Appendix

Release 2, October 2017

Fall Protection

Inspection Checklist/Logs

Full Body Harnesses

Harness Model: ________________________________________________ Manufacture Date: _________________________

Serial Number: ______________________ Lot Number: _______________ Purchase Date: ____________________________

Comments: _____________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

ACCEPTED/
GENERAL FACTORS REJECTED SUPPORTIVE DETAILS OR COMMENTS

1. Hardware: (Includes D-rings, buckles,

ACCEPTED
keepers, and back pads) Inspect for dam-
age, distortion, sharp edges, burrs, cracks
REJECTED
and corrosion.
2. Webbing: Inspect for cuts, burns, tears, ACCEPTED
abrasion, frays, excessive soiling and dis-
coloration. REJECTED

3. Stitching: Inspect for pulled or cut ACCEPTED

stitches.
REJECTED

4. Labels: Inspect, make certain all labels are ACCEPTED

securely held in place and legible.
REJECTED

ACCEPTED

REJECTED

ACCEPTED

REJECTED

ACCEPTED

REJECTED

ACCEPTED INSPECTED BY: _____________________________________________

Overall Disposition
REJECTED
DATE INSPECTED: __________________________________________
3M Personal Safety Division

Lanyards
Lanyard Model: ________________________________________________ Manufacture Date: _________________________

Serial Number: ______________________ Lot Number: _______________ Purchase Date: ____________________________

Comments: _____________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

ACCEPTED/
GENERAL FACTORS SUPPORTIVE DETAILS OR COMMENTS
REJECTED
1. Hardware: (Includes snap hooks,
carabiners, adjusters, keepers, thimbles ACCEPTED
and D-rings). Inspect for damage,
distortion, sharp edges, burrs, cracks, REJECTED
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 ACCEPTED

stitches.
REJECTED
4. Synthetic Rope: Inspect for pulled or cut ACCEPTED
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 ACCEPTED

for elongation, tears and excessive soiling.
REJECTED
7. Labels: Inspect, make certain all labels are ACCEPTED
securely held in place and legible.
REJECTED

ACCEPTED INSPECTED BY: _____________________________________________

Overall Disposition
REJECTED
DATE INSPECTED: __________________________________________

2 Appendix: Inspection Checklist/Logs- Release 2, October 2017

3M Personal Safety Division

Tie-Off Adaptors
Tie-Off Adaptor Model: _________________________________________ Manufacture Date: _________________________

Serial Number: ______________________ Lot Number: _______________ Purchase Date: ____________________________

Comments: _____________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

ACCEPTED/
GENERAL FACTORS SUPPORTIVE DETAILS OR COMMENTS
REJECTED
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 ACCEPTED
stitches.
REJECTED
4. Labels: Inspect, make certain all labels are ACCEPTED
securely held in place and legible.
REJECTED

ACCEPTED

REJECTED

ACCEPTED

REJECTED

ACCEPTED

REJECTED

ACCEPTED INSPECTED BY: _____________________________________________

Overall Disposition
REJECTED DATE INSPECTED: __________________________________________

Appendix: Inspection Checklist/Logs- Release 2, October 2017 3

3M Personal Safety Division

Hooks/Carabiners
Hook/Carabiner Model: _________________________________________ Manufacture Date: _________________________

Serial Number: ______________________ Lot Number: _______________ Purchase Date: ____________________________

Comments: _____________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

ACCEPTED/
GENERAL FACTORS 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 ACCEPTED
corrosion 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

ACCEPTED INSPECTED BY: _____________________________________________

Overall Disposition
REJECTED DATE INSPECTED: __________________________________________

4 Appendix: Inspection Checklist/Logs- Release 2, October 2017

3M Personal Safety Division

Anchorage Plates
Anchorage Plate Model: _________________________________________ Manufacture Date: _________________________

Serial Number: ______________________ Lot Number: _______________ Purchase Date: ____________________________

Comments: _____________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

GENERAL FACTORS ACCEPTED/ SUPPORTIVE DETAILS OR COMMENTS

REJECTED
1. Physical Damage: Inspect for cracks, ACCEPTED
sharp edges, burrs, deformities and locking
operation. REJECTED

2. Excessive Corrosion: Inspect for ACCEPTED

corrosion 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: __________________________________________

Appendix: Inspection Checklist/Logs- Release 2, October 2017 5

3M Personal Safety Division

Self Retracting Lifelines

Anchorage Plate Model: _________________________________________ Manufacture Date: _________________________

Serial Number: ______________________ Lot Number: _______________ Purchase Date: ____________________________

Comments: _____________________________________________________________________________________________

GENERAL FACTORS ACCEPTED/ SUPPORTIVE DETAILS OR COMMENTS

REJECTED
1. Impact Indicator: Inspect indicator for ACCEPTED
activation (rupture of red stitching, elon-
gated indicator, etc.) REJECTED

2. Screws/Fasteners: Inspect for damage ACCEPTED

and make certain all screws and fasteners
are tight. REJECTED
3. Housing: Inspect for distortion, cracks and ACCEPTED
other damage. Inspect anchoring loop for
distortion and damage. REJECTED

4. Lifeline: Inspect for cuts, burns, tears,

ACCEPTED
abrasion, frays, excessive soiling and
discoloration, broken wires (see impact
REJECTED
indicator section).
5. Locking Action: Inspect for proper lock- ACCEPTED
up 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 physical

ACCEPTED
damage, corrosion, proper operation and
markings (see separate checklist/log for
REJECTED
hooks and carabiners).
8. Reserve Lifeline: Inspect reserve lifeline ACCEPTED
retention systems for deployment.
REJECTED

9. Labels: Inspect, make certain all labels are ACCEPTED

securely held in place and legible.
REJECTED

ACCEPTED INSPECTED BY: _____________________________________________

Overall Disposition
REJECTED DATE INSPECTED: __________________________________________

6 Appendix: Inspection Checklist/Logs- Release 2, October 2017

3M Personal Safety Division

Inspection Checklist/Log
______________ Model: _________________________________________ Manufacture Date: _________________________

Serial Number: ______________________ Lot Number: _______________ Purchase Date: ____________________________

Comments: _____________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

GENERAL FACTORS ACCEPTED/ SUPPORTIVE DETAILS OR COMMENTS

REJECTED
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: __________________________________________

Appendix: Inspection Checklist/Logs- Release 2, October 2017 7

3M Personal Safety Division

Inspection Checklist/Log
______________ Model: _________________________________________ Manufacture Date: _________________________

Serial Number: ______________________ Lot Number: _______________ Purchase Date: ____________________________

Comments: _____________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

GENERAL FACTORS ACCEPTED/ SUPPORTIVE DETAILS OR COMMENTS

REJECTED
1.

2.

3.

4.

5.

6.

7.

INSPECTED BY: _____________________________________________

Overall Disposition
DATE INSPECTED: __________________________________________

8 Appendix: Inspection Checklist/Logs- Release 2, October 2017

 3M Personal Safety Division

Fall Protection Equipment Inspection Log Classification ____________________________ Company ____________________________

DATE INSPECTION INSPECTED INSPECTION INSPECTED INSPECTION INSPECTED

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

Green: Pass, Safe for Use Red: Remove from Service - Send to Manufacturer for Inspection/Servicing Black: Destroy Immediately