Atch 5. Boiler Plant Review Ft. Harrison MT March 16-18 2021.pdf

10NA5E Office of Healthcare Engineering BOILER PROGRAM REVIEW March 16-18, 2021

OHE Reviewers:

Steven Broskey, Compliance Engineer

BEI Reviewers:

Chase O’Mary, BEI Engineer

Karl Bohnenberger, BEI Engineer

VHA Healthcare Environment & Facilities Program Office of

Healthcare Engineering (10NA5E)

Boiler Efficiency Institute LLC.

FT. HARRISON VA MEDICAL CENTER HELENA, MT

Review Date: March 16-18, 2021

Boiler Program

Review

CONTENTS

1 Executive Summary

1.1 Overall Hospital Score

1.2 Summary of Critical Finding and Recommendations

2 Overview

3 Evaluation Criteria

4 Report Documentation

4.1 Entrance meeting (1hr) – To discuss the objectives and methods of the Review

4.2 Audit Process and Results

4.3 Background

4.4 Equipment Summary

4.5 Fourteen Questions

4.6 Safety Device Testing Survey Summary

4.7 Overall Hospital Score

4.8 Category 1 – Management

4.9 Category 2 – Directive 1810

4.10 Category 3 – Training

4.11 Category 4 – Parts and Supplies

4.12 Category 5 – References

4.13 Category 6 – Records

4.14 Category 7 – Physical Observations of The Boiler Plant

4.15 Category 8 – Facility Condition Assessment (FCA)

4.16 Category 9 - Testing and Inspection

4.17 Category 10 – Layup and Rotation

4.18 Additional Items (Some items listed here observed during the review may not pertain specifically to the boiler plant.)

4.19 Exit Meeting with VAMC Management

5 Safety Device Testing Partial Survey

5.1 Boiler Information

5.2 Boiler Safety Device Testing Results Summary

5.3 Detailed Safety Device Testing Results

6 Appendix A – Field Notes

1 EXECUTIVE SUMMARY

The following summary gives an overall composite review score, and critical findings that require immediate attention and/or high -level management attention. A Comprehensive, detailed list of review findings is given in section 4 of this report.

1.1 OVERALL HOSPITAL SCORE

The data is graphically depicted in figure 1-1 is a composite Overall Hospital Score. It depicts the composite score of policy, action, and documentation for all reviewed categories.

Figure 1-1. Overall Hospital Score

1.2 SUMMARY OF CRITICAL FINDING AND RECOMMENDATIONS

The key points and recommendations resulting from this review follow based on the nine categories covered in the review.

1.2.1 Category 1 – Management Summary

• There is no current boiler plant policy in place. The most recent policy expired in 2018. The older policy does describe a safety device failure process, but its is not being followed. Boiler plant supervisor indicate that deficiencies are verbally communicated up the chain of command.

• There is no evidence of any safety device failure reporting up the chain of command. Numerous safety device failures were reported in 2015 and 2017 during prior BEI visits. These issues have not been addressed.

• There is no policy or SOP that describes the process to deem a new hire boiler plant personnel competent to stand watch. The site must implement a new hire certification program with clearly defined system to deem new hire boiler plant personnel competent to stand watch.

• No new hire training records are in place.

• There is no centralized safety device failure tracking sheet. The site must implement a centralized safety device failure tracking sheet. The safety device failure tracking document must centrally track all deficiencies and document repairs. All safety device failures must be documented even if they are immediately repaired.

• There is no certification process for the quarterly compliance survey. There is no evidence of the quarterly compliance survey being viewed and certified by the chief engineer or medical facility director.

1.2.2 Category 2- Directive 1810 Summary

• Quarterly Compliance Survey has some inaccuracies related to both low pressure and high pressure boilers. For example, the survey states that safety device testing is performed on all low pressure / hot water boilers. No record of safety device testing for decentralized hot water equipment could be located. The survey also states that all safety devices within the high pressure plant are compliant which is also not accurate.

• There is no direct evidence that any safety device failures have been reported to the facility director.

• There is no policy/SOP for creating Interim Safety Measures (ISM) for failed safety devices. No

ISMs have ever been created. ISMs must be developed and implemented for all known safety device failures. Interim Safety Measures must remain in place until safety device failures are repaired.

1.2.3 Category 3 – Training

• The site must create and execute a recurring boiler plant specific training plan.

• The training plan must include extensive, detailed boiler plant related emergency operations and normal operations training. Consider performing casualty drills to ensure all operators can properly respond to common boiler plant emergency situations.

