CDRL D001 Safety Certification Form_USNS JOHN LENTHALL.pdf

CONTRACT DATA REQUIREMENTS LIST Form Approved (1 Data Item) 0MB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the lime for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0701-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if ii does not display a currently valid 0MB control number. Please DO NOT RETURN your form to the above address. Send completed form to the Government Issuing Contracting Officer for the ContracVPR No. listed in Block E.

A. CONTRACT LINE ITEM NO.

CLIN 0001

B. EXHIBIT

D

C. CATEGORY:

XXXX

TDP TM --------------- OTHER

D. SYSTEM/ITEM

Material Handling Equipment

E. CONTRACT/PR NO.

I

F. CONTRACTOR

1. DATA ITEM NO.

D001

2. TITLE OF DATA ITEM

MHE Safety Certification Form

3. SUBTITLE 17. PRICE GROUP

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE SOW 3. d N32205 (MSC N441)

18. ESTIMATED

TOTAL PRICE

7. DD250 REQ

DD

8. APP CODE

N/A

9. DIST STATEMENT

REQUIRED

See Block 16

10. FREQUENCY

ASGEN

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

ASGEN

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE Draft

b. COPIES

Final

Reg Repro

16.REMARKS

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 XX

G. PREPARED BY

HADLEY.RICHARD.T.III.1454717 Digitally signed by

. D AT E I. APPROVED BY

y s i gne d by (N441 Acting)

15. TOTAL

Digitally signed by Dennis Lewis

J.DATE

HADLEY.RICHARD.T.III.1454717569

Date: 2023.09.05 12:28:29 -04'00'

Date: 2023.09.05 12:46:40 -04'00'

DD FORM 1423-1, AUG 96 (EG) PREVIOUS EDITION MAY BE USED. Page of Pages Designed using Perform Pro, WHS/DIOR, Aug 96 mailto:MSC_MHEOHE@US.NAVY.MIL mailto:MSC_MHEOHE@US.NAVY.MIL

INSTRUCTIONS FOR COMPLETING DD FORM 1423

(See DoD 5010.12-M for detailed instructions.)

FOR GOVERNMENT PERSONNEL

Item A. Self-explanatory.

Item B. Self-explanatory.

Item C. Mark (X) appropriate category: TOP - Technical Data Package; TM - Technical Manual; Other - other category of data, such as "Provisioning, “Configuration Management," etc.

Item D. Enter name of system/item being acquired that data will support.

Item E. Self-explanatory (to be filled in after contract award).

Item F. Self-explanatory (to be filled in after contract award).

Item G. Signature of preparer of CORL.

Item H. Date CORL was prepared.

Item I. Signature of CORL approval authority.

Item J. Date CORL was approved.

Item 1. See DoD FAR Supplement Subpart 4.71 for proper numbering.

Item 2. Enter title as it appears on data acquisition document cited in Item 4.

Item 3. Enter subtitle of data item for further definition of data item (optional entry).

Item 4. Enter Data Item Description (DID) number, military specification number, or military standard number listed in DoD 5010.12-L (AMSDL), or one-time DID number, that defines data content and format requirements.

Item 5. Enter reference to tasking in contract that generates requirement for the data item (e.g., Statement of Work paragraph number).

Item 6. Enter technical office responsible for ensuring adequacy of the data item.

Item 7. Specify requirement for inspection/acceptance of the data item by the Government.

Item 8. Specify requirement for approval of a draft before preparation of the final data item.

Item 9. For technical data, specify requirement for contractor to mark the appropriate distribution statement on the data (ref. DoDD 5230.24).

Item 10. Specify number of times data items are to be delivered.

Item 11. Specify as-of date of data item, when applicable.

Item 12. Specify when first submittal is required.

Item 13. Specify when subsequent submittals are required, when applicable.

Item 14. Enter addressees and number of draft/final copies to be delivered to each addressee. Explain reproducible copies in Item 16.

Item 15. Enter total number of draft/final copies to be delivered.

Item 16. Use for additional/clarifying information for Items 1 through 15. Examples are: Tailoring of documents cited in Item 4;

Clarification of submittal dates in Items 12 and 13; Explanation of reproducible copies in Item 14.; Desired medium for delivery of the data item.

FOR THE CONTRACTOR

Item 17. Specify appropriate price group from one of the following groups of effort in developing estimated prices for each data item listed on the DD Form 1423.

a. Group I. Definition - Data which is not otherwise essential to the contractor's performance of the primary contracted effort (production, development, testing, and administration) but which is required by DD Form 1423.

Estimated Price - Costs to be included under Group I are those applicable to preparing and assembling the data item in conformance with Government requirements, and the administration and other expenses related to reproducing and delivering such data items to the Government.

b. Group II. Definition - Data which is essential to the performance of the primary contracted effort but the contractor is required to perform additional work to conform to Government requirements with regard to depth of content, format, frequency of submittal, preparation, control, or quality of the data item.

