Mobile Crane Permit, Lifting Plan Method & Risk Assessment
(For regulation covering issue of this permit, Refer to Labour Law For The Private Sector, 1977 and Legislation Relating Thereto GS/ILO Regulations and BS
7121
Project Name Date
Site / Location Revision Issued By
Permit Number From To
Contact Phone
Site Contact Phone
Description of lift:
Details of Loads
Weight Date of lift:
Dimension Time of lift
Position of Cof G Monetary value of load
Height of lift (worst case only) Max. radius (Worst case only)
Details of Cranes
Make & model Max. ground bearing capacity
Capacity Counterweight
Jib length Weight of crane
Outrigger spread Outrigger load
Ground Conditions (Visual assessment)
Access/Egress for crane &
transport
Lifting position:
Identification of Hazards
Proximity Hazard Present? Proximity Hazard (cont) Present?
Overhead power lines Building
Other overhead obstacles Other hazards identified
Underground services
Excavations
Unstable / Soft ground Load Hazard Present?
Hazardous chemicals/ materials Slinging difficulties
Confined working area Top heavy
Restricted access - width Other hazards identified
Other vehicles
Complete checklist below to ensure a safe lift is planned
The load weight is confirmed known.
The load hook is directly over the load center of gravity.
Boom angle, boom length, lift radius, and the crane capacity are known.
Outrigger pads are fully extended and blocking is sufficient for the load.
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Complete checklist below to ensure a safe lift is planned
Tires are clear of the ground and the crane is level.
Ground, soil, and/or pavement is confirmed to have capacity for the imposed load.
Rigging equipment has been inspected and in safe working condition.
All obstacles and obstructions have been identified.
A final check will determine the wind speed is within approved limits for this lift.
A signal method of communication has been determined between the crane operator and the signalman.
An individual has been designated to observe for obstructions and unauthorized personnel.
The crane operator meets MOL qualifications requirements to operate the crane.
Verify a "competent person" is to inspect prior to use and during use, all slings, fastenings, and attachments for damage or defects. Damaged or
defective equipment shall be immediately removed from service.
Verify a "competent person" is to inspect all crane equipment and machinery prior to use and during use to ensure it is in safe operating condition.
Any deficiencies shall be repaired prior to continued use.
Assessment of Risk
Hazard Present Risk Action to Avoid or Reduce Risk
Personnel Protective Equipment (PPE)
Steel-toed shoes Required for all personnel involved with lift activity to protect from crushing of feet/toes.
Gloves Required when handling materials or guiding a load.
Required for all personnel under the bridge of a moving bridge crane and whenever the potential
Hard hat
For head injury exists (e.g. Working near a load where the head could contact load).
Required when potential exists for objects to fall into eyes (e.g.. Working under bridge of crane and
Safety glasses
looking up).
Hi Vis
Other (specify)
Sketch intended to assist in clarification of crane set-up in relation to load, surrounding structures, rigging, and lay-down location. To
be completed at the discretion of the Lift Planner.
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Appointed Person's Acceptance of Responsibilities
I confirm that the lifts have been planned and will be carried out in accordance Signed Date Time
with current legislation (Order No. 14/1977 SHE-SM 25/24) and British Standard
7121 and that I accept responsibility for the preparation of this Risk Assessment
and Method Statement.
Cranes Supervisor's Acceptance of Duties
Signed Date Time
Issuing Authority
Signed Date Time
I have discussed the terms of this permit with the person responsible for the
work and now issue it
Issuing Authority
Signed Date Time
I am satisfied this permit can be cancelled.
Permit to be kept at work site. Permit must be returned to the issuing authority when job is completed or stopped.
Reset Print
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