• Ensure all TMS training is performed on time and documented.

1.2.4 Category 6 – Records

• Instrument and gage calibration records were not available. The site must maintain these records for 3 years. No gage or instrument calibration is performed.

• Update boiler plant policy to include formal review of all records annually.

• Safety Device testing records are not complete or compliant. Current records are handwritten on blank paper. No records past 2019 are in place. The site must have completed testing sheets from the VHA Safety Device Testing Manual 5th Edition for all monthly and semi-annual safety device tests.

1.2.5 Category 9 – Testing and Inspection Summary

• Instrumentation is not calibrated semi-annually. Per directive instrumentation must be calibrated semi-annually. No records were on file. An instrument calibration program is critical to proper control function and must be immediately implemented. Instrument calibration is typically handed through a vendor.

• No records of gauge calibration were on file. No gauge calibration is occurring.

• DA Tank NDT has not been performed and is due. DA tank NDT must be performed as soon as possible.

• Safety Device testing has not been performed since 2019. Prior to that, safety device testing was not complete or being performed in a compliant manner.

• Significant equipment upgrades will be required to bring the boiler plant into compliance with

VA standard.

1.2.6 Additional Items (Some items listed here observed during the review may not pertain specifically to the boiler plant.)

• Combustion Air to boiler damper not wired into alarm.

• Liquid relief valves on oil pump set can be isolated by three separate valves. Valves must be lock open only.

• No back pressure regulator installed on oil pump set.

• No Dangerous Gas Monitoring System is installed. No carbon monoxide, combustible alarms.

• Roll up door hits steam safety vents.

• Chemical feed is manual shot feed. No automatic system.

• No pressure gages on LP tanks.

• No Emergency Natural Gas Shutoff is installed.

• No Plant Master Control. All boilers are local control.

• No high pressure boiler SCADA.

• No steam flow meters installed.

• No feedwater flow meters installed.

• There are four decentralized hot water boilers serving building 141. Two Superior fire tube hot water boilers installed in 2010 with MAWP of 60 psig and rated at 200 Hp and two PK Boiler hot water boilers installed in 2015 with 160 psig MAWP rated at approx. 60 HP or two million

BTU/Hr.

o There is SCADA monitoring in the HP Boiler Plant, but boilers can be remotely started and operate on Lead/Lag control.

o No 4hr logs are taken. Boiler Plant only has Four operators including the supervisor and cannot leave high pressure plant.

o No safety device testing is performed.

2 OVERVIEW

Per contract 36E77620D0009 the Boiler Efficiency Institute (BEI) has been contracted to perform a boiler plant program review at VA hospitals from September 2020 – September 2021. A team consisting of two

BEI Engineers performed a detailed review of the Ft. Harrison, MT VA boiler plant program over the course of three eight-hour days.

The primary objective of this review is to provide support documentation to be used to strengthen the national Boiler Operations program. This review includes qualitative and quantitative surveys of each of the seven boiler plants long term plans, leadership, and operational efficiency. This information will determine which facilities are meeting long term goals and why long-term goals are or are not being met.

The team reviewed boiler plant and Engineering department documentation, conducted interviews with engineering management, staff, and performed a few selected safety device tests from the Boiler Plant

Safety Device Testing Manual 5th Edition.

3 EVALUATION CRITERIA

The Boiler Program Review targets ten evaluation categories. The evaluation categories include management, Directive 1810(1) compliance, training, parts and supplies, references, records, physical observations, facility condition assessment, testing and inspections, and layup and rotation.

A high performing, safe, and efficient boiler program includes: a complete up to date library of boiler plant policies, personnel who take systematic action, and proper documentation of all maintenance, training, and testing done. A boiler program can be evaluated using three distinct categories.

Are there written policies in place?

Are personnel qualified and acting systematically to achieve the requirements of the directive?

Are these actions being properly documented?

Policies are imperative as they guide boiler plant personnel and management on how decisions should be made. Policies give personnel the necessary tools to make routine and emergency boiler plant decisions in the best interest of the facility in support of the mission. Policies must be frequently reviewed to ensure they reflect the facilities current needs in support of the mission.

Actions and the qualified personnel that execute them are the heart of any boiler plant program. Boiler plant personnel and management must be qualified for the job at hand and take policy driven, systematic actions that result in full compliance with the directive. Though proper action can still occur without them, policy driven actions should be guided by written Standard Operation Procedures (SOPs).

