CDRL D001 Safety Certification Form- GDLd.pdf

CONTRACT DATA REQUIREMENTS LIST Form Approved

(1 Data Item) 0MB No. 0704-0188

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A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER ---

I

F. CONTRACTOR

1. DATA ITEM NO. 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.)

5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD250 REQ 9. DIST STATEMENT 10. FREQUENCY

REQUIRED

12. DATE OF FIRST SUBMISSION 14. DISTRIBUTION

b. COPIES 8.APP CODE 11. AS OF DATE 13. DATE OF SUBSEQUENT a. ADDRESSEE Final

SUBMISSION Draft Reg Repro

16. REMARKS

15. TOTAL

G. PREPARED BY H.DATE I. APPROVED BY J. DATE

DD FORM 1423-1, AUG 96 (EG) PREVIOUS EDITION MAY BE USED. Page __ of __ Pages Designed using Perform Pro, WHS/DIOR, Aug 96

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

D001

CLIN 0001

SOW 3.d N32205 (MSC N441)

DD

N/A

N/A

ASGENASGEN

N/AN/A

XXXX

A MHE Safety Certification Form shall be submitted for each forklift or pallet jack asset in accordance with NAVSUP Publication 538 (6th Rev) and NAVSEA SW023-AH-WHM-010 (8th Rev) Figure 6-1 at the completion of all other work and testing in accordance with Table 6-1.

Test criteria are documented in Chapter 6 of SW023-AH-WHM-010.

Any item failing to pass the test criteria shall be documented in a Condition Found Report (CDRL B001) .

Successful testing is documented directly on the Figure 6-1 form.

Forms shall be submitted in an Adobe or Microsoft compatible format with the following file naming convention:

CDRL#_MSC Barcode_Date in YYYYMMDD format example: CDRLD001_23-02785_20230821

Submit all forms in accordance with Block 14a to the MHE Type Desk at MSC_MHEOHE@US.NAVY.MIL

No Distribution Statement Required

MSC_MHEOHE@US.NAVY.MIL

D

D. SYSTEM/ITEM

Material Handling Equipment

2. TITLE OF DATA ITEM

MHE Safety Certification Form

E. CONTRACT/PR NO.

N2185631534415

XX

NAVSEA SW023-AH-WHM-010 EIGHTH REVISION

HOUR �!:..A����

USN/MSC REGISTRATION NO. MHE CLASS/LIFT CODE/TYPE SWL

METER

DATE

TEST PARAGRAPH PROCEDURE RESULTS

MARKINGS 6-6.1 VISUAL INSPECTION: ACCEPT REJECT

FUEL SYSTEM 6-6.2 LEAK INSPECTION: ACCEPT REJECT N/A

NCU fRAL.::, IA� I �n, 11..M

6-6.3 OPERATIONAL INSPECTION: ACCEPT REJECT N/A

(Fueled MHE)

WARNING DEVICES

6-6.4 OPERATIONAL INSPECTION: ACCEPT REJECT N/A

(Powered MHE)

SPARK EMISSION

6-6.5 VISUAL INSPECTION: ACCEPT REJECT N/A

(Powered MHE)

6-6.6 CONDUCTOR TYPE: TIRES STRAPS N/A

STATIC DISCHARGE

(Electric and HS/Ordnance RESISTANCE READING:

LEFT OHMS RIGHT_ OHMS

N/A

Pallet Truck)

ACCEPT REJECT N/A

CARRIAGE REACH & ROLLER

6-6.7 OPERATIONAL INSPECTION: ACCEPT REJECT N/A

(Reach & Tier)

DRIVE CONTROL

6-6.8 OPERATIONAL INSPECTION: ACCEPT REJECT N/A

(Powered Pallet Trucks)

6-6.9.1 TRAVEL DISTANCE (TABLE 6-2):

FEET ACCEPT REJECT N/A

BRAKE

PEDAL FEEL: ACCEPT REJECT N/A

(Except Straddle Carriers and Manual Pallet Trucks) 6-6.9.2 PARKING BRAKE: ACCEPT REJECT N/A

