B.08 PWS Attachment (Critical Lift Form_16-3_Final Fillable).pdf

Date:

Location:

A. TOTAL LOAD

lbs lbs lbs lbs lbs lbs lbs lbs lbs.

ft.

ft. 4. Designated in writing by employer: 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.

Offset ft.

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

5. Shackle Size(s):

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?

YES / NO

YES / NO

B. CRANE F. OPERATOR QUALIFICATIONS

YES / NO

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

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

E. CRANE PLACEMENT (Mobile Cranes Only)

YES / NO

YES / NO

1. Load Weight

3. Wt. of Main Block

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

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

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

1. Hitch Type(s)

2. No. of Slings:

3. Sling Type:

4. Sling Assembly Capacity:

D. RIGGING

9. Rigger Qualifications

10. Load Chart in Crane

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

7. Wt. of Hoist Rope

8. Other:

1. Type of Crane

3. Radius (Maximum)

4. Radius (Minimum)

5. Boom Length (Maximum)

6. Boom Length (Minimum)

8. Crane Capacity (Min Radius)

9. Boom Angle (Maximum)

USACE District:

Prepared By:

CRITICAL LIFT PLAN

Form 16-3

For use of this form, see EM 385-1-1, Section 16. Proponent is Crane HHWG.

6. Other?

PSF

H. SIGNATURES

2. Rigger

1. Crane Operator

3. Signal Person

4. Lift Supervisor

5. Other

6. Other

7. Crane Capacity (Max Radius)

5. Travel with Load Required?

4. Obstructions to Lift or Swing?

3. High Voltage or Electrical Hazards?

2. Ground Conditions Suitable for Load?

1. Maximum Bearing Pressure

11. Gross Load of Crane

4. Wt. of Lifting Beam

5. Wt. of Sling/Shackles

TOTAL WEIGHT

Mobile Hydraulic Truck

10. Boom Angle (Minimum)

2. Wt. of Aux. Block

2. Maximum Crane Capacity

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.

Show here or attach calculations, drawings, etc.

CRITICAL LIFT PLAN

Form 16-3

Page 2 of 6Apr-13

LOAD CALCULATIONS

For use of this form, see EM 385-1-1, Section 16. Proponent agency is Crane HHWG.

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. Proponent agency is Crane HHWG.

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. Proponent agency is Crane HHWG.

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. Proponent agency is Crane HHWG.

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. Proponent agency is Crane HHWG.

SITE PLAN

Apr-13 Page 6 of 6