Non-policy driven action based on oral procedure can lead to confusion, non-compliance and reduced operational efficiency.

Documentation and progress tracking are also essential parts of a safe and efficient boiler program.

Documentation allows boiler plant personnel and management to understand boiler plant trends, verify proper training, and improve operational efficiency. For example, the documentation of safety testing can flush out unseen boiler safety problems. This documentation is also useful to protect operators and is a record of how and when personnel accomplish their duties. As the boiler plant changes with time and technology, it is important that documentation be frequently reviewed and updated to reflect the most current state of the boiler plant and its operation.

4 REPORT DOCUMENTATION

4.1 ENTRANCE MEETING (1HR) – TO DISCUSS THE OBJECTIVES AND METHODS OF THE REVIEW.

Included: VAMC management and invited staff.

Name (Please Print) Title / location* phone

Wayne Delzer Energy Engineer 406-442-6410

Karl Bohnenberger BEI 334-821-3095

Chase O’Mary BEI 334-821-3095

Entrance Meeting Summary:

Chase O’Mary (BEI) explained the reason for the visit and described the agenda of the visit. Chase

O’Mary explained the purpose of the visit was to complete a thorough review of the boiler plant program with heavy focus on boiler plant policy and documentation.

4.2 AUDIT PROCESS AND RESULTS

This inspection was performed using the question rubric filled out in Appendix A that is based on the directive, safety device test manual and requirements developed by VHA central office. All questions were evaluated on a No, Partial, and Yes basis. A “No” evaluation was given to an item that appeared to be completely inadequate or missing. A “Partial” evaluation was given to items that have been attempted and have some proper information, but do not completely satisfy the directive or best practices. A “Yes” evaluation meets the minimum criteria in the spirit of the directive or best practices.

Scoring is generated based on the No, Partial, and Yes responses as listed above. A “No” response is awarded zero points. A partial response is awarded one point. A “Yes” response is awarded two points.

This scoring system is used to generate the graphics and tables

Questions are grouped into distinct categories:

Management

Directive

Training

Parts & Supplies

References

Records

Physical Observations of Boiler Plant

Facility Condition Assessment (FCA)

Testing & Inspection

Layup and Rotation

The scores for each group are summarized in tables, and the results are displayed graphically in horizontal bar charts. The bar charts indicate the percentage of total amount of points awarded on a scale of the total points possible.

The graphics and tables are to be used as a guide to help the facility improve its compliance with the directive and to achieve best practices exhibited in high performing boiler programs.

4.3 BACKGROUND

The Ft. Harrison VAMC boiler plant is manned and operated by four boiler plant operators. Boiler plant personnel are directly managed by a boiler plant supervisor. The boiler plant supervisor recently assumed the position last summer. Also the site has a new chief engineer. The plant has both high and low pressure boilers that are manned continuously. The site rarely uses the low pressure boilers. The low pressure boilers are always kept in hot standby.

4.4 EQUIPMENT SUMMARY

The site is equipped with three Superior fire tube low pressure steam boilers (2012 build) that feature a maximum allowable working pressure (MAWP) of 30 psig and have a rated capacity of 8,625 lb/hr steam. [National Board #’s 17252,17253,17254]

Additionally, the site is equipped with two Superior fire tube high pressure steam boilers (2012 build) that feature a maximum allowable working pressure (MAWP) of 150 psig and have a rated capacity of

5,175 lb/hr steam. [National Board #’s 17258,17259]

These boilers are equipped with Industrial Combustion Burners, that utilize natural gas as a primary fuel with a number two fuel oil and propane pilot fuel backup. Combustion is controlled through a

Pressuretrol proportional controller which employs a Fireye YB110 as a flame safeguard burner management system.

The boiler plant is equipped with a 9-year-old DA tank (2012 install, NDT not completed) rated at 30 psig. Feeding the DA tank is a 1,000 Gallon condensate tank also installed in 2012.

To complement the DA/condensate tank the plant is equipped with two non-VFD 60GPM Shipco condensate transfer pumps. Feedwater is pumped through either 3 non-VPD low pressure pumps or 2 non-VFD 60GPM Grundfos high pressure pumps.

Makeup water is fed to the plant through one of two Enpress, bottle style, softeners. The Softeners appeared to be a satisfactory working condition with no issues reported by the boiler plant personnel.

The plant is equipped with a fuel oil backup system that utilizes two pumps (2012 build estimated) with a hard piped propane pilot backup system.

