SOW M25-109.pdf

Statement of Work Periodic Elevator Inspections Edward Hines Jr. VA Hospital

STATEMENT OF WORK

1. GOAL

A. Edward Hines Jr. VA (Veterans Administration) Hospital requires a 3rd party, QEI‐1

Certified Elevator Inspection of all elevators two times per year. The type of tests includes one Periodic Inspection per year, one Annual Safety Test per year, and a Five‐

Year Load Test once every five years.

2. CURRENT CONDITIONS AND JUSTIFICATION

A. There are 47 active elevators and 1 dumbwaiter on the Hines Hospital campus. In addition, there is 1 elevator at the Joliet campus. These elevators vary in age, manufacturer, purpose, and design. For safety, reliability and building code compliance these elevators need to be routinely inspected by a 3rd party inspection group.

B. ELEVATOR LIST

Make Drive Type

Type/Capacity Serial No. Building name # of stops

# of doors

Last 5‐year test

1 Anderson Traction Passenger/4000lb A69696 Bldg. 1 A 4 1 02\22

2 Otis Traction Passenger/3000lb 322196 Bldg. 1 AB 4 2 02\22

3 Otis Traction Service/7000lb 322600 Bldg. 1 B 4 1 02\22

4 General Traction Passenger/4000lb 1964‐53 Bldg. 1 C 4 1 02\22

5 Mid‐American Traction Passenger/ 263067 Bldg. 1 CD 4 1 02\22

6 General Traction Passenger/4000lb 1964‐53 Bldg. 1 D 4 1 02\22

7 Anderson Traction Passenger/4000lb None Bldg. 1 E 4 1 02\22

8 Anderson Traction Passenger/4000lb None Bldg. 1 EF 4 1 02\22

9 General Traction Service/4000lb 85183 Bldg. 1 F 4 1 02\22

Type

Type/Capacity Serial No. Building name # of stops

# of doors

Last 5‐year test

10 Colley Traction Passenger/4000lb 78158 Bldg. 1 G 4 1 02\22

11 Colley Hydraulic Passenger/4000lb 80‐027 Bldg. 2 P1 3 1 10/15

12 Universal Traction Freight/3500lb U5843 Bldg. 7 F1 2 1 02\22

13 Minnesota Hydraulic Passenger/4000lb 1769 Bldg. 12 P1 3 1 10/15

14 Minnesota Hydraulic Passenger/4000lb 27052 Bldg. 13 P1 3 1 10/15

15 US Elevator Hydraulic Passenger/4000lb 25549 Bldg. 17 P1 3 1 10/15

16 Otis Elevator Hydraulic Passenger 431675 Bldg. 18 P1 3 1 10/15

17 Schindler Hydraulic Passenger 257‐1173 Bldg. 16 P1 3 1 10/15

18 Colley Hydraulic Passenger 80‐072 Bldg. 20 P1 2 1 10/15

19 S. Heller Hydraulic Freight/4000lb 54094 Bldg. 20 F1 2 2 10/15

20 Montgomery Hydraulic Passenger/5000lb CP53298 Bldg. 217 P1 2 1 10/15

21 Montgomery Hydraulic Passenger/5000lb CP53300 Bldg. 217 P2 2 1 10/15

22 Montgomery Hydraulic Passenger/5000lb CP53299 Bldg. 217 P3 2 1 10/15

23 Colley Hydraulic Freight/5000lb 1750 Bldg. 220 F1 2 1 02\22

24 MidAmerican Traction Dumbwaiter/500lb s

2388 Bldg. 200 DW‐1 16 1 10/15

25 Matot Drum Dumbwaiter/500lb 7313‐

DWZ

Bldg. 200 DW‐2 2 1 10/15

26 Mid‐American Traction Passenger/4000lb A72572 Bldg. 228 P1 6 2 02\22

27 Mid‐American Traction Passenger/4000lb A72631‐2 Bldg. 228 P2 6 1 02\22

28 Mid‐American Traction Passenger/4000lb A72681‐1 Bldg. 228 P3 6 1 02\22

29 Mid‐American Gearless Traction

Passenger/4000lb A72630 Bldg. 228 P4 6 1 02\22

30 Montgomery Gearless Traction

Passenger/4000lb 3115302 Bldg. 200 P1 16 1 02\22

31 Montgomery Gearless Traction

Passenger/4000lb 3115303 Bldg. 200 P2 16 1 02\22

Type

Type/Capacity Serial No. Building name # of stops

# of doors

Last 5‐year test

32 Montgomery Gearless Traction

Passenger/4000lb 3115304 Bldg. 200 P3 16 1 02\22

33 Montgomery Gearless Traction

Passenger/4000lb 3200000 Bldg. 200 P4 16 1 02\22

34 Montgomery Gearless Traction

Passenger/4000lb 3200002 Bldg. 200 P5 16 1 02\22

35 Montgomery Gearless Traction

Passenger/5000lb 3115313 Bldg. 200 S6 16 1 02\22

36 Montgomery Gearless Traction

Passenger/5000lb 3115314 Bldg. 200 S7 16 1 02\22

37 Montgomery Gearless Traction

Passenger/5000lb 3115315 Bldg. 200 S8 16 1 02\22

38 Minnesota Hydraulic Freight/5000lb 27049 Bldg. 200 S9 3 1 10/15

39 Allwieler

Hydraulic Passenger/4000lb 3115434 Bldg. 200 M‐10 2 2 10/15

40 Minnesota Hydraulic Passenger5000lb 3115482 Bldg. 200 F‐11 2 2 10/15

41 Minnesota

Hydraulic Passenger/10000lb 3115484 Bldg. 200 F‐12 2 2 10/15

42 Minnesota Hydraulic Passenger/4000lb 3115490 Bldg. 200 L‐13 2 2 10/15

43 Armstrong Hydraulic Passenger3500lb 3047367 Bldg. 200 P‐14 4 2 10/15

44 Armstrong Hydraulic Passenger3500lb 3047368 Bldg. 200 P‐15 4 2 10/15

45 THYSSEN

KRUPP

Hydraulic Passenger/5000lb ER 9666 Bldg. 128 P1 2 1 10/15

46 THYSSEN

KRUPP

Hydraulic Passenger/5000lb ER 9667 Bldg. 128 P2 2 1 10/15

47 THYSSEN

KRUPP

Hydraulic Passenger/4600lb ER 9668 Bldg. 113 P1 2 1 10/15

48 THYSSEN

KRUPP

Hydraulic Passenger/4600lb ER 9669 Bldg. 113 P2 2 1 10/15

Joliet CBOC

49 Dover Hydraulic Passenger/4000lb EB0592 Joliet

CBOC

P1 2 1 10/15

Fisher House

50 Thyssen Tac‐

Hydraulic Passenger/TBD EAG261‐

TAC20/30

Bldg. 100 P1 2 1 10/15

