Title Page
SCBA - Unit #4
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Select the month(s) which indicate the element passes inspection. When a deficiency has been identified, note it at the bottom of this form
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1. Mask and hose - Examine for contamination, damage, and deterioration
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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2. Stretch hose Mask and hose - Check for lightness of assembly and cracking
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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3. Examine harness for wear and function of hardware.
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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4. Test unit as worn (regular hooked up to cylinder)
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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a) Check cylinder gauge for full indication
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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b) Open cylinder valve, filling regulator and hose
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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c) Close cylinder valve. Compare regulator gauge to cylinder gauge (+50 pal allowable)
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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d) Watch regulator gauge for drop in reading which would indicate leakage. (one increment on gauge in 5 mins is allowable)
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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e) Breathe unit down until Pak Alarm starts. Check regulator gauge for indication of pressure. Alarm should start at about 1/4 full.
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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f) Close yellow knob; open and close cylinder valve
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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g) Slightly breathe on regulator to check shut-of of yellow know (On-Off Valve). Regulator should not flow.
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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h) open yellow know full and lock
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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i) Open red knob (bypass) and bleed off pressure
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
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j) Close red knob. Replace unit in ready
- Jan.
- Feb.
- Mar.
- Apr.
- May
- June
- July
- Aug.
- Sept.
- Oct.
- Nov.
- Dec.
Deficiencies
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Note the definiency, the date identified, the proposed corrective aciton, and the anticipated date of correction below.
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Deficiency:
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Date Identified:
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Corrective Action:
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Completion Date:
