Forklift – Non-Standard / Critical Lift Plan

A lift plan will be prepared and reviewed for all lifts. If a standard lift plan is not present and does not cover the lift then this
plan or a specific lift plan must be created. All non-standard or critical lift plans must be prepared by a qualified LHES or PIC
who will approve and oversee the load handling activity. The person(s) completing this lift plan will be held accountable for
the safe operation of the lift. Maintain all lift plans for one year.

Work Permit (if required): Date: 11/2/17

Facility: 1310 Rankin
Lift Location: Building 6
HARC No.’s (if required): 20150120230159, 20150116170304
1. Description of Lift: (For Step by Step Procedures – use page 3)
Picking up parts from inside metal baskets and loading them into a lathe for processing

2. Load Details:
Overall dimensions: Length: 24” Width: 11” dia Height: 11” dia Load Weight:
Location of COG: Symmetrical X Non Symmetrical Unknown
Source of Load Weight: Mfg. Dwgs. X Est./Calculated Scale Ticket 300 lbs
Load Center (inches):
Verified COG is located as close and low to the back rest of fork tines as possible.
3. Forklift Attachment (if applicable): Attachment
Description: Forklift jib arm attachment – 88” hook reach Weight:
WLL: 2000 lbs Weight: 500 lbs
Verified Identification markings are clearly legible. 500 lbs @ 30”
Verified attachment is approved by the OEM and installed properly.
4. Rigging (if applicable): Nylon Sling Rigging
Sling Type and Size: Nylon Hitch Type & WLL: Single Choke Weight:
Shackle(s) & WLL: Eye Bolts &WLL:
Swivel Hoist Ring(s) & WWL: Other &WLL: N/A
X Verified angular loading on slings and hardware are known and taken into account on WLL
requirements.
5. Gross Load Weight: 300 lbs @ 88”
Gross Load Weight = Load Weight (#2) + Attachment Weight (#3) + Rigging Weight (#4)
6. Forklift Data and Capacity: Forklift
Make/Model: Toyota 8FGCU25 Fork Length: 48” Capacity:
Tire Type: Solid Forklift Capacity: 4500 lbs
*Truck Weight: 8500 lbs Load Center: 24”
*Load Weight: 800 lbs Load Moment: 88” 4500lbs @ 24”
*Combined Weight: 9300 lbs **Recalculated Capacity: 1050 lbs -
*Is tire type suitable for surface? Can surface withstand bearing pressures from forklift and load
500 lbs @ 30”
Y weight. (Bridge Plates and/or Dock Boards may be required.) =
**Does forklift rating need to be recalculated due to load center location? To calculate new rating: 1050lbs @ 88”
Original forklift load center x forklift load rating = inch pounds. Divide inch pounds into actual load
Y center to calculate revised load rating of forklift.
7. Percent of Capacity: *Use the weakest or smallest of #3, #4, or #6 to calculate 30%
*Real Lifting Capacity is (#3) Attachment WLL: (#4) Rigging WLL: (#6) Forklift Capacity:
the weakest or smallest of: 2000 2000 1050
Percent of Capacity = Gross Load Weight (#5) ÷ Weakest WLL (#3), (#4), or (#6). WLL x 100 = %

If Percent of Capacity is 75% or Greater - STOP!

This lift has to be approved by a qualified Load Handling Equipment Supervisor or PIC.
8. Lift Documents, Inspections, and Personnel Qualifications - Valid and Current:

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 Forklift – Non-Standard / Critical Lift Plan
Lift Documents: Work Permit X HARC
Rigging Gear: X Inspection Safe-for-Use
Attachment: X Inspection Safe-for-Use
Training Qualifications: X Forklift Operator X Rigger/Signaler LHE Supervisor / PIC
Lift Truck: X Pre-Op Inspection X Annual Inspection Lift Truck Manual
9. Tick if relevant, address each point during the pre-lift meeting (use pocket HARC for guidance):
Y Is travel route clear / accessible? X Ground conditions must support forklift and load weight?
N Is travel route distance or condition a concern? Y Is travel route clear of other equipment and personnel?
X Travelling uphill, downhill, or across a slope? B Is travel forward or reverse or both?
X Are there underground hazards? N Is plating / blocking over underground hazard necessary?
Is garage door raised high enough to prevent mast or load
Y Is overhead travel clearance adequate? X
collision?
Is load landing area clear and suitable for the Is blocking, stands, or racks present and capable of
Y Y
load weight? withstanding load weight?
N Any power lines nearby? X Are Electrocution hazard warning signs available?
N Are environmental conditions a concern? X Allowances to be made for wind, rain, snow, fog, etc.?
N Are there fire or explosive hazards? Y Fire ext. / emergency response numbers available?
N Are chemicals being lifted? Y Is spill containment or a clean-up kit available?
Limited clearance, confined, restricted work
Y X Are safety cones or tape available for barricading?
area?
Is there a need for attaching/detaching load at Are portable stairs, work platform, safety harnesses
N X
heights? available and safe-for-use?
Has communication been established and work zone
Y Will other activities be near or in the lift area? Y
identified?
N Is load center of gravity extremely high? Y Can fork tines be positioned above loads C.O.G?
Have operator and signal person agreed on communication
N Is load lift height is out of operator view? Y
method (e.g. hand, voice, radio)?
Is load secured to skids/pallets or if needed to the forks
Y Load securement requirements? Y using appropriate lashing methods (ratchet tie-down straps,
banding, shrink wrap, etc.)?
Does load need to be oriented in flight or will the
Y X Are tag lines long enough and safe-for-use?
load spin or pose a risk?
Have all loose tools, items, and excess rigging been stored
N Is there a potential for falling objects? X or removed? Has the work zone been barricaded to
prevent pedestrian access?
Will lift require additional load handling If tandem lift, using two forklifts, complete page 1 for each
N X
equipment, is this a tandem lift? forklift.
If tandem lift, using a forklift and overhead crane, an
X
overhead crane lift plan form must also be included.
If tandem lift, using a forklift and mobile crane, a mobile
X
crane lift plan form must also be included.
10. Pre-Lift Safety Meeting Attendees and Required Signatures:
Lift Plan prepared by (print/sign): Ryan Jones
Operator (print/sign):
Rigger (print/sign):
Signalperson (print/sign):
Safety Meeting conducted by (print/sign):
Pre-Lift Safety Meeting Attendees (List authorized work crew below):
1. 3.
2. 4.
Approved by LHE Supervisor / PIC (print/sign): Ryan Jones

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11. Step by Step Procedures:

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Tie a choke hitch around the middle of the part
Clear personnel from the immediate area
Bring the forklift and its attachment to the location of the part
Attach the sling to the hook of the forklift attachment
Lift the part out of the basket
Reposition the forklift to carry the part to the opening of the lathe
Immobilize the forklift to prevent additional movement
Handle the part to within the chuck of the machine
Close the chuck to secure the part
Disconnect the part from the forklift attachment
Clear personnel from the immediate area
Back the forklift out of the way and park it in its designated spot

© 2016 Safety Resources Unlimited, Inc. 4 LHE Lift Truck Non-Std/Critical Lift Plan 7.14.17