Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25
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Observations: Name: MAIN BUILDING - Component: 01 - Tag: 0353 Based on document review, observation and interview, it was determined the facility failed to provide annual maintenance documentation, repair documentation, pressurized water tank documentation and sprinkler piping system, to be free of extraneous weight, and sprinkler system to be free of obstructions, affecting two of four smoke compartments within the component.
Findings include:
1. Review of documentation on January 23, 2024, between 8:55 AM and 8:59 AM, revealed the facility lacked documentation, of the following testing and inspections:
a. 8:55 AM, Wet System, annual main drain test; b. 8:56 AM. Wet System, annual, control valves; c. 8:59 AM. Wet System, quarterly, exterior tank inspections.
Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the facility could not provide results for the annual testing and inspections.
2. Review of documentation on January 23, 2024, between 8:45 AM and 10:30 AM, revealed the facility lacked documentation, verifying pressure switches had been replaced, which was recommended on the quarterly report, dated September 25, 2023, by Johnson Controls.
Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the facility could not provide documentation, verifying repairs had been performed, as recommended by the vendor.
3. Review of documentation and interview, on January 23, 2024, between 9:03 AM and 9:11 AM, revealed the facility failed to provide documentation for maintenance/repairs to the pressurized water storage tank for the sprinkler system, which were documented on November 8, 2022, by Pittsburgh Tank and Tower Group, during the internal tank inspection, as listed:
a. 9:03 AM, Wet System, 3/5 internal tank inspection, replace primary manway for compliance with OSHA confined space standards; b. 9:05 AM, Wet System, 3/5 internal tank inspection, hand washing, wire brush and applying a finish coat of acrylic, which was confirmed during inspection; installing a removable silt stop; c. 9:07 AM, Wet System, 3/5 internal tank inspection, installing a removable silt stop; d. 9:09 AM, Wet System, 3/5 internal tank inspection, performing a dry interior cleanout (noted sediment could clog sprinkler heads, rendering sprinkler system failures and deficient); e. 9:11 AM, Wet System, 3/5 internal tank inspection, performing power tool cleaning, stipe coating and applying an epoxy liner.
Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the facility could not provide documentation, verifying repairs had been performed by the vendor.
4. Observation on January 23, 2024, at 11:50 AM, revealed flex duct was sitting on the sprinkler piping system, in the 300 Hall, above the ceiling, by the Employee Lounge.
Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed the flex duct was supported by the sprinkler piping system.
5. Observation on January 23, 2024, between 12:15 PM and 12:20 PM, revealed sprinkler heads were subject to a load of lint/dust, at the following locations:
a. 12:15 PM, Laundry Room, Dryer Chase 2 sprinkler heads; b. 12:17 PM, Laundry Room, Dryer Room 1 sprinkler head; c. 12:20 PM, Laundry Room, Washer Room 1 sprinkler head.
Interview at the time of the exit conference with the Executive Director, Maintenance Director and Housekeeping Manager on January 23, 2024, at 1:45 PM, confirmed sprinkler heads were carrying an accumulated load of lint and dust.
| | Plan of Correction - To be completed: 03/12/2024
The facility will schedule annual maintenance of the sprinkler system to include an annual main drain test, annual control valves and a quarterly exterior tank inspection. The facility will schedule pressure switches to be replaced. The facility will also schedule repairs to the water storage tank as recommended by the Pittsburgh Tank and Tower Group in 2022. I am requesting a Time-Limited Waiver for the repairs that are needed to the water storage tank. I emailed the request for the TLW on 2/6/24. The duct work in the 300 hall will not be sitting on top of the sprinkler piping system. The sprinkler heads will be free of dust/lint in the laundry room. The Maintenance Supervisor and Housekeeping Supervisor will be re-educated on scheduling annual maintenance to the sprinkler system and a quarterly exterior tank inspection. They will also be re-educated on scheduling follow-up repairs as deemed necessary by outside contractors. They will also be re-educated on not having the duct work in the ceiling sitting on top of the sprinkler system. They will also be re-educated on making sure that all sprinkler heads are free of dust/lint. The facility will audit the TELS system monthly to ensure that all semi-annual and annual inspections are scheduled and complete and that follow-up repairs are scheduled as needed. The maintenance department will audit all ceiling work after vendors have completed necessary work in order to ensure that ductwork is not sitting on sprinkler piping. Audits will be reviewed at the next QAPI meeting.
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