A22 - Enclosure A - Critical Lift Form 16-3 (fillable).pdf

Date:

Location:

A. TOTAL LOAD

lbs lbs lbs lbs lbs lbs lbs lbs lbs.

ft.

ft. YES / NO

ft. G. PRE-LIFT CHECKLIST (YES) N/A ft.

lbs.

lbs.

deg.

deg.

lbs.

12. Lift is % of the Crane's rated capacity

13. If Jib/Ext. is to be used:

Length ft.

ft.Offset

14. Rated Capacity of Jib/Ext. lbs C. HOIST ROPE Main Aux 1

Size:

lbs.

lbs.

6. Shackle Rated Capacity(s) _________________

Aux 2

1. # of Parts

2. Rope Diameter

3. Capacity

8. Signal Person Qualifications

2. Rigging Inspected

3. Crane Set-up

4. Overhead Hazard Check

5. Swing Check

6. Counterweight Check

7. Operator Qualifications

15. Site Control

16. Signatures

14. Traffic Hazard Check

11. Load Test

12. Tag Lines

13. Wind Conditions

(NO)

1. Crane Inspected

YES / NO

1. Certified Operator?

2. Option?

3. Certified for Type, Class & Capacity?

4. Designated in writing by employer:

YES / NO

YES / NO

B. CRANE F. OPERATOR QUALIFICATIONS

YES / NO

E. CRANE PLACEMENT (Mobile Cranes Only)

YES / NO

YES / NO

Note: Source of load weight (Drawings, Calcs, etc.) must be attached on Page 2.

1. Hitch Type(s)

2. No. of Slings:

3. Sling Type:

4. Sling Assembly Capacity:

5. Shackle Size(s):

D. RIGGING

9. Rigger Qualifications

10. Load Chart in Crane

1. Type of Crane

USACE District:

Prepared By:

Form 16-3

CRITICAL LIFT PLAN

For use of this form, see EM 385-1-1, Section 16

PSF

H. SIGNATURES

1. Crane Operator

2. Rigger

3. Signal Person

4. Lift Supervisor

5. Other

6. Other

5. Travel with Load Required?

6. Other?

1. Maximum Bearing Pressure Note: Bearing Pressure Calculations must be attached on Page 3.

2. Ground Conditions Suitable for Load?

Note: Ground Condition Calculations must be attached on Page 3.

3. High Voltage or Electrical Hazards?

Note: If Electrical Hazards are present they must be shown on Page 4.

4. Obstructions to Lift or Swing?

Note: If Obstructions are present they must be shown on Page 4.

TOTAL WEIGHT

1. Load Weight

2. Wt. of Aux. Block

3. Wt. of Main Block

4. Wt. of Lifting Beam

5. Wt. of Sling/Shackles

6. Wt. of Jib/Ext. (erected/stowed)

7. Wt. of Hoist Rope

8. Other:

2. Maximum Crane Capacity

3. Radius (Maximum)

4. Radius (Minimum)

5. Boom Length (Maximum)

6. Boom Length (Minimum)

7. Crane Capacity (Max Radius)

8. Crane Capacity (Min Radius)

9. Boom Angle (Maximum)

10. Boom Angle (Minimum)

11. Gross Load of Crane

A "Critical Lift" is defined as any non-routine crane lift requiring detailed planning and additional or unusual safety precautions. Critical lifts include: lifts made where the load weight is greater than 75% of the rated capacity of the crane; lifts which require load to be lifted, swung or placed out of the operator's view ; lifts made with more than one crane; lifts involving non-routine/technically difficult rigging arrangement;

hoisting personnel with a crane or derrick; or any lift which the crane operator believes should be critical.

K7OPNMSA

Cross-Out

Show here or attach calculations, drawings, etc.

Page 2 of 6Apr-13

LOAD CALCULATIONS

Form 16-3

CRITICAL LIFT PLAN

For use of this form, see EM 385-1-1, Section 16

Show here or attach calculations, drawings, etc.

Form 16-3

CRITICAL LIFT PLAN

For use of this form, see EM 385-1-1, Section 16

BEARING PRESSURES & GROUND CONDITIONS

Apr-13 Page 3 of 6

Show here or attach load chart

CRITICAL LIFT PLAN

For use of this form, see EM 385-1-1, Section 16

LOAD CHART

Apr-13 Page 4 of 6

Show here or attach operator qualifications

CRITICAL LIFT PLAN

For use of this form, see EM 385-1-1, Section 16

OPERATOR, RIGGER, SIGNAL PERSON QUALIFICATIONS

Apr-13 Page 5 of 6

Show here or attach site plan and sequencing

CRITICAL LIFT PLAN

For use of this form, see EM 385-1-1, Section 16

SITE PLAN