Total of 49 items to inspect.

Hydraulic elevator with overspeed valve

3. SCOPE

A. The contractor shall provide a certified QEI‐1 (Qualified Elevator Inspector) to witness and certify, one periodic inspection per year, one annual safety test per year, and one

5‐year load test, every five years, for all of the traction elevators and all of the

Hydraulic elevators with overspeed valves, marked in green. The other eight unmarked

Hydraulic elevators do not require a five‐year load test.

B. Contractor shall furnish all supervision, labor, equipment, travel and supplies necessary to witness the testing, and provide certification and test report documents.

C. All tests are to be performed by the elevator maintenance company contracted with the Hines VA.

4. REQUIREMENTS AND QUALIFICATIONS OF INSPECTOR

A. The inspector must meet the qualification requirements of the ANSI/ASME QEI‐1 certification and be certified by an ANSI/ASME accredited organization.

B. Offeror/ Contractor must submit with their quote, the names and certifications of the inspectors that would do the work of this contract.

i. Evidence must be provided to show the individuals named have a successful history with the company and are currently employed on a permanent basis.

ii. If changes occur during the life of the contract the contractor must provide updated inspector information at least 60 days prior to the next inspection due date.

5. INSPECTIONS

A. There must be two inspections per year, six months apart, for all 49 vertical transport items indicated on the list.

i. The first inspection of the contract year is the Annual Inspection /

Category 1 Safety Inspection. It is a no‐load test and it is to be performed in July.

ii. The second inspection is the Periodic inspection / Routine inspection and it is to be performed in January.

iii. The Five‐year Full Load Test must be performed at the time that the

Annual Test is due, (July). It is done once every five years and fulfills the requirement of the Annual test for that year. The next 5‐year load test for the hydraulic elevators at Hines is due in July of 25, and for all the traction elevators in July of 2027.

a) The time‐of‐day schedule for the tests cannot have a detrimental effect on hospital operations. The inspections schedule needs to be coordinated with and approved by the COR.

b) The 5‐yr. full Load testing for the main elevators in building 200 and

228 is recommended to be done during off‐tour hours, between 5:00pm on a Friday and 8:00am on Monday, or before 7:30 am and after 4:30 pm on weekdays. Any 5‐year inspection done during the regular daytime hours needs to be approved by the COR.

B. Inspections must include but are not limited to: inside of the elevator, elevator machine room, elevator control room, secondary equipment machine room, top of elevator, hoistway, elevator lobbies, and elevator pit.

C. All inspections must be conducted in accordance with the ASME (American Society of

Mechanical Engineers) A17.1 code year edition the elevator was installed to comply with and ASME A17.2 Inspectors Guide.

D. The site visit/inspection must include a review of the existing equipment for safety code compliance, firefighters' service, ADAAG (Americans with Disability Act, Accessibility Guidelines) requirements, recommended upgrades, and modernization needs based on long term life expectancy of the current equipment.

E. Findings and recommendations must be submitted in the required narrative and included with the inspection report.

F. During any inspection where parts must be removed or cleaned to determine the exact condition of other parts, that work needs to be done by the maintenance contractor.

G. All inspections must be performed in the presence of the elevator maintenance technician currently under contract as the Hines VA elevator preventative maintenance contractor.

H. Each site visit/inspection must include an out‐brief meeting with the COR to discuss the inspection violations, findings, immediate needs, and necessary corrections.

6. DOCUMENTATION

A. The VA, TIL (Technical Information Library) provides and requires two inspection documents titled “Hydraulic Elevator Inspection Report” and “Traction Elevator

Inspection Report”. The Contractor is to completely fill in these documents for each elevator inspection and provide an electronic PDF copy of each report to the COR. It is acceptable if the contractor chooses to create a digital program form of these documents and then provide PDF copies to the COR. Reports are due within two weeks of the inspections. The report documents are provided at the end of this statement of work and as an attachment to the solicitation.