4.5 FOURTEEN QUESTIONS

Table 4-2 Fourteen Questions and Answers

1.

Did the site follow-up and correct deficiencies?

A previous site visit was done in 2015 and 2017, both noting multiple deficiencies in the safety device testing program, devices, and directive 1810 (1) compliance.

Many issues noted during past visits remain present with no apparent action to sustain compliance.

2.

If funding were needed to correct deficiencies, was the funding request for local station funds, NRM, or other (specify)?

It is unclear if the site has requested or received funds to sustain compliance. A previous project to replace the boiler plant reached the design/development phase but was not funded further.

3.

Did the site receive funding?

Funding for a new boiler plant has not been received. It is unclear if other funding has been requested or issued to resolve issues in the current boiler plant.

4.

Did the site take action to sustain compliance? If yes, specify what actions.

The site has taken little action to sustain compliance.

5.

How was the local program improved?

A previous visit noted that boiler plant personnel were NOT taking daily logs. This has since been instituted however, there is still not adequate equipment to log all required data. (i.e. Steam Flow)

6. Overall Condition of Plant?

The plant is clean, well lit, and relatively clutter free. However, much of the equipment is not configured in a way that is compliant with VHA directive 1810 (1).

7.

Engagement of Plant Operators and Supervisors?

The boiler plant is currently operating with minimal staff – given the situation there was acceptable engagement from the boiler plant personnel.

8.

What is the age of the equipment?

The plant was constructed new in 2012 and all equipment appears to be in satisfactory operational condition.

The NDT test on the DA tank is overdue (over 6 years) and should be done as soon as practical.

9.

Is any of the equipment in need of replacement per VA Directive?

No equipment is in need of replacement per VA directive.

10.

Were the boiler plant operators and supervisors involved the facility condition assessment?

Boiler plant supervisor was involved with the latest FCA (2019) which was completed by the sites Energy Engineer.

11.

Are the items on the FCA for the boiler plant being addressed?

Items noted on the most recent FCA include:

• D – Generator is not housed within a 2 hr fire wall.

• D – Overhead doors hit boiler relief plumbing.

• D – No Catwalks to access Cond/DA Tanks

• D – Signage is missing/Wayfinding is poor.

• D – Plant control system does not interface with Building controls.

• F – No access platforms to Boilers, Multiple Safety Devices missing.

No projects current in place to correct these deficiencies. There was an attempt to fund a project for a new boiler plant that reached design development but stopped at that point.

12.

Is there a formal local process for bringing up boiler plant deficiencies and is there evidence this is being followed?

The process described by boiler plant personnel consists of email chains that describe deficiencies and a resolution path. There are currently no examples of this occurring.

13.

What success has been accomplished, i.e. after the BEI safety device inspection? Did they address the other two boilers in the plant?

Little safety device related progress has been made since previous BEI visits. Many previously noted issues still remain.

14. Were items corrected?

Deficiencies noted on previous BEI visits still remain. Little sign of corrective action (Incomplete Daily log implementation only notable action)

4.6 SAFETY DEVICE TESTING SURVEY SUMMARY

Partial safety device testing was performed on one boiler only (subsequent boilers, ancillary devices, and general plant safety were not evaluated).

Of the six safety devices tested, zero devices were found compliant, no devices were repaired during the testing procedure.

Table 4-3 Safety Device Survey Results Summary

Total Devices Tested 6

Safety Devices Found Fully Compliant 0

Safety Devices Found Not Compliant 6

Safety Devices Repaired During Training 0

Safety Devices Left as Non-Compliant 6

4.7 OVERALL HOSPITAL SCORE

The data is graphically depicted in figure 3-1 is a composite Overall Hospital Score. It depicts the composite score of policy, action, and documentation for all reviewed categories.

Figure 3-1. Overall Hospital Score

Table 3-1 Overall Hospital Score

Overall Hospital Score (sum) Response count Totals

Max Points Possible

No - 0 points each

Partial- 1 point each

Yes-2 points each

Total Score

Percent

Policy 42 10 9 2 13 31%

Action 182 57 13 22 57 31%

Documentation 62 17 6 8 22 35%

Note:

4.8 CATEGORY 1 – MANAGEMENT

Figure 4-1

1. Management Response count Totals

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Policy 4 0 2 0 2 50%

Action 10 4 0 1 2 20%

Documentation 4 2 0 0 0 0%

Deficiencies found include but are not limited to:

• There is no current boiler plant policy in place. The most recent policy expired in 2018. The older policy does describe a safety device failure process, but its is not being followed. Boiler plant supervisor indicate that deficiencies are verbally communicated up the chain of command.

