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Elevator Safety Passed inspection Passed test Failed inspection (State of Iowa - OCIO)

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Annual Acceptance 5-Year Alteration
Complete all items at time of acceptance, alteration or 5-year tests. Write “N/A” if not applicable. Form will be returned if not
completed. Submit copy of step/skirt performance index computer printout with this report.
Iowa Division of Labor
Elevator Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
elevators@iwd.iowa.gov
www.iowaelevators.gov
Escalator Test & Inspection Report
ASME A17.1 – Sections 8.10.4 and 8.11.4
State ID:
Date tested:
Passed inspection
Passed test
Failed inspection
Failed test
Escalator Information
Owner name
Building name
Owner address
Location address
City
Zip
City
Zip
Manufacturer
Installed code edition
Serial #
Normal travel of direction:
. up down
Rated
Speed: fpm
Capacity: lbs
Brake torque
data plate:
(1983 or later)
Brake torque
Actual:
Calibration
Certificate #:
1. ASME A17.1 Section 8, step/skirt performance index
The escalator skirt shall not be cleaned, lubricated or otherwise modified in preparation for testing. The escalator instantaneous
step/skirt performance index measurements (ASME A17.1 Rule 8.6.8.3) shall be recorded at intervals no larger than 150 mm (6 in)
from each side of two distinct steps along the inclined portion of the escalator, where the steps are fully extended. Test steps shall
be separated by a minimum of 8 steps.
Step
1 left:
Step
1 right:
Step
2 left:
Step
2 right:
Skirt deflectors:
Yes No
2. ASME A17.1 Section 8, clearance between step and skirt (loaded gap installed under ASME A17.1d-2000)
Loaded gap measurements shall be taken at intervals not exceeding 300 mm (12 in) in transition region (ASME A17.1 Rule 8.6.8.2)
and before the steps are fully extended. These measurements shall be made independently on each side of the escalator.
Top
landing left:
Top
landing right:
Bottom
landing left:
Bottom
landing right:
3. ASME A17.1 Section 8, clearance between step and skirt (unloaded gap installed prior to ASME A17.1d-2000)
Unloaded gap measurements shall be taken at several locations through entire travel. Gaps cannot exceed maximums found in
ASME A17.1 Rule 8.6.8.2.
Top
landing left:
Top
landing right:
Bottom
landing left:
Bottom
landing right:
Top comb-step impact device (if provided)
Center: lbs
Right: lbs
Left: lbs
Bottom comb-step impact device (if provided)
Center: lbs
Right: lbs
Left: lbs
600-014
02.21.2020
?
PASS = meets requirements; FAIL = comment at the bottom of this checklist; N/A = not applicable
Item
PASS
FAIL
N/A
Item
PASS
FAIL
N/A
1. General fire protection
16. Caution signs
2. Geometry
17. Deck barricades and antislide
3. Handrails
18. Steps and upthrust device
4. Entrance and egress ends
19. Operating and safety devices
5. Lighting
20. Skirt obstruction device
6. Brake torque actual using certified wrench
21. Egress restriction (rolling shutter) device
7. Speed governor
22. Speed
8. Machinery, space access, lighting, receptacle
and condition stop switch
23. Broken drive chain and disconnected motor
. safety switch
9. Step/skirt clearance, panels and performance
index
24. Handrail systems and safety devices (speed-
. stall device)
10. Outdoor protection
25. Broken step chain device
11. Steps and upthrust device
26. Missing step device
12. Balustrades
27. Steps, step chains and trusses
13. Controller and wiring
28. Reversal stop switch
14. Drive machine and brake
29. Code data plate
15. Response to smoke detectors
30. Step lateral displacement devices
Each item is referenced in ASME A17.2 – 2014 guide for inspection
Page 2
State ID#: Date Tested: Escalator Test & Inspection Report Continued
Reference the number above that failed to meet requirements and explanation of why it did not prove satisfactory
#
Explanation
Comments
4. ASME A17.1 section 8 metal tag with the test date, the requirement number requiring the test and the name of the
person or firm performing the test shall be installed in each machine room.
I certify that the above tests were performed in compliance with ASME A17.1 section 8.6
Company performing test
Name
Phone number
Date
Elevator company address
City
State
Zip
Test witnessed by (name)
Date
Phone number
QEI provider
QEI number
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Elevator Safety Passed inspection Passed test Failed inspection (State of Iowa - OCIO)

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Completed 20 July 2020

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