B. Each inspection survey/evaluation must include a comprehensive report including the following:

i. summary narrative of the operating performance for each elevator/lift.

ii. description of inspection or test.

iii. deficiencies and recommendations.

iv. any adjustments, repairs, or replacements necessary to correct troubles encountered.

v. Furnish specifications (if requested by the COR) sufficient to enable the VA to purchase the materials required for those purposes.

C. Contractor shall provide certificates of inspection that demonstrate compliance with the applicable code and can be posted in the elevator demonstration window. These certificates need to be provided on good quality paper and delivered within two weeks of the inspections.

7. RECOGNIZED HOLIDAYS

A. Unless otherwise indicated the contractor is not required to perform services on these

Federal holidays.

New Year Day Presidents Day Independence Day Veterans Day

MLK Birthday Memorial Day Labor Day Thanksgiving Day

Inauguration Day June 19th Columbus Day Christmas Day

8. HOURS OF OPERATION

A. Except as previously indicated the contractor shall conduct business, between the hours of 6:00AM and 6:00PM Monday thru Friday except Federal holidays or when the

Government facility is closed due to local or national emergencies, administrative closings, or similar Government directed facility closings.

9. PLACE OF PERFORMANCE

A. The work to be performed under this contract will be performed at the following government facility:

Edward Hines Jr. VA Hospital.

5000 S. 5th Avenue Hines, Illinois, 60141

10. CHECK‐IN REQUIREMENT

A. Contractor personnel performing work under this contract must check in with the

Contracting Officer Representative.

11. INTERFERENCE TO NORMAL FUNCTION

A. Contractor personnel are required to interrupt their work at any time so as not to interfere with the normal functioning of the facility, including utility services, fire protection systems, and passage of patients, personnel, equipment, and carts.

12. SAFETY

A. The Contractor must consider the clinical environment and instruct his/her employees on applicable safety precautions and specific requirements.

13. CONTRACTORS ON SITE RESPONSIBILITIES

A. At all times while performing work under the provisions of this contract, each of the contractor’s employees must wear, in full view, a Hines Hospital contractor’s identification badge. Contractor is responsible to complete the Hines process for the issuance of the badge.

B. It is the responsibility of the Contractor to park in the appropriate designated parking areas. Information on parking is available from the VAMC Police Section. The VAMC will not invalidate or make reimbursement for parking violations of the Contractor under any conditions.

C. Contractors, Contractor personnel, subcontractors, and subcontractor personnel shall be subject the same Federal laws, regulations, standards, and VA directives and handbooks as VA and VA personnel regarding information and information security.

D. The Contractor agrees that none of its officers or employees must use or reveal any research, statistical, medical, or security information which may be obtained or observed during the performance of the work or as a result their presence on

Government premises without the written consent of the Government.

E. Smoking is prohibited inside any buildings at the VAMC.

F. Possession of weapons is prohibited.

End

INSPECTOR SIGN___________________BUILDING NAME/#____________________________ELEVATOR#________ November 1, 2023 Page 1 of 6

