Standard Lift Plan Form

(To be filled out prior to lift.)

Date_____/_____/_____ Operator_______________ Crane Make________ Model________ Trained on crane? Yes No

Facility____________ Area_________ Job Description___________________ Operator Signature____________________________

WEATHER CONDITIONS
Day Night Clear Cloudy Lightning Raining Restricted Visibility
Estimated wind speed_______ (No operations in winds above 20 mph)
GROUND CONDITIONS
Asphalt Concrete Other______________ Type of Soil_______________
CRANE CONFIGURATION
Load Moment Indicator (LMI) working? Yes No LMI Yes No
Jib / Extensions Stowed Erected N/A
OUTRIGGERS
On rubber Retracted and down Mid extension and down Fully extended and down
MATS/ CRIBBING NEEDED?
Yes No If yes, what type: Wood Composite Metal Other

Complete the following using worst case scenario calculations (Consider boom length, radius, weight)
Boom Configuration From Load Chart As Per Manufacturer
Lift 1 Lift 2 Lift 3 Lift 4 Lift 5
Boom length
Radius
Load weight provided
Load weight actual or estimated?
Gross Load (use table below to calculate)
Gross Capacity
Percentage of Gross Capacity (Gross Load Gross Capacity = %)
Actual LMI

LOAD & ACCESSORIES WEIGHT A CRITICAL LIFT PLAN IS REQUIRED IF ANY OF THE CRITERIA
LOAD WEIGHT
BELOW ARE MET:
AUX BALL

The gross load being lifted or the actual LMI weight exceeds 75% of the gross
MAIN BLOCK
capacity.
JIB

For a lift involving more than one crane - Total gross load weight must not
EXTENSIONS exceed 75% of either cranes gross capacity.
AUX BOOM HEAD
Lift within 20 feet of energized power lines (See Mobile Cranes Program - 4.7)
RIGGING
Hoisting personnel (Permit required. See Mobile Crane Program - Appendix B)
CRANE WIRE ROPE
Lifting over tanks or pressure vessels containing ammonia, sulfuric acid,
OTHER gasoline, diesel, fuel-oil, or propane.
GROSS LOAD TOTAL
When management determines it is required.
(ADD ALL ABOVE ITEMS) Is this a critical lift? Yes No
If YES, a Critical Lift Plan is required attach this plan to the Critical Lift Plan.

Phosphate Mobile Crane Program Lift Plans Addendum - Appendix A1

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