Estimated Price - Costs to be included under Group II are those incurred over and above the cost of the essential data item without conforming to Government requirements, and the administrative and other expenses related to reproducing and delivering such data item to the Government.

c. Group Ill. Definition - Data which the contractor must develop for his internal use in performance of the primary contracted effort and does not require any substantial change to conform to Government requirements with regard to depth of content, format, frequency of submittal, preparation, control, and quality of the data item.

Estimated Price - Costs to be included under Group Ill are the administrative and other expenses related to reproducing and delivering such data item to the Government.

d. Group IV. Definition - Data which is developed by the contractor as part of his normal operating procedures and his effort in supplying these data to the Government is minimal.

Estimated Price - Group IV items should normally be shown on the DD Form 1423 at no cost.

Item 18. For each data item, enter an amount equal to that portion of the total price which is estimated to be attributable to the production or development for the Government of that item of data. These estimated data prices shall be developed only from those costs which will be incurred as a direct result of the requirement to supply the data, over and above those costs which would otherwise be incurred in performance of the contract if no data were required. The estimated data prices shall not include any amount for rights in data. The Government's right to use the data shall be governed by the pertinent provisions of the contract.

DD FORM 1423-1, AUG 96

6-

NAVSEA SW023-AH-WHM-010 EIGHTH REVISION

USN/MSC REGISTRATION NO. MHE CLASS/LIFT CODE/TYPE SWL HOUR �!:..A����

METER

MARKINGS

TEST PARAGRAPH PROCEDURE RESULTS

FUEL SYSTEM

NCU fRAL.::, IA� I �n, 11..M (Fueled MHE)

WARNING DEVICES

(Powered MHE)

SPARK EMISSION

(Powered MHE)

STATIC DISCHARGE

(Electric and HS/Ordnance Pallet Truck)

CARRIAGE REACH & ROLLER

(Reach & Tier)

DRIVE CONTROL

(Powered Pallet Trucks)

BRAKE

(Except Straddle Carriers and Manual Pallet Trucks)

6-6.6 CONDUCTOR TYPE: TIRES STRAPS N/A

I

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

-- FEET ACCEPT REJECT N/A

BRAKE

(Straddle Carrier)

OPERATIONAL WEIGHT TEST 6-6.11 100% RATED LOAD ACCEPT REJECT N/A

(Forklift Trucks) HELD FOR 2 MINUTES:

OPERATIONAL WEIGHT TEST

(Powered Pallet Trucks)

KING PIN (Straddle Carrier)

LIFTING WEIGHT TEST

(Straddle Carrier)

OVERLOAD WEIGHT TEST

(Except Pallet Trucks and Straddle Carriers)

LIFT EYES 6-5.4 AFTER REPAIR/REPLACEMENT YES NO N/A

(Except Straddle Carriers) 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:

DATE

MONTHNEAR

FIGURE 6-1. MHE Safety Certification Form

6-5

6-6.1 VISUAL INSPECTION: ACCEPT REJECT

6-6.2 LEAK INSPECTION: ACCEPT REJECT N/A

6-6.3 OPERATIONAL INSPECTION: ACCEPT REJECT N/A

6-6.4 OPERATIONAL INSPECTION: ACCEPT REJECT N/A

6-6.5 VISUAL INSPECTION: ACCEPT REJECT N/A

RESISTANCE READING: LEFT -OHMS RIGHT_ OHMS N/A

6-6.7

OPERATIONAL INSPECTION:

ACCEPT

REJECT

6-6.8 OPERATIONAL INSPECTION: ACCEPT REJECT N/A

PEDAL FEEL: ACCEPT REJECT N/A

6-6.9.2 PARKING BRAKE: ACCEPT REJECT N/A

6-6.9.3 SAFETY BRAKING/DISCONNECT ACCEPT REJECT N/A

SYSTEM:

6-6.10 OPERATIONAL INSPECTION: ACCEPT REJECT N/A

6-6.12

6-6.13

100% RATED LOAD

HELD FOR 2 MINUTES:

VISUAL INSPECTION:

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

6-5.3 AFTER REPAIRS/MODIFICATIONS

AFFECTING LOAD-BEARING YES NO N/A

COMPONENTS

6-7 100% LOAD HELD FOR 2 MINUTES: ACCEPT REJECT N/A

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

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

Brakes (6-6.10)

X

Operational Weight Test (6-6.11)

X X X X X

Operational Weight Test (6-6.12)

X

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

NAVSEA SW023-AH-WHM-010 EIGHTH REVISION

Table 6-1. Periodic Tests for MHE

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.

6-4