Form No.

QHSE-ST104
METITO (OVERSEAS) QATAR W.L.L.
Revision
1
Date
25.04.2019
Permit To Work - Lifting Operations
Page
2

Part 1 GENERAL INFORMATION (To be filled by Permit Raiser )

Permit Number Date
Name and position of the executor of the job ( Precise name of COMPANY IF SUBCONTRACTOR ) :

Contractor Phone No :
Work location : Related PTW No : Date & Time Start :
Date & Time End :
Work description :
Weight of Item to be lifted:
Type of Lifting device ( mobile crane … ect ) - date of annual load test :
Rated Capacity of crane or hoist :
Name of Licensed / Trained Operators :
Name of Licensed / Trained Riggers :
Name of Responsible Supervisor , Coordinator :
Rigging equipment : ( Type / size / capacity/ date of last load test ) :
Shackles ( Type/Size/Capacity):
Part 2 LIFT EQUIPMENT CONDITION ( To be filled by Permit Authorizer)
Note: The following section of this permit must be completed by the Permit Authorizer before work is to proceed and only work listed above
may be completed.
Does the following equipment to be used during the works is in good condition, with current inspection tags and is fit for use ?:
Current lifting accessories Lifting accessories ( chain slings , webbing
inspection (Attach a copy of slings , rope sling, ring ,link , hook,
the last inspection and load ☐Yes ☐No ☐Yes ☐No ☐NA
shackle, eyebolt , swivel …. )
test ) Others :
Current lifting equipment Lifting equipment used ( crane, crab ,
Inspection (Attach a copy winch , pulley block, gin wheel , sheerleg,
☐Yes ☐No ☐Yes ☐No ☐NA
of the last inspection and excavator, dragline etc .. )
load test) Others :
Matting acceptable ☐Yes ☐No ☐NA Tag Line Installed ☐Yes ☐No ☐NA
Trained Operator,
Functional Test of Crane ☐Yes ☐No ☐NA Flagman(Designated),Rigger present (attached ☐Yes ☐No ☐NA
certificate )
Verify Load Capacity ☐Yes ☐No ☐NA Outriggers Extension Acceptable ☐Yes ☐No ☐NA
Others :
The following control measures have been assessed and implemented for the duration of the works:
Survey of electrical Training of concerned workers
systems hazards
☐Yes ☐No ☐NA ☐Yes ☐No ☐NA
Barricades for lift area in Rescue equipment and person
☐Yes ☐No ☐NA ☐Yes ☐No ☐NA
place available on site
Rescue plan prepared ☐Yes ☐No ☐NA Required PPE issued ☐Yes ☐No ☐NA
Lift area free of Slewing Area checked
☐Yes ☐No ☐NA ☐Yes ☐No ☐NA
obstructions
Head room checked ☐Yes ☐No ☐NA Access / egress identified ☐Yes ☐No ☐NA
Impacted personnel clear Communication procedure
☐Yes ☐No ☐NA ☐Yes ☐No ☐NA
of lift area established
Lifting plan available Daily prelift inspection
☐Yes ☐No ☐NA ☐Yes ☐No ☐NA
completed prior to lift
Lifting route plan Weather conditions acceptable:
☐Yes ☐No ☐NA ☐Yes ☐No ☐NA
The permit is immediately void if any items of the above section are checked “NO.”
Attached lifting plan with sketch or drawing ☐Yes ☐No
Permit Authorizer to fill the above section - Name & signature : HSE Assigned Person to review the compliance of above section : Name
& signature :
 Part 3 CHECK ON-SITE AND AUTHORIZE THE Lifting Operation
To be filled in by Permit Authorizer after check on-site
I confirm that all control measures are implemented and all workers understand the
requirements of this permit ☐Yes ☐No

I authorize the Lifting operations to start

☐Yes ☐No

Date &
Name /position Signature
time

To be filled in by Permit Raiser

I acknowledge the receipt of this Lifting operations Permit and understand its requirements. I confirm that the
requirements of this document will be fully briefed to all employees carrying out the work

Date &
Name /position Signature
time

Part 4 CLOSURE OF THE PERMIT

Work site have been inspected - The work is complete , all equipment returned and the site is safe .
To be signed by Permit Raiser : To be signed by Permit Authorizer:
Date and Time: Date and Time:

Signature: Signature:

Part 5 CANCELATION (IF REQUIRED)

REASONS :

No further work is permitted. A new permit must be issued prior to continuation of any further work

Name /position Signature Date & time