Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
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Observations: Name: CHAPEL - Component: 02 - Tag: 0918
Based on document review and interview, it was determined the facility lacked annual fuel quality analysis for the emergency generator, which serves the entire component.
Findings include:
1. Review of documentation on February 21, 2024, between 8:45 AM and 10:45 AM, revealed the facility lacked documentation for the annual fuel quality test. A sample was taken on June 7, 2023, but the facility never received the analysis report.
Interview at the time of the exit conference with the Director of Environmental Service and Maintenance Manager on February 21, 2024, at 1:45 PM, confirmed the lack of documentation for emergency generator fuel analysis.
| | Plan of Correction - To be completed: 04/30/2024
1. The annual fuel sample test was drawn on 06/23/2023 and sent to the testing laboratory for analysis. At some point the sample was lost. A new sample was taken on 01/24/2024 and sent to the lab for analysis. Results from the testing of the 01/24/2024 sample are not expected until April. 2. The Maintenance Manager shall maintain a file with all inspections' and results, including any repairs that may be required. The annual inspection will be added to the Facilities preventive maintenance schedule for tracking. 3. The Director of Environmental Services shall report the results of all inspections and results at the Facilities QAPI meetings.
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