• There is no evidence of any safety device failure reporting up the chain of command. Numerous safety device failures were reported in 2015 and 2017 during prior BEI visits. These issues have not been addressed.

• There is no policy or SOP that describes the process to deem a new hire boiler plant personnel competent to stand watch. The site must implement a new hire certification program with clearly defined system to deem new hire boiler plant personnel competent to stand watch.

• No new hire training records are in place.

• There is no centralized safety device failure tracking sheet. The site must implement a centralized safety device failure tracking sheet. The safety device failure tracking document must centrally track all deficiencies and document repairs. All safety device failures must be documented even if they are immediately repaired.

• There is no certification process for the quarterly compliance survey. There is no evidence of the quarterly compliance survey being viewed and certified by the chief engineer or medical facility director.

Notes:

• Boiler plant supervisor is currently working on a new draft boiler plant policy.

• Boiler plant supervisor is currently working to develop a new hire training curriculum.

4.9 CATEGORY 2 – DIRECTIVE 1810

Figure 4-2

2. Directive Response count Totals

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Policy 16 4 3 1 5 31%

Action 16 4 2 2 6 38%

Documentation 18 6 1 2 5 28%

Deficiencies found include but are not limited to:

• Quarterly Compliance Survey has some inaccuracies related to both low pressure and high pressure boilers. For example, the survey states that safety device testing is performed on all low pressure / hot water boilers. No record of safety device testing for decentralized hot water equipment could be located. The survey also states that all safety devices within the high pressure plant are compliant which is also not accurate.

• There is no direct evidence that any safety device failures have been reported to the facility director.

• There is no policy/SOP for creating Interim Safety Measures (ISM) for failed safety devices. No ISMs have ever been created. ISMs must be developed and implemented for all known safety device failures. Interim Safety Measures must remain in place until safety device failures are repaired.

• Missing Policy/ SOP for testing Emergency Water Source. Site must identify an emergency water source and connection and also implement complete testing of emergency water source and document testing.

• Site must create a policy requiring the boiler plant maintain a boiler plant drawing master list/change log to track boiler plant drawings as well as create the log.

• There is no policy in place requiring the site maintain site specific safety device testing procedures. No site specific testing procedures are in place for safety device testing. The site must create and implement procedures to apply to current equipment for all safety devices.

• There is no policy in place requiring consistent health and wellness checks for boiler plant operators on night shifts. Health and wellness checks are performed by VA police but not on a consistent basis. Site must create a policy and implement a system that ensures health and wellness checks are performed consistently. Recommend an automated system to ensure consistency.

• Boiler Plant personnel do not fire every boiler on backup fuel monthly. All boilers must be fired monthly for one hour on back up fuel. Boiler plant policy must be updated to require monthly oil firing on all boilers.

• Interim Safety Measures must provide an alternate operating procedure or setup that provides an equivalent level of safety as the failed safety device.

• Site must identify an emergency water source and alternate connection for the boiler plant.

4.10 CATEGORY 3 – TRAINING

Figure 4-3. Training

3. Training Response count Totals

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Policy 6 2 1 0 1 17%

Action 6 2 1 0 1 17%

Documentation 6 2 1 0 1 17%

• There is a generic training policy in an expired (2018) policy. This policy /SOP does not provide training plan specifics or a predefined recurring training curriculum.

• Site personnel indicated the only training they receive on a recurring basis other than TMS is OJT. This OJT is not documented.

• The site must create and execute a recurring boiler plant specific training plan.

• The training plan must include extensive, detailed boiler plant related emergency operations and normal operations training. Consider performing casualty drills to ensure all operators can properly respond to common boiler plant emergency situations.

• Ensure all TMS training is performed on time and documented.

Notes:

• Training plans should include training on all relevant normal and emergency operations procedures.

4.11 CATEGORY 4 – PARTS AND SUPPLIES

Figure 4-4. Parts & Supplies

4. Parts & Supplies Response count Totals

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Policy 6 2 0 1 2 33%

Action 8 0 2 2 6 75%

Documentation 6 2 0 1 2 33%

• The site has no policy for maintaining general and emergency spare parts and supplies. This policy should communicate program responsibility and inventory par levels.