TRACTION ELEVATOR INSPECTION REPORT

BUILDING NAME:_______________________________________________________________________________

BUILDING NUMBER:___________________________ELEVATOR NUMBER:_____________________________

ADDRESS:_____________________________________________________________________________________

BUILDING REPRESENTATIVE:______________________________________________________________________

CONTACT NUMBER:_____________________________________________________________________________

DATE OF INSPECTON:_________________________ ASME A17.1 CODE YEAR:__________________________

TYPE OF ELEVATOR: PASSENGER____ SERVICE____ FREIGHT____ CARTLIFT____ DUMBWAITER____

MATERIAL LOADING CLASS: A___ B____ C1____ C2____ C3____

MACHINE: OVERHEAD GEARED____ GEARLESS____ WINDING DRUM____ BASEMENT GEARED____

MANUFACTURER:______________________________________________________________________

CAPACITY (LBS):________________________ CONTRACT SPEED(FPM):_______________________

1.0 ELEVATOR TEST DATA

1.1 FULL LOAD SPEED: UP____ DOWN_____ EMPTY SPEED: UP_____ DOWN_____

1.2 MOTOR VOLTS: UP DOWN MOTOR AMPS: UP DOWN

FULL LOAD: ______ _______ FULL LOAD: ______ _______

BALANCE LOAD: ______ _______ BALANCE LOAD: ______ _______

EMPTY CAR: ______ _______ EMPTY CAR: ______ _______

1.3 TYPE OF SAFETY: A______ B______ C______

CAR SLIDE DISTANCE:____________ COUNTERWEIGHT SLIDE DISTANCE:___________

1.4 GOVERNOR TRIP SPEED: CAR_________ COUNTERWEIGHT________

1.5 OVERSPEED SWITCH TRIP SPEED: CAR______ COUNTERWEIGHT________

1.6 SPEED REDUCING SWITCH: CAR________ COUNTERWEIGHT________

1.7 GOVERNOR ROPE PULL THROUGH FORCE (LBF): CAR_______ COUNTERWEIGHT________

1.8 LOWER AND HOLD WITH 125% RATED LOAD: PASS______ FAIL______

1.9 UNINTENDED MOTION DEVICE STOPPING DISTANCE: 125% LOAD DOWN_______EMPTY CAR UP_______

1.10 OIL BUFFER TEST: CAR FULL LOAD PASS____FAIL____ COUNTERWEIGHT EMPTY CAR PASS____ FAIL___

1.11 OIL BUFFER RETURN TEST: CAR BUFFER-PASS____FAIL____ COUNTERWEIGHT PASS____ FAIL____

1.12 ONE HOUR RUN TEST: PASS____ FAIL____ MOTOR TEMPERATURE: START______ FINISH______

1.13 DOOR SPEED (SEC): CLOSE______ OPEN______ CLOSING FORCE (LBF)_______

November 1, 2023 Page 2 of 6

2.0 ELEVATOR MACHINE ROOM

2.1 ACCESS TO MACHINE ROOM PASS____ FAIL____ N/A____

2.2 HEADROOM (7 FEET MINIMUM) PASS____ FAIL____ N/A____

2.3 LIGHTING AND GFCI RECEPTACLES PASS____ FAIL____ N/A____

2.4 MACHINE SPACE PASS____ FAIL____ N/A____

2.5 HOUSEKEEPING – CLEANED AND PAINTED PASS____ FAIL____ N/A____

2.6 HVAC – VENTILATION PASS____ FAIL____ N/A____

2.7 FIRE EXTINGUISHER PASS____ FAIL____ N/A____

2.8 GUARDS ON EQUIPMENT PASS____ FAIL____ N/A____

2.9 PIPE, DUCT, WIRING AND BUSHINGS PASS____ FAIL____ N/A____

2.10 NUMBER EQUIPMENT PASS____ FAIL____ N/A____

2.11 FUSED DISCONNECT – SHUNT TRIP BREAKER PASS____ FAIL____ N/A____

2.12 CONTROLLER FUSES AND OVERLOADS PASS____ FAIL____ N/A____

2.13 BONDING WIRE AND GROUNDING PASS____ FAIL____ N/A____

2.14 INSPECTION CONTROL PASS____ FAIL____ N/A____

2.15 ABSORPTION OF REGENERATIVE DRIVE PASS____ FAIL____ N/A____

2.16 GOVERNOR, OVERSPEED SWITCH TESTED AND SEALED PASS____ FAIL____ N/A____

2.17 CODE DATA PLATE PASS____ FAIL____ N/A____

2.18 DRIVE MACHINE AND SHEAVE PASS____ FAIL____ N/A____

2.19 DRIVE MACHINE BRAKE PASS____ FAIL____ N/A____

2.20 WINDING DRUM MACHINE, SLACK ROPE SWITCH AND ROPE FASTENINGPASS____ FAIL____ N/A____

2.21 GEARS, BEARINGS AND FLEXIBLE COUPLINGS PASS____ FAIL____ N/A____

2.22 MOTOR GENERATOR SET PASS____ FAIL____ N/A____

2.23 ROPE GRIPPER/SECONDARY BRAKE PASS____ FAIL____ N/A____

2.24 SECONDARY LEVEL AND DEFLECTOR SHEAVES PASS____ FAIL____ N/A____

2.25 DEADEND HITCH PLATES PASS____ FAIL____ N/A____

2.26 MAINTENANCE CONTROL PROGRAM AND RECORDS PASS____ FAIL____ N/A____

2.27 MONTHLY FIRE SERVICE TEST LOG PASS____ FAIL____ N/A____

