ a (dd/mm/yy)_____________________________________
(From) (To)
Job Location/Description:
1. Identify Potential Fall Hazards
o Elevating work platforms (boom operated) o Scaffold erection/ dismantling

o Excavations o Stairways
o Floor openings/ skylights o Swing Fall
o Skeletal framing o Wall opening
o Hazardous processes/ equipment o Reinforcing steel installation
o Ladders (fixed or portable) o Other (Identify)
2. Describe the hazard(s) including specific dimensions, locations, levels, etc.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. Identify Fall Protection Systems to be used
o Guard rails o Fall arrest

o Fall restraint o Control zone with monitor
o Procedures o Safety net
o Work Platform o Catch platform
o Self propelled elevated work platform o Other (identify)
o Scaffold o Other (identify)
Rev. June 2010
T 604.733.4682 / 1.888.229.1455 www.actsafe.ca

F 604.733.4692
E [email protected]
2 Fall Protection Work Plan
4. Describe the procedures for handling, storing and securing tools and materials
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
5. Identify the method of providing protection for workers who may be in or pass through the area below the over-
head work activity
o Barricading o Toe boards/ screens on scaffolds

o Hard hats required o Toe boards/ covers on floor openings
o Catch net o Other (identify)
o Warning signs o Other (identify)
6. Identify the method for prompt, safe removal of injured workers
o Written agreement with: o Self-rescue (Training Documentation)

(Identify Fire Department and attach agreement) o Site First Aid
o Other employees of employer (Training Documentation)
o Elevators/ stairs o Other (Identify)
7. Identify the method used to determine the adequacy of anchorage points
o Evaluation by a professional engineer o Existing engineering/ design documents

o Manufacturers data o Other (identify)
8. Describe and identify locations of anchorage points
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
9. Name of project site safety and health representative:______________________________________________
10. Name of Safety Monitor if control zone used:____________________________________________________
11. Name of person(s) trained to work under this plan:_______________________________________________
© 2010 Actsafe. All rights reserved. Actsafe encourages the copying, reproduction, and distribution of this document to promote health and safety in the workplace, provided that
SHAPE is acknowledged. However, no part of this publication may be copied, reproduced, or distributed for profit or other commercial enterprise,
nor may any part be incorporated into any other publication, without written permission of Actsafe.
Fall Protection Work Plan
3
12. Select System Components
o Full body harness o Choker

o Vertical lifeline o Carabineer
o Horizontal lifeline o Rope Grab
o Lanyard o Personal shock absorber
o Boatswains chair o Beamer
o Connecting Devices (identify) o Anchorage points (identify)

13. Identify maximum free fall distance:__________________________________________________________
14. Identify total fall distance:__________________________________________________________________
15. Describe the procedures for the assembly, maintenance, inspection and disassembly of the fall protection
system to be used
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
16. Inspection checklist
o Identification tags
o Horizontal lifeline tension is correct
o Integrity of stitching in shock absorber
o Integrity of stitching in harness/ belt/ lanyard
o Manufacturer’s assembly/ disassembly instructions
o Locking capability of retractable lanyards assured
o Locking capability of carabineers assured
o Locking capability of snap hooks assured
o Knots and other connection methods do not weaken lifeline
o Lifelines installed and used under supervision of competent person and protected from cuts or abrasions
o Rope (wear, fraying, damage, mildew)
o Lanyard (wear, fraying, damage, mildew)
o Dee-rings have adequate strength, are not cracked or deformed
o Guardrails are sound and of adequate strength
o Devices are used to connect to horizontal lifelines lock in both directions
o Anchorage points provide adequate strength and are capable of meeting regulated strength requirements
o Safety monitor is competent, can see all workers, is close enough to communicate, has no other duties
o Warning lines are adequately marked and are at appropriate distance from fall hazard
o Hole covers are secured, marked and capable of withstanding anticipated weight loads
o Other (identify):
Rev. June 2010
o Other (identify):
Note: This publication does not replace the Occupational Health and Safety Regulation administered by the WorkSafeBC. Employers and workers should always refer to the Regulation
for specific requirements that apply to their activities.

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Fall Protection Work Plan

Jobsite Name & Address: __________________________________________________________________

Job Task: _______________________________________________________________________________

Effective period for plan:

1. Identify Potential Fall Hazards

o Elevating work platforms (boom operated) o Scaffold erection/ dismantling

2. Describe the hazard(s) including specific dimensions, locations, levels, etc.

3. Identify Fall Protection Systems to be used

o Guard rails o Fall arrest

T 604.733.4682 / 1.888.229.1455 www.actsafe.ca

o Barricading o Toe boards/ screens on scaffolds

6. Identify the method for prompt, safe removal of injured workers

o Written agreement with: o Self-rescue (Training Documentation)

7. Identify the method used to determine the adequacy of anchorage points

o Evaluation by a professional engineer o Existing engineering/ design documents

8. Describe and identify locations of anchorage points

9. Name of project site safety and health representative:______________________________________________

10. Name of Safety Monitor if control zone used:____________________________________________________

11. Name of person(s) trained to work under this plan:_______________________________________________

o Full body harness o Choker

13. Identify maximum free fall distance:__________________________________________________________

14. Identify total fall distance:__________________________________________________________________

16. Inspection checklist

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