• Some spare parts are onsite and organized.

• Parts are tracked when ordered and site gets needed parts in a timely manner.

• Refer to the VA Master Specification for lists of required spare parts par levels and inventory.

4.12 CATEGORY 5 – REFERENCES

Figure 4-5. References Score

5. References Response count Totals

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Policy 0 0 0 0 0 N/A

Action 0 0 0 0 0 N/A

Documentation 10 0 3 2 7 70%

• The library has most equipment reference materials available.

• The site should remove all dated material no longer relevant to the plant.

• The boiler plant does not have adequate boiler plant specific emergency operations procedures.

A best practice program generally has 10+ emergency operations procedures.

• The boiler plant does not have adequate boiler plant specific normal operations procedures. A best practice program generally has 20+ normal operations procedures.

• All procedures must be kept current.

• The site should consolidate normal and emergency operations procedures into a single binder.

• Consideration should be given to digitizing as much of the reference material as possible.

4.13 CATEGORY 6 – RECORDS

Figure 4-6. Records Score

6. Records Response count Totals

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Policy 4 1 1 0 1 25%

Action 4 1 1 0 1 25%

Documentation 10 2 1 2 5 50%

• Instrument and gage calibration records were not available. The site must maintain these records for 3 years. No gage or instrument calibration is performed.

• Update boiler plant policy to include formal review of all records annually.

• Safety Device testing records are not complete or compliant. Current records are handwritten on blank paper. No records past 2019 are in place. The site must have completed testing sheets from the VHA Safety Device Testing Manual 5th Edition for all monthly and semi-annual safety device tests.

4.14 CATEGORY 7 – PHYSICAL OBSERVATIONS OF THE BOILER PLANT

Figure 4-7. Physical Observations

7. Physical Observations B.P Response count Totals

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Policy 0 0 0 0 0 N/A

Action 12 0 2 4 10 83%

Documentation 0 0 0 0 0 N/A

• All Arc flash labeling is not place on electrical panels and electrical panels are not locked.

• Safety valve on the DA tank does not discharge outside the plant. The safety valve discharges within the plant. This is a safety issue. Steam safety valve must discharge outside the plant into an unoccupied area.

• The plant is clean and organized.

4.15 CATEGORY 8 – FACILITY CONDITION ASSESSMENT (FCA)

Figure 4-8. Facility Condition Assessment

8. Facility Condition Assessment Response count Totals

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Policy 0 0 0 0 0 N/A

Action 4 1 1 0 1 25%

Documentation 0 0 0 0 0 N/A

• FCA was performed in 2019. the results of the FCA give 5 D grades and one F grade. D- Boiler Plant Generator not within 2 hr fire wall. D- Overhead door hits boiler vent when open. D-no platforms/catwalks over tops of tanks. D-signage missing. D- No SCADA for Boilers. D- Boilers missing safety devices.

• No current projects are in place to correct.

• A project for a new boiler plant was began, but has been halted.

4.16 CATEGORY 9 - TESTING AND INSPECTION

Figure 4-9. Testing & Inspection Score

9. Testing & Inspection Response count Totals

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score Percent

Policy 2 0 1 0 1 50%

Action 12 45 3 12 27 23%

Documentation 4 2 0 0 0 0%

• Instrumentation is not calibrated semi-annually. Per directive instrumentation must be calibrated semi-annually. No records were on file. An instrument calibration program is critical to proper control function and must be immediately implemented. Instrument calibration is typically handed through a vendor.

• No records of gauge calibration were on file. No gauge calibration is occurring.

• DA Tank NDT has not been performed and is due. DA tank NDT must be performed as soon as possible.

• Safety Device testing has not been performed since 2019. Prior to that, safety device testing was not complete or being performed in a compliant manner. The facility lacks several required safety devices. The missing devices are as follows:

o Gas Train:

▪ Gas train missing manual valve downstream of vent valve and test port.

▪ Low and High Gas pressure switches missing LOOP valves.

▪ No double block and bleed on pilot line.

▪ No low pilot gas pressure switch installed.

o Air Train:

▪ No PAPS switch installed.

▪ CAPS not plumbed for testing-missing isolation valves and test ports.

▪ No low O2 analyzer, alarm, or cutout

▪ Linkages not drilled and pinned.

▪ Low fire proving switch setpoint not compliant- switch always made.

