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Periodic Hydraulic Elevator Test 2 (Office of the Chief Information Officer)

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Data Plate Information
Capacity: lbs
Speed: fpm
Governor
Tripping Speed: fpm
Loaded
Working Pressure: psi
Front Door (2000 or later) (Code zone)
Closing Speed: sec
Rear Door (2000 or later) (Code zone)
Closing Speed: sec
Controller
Manufacturer:
# of Front
Landings:
# of Rear
Landings:
Total # of
Landings:
REF
#
Category 1
Is Test
Satisfactory?
1
8.6.5.14.1 Relief Valve Verification of Setting and System Pressure Test: Relief Valve Pressure: psi
P F N/A
2
8.6.5.14.2 Hydraulic Cylinders and Pressure Piping
P F N/A
3
8.6.5.14.3(a) Normal and Final Terminal Stopping Devices
P F N/A
4
8.6.5.14.3(b) Governors
P F N/A
5
8.6.5.14.3(c) Safeties Type (no load) A B C
P F N/A
6
8.6.5.14.3(d) Oil Buffers
P F N/A
7
8.6.5.14.3(e) Firefighters’ Emergency Operation
P F N/A
8
8.6.5.14.3(f) Standby or Emergency Power Operation (no load)
P F N/A
9
8.6.5.14.3(h) Emergency Terminal Speed-Limiting Device & Emergency Terminal Stop Device
P F N/A
10
8.6.5.14.3(i) Low Oil Protection Operation
P F N/A
11
8.6.5.14.4 Flexible Hose and Fitting Assemblies
P F N/A
12
8.6.5.14.5 Pressure Switch
P F N/A
13
8.6.5.14.6 Power Operation of Door System: Door Closing Speed (Code Zone): Front sec; Rear
sec; Door Closing Force: Front lbf; Rear lbf
P F N/A
14
8.6.5.14.7 Slack-Rope Device
P F N/A
15
8.6.4.19.10 Functional Safety of SIL Rated Devices
P F N/A
16
8.6.4.19.15 Emergency Communications
P F N/A
17
8.6.4.19.16 Means to Restrict Hoistway or Car Door Opening
P F N/A
18
Miscellaneous Concerns – list on page 2
Y N
Category 5 – Must complete Category 1 with this section
19
8.6.5.16.1 Car: Gov jaw trip: fpm; Gov overspeed switch: fpm; Gov Safety slide distance: in;
Safety release carrier pull force: lbf; Gov pull through force: lbf
Counterweight: Gov jaw trip: fpm; Gov overspeed switch: fpm; Safety slide distance: in;
Safety release carrier pull force: lbf; Gov pull through force: lbf
P F N/A
20
8.6.5.16.2 Coated Ropes
P F N/A
21
8.6.5.16.3 Wire Rope Fastenings
P F N/A
22
8.6.5.16.4 Plunger Gripper
P F N/A
23
8.6.5.16.5 Overspeed Valves
P F N/A
24
8.6.5.16.6 Freight Class C2 Full Loading
P F N/A
Category 3 – Must complete Category 1 with this section
25
8.6.5.15.1 Unexposed Portions of Pistons
P F N/A
26
8.6.5.15.2 Pressure Vessels
P F N/A
The tests were performed in compliance with ASME 17.1, A117.1, and Iowa Code 89A and in accordance with the code in
effect at time of the original installation and/or any applicable alteration(s). Complete page 2 for each failed item.
Periodic Hydraulic Elevator Test
Iowa Division of Labor
Elevator Safety
150 Des Moines Street
Des Moines, IA 50309
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
elevators@iwd.iowa.gov
www.iowaelevators.gov
State ID
Check one: Annual
3 year 5 year
Last Category 1
Test Date:
Last Category 5
Test Date:
Building Name
Owner Name
Address
Company Performing Test Company Address, City, State, Zip Date
Individual Performing Test Signature Witness (if required) QEI #
Page 1 of 2
click to sign
signature
click to edit
Unsatisfactory Test Component
REF #
(Page 1)
Part
Violative
Condition
Suggested
Remedy
Corrected
During
Test
Comments
Part
Inside Car
01 Emergency Stop Switch
02 Alarm System
03 Car Phone
04 Car Enclosure
05 Side Emergency Exit
06 Car Door/Gate
07 Car Door/Gate Contact
08 Door Reopening Device
09 Car Sill to Hatch Sill
10 Car Floor
11 Car Door Gibs
12 Car Button Station
13 Car Lighting
14 Emergency Lighting
15 Car Mirror
16 Certificate Frame
Hoistway
17 Hoistway Doors
18 Hoistway Door Gibs
19 Hoistway Door
Reinforcements
20 Hoistway Door Safety
Retainer
21 Vision Panel
22 Interlocks
23 Parking Device
24 Hall Button Station
25 Indicators
26 Car Door Restrictor
Top of Car
27 Top Emergency Exit
Cover
28 Governor Release
Carrier
29 Door Hangers &
Connectors
30 Door Operator
31 Normal Limits
32 Final Limits
33 Guide Shoes / Roller
Guides
34 Counterweight
35 Hoistway
36 Electrical Wiring
37 Pipes and Ducts
38 Overhead & Deflector
Sheave
39 Traveling Cable &
Junction
40 Car Top
Machine Room
41 Machine Room
42 Machine Room Door
43 Controller—Selector
44 Reverse Phase Relay
45 Traction Sheave
46 Governor
47 Governor Switch
48 Drum
49 Pump Unit
50 Drum Machine Limit SW
51 Generator
52 Slack Rope Switch
53 Hoist Cables
54 Governor Ropes
55 Car Counterweight
Rope
56 Drum Counterweight
Rope
57 Hoist Machine
58 Hoist Motor
59 Worm / Gear / Bearings
60 Machine Brake
61 Lighting Machine Space
62 Machine Disconnect SW
63 Commutator
64 Motor Brushes
65 Unintended Car
Movement
66 Emergency Brake/Rope
Gripper
67 Communication
68 Maintenance Log
69 Code Data Plate
Pit
70 Pit
71 Pit Light
72 Pit Stop Switch
73 Car Guide-Rails &
Brackets
74 Cwt Guide-Rails &
Brackets
75 Buffers
76 Car Safety & Tail Rope
77 Underside Platform
78 Tension Weight
79 Comp / Chains / Ropes
/ Switch
80 Counterweight Runby
81 Counterweight Runby
Signage
82 Plunger Gripper
Miscellaneous
83 Entire Device
84 Miscellaneous
Violative Conditions
A Altered
B Insufficient
C Padlocked
D Unsecured
E Rubbing
F Lost Motion
G Improper Fuses
H Worn
I Damaged
J Misaligned
K Rusted
L Defective
M Missing
N By-Passed
O Dirty
P No Means of Access
Q Unguarded
R Illegal
S Not Fire Retardant
T Unlabeled
U Device Not Tagged
V Not Level
W Unlocked
X Inoperative
Y Oil Leak
Z Water Leak
AA Carbon Buildup
BB Expired Tag
Suggested Remedy
01 Adjust
02 Clean
03 Install Guards
04 Patch
05 Perform Test
06 Properly Secure
07 Provide
08 Regroove
09 Remove
10 Repair
11 Replace
12 Reshackle
13 Seal
14 Shorten
15 Tag Device
16 Provide Means of
Access
17 Reinspection Required
600-004
02.21.2020
Page 2 of 2
State ID #:
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Periodic Hydraulic Elevator Test 2 (Office of the Chief Information Officer)

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Completed 13 August 2020

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