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A PRESENTATION FOR TAHFM 2013 Interlink NFPA 110 Update + Expanding the Concept of EP Reliability David Stymiest, PE, CHFM, CHSP, FASHE (PE in LA, MS, MA) DStymiest@ssr-inc.com, cell 504.232.1113 Copyright 2013, Smith Seckman Reid, Inc., Nashville, TN NFPA Disclaimer Although the speaker is Chairman of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this presentation are purely those of the speaker and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire texts of all referenced documents. NFPA members can obtain staff interpretations of NFPA standards at www.nfpa.org. All Rights Reserved 1

Learning Objectives Discuss NFPA 110-2013 current status List lessons learned from recent natural disasters List what else we can take away? Describe how we can make EP systems more dependabled Major 110 Changes in 2013 Fuel oil ASTM, maintenance, storage, tanks, quality, sampling, testing Relaxed 96 hour seismic language Testing NFPA 70B Reference All Rights Reserved 2

NFPA 110 major changes 1999 to 2013 Major 111 NFPA Changes for 2013 Exclude Level 1 SEPSS from high energy normal power room This does NOT apply to non-sepss UPSs Add DC Rectifier Plants to get ready for upcoming changes in telecom industry that will bring more DC systems into facilities All Rights Reserved 3

Want to make a change? Both standards are in the Annual 2015 update cycle. Public input closing date: July 8, 2013 www.nfpa.org/110 www.nfpa.org/111 Go to any NFPA code page For example, for 110: www.nfpa.org/110 All Rights Reserved 4

www.nfpa.org/110 Next edition tab NFPA 110 & NFPA 111 Revision Cycle The next edition of this standard is now open for Public Input (formerly proposals). Revision cycle information Revision Cycle: Annual 2015 Revised Edition Date: 2016 First Draft (previously Report on Proposals (ROP)) Public Input Closing Date: 7/8/2013 Public Input form (word) or Submit Public Input online First Draft Report Posting Date: 3/7/2014 Second Draft (previously Report on Comments (ROC)) Public Comment Closing Date: 5/16/2014 Second Draft Report Posting Date: 1/16/2015 Notice of Intent to Make a Motion (NITMAM) NITMAM Closing Date: 3/6/2015 NITMAM Posting Date: 5/1/2015 All Rights Reserved 5

NFPA 110 & 111 Public Input EP Reliability Original content published in the January 2013 issue of HFM magazine, Vol. 26, No. 1, 2013 by Health Forum Inc. All rights reserved. Reprint permission granted to SSR for digital use only All Rights Reserved 6

Lessons learned Pay attention to details Analyze impact of what if scenarios Things break Critical questions to ask Importance of testing & maintenance Commonalities between emergencies Vulnerability analyses Common-mode failures Other Lessons Learned Basic EM Concepts Ran out of fuel oil, no replacement oil Lack of cellular communications could not reach service companies to request help EP service company could not reach facility Staff not trained to make portable generator Staff not trained to make portable generator connections All Rights Reserved 7

Communications with caregivers General Issues Some clinical personnel believe EP is or should be uninterruptible, should never fail. Misunderstandings: unrealistic expectations Medical journal article: usually less than 1- second duration upon loss of commercial power Different types of failures Different responses Updated failure procedures More pervasive, more complex systems now Types of Failures Normal down with emergency power online 1 emergency power branch down, normal online 1 CB down with other CB still online Total electrical failure Simultaneously Cascading events All Rights Reserved 8

Explaining Normal vs. Emergency Power Normal Outlet Red (Emerg.) Outlet Generator is usually off Emergency Generator Explaining Normal vs. Emergency Power Simplified Emergency Power Supply System Generator on Red (Emerg.) Outlet Emergency Generator All Rights Reserved 9

Hospital Emergency Power Supply System (Before NFPA 99-2012 brought back EB) (Before NFPA 99-2012) What will happen? Communicate the Impact: Outage of a NP switchboard Power that will not be available (utility power fed through that switchboard) Selected normal lighting Selected NP receptacles (white & brown face) Selected equipment served from normal power Power that will be available (on generator) Power fed through other normal power switchboards Emergency lighting (includes egress lighting) Emergency receptacles (red face) Equipment served from emergency power All Rights Reserved 10

Communicate the Impact: Emergency power branch outage What will happen? Power that will be available (utility power) Normal lighting Normal receptacles (white & brown face) Equipment served from normal power Power that will not be available (load side of selected transfer switch[es]) Emergency lighting (includes egress lighting) Emergency receptacles (red face) Equipment served from emergency power Life safety branch outage Emergency lighting Exit signs Fire alarms Medical gas and vacuum alarms Emergency communication systems Generator (& ATS?) room lighting/outlets g Elevator cab lighting, commun., signals Automatic doors in means of egress Generator fuel pump? All Rights Reserved 11

