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SI/PERL/CR/01

LIFT PLANDATE: LOCATION: JOB #

PERMIT TO WORK # RISK ASSESMENT #

SUPERVISOR ON SITE:

GENERAL INFORMATIONWEIGHT OF LOAD (ACTUAL OR ASSESSED):

OVERHEAD LINES - YES NO TOOLBOX MEETING - YES NO

CRANE PROPERLY POSITIONED - YES NO OUTRIGGERS FULLY EXTENDED - YES NO

IS AREA PROPERLY BARRICADED - YES NO CRANE MATS REQUIRED - YES NO

INSPECT SLING AND SHACKLES - YES NO TAG LINES SECURED - YES NO

CAN THE LOAD BE SECURELY LIFTED AND PUT IN PLACE? YES NO

BRIEF DESCRIPTION OF LIFTING OPERATION:

EQUIPMENT INFORMATION

CRANE TYPE: MOBILE TRUCK MOUNTED TELESCOPICEQUIPMENT ID: EQUIPMENT MAKE:

BOOM ANGLE: RADIUS OF OBJECT TO CRANE:

LENGTH OF BOOM: RADIUS OF CRANE WHERE OBJECT IS TO BE PLACED:

RATED CAPACITY: MAIN BOOM SECTIONS:

MAX MAIN BOOM LENGTH:

BIFOLD LATTICE SWINGAWAY HYDRAULIC LUFFING OR MANUAL OFFSET:

SLEW : COUNTERWEIGHT:

EQUIPMENT OPERATOR: BANKSMAN:

SLINGS AND SHACKLES INFORMATIONNUMBER OF SLINGS: NUMBER OF SHACKLES: N/A

SLING SIZE: RATED CAPACITY: N/A

SLING LENGTH: PIN DIAMETER: N/A

RATED CAPACITY OF SLINGS: TYPE OF SHACKLE: N/A

PERSONAL PROTECTIVE EQUIPMENTSTEEL TOED SHOES

HARD HAT

GLOVES REQUIRED WHEN HANDLING MATERIALS OR GUIDING A LOAD

SAFETY GLASSES REQUIRED WHEN POTENTIAL EXISTS FOR OBJECTS TO FALL INTO EYES

BANKSMAN REQUIRED TO WEAR HIGH VISIBILITY WORK VEST

LIFT PLAN # SI/PERL/LP/REV01

PREPARED BY: A.RAMDATT

COULD THE LOAD IF DROPPED RELEASE HAZARDOUS MATERIALS OR RADIOACTIVITY? YES NO IF YES PLEASE DESCRIBE:

IS THE LOAD IRREPLACEABLE OR WOULD IT BE COSTLY TO REPLACE IF DAMAGED ? YES NO IF YES PLEASE DESCRIBE:

REQUIRED FOR ALL PERSONNEL INVOLVED WITH LIFT ACTIVITY TO PROTECT FROM CRUSH OF FEET AND TOES

REQUIRED FOR ALL PERSONNEL WHENEVER THE POTENTIAL FOR A HEAD INJURY EXISTS I.E, WHERE THE LOAD COULD GET IN CONTACT WITH LOAD

OTHER (SPECIFY)

RADIO CONTACT AT ALL TIMES BETWEEN CRANE OPERATOR AN BANKSMAN

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SI/PERL/CR/01

ADDITIONAL HAZARDS

APPROVALS

PRINT NAME SIGNATURE DATE

AUTHORIZED PERSONNELPRINT NAME SIGNATURE DATE

IDENTIFY AND LIST ADDITIONAL HAZARDS SUCH AS OBSTACLES OR OPERATOR PATH, OILY SURFACES/MATERIALS,FOOT TRAFFIC OR OTHER OTHER OPERATIONS IN AREA (SIMOPS) AND HOW THE HAZARDS WILL BE CONTROLLED OR MITIGATED:

ANY SUPERVISOR AUTHORIZING PERSONNEL TO USE THIS PLAN MUST FIRST REVIEW AND APPROVE THE PLAN/PROCEDURE. LIFTS THAT INVOLVE FLIPPING OR ROLLING THE LOAD REQUIRE PERL RIGGING PANEL APPROVAL. LIFTS THAT INVOLVE LOADS THAT, IF DROPPED, COULD RELEASE HAZARDOUS OR RADIOACTIVE MATERIALS OR LOADS THAT ARE IRREPLACEABLE OR VERY COSTLY TO REPLACE REQUIRE APPROVAL FROM THE PERL SAFETY OFFICER AND THE PERL RIGGING PANEL MEMBER.