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VISUAL FALL ARRESTER SYSTEM Page 1 of 1

Certificate No. : Issue Date :


Customer :
Owner :
Customer Work Order : ABC Job No. :
Job Location :

EQUIPMENT DETAIL
Description :
Serial Number :
Maximum Arrest Force :
Arrest Distance :
Lanyard Width Lanyard Thickness :
Wire Rope Material : Diameter / SWL :

VISUAL INSPECTION ( HARDWARE & LANYARDS & SELF RETRACTING LIFE LINE)
Illumination : External Day Light Surface Temperature : 30 ° C

Acceptance Criteria
In compliance with ANSI/ASSE Z359-1 Latest Edition and internal procedure no. ABC-LG-16 REV
00 (inspection of personal fall protection equipment)
Y N
No Marking and Identification ✘

Illegibility of Unique Identification number ✘

Distortions, cracks, corrosion, or pitted surfaces on hardware snaps ✘

Loose, cut strands, sharp edges, distortion, or cracks on hardware timble ✘

Cuts, frayed areas, or unusual wearing patterns on the wire rope lanyards ✘

Cuts, swelling, discoloration, cracks and charring on web lanyards ✘

Diameter reduction on wire rope lanyards ✘

Burn holes, tears,stitching on areas where the pack is sewn to D-rings ✘

Loose strands, rips and deterioration on belts or lanyards ✘

Loose fasteners, bent, cracked, distorted, worn, malfunctioninG ON Housing unit ✘

The lifeline is not pull out freely and retract all the way back into the unit ✘

Cuts, burns, corrosion, kinks, frays, loose, broken or damaged stitching on life line ✘

Brake engagement malfunction ✘

EXAMINATION AND TEST RESULT


Date Examination : 22-Dec-16 Inspection Status : Passed
The lanyard has passed visual examination satisfactorily and there is no apparent discountinuities
were detected during Visual Inspection. It is fit to it's intended use.
PICTURE

Inspector Name : Ananto Wibowo


Inspector Certificate : 008/MT–II–ABC/IV/2014 Valid until : 26-Apr-19
LEEA Student No : 025846 Valid until : 30-Oct-18
Inspector Signature, Reviewed and Approved, Customer Representative
Ananto Wibowo Andi Setyo Budianto __________________
ASNT-NDT-MT/PT Level II QHSE Manager / ASNT NDT Level III
FORM 5.7.7-VIS-SL-07B REV. 00 ISSUED DATE 01/06/2014
VISUAL FALL ARRESTER SYSTEM Page 1 of 1

Certificate No. : Issue Date :


Customer :
Owner :
Customer Work Order : ABC Job No. :
Job Location :

EQUIPMENT DETAIL
Description :
Serial Number :
Maximum Arrest Force :
Arrest Distance :
Lanyard Width Lanyard Thickness :
Wire Rope Material : Diameter / SWL :

Fuction Test
Acceptance Criteria
In compliance with ANSI/ASSE Z359-1 Latest Edition and internal procedure no. ABC-LG-16 REV
00 (inspection of personal fall protection equipment)

Fuction Test Retraction Tension Static Strength


Standard 0.6 -11.4 kg Minimum 13.3 kN
Actual

Fuction Test Dynamic Strength Dynamic Performance


Standard Minimum 4.4 kN Maximum 8 kN
Arrest Distance Maximum 54 Inches
Actual

EXAMINATION AND TEST RESULT


Date Examination : 22-Dec-16 Inspection Status : Passed
The lanyard has passed visual examination satisfactorily and there is no apparent discountinuities
were detected during Visual Inspection. It is fit to it's intended use.
PICTURE

Inspector Name : Ananto Wibowo


Inspector Certificate : 008/MT–II–ABC/IV/2014 Valid until : 26-Apr-19
LEEA Student No : 025846 Valid until : 30-Oct-18
Inspector Signature, Reviewed and Approved, Customer Representative
Ananto Wibowo Andi Setyo Budianto __________________
ASNT-NDT-MT/PT Level II QHSE Manager / ASNT NDT Level III
FORM 5.7.7-VIS-SL-07B REV. 00 ISSUED DATE 01/06/2014