2.28 EMERGENCY POWER OPERATION (FULL LOAD IN CAR) PASS____ FAIL____ N/A____

2.29 EARTHQUAKE INSPECTION AND TESTS PASS____ FAIL____ N/A____

2.30 SMOKE DETECTORS_____ HEAT DETECTORS_____ SPRINKLERS_____ PASS____ FAIL____ N/A____

3.0 ELEVATOR HOISTWAY – INSIDE

3.1 ACCESS TO HOISTWAY – CARTOP AND PIT PASS____ FAIL____ N/A____

November 1, 2023 Page 3 of 6

3.2 HOISTWAY AND PIT LIGHTING PASS____ FAIL____ N/A____

3.3 HOISTWAY ENCLOSURE PASS____ FAIL____ N/A____

3.4 HOISTWAY DEVIDER BEAMS AND LEDGES PASS____ FAIL____ N/A____

3.5 ENTRANCE FRAMES (FULLY GROUTED) PASS____ FAIL____ N/A____

3.6 DUST COVERS2, FACIAS, TOP AND BOTTOM SHEAR GUARDS PASS____ FAIL____ N/A____

3.7 VISION PANELS PASS____ FAIL____ N/A____

3.8 HOISTWAY DOORS PASS____ FAIL____ N/A____

3.9 HOISTWAY DOOR LOCKING DEVICES PASS____ FAIL____ N/A____

3.10 MECHANICAL HOISTWAY DOOR CLOSURE PASS____ FAIL____ N/A____

3.11 EMERGENCY DOORS IN BLIND HOISTWAY PASS____ FAIL____ N/A____

3.12 HOISTWAY VENTILATION PASS____ FAIL____ N/A____

3.13 TRAVELING CABLE SUSPENSION PASS____ FAIL____ N/A____

3.14 TOP OF COUNTERWEIGHT CLEARANCE AND RUNBY PASS____ FAIL____ N/A____

3.15 BOTTOM OF CAR CLEARANCE, RUNBY AND REFUGE SPACE PASS____ FAIL____ N/A____

3.16 COUNTERWEIGHT, FRAME AND ROLLER GUIDES PASS____ FAIL____ N/A____

3.17 COUNTERWEIGHT SHEAVE OR SHACKLES AND HITCH PLATE PASS____ FAIL____ N/A____

3.18 COUNTERWEIGHT SAFETIES PASS____ FAIL____ N/A____

3.19 CAR OVERHEAD AND DEFLECTOR SHEAVE CLEARANCE PASS____ FAIL____ N/A____

3.20 NORMAL TERMINAL STOPPING DEVICES PASS____ FAIL____ N/A____

3.21 FINAL TERMINAL STOPPING DEVICES PASS____ FAIL____ N/A____

3.22 CAR AND COUNTERWEIGHT BUFFERS AND TAGS PASS____ FAIL____ N/A____

3.23 PIT STOP SWITCHES PASS____ FAIL____ N/A____

3.24 GOVERNOR ROPE TENSION SHEAVE PASS____ FAIL____ N/A____

3.25 GUIDE RAILS, BRACKETS AND FASTENERS PASS____ FAIL____ N/A____

3.26 COMPENSATION CHAINS – ROPES AND SHEAVE PASS____ FAIL____ N/A____

3.27 FLOOR NUMBERS ANS EMERGENCY IDENTIFICATION PASS____ FAIL____ N/A____

3.28 PIPE, DUCT, WIRING AND BUSHINGS PASS____ FAIL____ N/A____

3.29 EARTHQUAKE INSPECTION AND TESTS PASS____ FAIL____ N/A____

3.30 SMOKE DETECTORS_____ HEAT DETECTORS_____ SPRINKLERS_____ PASS____ FAIL____ N/A____

4.0 ELEVATOR CAR – OUTSIDE

4.1 CROSSHEAD DATA, HOIST ROPE AND GOVERNOR ROPE TAGS PASS____ FAIL____ N/A____

4.2 STOP SWITCH PASS____ FAIL____ N/A____

4.3 LIGHT AND GFCI RECEPTACLES – TOP AND BOTTOM PASS____ FAIL____ N/A____

November 1, 2023 Page 4 of 6

4.4 CARTOP OPERATING DEVICE PASS____ FAIL____ N/A____

4.5 DOOR REOPENING DEVICE PASS____ FAIL____ N/A____

4.6 DOOR OPENING RESTRICTOR PASS____ FAIL____ N/A____

4.7 CLEARANCE, REFUGE SPACE AND CARTOP RAILING PASS____ FAIL____ N/A____

4.8 CAR LEVELING DEVICE PASS____ FAIL____ N/A____

4.9 CARTOP EMERGENCY EXIT AND SAFETY SWITCH PASS____ FAIL____ N/A____

4.10 ELEVATOR NUMBER – TOP, BOTTOM AND COUNTERWEIGHT GUARD PASS____ FAIL____ N/A____

4.11 PIPE, DUCT, WIRING AND BUSHINGS PASS____ FAIL____ N/A____

4.12 HOISTWAY RUNNING CLEARANCE PASS____ FAIL____ N/A____

4.13 CAR DOOR OPERATOR PASS____ FAIL____ N/A____

4.14 TRAVELING CABLE SUSPENSION AND RUNNING CLEARANCE PASS____ FAIL____ N/A____

4.15 CROSSHEAD, SIDE STILES AND SAFETY PLANK PASS____ FAIL____ N/A____

4.16 CAR SAFETIES PASS____ FAIL____ N/A____

4.17 GOVERNOR ROPE AND RELEASE CARRIER PASS____ FAIL____ N/A____

4.18 HOIST ROPES, CARTOP SHEAVE OR SHACKLES AND HITCH PLATE PASS____ FAIL____ N/A____

4.19 CAR PLATFORM GUARD – TOE GUARD PASS____ FAIL____ N/A____

5.0 ELEVATOR CAR – INSIDE

5.1 CAR DOOR OR GATE PASS____ FAIL____ N/A____

5.2 DOOR CLOSING FORCE PASS____ FAIL____ N/A____

5.3 POWER OPENING OF DOOR OR GATE PASS____ FAIL____ N/A____

5.4 POWER CLOSING OF DOOR OR GATE PASS____ FAIL____ N/A____

5.5 CAR ENCLOSURE, INTERIOR FINISHES, SILL, FLOOR AND CEILING PASS____ FAIL____ N/A____

