This section documents the complete qualification and assignment details for all personnel involved in the critical lift operation. All fields marked mandatory must be completed before proceeding to subsequent sections.
Crane Operator Full Legal Name
Crane Operator Certification Number
Certification Expiry Date
Is the certification valid for at least 30 days beyond this operation date?
Total Crane Operating Hours (All Types)
High-Capacity Lift Experience Hours (>75% Rated Capacity)
Does the operator have documented experience with this specific crane model?
Last Medical Fitness Assessment Date
Operator Proficiency Rating for This Lift Complexity (1=Novice, 5=Expert)
Signal Person Full Legal Name
Signal Person Qualification ID
Number of Additional Riggers in Team
List all rigging team members with their specific roles and qualifications:
Pre-Shift Safety Briefing Date & Time
Was a documented lift plan review conducted with all team members?
Primary Radio Communication Channel/Frequency
Emergency Assembly Point Location
On-Site Emergency Contact Number
Comprehensive assessment of ground conditions and outrigger support systems is mandatory for high-capacity lifts. This section verifies that the ground can safely support all crane loading conditions including dynamic factors.
Soil Classification Based on Geotechnical Report
Cohesive Clay (High Bearing)
Cohesive Clay (Low Bearing)
Granular Sand (Compact)
Granular Sand (Loose)
Granular Gravel (Well-graded)
Granular Gravel (Poorly-graded)
Bedrock (Weathered)
Bedrock (Sound)
Fill Material (Engineered)
Fill Material (Non-engineered)
Other
Most Recent Geotechnical Assessment Date
Geotechnical Engineer License/Registration Number
Has the ground bearing capacity been verified within 50 meters of all outrigger positions?
Calculated Maximum Ground Pressure (kPa or psi)
Verified Ground Bearing Capacity (kPa or psi)
Is the safety factor for ground bearing capacity at least 1.5:1?
Outrigger Pad Configuration & Inspection Details
Outrigger Position ID | Pad Length (meters) | Pad Width (meters) | Pad Thickness (cm) | Pad Material | Pad Structurally Sound? | Ground Condition Beneath Pad | Distance to Nearest Excavation (meters) | |
|---|---|---|---|---|---|---|---|---|
Front Left | 3 | 3 | 15 | Steel-Composite | Yes | Compacted Gravel | 12.5 | |
Front Right | 3 | 3 | 15 | Steel-Composite | Yes | Compacted Gravel | 15 | |
Rear Left | 3 | 3 | 15 | Steel-Composite | Yes | Native Soil | 8 | |
Rear Right | 3 | 3 | 15 | Steel-Composite | Yes | Native Soil | 10 | |
Rate Ground Stability at Each Outrigger Position (1=Poor, 5=Excellent)
Front Left Pad Position | |
Front Right Pad Position | |
Rear Left Pad Position | |
Rear Right Pad Position |
Are all outrigger pads positioned on level ground within manufacturer tolerance (typically ±1°)?
Has a structural engineer approved all outrigger positions when located on temporary structures or near excavations?
Final Ground & Outrigger Inspection Completion Time
I confirm that all outrigger beams are fully extended per manufacturer specifications and locked in position.
This section requires precise calculation and verification of all load parameters against crane capacity charts. All measurements must be confirmed by both the operator and rigging supervisor before lift authorization.
Load Description & Unique Identifier
Gross Load Weight (kg or lbs)
Detailed Load Weight Breakdown & Rigging Components
Component Description | Weight (kg or lbs) | Weight Verification Method | Certificate/Tag Number | |
|---|---|---|---|---|
Primary Load Item | 16500 | Manufacturer Data Plate | MDP-2024-7741 | |
Rigging Gear (Slings, Shackles) | 850 | Calculated Sum | RG-SET-12 | |
Spreader Beam Assembly | 650 | Weighbridge Certificate | WB-2024-0923 | |
Tag Lines & Accessories | 125 | Estimated | N/A | |
Contingency Allowance (5%) | 375 | Calculated Percentage | N/A | |
Total Calculated Gross Load Weight
Has the load weight been verified by independent weighing within the last 7 days?