▪ No current relays on fan legs.

o BMS/Flame Scanner

▪ Flame Scanner not Self Checking

▪ No annunciation-no expanded annunciator o Oil Train:

▪ Low oil pressure switch has snubber installed and is not plumbed for testing.

▪ No High oil pressure switch installed.

▪ No Proof of Closure installed

▪ Low Atomizing Media Switch not plumbed for testing.

o Water:

▪ No High Water Alarm installed.

▪ Probe Low Water Cutout wired as recycle cutout-must be nonrecycle.

▪ No shunt Switch installed for float cutout.

▪ No blowdown line on sight glass o Steam:

▪ Steam Safety Vent lines are combined. No individual vent.

o DA Tank

▪ DA steam safety valve plumbed into open drain inside plant. If valve lifts steam will discharge directly into boiler plant.

▪ DA steam is not plumbed into tray section of DA. DA ineffective as oxygen removal device.

▪ No Safety Valve downstream of DA PRV station is installed.

▪ No independent High and Low Water level alarms-single transmitter triggers both alarms.

▪ Overflow is float type – not allowed by VA.

▪ No DA tank Bypass installed.

o Condensate Tank

▪ High water alarm is float type device and is installed well above 2/3 of tank height.

▪ Low Water alarm is installed well below 1/3 of tank height.

▪ No condensate tank bypass is installed.

o Combustion Air to boiler damper not wired into alarm.

o Liquid relief valves on oil pump set can be isolated by three separate valves. Valves must be lock open only.

o No back pressure regulator installed on oil pump set.

o No Dangerous Gas Monitoring System is installed. No carbon monoxide, combustible alarms.

o No Emergency Natural Gas Shutoff is installed.

• No safety device testing is performed on decentralized hot water boilers. There are four decentralized hot water boilers.

• Safety device testing program is not in place and a substantial upgrade project is needed so that complaint safety device testing can be performed.

4.17 CATEGORY 10 – LAYUP AND ROTATION

Figure 4-10. Testing & Inspection Score

10. Layup and Rotation Response count Totals

Max Points Possible

No - 0 points each

Partial-1 point each

Yes-2 points each

Total Score

Percent

Policy 4 1 1 0 1 25%

Action 4 0 1 1 3 75%

Documentation 4 1 0 1 2 50%

• The site must develop a policy and SOP for boiler layup.

• The site must develop a written equipment rotation plan and follow it accordingly.

4.18 ADDITIONAL ITEMS (SOME ITEMS LISTED HERE OBSERVED DURING THE REVIEW MAY NOT

PERTAIN SPECIFICALLY TO THE BOILER PLANT.)

• Combustion Air to boiler damper not wired into alarm.

• Liquid relief valves on oil pump set can be isolated by three separate valves. Valves must be lock open only.

• No back pressure regulator installed on oil pump set.

• No Dangerous Gas Monitoring System is installed. No carbon monoxide, combustible alarms.

• Roll up door hits steam safety vents.

• Chemical feed is manual shot feed. No automatic system.

• No pressure gages on LP tanks.

• No Emergency Natural Gas Shutoff is installed.

• No Plant Master Control. All boilers are local control.

• No high pressure boiler SCADA.

• No steam flow meters installed.

• No feedwater flow meters installed.

• There are four decentralized hot water boilers serving building 141. Two Superior fire tube hot water boilers installed in 2010 with MAWP of 60 psig and rated at 200 Hp and two PK Boiler hot water boilers installed in 2015 with 160 psig MAWP rated at approx. 60 HP or two million BTU/Hr.

o There is SCADA monitoring in the HP Boiler Plant but boilers can be remotely started and operate on Lead/Lag control.

o No 4hr logs are taken. Boiler Plant only has Four operators including the supervisor and cannot leave high pressure plant.

o No safety device testing is performed.

4.19 EXIT MEETING WITH VAMC MANAGEMENT

Below is a summary of the exit meeting with VAMC management. In this meeting, the contractor (BEI) summarized the findings and recommendations gathered throughout the review session.

Name (Please Print) Title / location*

Jose Rivera Hernandez Chief Engineer

Wayne Delzer Energy Engineer

Steven Broskey (Remote) HEFP

Chase O’Mary BEI

Karl Bohnenberger BEI

Exit Meeting Summary:

An out briefing was held March 18, 2021. The review team and the local VA representatives are listed in the table above. The purpose of the meeting was to provide the local VA administration with the findings of the review. Mr. OMary led the discussion. The discussion was based around the points listed below:

Category 1 – Management

• Create and implement boiler plant policy.

