Annual Escalator Safety Test Form
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1State of Ohio
Annual Escalator Safety Test Form
State ID#: _______________
Mail this form to: State of Ohio, Department of Commerce Elevator Inspection Section
6606 Tussing Road • P.O. Box 4009 Reynoldsburg, OH 43068-9009
Test form must be filed within 5 days of the completion of the test
Email:elevators@com.ohio.gov
Fax:614-644-2428
Location: ____________________________________________ Address: _________________________________________________
City: ________________________________________Zip: ___________________ County: __________________________________
Owner ID#:___________________
Normal Direction of travel (____up), (____down), (____ up & down)
INSTRUCTIONS:
Annual safety tests are required to be filed as outlined in ASME A17.1 part 8, and Ohio Revised Code Section 4105. This test is
required in addition to the field inspections by the State of Ohio. State Inspectors do not perform safety tests. File the completed
safety test form within 5 days following the completion of the test. Submit the test to the above address, email or fax. Additional
explanations of each test component can be found in the ASME A17.2 Inspector’s Manual.
ASME Inspection Standard to be applied for this unit: ________________________________________________
Year of Installation_____________ Testing Equipment Certification Date: Head ___________________
Processor _________________
People per hour (pph):_____________
Total Travel (ft):___________
NOTES: ___________________________________________________________
Yes
NO
Step Skirt Performance Index
Rated Speed (fpm):_________
Has the escalator skirt been cleaned?
___________________________________________________________
Is all equipment calibrated and current?
Was the unit tested in the normal direction of travel?
Was the applied load 25 lbf
Did it deviate more than +/- 2.5 lbf
2
2
Is the distributed load area between 3in
& 6in
Did the index polycarbonate test specimen meet the following criteria:
(1). Material: Polycarbonate without fillers.
(2). Color: Natural, no pigments.
(3)-Finish: Glossy (roughness less than 0.32µin.)
2
(4). Area in contact with skirt panel: 4.5+/- 0.5in
and at least 0.03 in thick. (5) Specification: GE Lexan 100 series or
equivalent polycarbonate.
Does this unit have skirt deflection devices?
At what intervals was the index recorded?
Left
Right
What were the Step/Skirt Performance Index measurements?
Left
Right
How many readings per side were taken during the test? (Identified when looking up from the bottom on the unit)
Yes
No
CHOOSE ONE OF THE FOLLOWING THREE ITEMS as described in ASME A17.1a 2000 Item 8.6.8.3.3
1
Condition 1: All units range <.15
Condition 2: Escalators installed under ASME A17.1a-2002 and later editions Range: < .25 with skirt deflection
2
devices.
Condition 3: Escalators installed under ASME A17.1-2000 and earlier editions Range: < .4 with skirt deflection
3
devices.
Did the escalator meet one of the applicable conditions above using the highest measurement obtained?
Have all readouts been attached to this form? Must be submitted for each test, properly labeled and dated?
DID THE UNIT PASS ALL TESTING REQUIREMENTS PRIOR TO BEING RETURNED TO SERVICE?*
*If “NO” a written statement as to why the unit failed must be sent to this office. THE UNIT MAY NOT RETURN TO SERVICE IF
ANY SAFETY DEVICE FAILED,(INCLUDING THE LACK OF PROPERLY INSTALLED SKIRT DEFELECTION DEVICES)
Company Conducting the Test
Address
Person Conducting Test
(print)
City
zip
Phone
Signature
Date
DIC4330 (revised 06.12.2013)
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