Load Radius from Crane Center to Load Center of Gravity (meters)
Boom Length Required (meters)
Boom Angle at Pick Position (degrees)
Crane Model & Configuration
Manufacturer Rated Capacity at Specified Radius & Configuration (kg or lbs)
Calculated Safety Factor (Rated Capacity ÷ Gross Load)
Is the safety factor at least 1.25:1 for single crane lifts or 1.5:1 for tandem lifts?
Is this a tandem or multi-crane lift operation?
Load Complexity & Stability Rating (1=Simple, 5=Highly Complex)
Most Recent Load Moment Indicator (LMI) Calibration Date
Has the capacity chart been verified as the correct revision for this crane serial number?
I confirm that the load center of gravity has been marked and communicated to all team members.
Real-time environmental conditions and hazard zone verification is critical for safe lift operations. This section must be completed immediately prior to lift commencement and monitored continuously throughout the operation.
Current Wind Speed at Load Height (m/s or mph)
Maximum Permissible Wind Speed for This Load (m/s or mph)
Is current wind speed below 75% of maximum permissible?
Wind Speed Monitoring Device Model & Location
Last Wind Speed Reading Timestamp
Overhead Obstacle Inventory & Clearance Assessment
Obstacle Type | Obstacle Description | Vertical Clearance (meters) | Horizontal Distance (meters) | Voltage/Hazard Rating | Energized During Lift? | Mitigation Measures | |
|---|---|---|---|---|---|---|---|
Power Line | 345kV Transmission Line | 25.5 | 18 | 345kV | Yes | De-energized per Utility Co. #8892 | |
Structure | Adjacent Building Parapet | 42 | 12.5 | N/A | Barricade & Spotter Monitoring | ||
Crane | Tower Crane Jib | 35 | 22 | N/A | Coordinated Movement Plan | ||
Are all overhead obstacles maintaining minimum approach distances per safety standards?
Exclusion Zone Radius from Load Path (meters)
Is the exclusion zone clearly marked with physical barriers and warning signage?
Select all exclusion zone control measures implemented:
Hard barricades (concrete barriers)
Soft barricades (tape/fencing)
Warning signs at 10m intervals
Spotters at all access points
Public address announcements
Drone surveillance
Other
Does the lift path cross any active public walkways or roadways?
Minimum Distance from Load to Nearest Uninvolved Personnel (meters)
Are all spotters positioned with clear line-of-sight to both load and operator?
Environmental Condition Confidence Assessment (1=Very Unhappy/Unsafe, 5=Very Happy/Safe)
Weather Forecast Source & Next Update Time
I confirm that a continuous weather monitoring protocol is active for the duration of this lift.
This final authorization section requires joint verification by the Master Rigger and Site Safety Lead that all prerequisites have been met, risks have been adequately controlled, and the lift operation may proceed. This sign-off represents formal acceptance of residual risk.
Lift Plan Document Reference Number
Lift Plan Approval Date & Time
Has a comprehensive risk assessment been completed for this specific lift operation?
Select all pre-lift verification checks completed:
Load weight independently verified
Crane capacity chart double-checked
Ground conditions inspected
Weather conditions assessed
All personnel briefed
Exclusion zone established
Emergency services notified
Communication systems tested
Rigging gear inspected
Other
Are emergency services (fire, medical) aware of the lift operation?
Describe the specific Stop Work Authority protocol and conditions that would trigger immediate cessation:
Is a rescue plan in place for personnel at height or in case of equipment failure?
Planned Lift Start Time
Estimated Lift Duration
Will continuous monitoring be maintained throughout the entire lift operation?
Post-Lift Inspection Requirements & Equipment Release Criteria:
Overall Operational Readiness Score (1=Not Ready, 5=Fully Ready)
Master Rigger Full Name & Credential Number
Master Rigger Digital Signature
Master Rigger Sign-Off Timestamp
Site Safety Lead Full Name & Credential Number
Site Safety Lead Digital Signature
Site Safety Lead Sign-Off Timestamp
Has the Site Manager/Project Director been notified and provided final authorization?
I acknowledge that this permit is valid only for the specific lift parameters documented and expires immediately upon completion of the lift or at the end of the shift, whichever occurs first.