6-6.9.3

SAFETY BRAKING/DISCONNECT

ACCEPT REJECT N/A

SYSTEM:

BRAKE

(Straddle Carrier)

6-6.10 OPERATIONAL INSPECTION: ACCEPT REJECT N/A

OPERATIONAL WEIGHT TEST

6-6.11

100% RATED LOAD

ACCEPT REJECT N/A

(Forklift Trucks) HELD FOR 2 MINUTES:

OPERATIONAL WEIGHT TEST

6-6.12

100% RATED LOAD

ACCEPT REJECT N/A

(Powered Pallet Trucks) HELD FOR 2 MINUTES:

KING PIN (Straddle Carrier) 6-6.13 VISUAL INSPECTION: ACCEPT REJECT N/A

LIFTING WEIGHT TEST

6-6.14 100% RATED LOAD: ACCEPT REJECT N/A

(Straddle Carrier)

6-5.3 AFTER REPAIRS/MODIFICATIONS

AFFECTING LOAD-BEARING YES NO N/A

OVERLOAD WEIGHT TEST COMPONENTS

(Except Pallet Trucks and

100% LOAD HELD FOR 2 MINUTES: ACCEPT REJECT N/A

Straddle Carriers)

6-7

150% LOAD HELD FOR 2 MINUTES: ACCEPT REJECT N/A

LIFT EYES

6-5.4 AFTER REPAIR/REPLACEMENT

YES NO

N/A

(Except Straddle Carriers) 6-8

150% WEIGHT OF MHE HELD FOR

ACCEPT REJECT N/A

2 MINUTES:

TIDS IS TO CERTIFY THAT THE ABOVE MHE WAS INSPECTED AND TESTED IN ACCORDANCE WITH NAVSEA SW023-AH-WHM-010.

MECHANIC/MAINTENANCE PROVIDER:

PRINT FULL NAME SIGNATURE

CERTIFIED BY:

PRINT FULL NAME SIGNATURE

THIS 18 MONTH CERTIFICATION EXPIRES ON:

MONTHNEAR

FIGURE 6-1. MHE Safety Certification Form

DATE

DATE

6-5

I

NAVSEA SW023-AH-WHM-010 EIGHTH REVISION

6-4

Note: Overload weight testing shall only be conducted whenever MHE has undergone repairs or modifications affecting load-bearing components.

*Electric-powered MHE contain designations E, EE, or EX.

**Fuel-powered MHE contain designations CN, CNS, D, DS, DY, G, G/CN, GS, GS/CNS, LP, LPS, G/LP, or GS/LPS.

Table 6-1. Periodic Tests for MHE

Test Forklift/

Swingmast (Electric)*

Forklift/ Swingmast

(Fuel)**

Rough Terrain (Fuel)**

Sideloader (Electric)*

Reach & Tier

(Electric)*

Pallet Truck (Electric* or Manual)

Straddle Carrier (Fuel)**

Markings (6-6.1) X X X X X X X

Fuel System (6-6.2)

X X X

Neutral Start Switch (6-6.3)

X X X

Warning Devices (6-6.4)

X X X X X X Electric only

X

Spark Emission (6-6.5)

X X X X X X Electric only

X

Static Discharge Test (6-6.6)

X X X X HS/Ordnance and Electric only

Carriage Reach and Roller Inspection (6-6.7)

X

Drive Control Test (6-6.8)

X Electric only

Brake Tests (6-6.9)

X X X X X X Electric only

Brakes (6-6.10)

X

Operational Weight Test (6-6.11)

X X X X X

Operational Weight Test (6-6.12)

X Electric only

King Pin (6-6.13)

X

Lifting Weight Test (6-6.14)

X

Overload Weight Testing (See Note and 6-7)

X X X X X

Lifting Eyes Test (See Note and 6-8)

X X X X X X