Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
Permit / Checklist
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Job Number
- 317901
- 317906
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Date
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Work Location
- Segment 1
- Segment 6
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Duration
All conditions below must be satisfied prior to use of any crane or Derrick for hoisting personnel
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1. The highest level of job site management will determine and certify that conventional means of reaching the work site, such as personnel hoist, ladder, scaffold, aerial lift or elevating work platform would be more hazardous, or is not possible because of structural design or work site conditions.
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2. Task Description
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3. Crane Description
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Equipment number
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Date of last inspection
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Make
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Model
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4. Maximum operational radius required
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5. Fifty percent of rated capacity for above radius
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6. Total weight of loaded platform (including rigging)
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7. All crane safety devices and components are functioning properly
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Power controlled load lowering
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Positive anti-two block device
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Brakes and locking device
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Boom angle indicator
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Telescoping boom length indicator
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Outriggers fully deployed
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8. Rigging has been inspected and meets all safety requirements
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9. Personnel platform inspected and meets all safety requirements
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Pre-lift meeting with the following personnel completed.
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Crane Operator
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Signal person
Workers to be lifted
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Add signature
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Supervisor
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11. Has proof test at 125% been completed?
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12. Has trial lifts been completed?
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Note: if crane changes location, a new permit must be completed
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13. Has post proof and trial lift inspection been completed
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14. Proof test weight removed before personnel use
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15. Personnel in lift will be 100% tied off?
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16. AdditIonal info (I.e. Weather, time)
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17. Certification and approval by Project Manager
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Date:
