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Rescue Plan Form

The Fall Protection and Rescue Plan Form outlines the necessary steps and precautions for ensuring worker safety in environments with potential fall hazards. It includes sections for identifying hazards, selecting fall protection systems, and detailing rescue procedures. Workers must review and sign the plan, which must be posted at the worksite during activities.

Uploaded by

Dr.Mohamed Bakry
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
58 views5 pages

Rescue Plan Form

The Fall Protection and Rescue Plan Form outlines the necessary steps and precautions for ensuring worker safety in environments with potential fall hazards. It includes sections for identifying hazards, selecting fall protection systems, and detailing rescue procedures. Workers must review and sign the plan, which must be posted at the worksite during activities.

Uploaded by

Dr.Mohamed Bakry
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Fall Protection and Rescue Plan Form

Department Site Location

Job Task

Job Location/Description

Plan prepared by Date

➢ Workers must review and sign this plan prior to starting work. 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 work activities.

1. Identify potential fall hazards (check all that apply)


Mobile elevating work platforms Stairways
Excavations/trenches Roof steep slope (greater than 4:12)
Floor openings Roof low slope (4:12 or less)
Wall openings Swing fall
Skylight openings Hazardous process/equipment
Roof openings Debris/objects falling to lower level
Elevator shaft Sharp edges
Ladders (fixed or portable) Reinforcing steel installation
Scaffold Other:
2. Describe the fall hazard(s) details

3. Identify fall protection systems to be used


Guardrail system Aerial lift
Covers (holes and openings) Horizontal lifeline
Appropriate anchors for systems used Vertical lifeline and rope grab
Personal fall arrest system Warning line
Personal fall restraint system Safety monitor
Positioning device system Safety watch
Scaffold with guardrail Other:
Scissor lift Other:

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4. Describe procedures for assembly, maintenance, inspection, disassembly of fall protection
system to be used

5. Describe procedures for handling, storage, securing tools and materials

6. Identify methods of overhead protection for workers who may be in, or pass through the area
below worksite
Barricading Toe boards/screens on scaffolds
Hard hats required Toe boards/covers on floor openings
Catch net Screens on guardrails
Warning signs Secure large tools
Tool belts Other:
Tool lanyards Other:
7. Identify method for prompt, safe rescue of injured workers CALL 911 IF FALL OCCURS
Police/Fire Response Self-Rescue Options?

On-Site Equipment Available: Ladders, Lifts, On-Site Attendants


Winches, Pulleys, Work Platforms, etc?

Obstructions that may impede rescue? Methods of Communication with Injured Worker:
Cell Phone Numbers 1) 2)
Supervisor:
On-Site Attendant:
Injured Employee:
8. Identify method used to determine adequacy of anchorage points
Evaluation by professional engineer Existing engineering/design documents
Manufacturer’s data Other:
9. Describe and identify locations of anchorage points

10. Select system components


Full body harness Choker
Vertical lifeline Carabiner
Horizontal lifeline Rope grab
Lanyard Personal shock absorber
Boatswains chair Beamer
Connecting devices (identify) Anchorage points (identify)

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Other: Other:

11. Distance from anchor to ground, lower level or obstruction

12. Calculated minimum fall clearance

13. Inspection Checklist


Identification tags
Horizontal lifeline tension is correct
Integrity of stitching in shock absorber
Integrity of stitching in harness/lanyard
Manufacturers assembly/disassembly instructions
Locking capability of retractable lanyards assured
Locking capability of carabiners assured
Locking capability of snap hooks assured
Knots and other connection methods do not weaken lifeline
Lifelines installed and protected from cuts or abrasions
Rope (wear, fraying, damage, mildew)
Lanyards (wear, fraying, damage, mildew)
D-rings have adequate strength, are not cracked or deformed
Guardrails are sound and of adequate strength
Devices that are used to connect to horizontal lifelines lock in both directions
Anchorage points provide adequate strength and are capable of meeting requirements
Hole covers are secured, marked and capable of withstanding anticipated weight loads
Warning line meets strength and other requirements
Safety Monitor is Competent Person, can see workers, is close enough to communicate, has no other duties
Safety Watch is Competent Person, can see worker, is close enough to communicate, has no other duties
Other
Other
14. Employee(s) trained to work under this plan
Name (print) Signature Date

Name/title of Competent Person who provided training under this plan

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15. Work plan approval(s)
Name of lead worker or supervisor Signature Date

Name of Competent Person (If engineered system: Name of Qualified Person)

If administrative controls: Name of department manager

Calculating Fall Clearance using a Shock Absorbing Lanyard

Example:
• First, add the length of the shock absorbing lanyard (6
ft.) to the maximum elongation of the shock absorber
during deceleration (3 ½ ft.) to the average height of a
worker (6 ft.)
• Then, add a safety factor of 3 ft. to allow for the
possibility of an improperly fit harness, a taller than
average worker and/ or a miscalculation of distance.
• The total, 18 ½ ft. is the suggested safe fall clearance
distance for this example.

NOTE: Should the shock absorbing lanyard be used in


conjunction with a cross- arm anchorage connector or other, the
additional length of the anchorage connector must be taken into
consideration.

Calculating Fall Clearance using a Self- Retracting Lifeline

Example:
• First, add the maximum free fall distance (2 ft.)
with a retractable lifeline to the maximum
deceleration distance (3 ½ ft.) to the average
height of a worker (6 ft.)
• Then, add a safety factor of 3 ft. to allow for the
possibility of an improperly fit harness, a taller
than average worker and/ or a miscalculation of
distance.
• The total, 14 ½ ft. is the suggested safe fall
clearance distance for this example.
NOTE: When using a retractable lifeline, the distance is
calculated from the point where the retractable attaches
to the back D- ring of the worker’s harness.

Fall clearance is the minimum vertical distance needed between the anchor point and a lower level (this can be the
ground or lower obstruction) with a safety factor to prevent the worker from hitting the lower level in a fall.

What is the distance from the anchor point to the ground or lower level where a worker would fall?

If a worker falls, when wearing a fall protection system, what is the minimum fall clearance from the anchor
point to the worker’s feet including a 3 ft. safety factor? (Calculate as shown below)

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The calculated minimum fall clearance of a specific fall protection system may never be equal or greater than the
distance between the anchor point and the lower level.

Description Distance (ft.)


Lanyard length or free fall distance for self-retracting lifeline
Maximum allowable deceleration distance 3 ½ ft.
Worker’s height
Other components if applicable
Safety factor 3
Minimum fall clearance (sum of above)

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