Department of Labor and Industries Elevator Section PO Box 44480 Olympia WA 98504-4480 Phone: (360) 902-6130 FAX (360) 902-6132
www.Lni.wa.gov/TradesLicensing/Elevators
ELEVATOR FIVE YEAR SAFETY TEST REPORT
Send originals to above address File a separate report for each car and counterweight tested. Car 1. Building name 2. Building Address 3. Elevator Conv # 4. Capacity 5. Governor Type 6. Condition of Governor 7. Governor Data Plate 8. Governor Rope Trip Speed Type Yes Yes Yes Bail Owner ID Speed Flyball Centrifugal Jaw Type Pull Through Size No No No Where located? Type of Machine Rail type Other Condition Pull Out Condition or Counterweight
9. Governor Rope Cable Tag attached? 10. Governor Overspeed Switch? 11. S.O.S Switch? 12. Governor Tension Frame condition 13. Releasing Carrier condition 14. Type of Safeties A B
C
15. Condition of Safeties & Actuating Rods 16. Buffer Type
17. Buffer Data Plate
Standard
Min Load
Reduced Stroke
Max Load
Other
Max speed
Car
Car
Cwt
Cwt
18. Buffer Switch 19. Run by Car
Yes
No
Buffer Oil Level Cwt Yes No (dimension in inches) Tags attached? Yes No Inches
20. Have all annual tests been completed?
F621-051-000 elevator five year safety test report 05-2006
21. Length of governor rope movement for safety jaws to touch rail
22. Clearance between the safety jaws and rail 23. Governor tripped at? 24. Overspeed switch trips at 25. Governor rope pull thru 26. Safeties tested with fpm Is the governor sealed? Yes
Inches No fpm lbs fpm Yes feet No inches
fpm Governor switch trips at lbs lbs at Releasing carrier pull out
27. Did the car stop level (3/8" per foot DBG maximum?) 28. Length of safety rope pull out 29. Number of turns remaining on drum 30. Safety jaw rail marks (average of 4 marks) 31. Oil buffer test: Car buffer with Counterweight buffer with no load 32. Did plunger return within 90 seconds? Yes No Yes Yes Yes No Yes Yes Yes
feet lbs at
inches fpm fpm
Car No No Car No No No
Cwt Bottom? Yes No
33. Were final limits actuated during the buffer test? 34. Did buffer switch actuate? Did buffers fully compress? 35. Was brake tested with 125% of rated load? 36. Did brake hold? 37. Are load weighting switches properly set? 38. Condition after test
Cwt
39. Have unsatisfactory conditions been corrected? If not, explain
40. Have all test tags been applied? Governor Yes No Releasing Carrier Date Signature
Yes
No
Buffers
Yes
No
Firm performing test
Phone
F621-051-000 elevator five year safety test report 05-2006
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