CRANE CRITICAL LIFT CHECKLIST

SAFETY FORM

Date:          Time:         AM PM
 
Project Number:          Project Name:          
Location of Critical Lift:         
Name Competent Person:         
Contractor Name:          Tel:          
The use of this checklist is mandatory if any of the following are answered Yes
Yes No Load exceeds 80% of load chart for crane or lifting device
Yes No Load exceed 50 % of load chart and failure endangers existing facilities
Yes No Two (2) booms are required for lift
Yes No Poles or derricks have been erected for this lift

Detailed description of item to be lifted - use separate sheet(s) as necessary

        
        
List hoisting equipment to be used. Include inspection tag number and date
1.          
2.          
3.          
4.          

Equipment / Lift Relationship

Lift Unit 1 Lift Unit 2
Operating Radius                

Boom length                

Allowable load (Load Chart)                

Ratio Lift / Allowable Load                

Clearance between boom & Lift                

Clearance to surroundings                

Attach schedule of operations including time for rigging and equipment inspection

An Equal Opportunity-Affirmative
375334278.doc Rev Date 9/97 1 of 2 Action Employer
CRANE CRITICAL LIFT CHECKLIST
SAFETY FORM

Weight of Critical Lift (Use A, B, or C)

A. Certified Scale Weight (attach           lbs.
ticket) :
B. Calculated independently by more than one source
1. Source Name:                   lbs.
2. Source Name:                   lbs.
C. If lift is an existing item being removed or demolished, recalculate weight as in B.
above including internal/external modifications and sludge, liquid, etc.
Yes No Hoisting equipment and rigging has been re-inspected for this lift
Yes No Inspection was Satisfactory
Yes No If No, corrections made prior to lift
Yes No Foot block foundations are adequate
Yes No Guys and anchors have adequate number & are in correct location
Yes No Foot blocks are to be anchored
Yes No All cable including splices, clamps, thimbles has been check & OK
Yes No Ground area soil bearing allowable load checked and adequate
Yes No Mats are required
Yes No Underground installations checked and found adequate

Operator Experience
List experience on this type of equipment and type of lift (use separate sheet when
required)
1.          
2.          
3.          
4.          
Remarks
        

An Equal Opportunity-Affirmative
375334278.doc Rev Date 9/97 2 of 2 Action Employer