• Establish improved lines of communication between the boiler plant and management.

• Chief engineer must deem new hires competent.

• Chief engineer and facility director must certify quarterly compliance survey.

Category 2 - Directive 1810

• The boiler plant is missing many directive required policies.

• A process for developing ISMs must be implemented immediately.

• ISMs must be generated immediately for all known safety device failures.

Category 3- Training

• New Hire and Ongoing Training plans must be developed and implemented.

Category 4- Parts and Supplies

• Focus on maintaining boiler related long lead time parts.

• Create a formal parts tracking and inventory system.

Category 5- References

• The site must update normal operations procedures and create additional emergency operations procedures.

Category 6- Records

• Safety Device testing records must be updated to meet current requirements for monthly and semiannual safety device testing.

Category 7 - Physical Observations of Boiler Plant

• Label all panels with arc flash labeling.

Category 8 - Facility Condition Assessment (FCA)

• Address issues graded D and F.

Category 9 - Testing and Inspection

• Site must immediately implement safety device testing program. Many equipment upgrades will be required to perform complaint safety device testing.

• Site must acquire Non-Destructive Testing for the DA tank as soon as possible.

• Monthly and semiannual safety device testing must be documented using the test sheets found in the VHA Boiler Plant Safety Device Testing Manual 5th Edition.

• Site must implement and instrumentation and gage calibration program.

Category 10 – Layup and Rotation

• Develop a written equipment rotation plan/SOP.

5 SAFETY DEVICE TESTING PARTIAL SURVEY

5.1 BOILER INFORMATION

Boiler # 4

Manufacturer: Superior

Model: Fire Tube

Serial #: National Board No.: 17259

Typical Operating Pressure: 90 psig

Date of Manufacture: 2012

Design Pressure/Capacity: 150 psig/ 5,175 lbs/hr

Burner

Manufacturer: Industrial Combustion

Fuels: Natural Gas / #2 Fuel Oil

Comments:

Safety Device Testing survey was conducted on boiler number 4.

5.2 BOILER SAFETY DEVICE TESTING RESULTS SUMMARY

Total Devices Tested 6

Safety Devices Found Fully Compliant 6

Safety Devices Found Not Compliant 0

Safety Devices Repaired During Training 0

Safety Devices Left as Non-Compliant 6

5.3 DETAILED SAFETY DEVICE TESTING RESULTS

Safety Test Procedure

Not Adequate

Issue last

Inspection

Compliant as found

Failed

Repaired

Failed Not

Repaired

Low Fire Proving

Switch (Air) ☐ ☐ ☐ ☐ ☒

Comments:

Single Point position Installation: Fail - Not drilled and pinned Setpoint: Fail- Always Made.

Logic: Pass- Switch holds boiler and prevents lightoff.

Not Adequate

Issue Last

Inspection

Compliant as found

Failed

Repaired

Failed Not

Repaired

Low Fire Proving

Switch (GAS) ☐ ☐ ☐ ☐ ☒

Comments:

Single point position.

Installation: Fail - Not drilled and pinned Setpoint: Fail- Always Made.

Logic: Pass- Switch holds boiler and prevents lightoff.

Issue Last

Inspection

Compliant as found

Failed

Repaired

Failed Not

Repaired

Purge Airflow Proving Switch

Comments:

Installation: Fail-Not installed PAPS Switch is required to be installed per VA standard.

Issue Last

Inspection

Compliant as found

Failed

Repaired

Failed Not

Repaired

Combustion Air Pressure Switch

Comments:

Installation: Fail- Not plumbed for testing No test ports in place. Plumb per diagram in VHA Boiler Plant Safety Device Testing Manual 5th Edition.

Issue Last

Inspection

Compliant as found

Failed

Repaired

Failed Not

Repaired

Low Gas Pressure Switch

Comments:

Installation: Fail- Isolation Valve must lockable only in open position. Add lock.

Setpoint: Pass – Switch set to trip at 19.5 in wc. Regulated pressure was 24.4 in wc..

Logic: Pass- Shut boiler down

Issue Last

Inspection

Compliant as found

Failed

Repaired

Failed Not

Repaired

High GAS Pressure Switch

Comments:

Installation: Fail- Isolation Valve must lockable only in open position. Add lock.

Setpoint: Pass -Regulated pressure is 24 in wc. Switch activated at 28 in wc.

Logic: Pass- Shut boiler down.

6 APPENDIX A – FIELD NOTES