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Lifting Plan, Risk Assessment Lifting Method Statement FORM

Details of the Job


Project :

Contract No. :

Site/location :

Date :

Document Ref. :

Rev. :

Appointed Person carrying


out the Assessment:

Name
Day / Month / Year

Signature

Day
Issued by

Reviewed by :

Nam

Authorised by :

Nam

LOLEM Details:

Name

Phone:

LLO Details:

Name

Phone:

Description of the lift:


NB 50% reduction in load capability if man basket is used.

Details of Loads
Load Position 1

Load Position 2

Weight:
Dimensions:
Position of the C. G.:
Height of lift (worst case only):
Max. radius (worst case only):
Date of lift:
Time of lift:
Monetary value of load:
C. G. stands for Center of Gravity for other abbreviations refer to Heavy Lifting Safe Guide Line Ref. No. PMF-015-HSE-150

Details of Crans Participating in the Lift


1st

2nd

Make & model:


Capacity:
Jib length:
Outrigger spread:
Outrigger load:
Max. ground bearing capacity:
Counterweight:
Weight of crane:

Ground Conditions (Visual assessment)


Access/Egress for crane and
transport:

Doc. Ref. No.: PMF-015-HSE-151 v1

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Lifting Plan, Risk Assessment Lifting Method Statement FORM


Lifting position:

Lifting Accessories
Slings (wire rope):

Slings (webbing):

Slings (chains):

Shackles:

Other Accessories:

Other Accessories:

Risk

Severity

Likelihood

Proximity Hazard

Present?
Yes / No

Risk Assessment

Control Measures to

Overhead power lines


Other hazards identified
Other overhead obstacles
Underground services
Excavations
Unstable/ Soft ground
Hazardous chemicals/materials
Confined working area
Restricted access - width
Restricted access - height
Other vehicles
Slinging difficulties
Sharp edges
Top heavy
Others

Operational Requirements:

Site Provisions:

Doc. Ref. No.: PMF-015-HSE-151 v1

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Lifting Plan, Risk Assessment Lifting Method Statement FORM

Remarks:

Authentication

Relevant Drawings, Plans and/or Sketches List


010203040506-

Lifting Accessories

- The lifting accessories, as detailed previously, will be provided complete with all statutory documentation

- The lifting accessories will be inspected/tested periodically as detailed in Heavy Lifting Safe Guideline R
PMF-015-HSE-150 and SWL should be shown clearly on each piece.

- The lifting accessories will be visually checked before each lifting operation. Damaged parts/accessorie
be immediately removed from operations and reported as detailed in Heavy Lifting Safe Guideline Ref.
No. PMF-015-HSE-150

Weather Conditions

- The Appointed Person (LLO) or, in his absence, the Crane Supervisor, will ensure that the lifting operatio
takes place if the weather conditions are within the limits recommended by the crane manufacturer.

- The Appointed Person (LOLEM, LLO or, in his absence, the Crane Supervisor), will ensure that weather
information are obtained for at least 3 days in advance.

Doc. Ref. No.: PMF-015-HSE-151 v1

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Lifting Plan, Risk Assessment Lifting Method Statement FORM


Ground Conditions

- No heavy lifting operation shall start unless assurances have been obtained that the ground can withstan
the load exerted from the lifting equipment and the job to be lifted.

Lifting Teamwork
Title

Name

Title

Appointed Person
Crane Supervisor
Crane Operator(s)

Slinger(s)

Signaller(s)
Appointed Persons Acceptance of Responsibilities

I confirm that the lifts have been planned and will be carried out in accordance with current legislation and British
Standard 7121 and that I accept responsibility for the preparation of this Risk Assessment and Lifting Plan.
Name / Signature
Signed:
Date:

day

Crane Supervisors Acceptance of Duties

I confirm that I have been fully briefed on the contents of this Risk Assessment and Lifting Plan and that I accept
the duty of ensuring that the lift(s) will be carried out in accordance with the method and procedures set out in this documen
Name / Signature
day
Signed:
Date:

Doc. Ref. No.: PMF-015-HSE-151 v1

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Lifting Plan, Risk Assessment Lifting Method Statement FORM

Day
Issued by

Position 2

2nd

/ Month / Year

Name

/ Signature

Name

/ Signature

Mob.:
Mob.:

Load Position 3

3rd

Doc. Ref. No.: PMF-015-HSE-151 v1

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Lifting Plan, Risk Assessment Lifting Method Statement FORM

Control Measures to Avoid or Reduce Risk

Doc. Ref. No.: PMF-015-HSE-151 v1

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Lifting Plan, Risk Assessment Lifting Method Statement FORM

ll statutory documentation.

y Lifting Safe Guideline Ref No.

amaged parts/accessories should

fting Safe Guideline Ref.

ure that the lifting operation only

e crane manufacturer.

), will ensure that weather forecast

Doc. Ref. No.: PMF-015-HSE-151 v1

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Lifting Plan, Risk Assessment Lifting Method Statement FORM

at the ground can withstand

Name

nsibilities

tion and British


day

/ Month / Year

uties

d that I accept
es set out in this document.
day / Month / Year

Doc. Ref. No.: PMF-015-HSE-151 v1

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