APPENDIX 1: INSPECTION CHECKLIST/LOGS

FULL BODY HARNESS

Inspection Checklist / Log

Harness Model: Manufacture Date:

Serial Number:
Lot Number: Purchase Date:
Comments:

GENERAL FACTORS ACCEPTED / REJECTED SUPPORTIVE DETAILS OR COMMENTS

1.) Hardware: (Includes D-rings, buckles,  ACCEPTED

keepers and back pads) Inspect for
damage, distortion, sharp edges, burrs, REJECTED

cracks
and corrosion.
2.) Webbing: Inspect for cuts, burns, tears,  ACCEPTED
abrasion, frays, excessive soiling
and discoloration. REJECTED


3.) Stitching: Inspect for pulled or cut stitches.  ACCEPTED

 REJECTED

4.) Labels: Inspect, make certain all labels  ACCEPTED

are securely held in place and legible.
 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED INSPECTED BY:

OVERALL
DISPOSITION  REJECTED DATE INSPECTED:

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APPENDIX 1: INSPECTION

LANYARDS
Inspection Checklist / Log

Lanyard Model: Manufacture Date:

Serial Number:
Lot Number: Purchase Date:

Comments:

GENERAL FACTORS ACCEPTED / REJECTED SUPPORTIVE DETAILS OR COMMENTS

1.) Hardware: (Includes snap hooks, carabiners,  ACCEPTED

adjusters, keepers, thimbles and D-rings).
Inspect for damage, distortion, sharp edges, REJECTED

burrs, cracks, corrosion and proper
operation.
2.) Webbing: Inspect for cuts, burns, tears,  ACCEPTED
abrasion, frays, excessive soiling
and discoloration. REJECTED


3.) Stitching: Inspect for pulled or cut stitches.  ACCEPTED

 REJECTED

4.) Synthetic Rope: Inspect for pulled or  ACCEPTED

cut yarns, burns, abrasion, knots,
excessive soiling and discoloration. REJECTED


5.) Wire Rope: Inspect for broken wires,  ACCEPTED

corrosion, kinks and separation of strands.
 REJECTED

6.) Energy Absorbing Component: Inspect for  ACCEPTED

elongation, tears and excessive soiling.
 REJECTED

7.) Labels: Make certain all labels are  ACCEPTED

securely held in place and legible.
 REJECTED

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APPENDIX 1: INSPECTION
 ACCEPTED INSPECTED BY:
OVERALL
DISPOSITION  REJECTED INSPECTED BY:

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APPENDIX 1: INSPECTION

TIE-OFF ADAPTORS
Inspection Checklist / Log

Tie-Off Adaptor Model: Manufacture Date:

Serial Number:
Lot Number: Purchase Date:
Comments:

GENERAL FACTORS ACCEPTED / REJECTED SUPPORTIVE DETAILS OR COMMENTS

1.) Hardware: (Includes D-rings) Inspect for  ACCEPTED

damage, distortion, sharp edges, burrs,
cracks and corrosion. REJECTED


2.) Webbing: Inspect for cuts, burns, tears,  ACCEPTED

abrasion, frays, excessive soiling
and discoloration. REJECTED


3.) Stitching: Inspect for pulled or cut stitches.  ACCEPTED

 REJECTED

4.) Labels: Inspect, make certain all labels  ACCEPTED

are securely held in place and legible.
 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED INSPECTED BY:

OVERALL
DISPOSITION  REJECTED DATE INSPECTED:

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 APPENDIX 1: INSPECTION

HOOKS / CARABINERS
Inspection Checklist / Log

Hook / Carabiner Model: Manufacture Date:

Serial Number:
Lot Number: Purchase Date:

Comments:

GENERAL FACTORS ACCEPTED / REJECTED SUPPORTIVE DETAILS OR COMMENTS

1.) Physical Damage: Inspect for cracks,  ACCEPTED

sharp edges, burrs, deformities and
locking operation. REJECTED


2.) Excessive Corrosion: Inspect for corrosion  ACCEPTED

which effects the operation and/or strength.
 REJECTED

3.) Markings: Inspect, make sure certain  ACCEPTED

marking(s) are legible.
 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED

 REJECTED

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APPENDIX 1: INSPECTION
 ACCEPTED INSPECTED BY:
OVERALL
DISPOSITION  REJECTED DATE INSPECTED:

6 Appendix 1: Inspection 1-800-328- © 2014 Capital

APPENDIX 1: INSPECTION

ANCHORAGE PLATES
Inspection Checklist / Log

Anchorage Plate Model: Manufacture Date:

Serial Number:
Lot Number: Purchase Date:
Comments:

GENERAL FACTORS ACCEPTED / REJECTED SUPPORTIVE DETAILS OR COMMENTS

1.) Physical Damage: Inspect for cracks,  ACCEPTED

sharp edges, burrs and deformities.
 REJECTED

2.) Excessive Corrosion: Inspect for corrosion  ACCEPTED

which effects the operation and/or strength.
 REJECTED

3.) Fasteners: Inspect for corrosion, tightness,  ACCEPTED

damage and distortion. If welded, inspect
weld for corrosion, cracks and damage. REJECTED


4.) Markings: Inspect, make sure certain  ACCEPTED

marking(s) are legible.
 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED

 REJECTED

 ACCEPTED INSPECTED BY:

OVERALL
DISPOSITION  REJECTED DATE INSPECTED:

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APPENDIX 1: INSPECTION

SELF RETRACTING LIFELINES

Inspection Checklist / Log

Self Retracting Lifeline Model: Manufacture Date:

Serial Number:
Lot Number: Purchase Date:

Owner / Dept. / Location:

Owner's ID #:
Comments:

GENERAL FACTORS ACCEPTED / REJECTED SUPPORTIVE DETAILS OR COMMENTS

1.) Impact Indicator: Inspect indicator for  ACCEPTED

activation (rupture of red stitching,
elongated indicator, etc.)  REJECTED

2.) Screws / Fasteners: Inspect for  ACCEPTED

damage and make certain all screws and
fasteners are tight.  REJECTED

3.) Housing: Inspect for distortion, cracks  ACCEPTED

and other damage. Inspect anchoring
loop for distortion and damage.  REJECTED

4.) Lifeline: Inspect for cuts, burns,  ACCEPTED

tears, abrasion, frays, excessive
soiling and discoloration, broken  REJECTED
wires (see impact indicator section).

5.) Locking Action: Inspect for proper lock-up  ACCEPTED

of brake mechanism.
 REJECTED

6.) Retraction/Extension: Inspect spring  ACCEPTED

tension by pulling lifeline out fully and
allowing it to retract fully (no slack).  REJECTED

7.) Hooks / Carabiners: Inspect for  ACCEPTED

physical damage, corrosion, proper
operation and markings (see separate  REJECTED
checklist/log for hooks and carabiners).

8.) Reserve Lifeline: Inspect reserve lifeline  ACCEPTED

retention systems for deployment.
 REJECTED

9.) Labels: Inspect, make certain all  ACCEPTED

labels are securely held in place and
legible.  REJECTED

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 APPENDIX 1: INSPECTION
OVERALL  ACCEPTED INSPECTED BY:
DISPOSITION  REJECTED DATE INSPECTED:

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APPENDIX 1: INSPECTION

INSPECTION CHECKLIST / LOG

Model: Manufacture Date:
Serial Number:
Lot Number: Purchase Date:
Comments:

GENERAL FACTORS ACCEPTED / REJECTED SUPPORTIVE DETAILS OR COMMENTS

1.)  ACCEPTED

 REJECTED

2.)  ACCEPTED

 REJECTED

3.)  ACCEPTED

 REJECTED

4.)  ACCEPTED

 REJECTED

5.)  ACCEPTED

 REJECTED

6.)  ACCEPTED

 REJECTED

7.)  ACCEPTED

 REJECTED

 ACCEPTED INSPECTED BY:

OVERALL
DISPOSITION  REJECTED DATE INSPECTED:

1 Appendix 1: Inspection 1-800-328- © 2014 Capital

 APPENDIX 1: INSPECTION

INSPECTION CHECKLIST / LOG

Model: Manufacture Date:
Serial Number:
Lot Number: Purchase Date:

Comments:

GENERAL FACTORS ACCEPTED / REJECTED SUPPORTIVE DETAILS OR COMMENTS

1.)  ACCEPTED

 REJECTED

2.)  ACCEPTED

 REJECTED

3.)  ACCEPTED

 REJECTED

4.)  ACCEPTED

 REJECTED

5.)  ACCEPTED

 REJECTED

6.)  ACCEPTED

 REJECTED

7.)  ACCEPTED

 REJECTED

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APPENDIX 1: INSPECTION
 ACCEPTED INSPECTED BY:
OVERALL
DISPOSITION  REJECTED DATE INSPECTED:

1 Appendix 1: Inspection 1-800-328- © 2014 Capital

FALL PROTECTION EQUIPMENT INSPECTION LOG Classification Company

DATE OF INSPECTION INSPECTED INSPECTION INSPECTED INSPECTION INSPECTED

SERIAL # MODEL # DESCRIPTION PASS FAIL PASS FAIL PASS FAIL COMMENTS
MFG. DATE BY DATE BY DATE BY

Form 5-1 Green: Pass, Safe for Use Red: Remove from
Service – Send to Manufacturer for
 APPENDIX 1: INSPECTION
Inspection/Servicing Black: Destroy Immediately

Appendix 2: Detailed inspection Logs 59