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Based on observation the facility did not insure that hazardous areas are maintained with proper fire rated door enclosures.

Findings:

During the facility tour on 4/6/16 at 9:15AM it was observed that the storage room on the sub ground level, which contains hazardous quantities of combustible materials, and the paint shop, do not have ¾ hour fire resistance rated doors. These areas are not equipped with an automatic extinguishing system.


Additionally, it was noted that the horizontal sliding doors in the boiler room were open, and the self-closing mechanism did not appear to be functional. The fusible link mechanism was hanging loosely on the main door and the weight was missing.
The self-closing mechanisms on the door covering the elevator and the door to a storage and shaft area also appeared nonfunctional. The facility could not produce any testing or maintenance records for these doors.


This finding was confirmed with the Director of Facilities Operations, and the Manager of Plant Operations at the time of observation.

Based on observation and interview, the facility did not maintain the fire alarm system in accordance with NFPA 72.

Findings:

During the facility tour with the Director of Facilities Operations and the Manager of Plant Operations on 4/5/16 at 11:47 AM a trouble signal was observed on the Fire Alarm Control Panel in the main generator room. The electrician was called and he said that the trouble signal indicated a problem with the battery charger and probably was a bad fuse. He then changed the fuse which did not resolve the trouble signal.

NFPA 72 states: System defects and malfunctions shall be corrected.

During an interview on 4/5/16, at 2:30PM, the Lead Security Officer said that this trouble signal has been on 2 or 3 times a week for the last three weeks.

Based on observation and document review the facility did not test sprinklers as required by NFPA 25.

Findings:

During document review on 4/7/16, a fire inspection report done by RBM-Guardian Fire Protection Inc., noted that there are sprinklers in the building that are more than 50 years old.

NFPA 25, 1998 states: Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. Test procedures shall be repeated at 10- year intervals.


During an interview with the Director of Facilities Operations, and the Manager of Plant Operations on 4/7/16 at 11:30 AM, they stated that they are unable to confirm sprinkler testing.