5.6 CAR VISION PANELS AND GLASS DOORS PASS____ FAIL____ N/A____

5.7 STOP SWITCHES PASS____ FAIL____ N/A____

5.8 OPERATING CONTROL DEVICES PASS____ FAIL____ N/A____

5.9 CAR LIGHTING AND GFCI RECEPTICLE PASS____ FAIL____ N/A____

5.10 EMERGENCY LIGHT AND ALARM PASS____ FAIL____ N/A____

5.11 EMERGENCY EXIT SECURED FROM OUTSIDE PASS____ FAIL____ N/A____

5.12 VENTILATION PASS____ FAIL____ N/A____

5.13 ELEVATOR NUMBER PASS____ FAIL____ N/A____

5.14 DATA PLATE: CAPACITY, LOADING CLASS AND NUMBER OF PASSENGER PASS____ FAIL____ N/A____

5.15 SIGNAGE AND BRAILLE PLATES PASS____ FAIL____ N/A____

5.16 MEDICAL EMERGENCY PASS____ FAIL____ N/A____

November 1, 2023 Page 5 of 6

5.17 CAR RIDE QUALITY PASS____ FAIL____ N/A____

5.18 EARTHQUAKE INSPECTION AND TEST PASS____ FAIL____ N/A____

5.19 FIREFIGHTER’S PHASE 2 OPERATION PASS____ FAIL____ N/A____

6.0 ELEVATOR HALL FIXTURES AND HOISTWAY ENTRANCES

6.1 HALL LANTERNS PASS____ FAIL____ N/A____

6.2 POSITIONS INDICATORS PASS____ FAIL____ N/A____

6.3 HALL CALL PUSH BUTTONS PASS____ FAIL____ N/A____

6.4 COMMUNICATION (LIGHT ANNUNCIATOR AND KEY SWITCH) PASS____ FAIL____ N/A____

6.5 MEDICAL EMERGENCY CALL – KEY SWITCH OR CARD READER PASS____ FAIL____ N/A____

6.6 BRAILE PLATES AND EMERGENCY EVACUATION PLATES PASS____ FAIL____ N/A____

6.7 ELEVATOR NUMBER ON ENTRANCE FRAMES PASS____ FAIL____ N/A____

6.8 FIREFITHER’S PHASE 1 OPERATION AND INDICATOR LIGHT PASS____ FAIL____ N/A____

6.9 SMOKE DETECTORS______HEAT DETECTORS______SPRINKLERS______ PASS____ FAIL____ N/A____

6.10 EMERGNECY POWER INDICATOR LIGHT PASS____ FAIL____ N/A____

6.11 EMERGENCY POWER SELECTOR KEY SWITCH PASS____ FAIL____ N/A____

ITEM # COMMENT CODE REFERENCE

November 1, 2023 Page 6 of 6

ITEM # COMMENT CODE REFERENCE

COMPANY NAME:________________________________

ADDRESS:_______________________________________

CITY, STATE, ZIP: _________________________________

INSPECTOR’S QEI-1:#______________________________

PRINT NAME:____________________________________

SIGNATURE:_____________________________________

DATE OF INSPECTION_________________

CODE EDITION_______________________

PASS_____________FAIL______________

HYDRAULIC ELEVATOR INSPECTION REPORT

INSPECTOR SIGN___________________BUILDING NAME/#__________________ELEVATOR#________

BUILDING NAME:_______________________________________________________________________________

BUILDING NUMBER:___________________________ELEVATOR NUMBER:_____________________________

ADDRESS:_____________________________________________________________________________________

BUILDING REPRESENTATIVE:______________________________________________________________________

CONTACT NUMBER:_____________________________________________________________________________

DATE OF INSPECTON:_________________________ ASME A17.1 CODE YEAR:__________________________

TYPE OF ELEVATOR: PASSENGER____ SERVICE____ FREIGHT____ CARTLIFT____ DUMBWAITER____

MATERIAL LOADING CLASS: A____ B____ C1____ C2____ C3____

TYPE OF PUMP UNIT: INTANK_______V-BELT_______ VALVE AND MOTOR ABOVE TANK______

MANUFACTURER:______________________________________________________________________

CAPACITY (LBS):______________________ CONTRACT SPEED(FPM):_______________________

1.0 ELEVATOR TEST DATA

1.1 FULL LOAD SPEED: UP_____DOWN_____ EMPTY SPEED: UP_____ DOWN_____

1.2 MOTOR VOLTS: UP DOWN MOTOR AMPS: UP DOWN

FULL LOAD: ______ _______ FULL LOAD: ______ _______

EMPTY CAR: ______ _______ EMPTY CAR: _______ _______

1.3 STATIC PRESURE (PSI): EMPTY CAR______ FULL LOAD______

1.4 WORKING PRESURE (PSI):EMPTY CAR______ FULL LOAD______

1.5 RELIEF VALVE PRESURE (PSI): FULL LOAD ON STOP RING______

1.6 DOWN OVERSPEED/RUPTURE VALVE: 10% ABOVE CONTRACT SPEED PASS______ FAIL______

1.7 ROPED HYDRAULIC SAFETIES: A____ B____ C____ N/A____

1.8 CAR SLIDE DISTANCE:_________ N/A_______

1.9 GOVERNOR TRIP SPEED (FPM):__________

