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Annex 21 3

Certificate of thorough examination of lifting appliance*/

Derricks used in union purchase*/loose gear*/wire rope*

as required by regulation 11 of the merchant shipping

(lifting operations and lifting equipment) regulations 2006

(* Delete as appropriate)

Name of Ship Certificate No. ...............

Official Number

Call sign

Port of Registry

Name of EmployerName of Equiment Owner

(if different to Employer)

Description

(State here the location, type and full description (including any distinguishing numbers or marks) of the lifting appliance,

derrick, loose gear, wire rope etc which was thoroughly examined for the issue of this certificate)

Name and address of company or Competent ..... ..... .... ..... ..... ..... .... ..... ..... ..... .... ..... ..... ..... .... ..... ..

Person carrying out the Thorough Examination ..... ..... .... ..... ..... ..... .... ..... ..... ..... .... ..... ..... ..... .... ..... ..

..............................................................................

I certify that on ............................................. (inser(inser(inser(inser(insert date)t date)t date)t date)t date)I car ried out a Thorough Examination of the Lifting Appliance*/Derricks

Used In Union Purchase*/Loose Gear*/Wire Rope (*Delete as appropriate), referred to above, as required by Regulation

11 of the Merchant Shipping (Lifting Operations and Lifting Equipment) Regulations 2006 and:-

(a) * Found no defects and/or deficiencies

or(b) * Found the following defects and/or deficiencies which are/are not considered to be, or have the potential

to become, a danger to person :-

Signature: ..................................... Name ( in c apitals): .........................

Date: ............................................... P lace: .......................................................

Notes:

1. A copy of this certificate shall be provided to the employer and, where the employer is not the owner of the equipment

etc e.g. because it is hired or leased, to the person from whom the equipment etc has been hired or leased.

2. Where the person carrying out the Thorough Examination identifies any defects and/or deficiencies in the equipment etc

which in his opinion are or could become a danger to persons he shall for thwith make a report to the employer and,

where appropriate, to any person from whom the equipment etc has been hired or leased, and

3. Send a copy of the repor t as soon as is practicable to the relevant enforcing authority as indicated in Regulation 11.

4. Where an employer or the owner of any equipment etc has been notified of any deficiency under paragraph (2) or (4),

he shall ensure that any condition liable to result in a dangerous situation is remedied in good time, and that any lifting

equipment is not used unless and until the defect and/or deficiency is rectified.