Deficiency in Emergency Generator Maintenance and Testing
Penalty
Summary
The facility failed to meet the requirements for maintenance and testing of its emergency generator system, which serves the entire component. During a document review and interview process, it was discovered that the facility did not have documentation verifying that the quality of diesel fuel for the emergency generator had been inspected within the previous twelve months. This was confirmed during an exit conference with the Administrator and Maintenance Director, who acknowledged the lack of verification for diesel fuel quality testing. Additionally, the facility was unable to provide documentation for critical tests of the emergency generator. Specifically, there was no record of an annual 90-minute load bank test or a 3-year, 4-hour load test being performed. These deficiencies were confirmed during the exit conference, indicating a failure to adhere to the required maintenance and testing protocols for the emergency power system as outlined by NFPA standards.
Plan Of Correction
Diesel fuel for the generator will be inspected. A 90-minute load bank test will be completed as well as a 4 hour load test. Maintenance staff will be educated on the necessary inspections needed for the emergency generator. A semi annual audit will be completed to ensure that the necessary tests for the emergency generator have occurred. Audit results will be reported to QAPI.