1.10 OVERSPEED SWITCH TRIP SPEED (FPM):__________

1.11 GOVERNOR ROPE PULL THROUGH FORCE (LBF):_______ N/A_______

1.12 ONE HOUR RUN TEST:PASS____ FAIL____

1.13 MOTOR TEMPERATURE: START______ FINISH______

1.14 OIL TEMPERATURE RISE: START______ FINISH______

1.15 DOOR SPEED (SEC): CLOSE______ OPEN______ CLOSING FORCE (LBF)_______

2.0 ELEVATOR MACHINE ROOM

2.1 ACCESS TO MACHINE ROOM PASS____ FAIL____ N/A____

2.2 HEADROOM (7 FEET MINIMUM) PASS____ FAIL____ N/A____

2.3 LIGHTING AND GFCI RECEPTACLES PASS____ FAIL____ N/A____

2.4 MACHINE SPACE PASS____ FAIL____ N/A____

2.5 HYDRAULIC POWER UNIT – MOTOR, PUMP AND TANK PASS____ FAIL____ N/A____

2.6 CONTROL AND RELIEF VALVE PASS____ FAIL____ N/A____

2.7 PRESURE SWITCH PASS____ FAIL____ N/A____

2.8 SUPPLY LINE AND SHUTOFF VALVE PASS____ FAIL____ N/A____

2.9 FLEXIBLE HOSE AND FITTINGS PASS____ FAIL____ N/A____

2.10 HOUSE KEEPING – CLEANED AND PAINTED PASS____ FAIL____ N/A____

2.11 HVAC - VENTILATION PASS____ FAIL____ N/A____

2.12 FIRE EXTINGUISHER PASS____ FAIL____ N/A____

2.13 GUARDS ON EQUIPMENT PASS____ FAIL____ N/A____

2.14 PIPE, DUCT, WIRING AND BUSHINGS PASS____ FAIL____ N/A____

2.15 NUMBERING OF EQUIPMENT PASS____ FAIL____ N/A____

2.16 FUSED DISCONNECT – SHUNT TRIP BREAKER PASS____ FAIL____ N/A____

2.17 CONTROLLER FUSES AND OVERLOADS PASS____ FAIL____ N/A____

2.18 LOW OIL PROTECTION PASS____ FAIL____ N/A____

2.19 BONDING WIRE AND GROUDING PASS____ FAIL____ N/A____

2.20 INSPECTION CONTROL PASS____ FAIL____ N/A____

2.21 CODE DATA PLATE PASS____ FAIL____ N/A____

2.22 MAINTENANCE CONTROL PROGRAM AND MAINTENANCE RECORDS PASS____ FAIL____ N/A____

2.23 MONTHLY FIRE SERVICE TEST LOG PASS____ FAIL____ N/A____

2.24 EMERGENCY POWER OPERATION (FULL LOAD IN CAR) PASS____ FAIL____ N/A____

2.25 EARTHQUAKE INSPECTION AND TESTS PASS____ FAIL____ N/A____

2.26 SMOKE DETECTORS_____ HEAT DETECTORS_____ SPRINKLERS_____ PASS____ FAIL____ N/A____

3.0 ELEVATOR HOISTWAY – INSIDE

3.1 ACCESS TO HOISTWAY – CARTOP AND PIT PASS____ FAIL____ N/A____

3.2 HOISTWAY AND PIT LIGHTING PASS____ FAIL____ N/A____

3.3 HOISTWAY ENCLOSURE PASS____ FAIL____ N/A____

3.4 HOISTWAY DEVIDER BEAMS AND LEDGES PASS____ FAIL____ N/A____

3.5 ENTRANCE FRAMES (FULLY GROUTED) PASS____ FAIL____ N/A____

3.6 DUST COVERS2, FACIAS, TOP AND BOTTOM SHEAR GUARDS PASS____ FAIL____ N/A____

3.7 VISION PANELS PASS____ FAIL____ N/A____

3.8 HOISTWAY DOORS PASS____ FAIL____ N/A____

3.9 HOISTWAY DOOR LOCKING DEVICES PASS____ FAIL____ N/A____

3.10 MECHANICAL HOISTWAY DOOR CLOSURE PASS____ FAIL____ N/A____

3.11 EMERGENCY DOORS IN BLIND HOISTWAY PASS____ FAIL____ N/A____

3.12 HOISTWAY VENTILATION PASS____ FAIL____ N/A____

3.13 TRAVELING CABLE SUSPENSION PASS____ FAIL____ N/A____

3.14 TOP OF COUNTERWEIGHT CLEARANCE AND RUNBY (ROPED) PASS____ FAIL____ N/A____

3.15 BOTTOM OF CAR CLEARANCE, RUNBY AND REFUGE SPACE PASS____ FAIL____ N/A____

3.16 COUNTERWEIGHT, FRAME AND ROLLER GUIDES (ROPED) PASS____ FAIL____ N/A____

3.17 COUNTERWEIGHT SHEAVE OR SHACKLES AND HITCH PLATE (ROPED) PASS____ FAIL____ N/A____

3.18 CAR OVERHEAD CLEARANCE PASS____ FAIL____ N/A____

3.19 NORMAL TERMINAL STOPPING DEVICES PASS____ FAIL____ N/A____

3.20 FINAL TERMINAL STOPPING DEVICES PASS____ FAIL____ N/A____

3.21 CAR AND COUNTERWEIGHT BUFFERS AND TAGS PASS____ FAIL____ N/A____

3.22 PIT STOP SWITCHES PASS____ FAIL____ N/A____

3.23 GOVERNOR ROPE TENSION SHEAVE (ROPED) PASS____ FAIL____ N/A____

3.24 GUIDE RAILS, BRACKETS AND FASTENERS PASS____ FAIL____ N/A____

3.25 FLOOR NUMBERS ANS EMERGENCY IDENTIFICATION PASS____ FAIL____ N/A____

3.26 PIPE, DUCT, WIRING AND BUSHINGS PASS____ FAIL____ N/A____

3.26 EARTHQUAKE INSPECTION AND TESTS PASS____ FAIL____ N/A____

3.27 SMOKE DETECTORS_____ HEAT DETECTORS_____ SPRINKLERS_____ PASS____ FAIL____ N/A____

4.0 ELEVATOR CAR – OUTSIDE

