SOP 511.18-att-1: Monthly SCBA Inspection Form

GDC-SOP IVN09-0005

ATTACHMENT 1

4/01/02

|MONTHLY SCBA INSPECTION FORM|Col2|Col3|Col4|
|---|---|---|---|
|SCBA No:
|SCBA No:
|Cylinder No.:
|Cylinder No.:
|
|Mask No.
|Mask No.
|Apparatus:
|Apparatus:
|
|Date:
|Date:
|Shift:
|Shift:
|
|
I. Visual Inspection:|
I. Visual Inspection:|
I. Visual Inspection:|
I. Visual Inspection:|
|Mask:

For facepiece-mounted regulators:|Mask:

For facepiece-mounted regulators:|

Low-pressure hose.|

Low-pressure hose.|
|
|
Intermediate pressure hose|
|
Exhalation value|
|
|
Gaskets|
|
O-rings, gaskets, and screens|
|
|
Lens, hardware, buckles, straps|
|
Speaking diaphragm|
|
|
Connections and threads|
|
Lens, hardware, buckles, etc.|
|
|
Connections and threads|
Connections and threads|
Connections and threads|
|
Cylinder:|
Cylinder:|
Regulator:|
Regulator:|
|
|
Cylinder pressure|
|
Values, gauges, and controls|
|
|Check for gouges, corrosion, chipping, and
cracking|
|
Exhalation valve on facepiece-mounted regulators|
|
|
Gauges and valves|
|
Gaskets, O-rings, screens, etc.|
|
|
Seals, gaskets and screens|
|
Alarm|
|
|
High-pressure hose|
|
High-pressure hose|
|
|
Hydrostatic test date|
Hydrostatic test date|
Hydrostatic test date|
|
Backpack:|
Backpack:|
Backpack:|
Backpack:|
|
|
Straps, buckles, cylinder lock, and frame|
Straps, buckles, cylinder lock, and frame|
Straps, buckles, cylinder lock, and frame|
|
II. Operational Inspection|
II. Operational Inspection|
II. Operational Inspection|
II. Operational Inspection|
|
|Don mask, check facepiece seal
|
|
Operate bypass valve|
|
|Open cylinder value. Check for leaks in hose,
alarm or regulator|
|
Check alarm|
|

|Operate pressure/demand switch and check for
positive pressure|

|Clean recharge, and restore to service. Remove and
report any unit that fails to operate properly.|
|Signature of Inspector:
|Signature of Inspector:
|Signature of Inspector:
|Signature of Inspector:
|