4.1 CROSSHEAD DATA, HOIST ROPE AND GOVERNOR ROPE TAGS PASS____ FAIL____ N/A____

4.2 STOP SWITCH PASS____ FAIL____ N/A____

4.3 LIGHT AND GFCI RECEPTACLES – TOP AND BOTTOM PASS____ FAIL____ N/A____

4.4 CARTOP OPERATING DEVICE PASS____ FAIL____ N/A____

4.5 DOOR REOPENING DEVICE PASS____ FAIL____ N/A____

4.6 DOOR OPENING RESTRICTOR PASS____ FAIL____ N/A____

4.7 CLEARANCE, REFUGE SPACE AND CARTOP RAILING PASS____ FAIL____ N/A____

4.8 CAR LEVELING DEVICE PASS____ FAIL____ N/A____

4.9 CARTOP EMERGENCY EXIT AND SAFETY SWITCH PASS____ FAIL____ N/A____

4.10 ELEVATOR NUMBER – TOP, BOTTOM AND PIT SWITCH PASS____ FAIL____ N/A____

4.11 PIPE, DUCT, WIRING AND BUSHINGS PASS____ FAIL____ N/A____

4.12 HOISTWAY RUNNING CLEARANCE PASS____ FAIL____ N/A____

4.13 CAR DOOR OPERATOR PASS____ FAIL____ N/A____

4.14 TRAVELING CABLE SUSPENSION AND RUNNING CLEARANCE PASS____ FAIL____ N/A____

4.15 CROSSHEAD, SIDE STILES AND BOLSTER CHANNEL/SAFETY PLANK PASS____ FAIL____ N/A____

4.16 CAR SAFETIES (ROPED) PASS____ FAIL____ N/A____

4.17 GOVERNOR ROPE AND RELEASE CARRIER (ROPED) PASS____ FAIL____ N/A____

4.18 HOIST ROPES, CARTOP SHEAVE OR SHACKLES AND HITCH PLATE (ROPED)PASS____ FAIL____ N/A____

4.19 CAR PLATFORM GUARD – TOE GUARD PASS____ FAIL____ N/A____

5.0 ELEVATOR CAR – INSIDE

5.1 CAR DOOR OR GATE PASS____ FAIL____ N/A____

5.2 DOOR CLOSING FORCE PASS____ FAIL____ N/A____

5.3 POWER OPENING AND CLOSING OF DOOR OR GATE PASS____ FAIL____ N/A____

5.4 CAR ENCLOSURE, INTERIOR FINISHES, SILL, FLOOR AND CEILING PASS____ FAIL____ N/A____

5.5 CAR VISION PANELS AND GLASS DOORS PASS____ FAIL____ N/A____

5.6 STOP SWITCHES PASS____ FAIL____ N/A____

5.7 OPERATING CONTROL DEVICES PASS____ FAIL____ N/A____

5.8 CAR LIGHTING AND GFCI RECEPTICLE PASS____ FAIL____ N/A____

5.10 EMERGENCY LIGHT AND ALARM PASS____ FAIL____ N/A____

5.11 EMERGENCY EXIT SECURED FROM OUTSIDE PASS____ FAIL____ N/A____

5.12 VENTILATION PASS____ FAIL____ N/A____

5.13 ELEVATOR NUMBER PASS____ FAIL____ N/A____

5.14 DATA PLATE: CAPACITY, LOADING CLASS AND NUMBER OF PASSENGER PASS____ FAIL____ N/A____

5.15 SIGNAGE AND BRAILLE PLATES PASS____ FAIL____ N/A____

5.16 MEDICAL EMERGENCY PASS____ FAIL____ N/A____

5.17 CAR RIDE QUALITY PASS____ FAIL____ N/A____

5.18 EARTHQUAKE INSPECTION AND TEST PASS____ FAIL____ N/A____

5.19 FIREFIGHTER’S PHASE 2 OPERATION PASS____ FAIL____ N/A____

6.0 ELEVATOR HALL FIXTURES AND HOISTWAY ENTRANCES

6.1 HALL LANTERNS PASS____ FAIL____ N/A____

6.2 POSITIONS INDICATORS PASS____ FAIL____ N/A____

6.3 HALL CALL PUSH BUTTONS PASS____ FAIL____ N/A____

6.4 COMMUNICATION MONITORING LIGHT - ANNUNCIATOR AND KEY SWITCHPASS____ FAIL____ N/A____

6.5 MEDICAL EMERGENCY CALL – KEY SWITCH OR CARD READER PASS____ FAIL____ N/A____

6.6 BRAILE PLATES AND EMERGENCY EVACUATION PLATES PASS____ FAIL____ N/A____

6.7 ELEVATOR NUMBER ON ENTRANCE FRAMES PASS____ FAIL____ N/A____

6.8 FIREFITHER’S PHASE 1 OPERATION AND INDICATOR LIGHT PASS____ FAIL____ N/A____

6.9 SMOKE DETECTORS______HEAT DETECTORS______SPRINKLERS______ PASS____ FAIL____ N/A____

6.10 EMERGNECY POWER INDICATOR LIGHT PASS____ FAIL____ N/A____

6.11 EMERGENCY POWER SELECTOR KEY SWITCH PASS____ FAIL____ N/A____

ITEM # COMMENT CODE REFERENCE

ITEM # COMMENT CODE REFERENCE

COMPANY NAME:_____________________________________________________________________

ADDRESS:____________________________________________________________________________

CITY, STATE, ZIP:_______________________________________________________________________

INSPECTOR’S QEI-1:#___________________________________________________________________

PRINT NAME:_________________________________________________________________________

SIGNATURE:__________________________________________________________________________

PASS____________FAIL____________ DATE OF INSPECTION___________________________________

inspElevHydraulicReport