Critical branch outage EP (red) outlets Selected task lighting in many pt care areas Critical care areas: PACUs, ICUs, ORs, ERs, procedure rooms, etc. Medication prep / dispensing areas Nurse call system Telephone equipment rooms/closets Generator fuel pump? Central med/surg suction systems/controls? Equipment branch outage (NFPA 99-2012 nomenclature) Critical care area ventilation Isolation room exhaust fans Hazardous exhaust fans Central med/surg suction systems/controls? Sump pumps Compressed air systems Smoke control, stair pressurization Kitchen hood supply/exhaust Heating, Jockey pump, elevators, All Rights Reserved 12

So what do we want from EP? Our emergency power systems need to power What they must When they must For as long as they must And we need to be able to roll with the punches when things go wrong Reliability A new paradigm? Probability that system operates and gives the same result on successive trials Availability Probability that system will function at any instant required, including the next instant, and for as long as required from that t point Dependability Measures availability, reliability & maintenance support All Rights Reserved 13

Availability Consider this If no facilities system stem can guarantee 100% reliability, can any facilities system assure 100% percent availability? Common metric for large data centers 4 nines facility availability - 99.99% 99% How does your power system compare with data center power system design? Consider revisiting TJC s Sentinel Event Alert 37 Preventing adverse events caused by emergency electrical power system failures published by TJC 9/6/2006 Also in TJC s 9/2007 EC News Recent events: Should we address the vulnerability analysis again perhaps more comprehensively this time? All Rights Reserved 14

Common-mode failures Failures of two or more components or systems due to a single event or cause A safety engineering concept: once a failure mode is identified, it usually can be mitigated by adding extra or redundant equipment to the system The existence of an uncorrected common mode failure potentially removes the advantage of other redundancies. You cannot correct what you have not yet identified. Duplex equipment can have common mode failures The two fuel oil pumps on this duplex pump set mitigate the impact of a single pump failure, but potential failures can occur due to common location or a single power circuit to the control panel. All Rights Reserved 15

Redundant equipment in common locations Paralleled generator sets can mitigate the impact of a single generator failure, but also can be subject to common mode failures due to shared location, shared fuel or cooling systems. Major Changes in NFPA 110 1999 to 2010 Category / Topic Protection from hazards 1999 Edition (Ref. by 2000 LSC) Rooms, shelters, or separate buildings located to minimize the possibility of damage from flooding (fire fighting, sewer, similar) 2010 Edition (Ref. by 2012 LSC) Rooms, shelters, or separate buildings designed and located to minimize the damage from flooding (fire fighting, sewer, similar) 2013 Edition Rooms, enclosures, or separate buildings designed and located to minimize the damage from flooding (fire fighting, sewer, other) All Rights Reserved 16

Other types of common-mode failures Contaminated fuel oil system Normal and emergency power equipment on same level Fuel oil storage tank subject to flooding Common fuel oil transfer pumps, controls, power circuits Feeders for elevated equipment located in flooded levels Other types of damage also Other types of common-mode failures One sump pump Multiple l sump pumps on same branch Transfer switch failure Paralleling switchgear failure All Rights Reserved 17

Maintenance improves dependability Bypass isolation transfer switches can be maintained without turning off their loads, improving i operational dependability. Major Changes in NFPA 110 1999 to 2010 Category / Topic Stipulated generator maintenance Stipulated ATS maintenance 1999 Edition (Ref. by 2000 LSC) None stated. All EPSS per manufacturer. Suggest Annex if no mfr. Basic All EPSS per manufacturer. 2010 Edition (Ref. by 2012 LSC) No change; Major annual PM in Annex 2013 Edition, but also references NFPA 70B for info, but also references NFPA 70B for info All Rights Reserved 18

Major Changes in NFPA 110 1999 to 2010 Category / Topic Stipulated paralleling gear maintenance Stipulated battery maintenance 1999 Edition (Ref. by 2000 LSC) None stated. All EPSS per manufacturer. inspections; follow manufacturer s specs 2010 Edition (Ref. by 2012 LSC) Similar to ATS stipulated maintenance 2013 Edition, but also references NFPA 70B for info Weekly Also permits, but battery also conductance references testing in lieu of NFPA 70B specific gravity for info Lessons Learned Ongoing testing & maintenance are crucial Generation, Switching, Distribution Don t forget other utilities You can t control what you can t control So plan for it Without t information you have only opinions The details will get you sweat the small stuff All Rights Reserved 19

Recommended Approach 1. Consider each component that must operate; 2. Determine what scenarios will cause it to fail, including all What if? scenarios that could damage the power sources or feeders that keep it running; 3. Compare those scenarios with others that may take out other redundant components, redundant power sources or redundant feeders; 4. Investigate t all the possible causes of those scenarios, including commonalities in power sources, feeders or controls; 5. Address all of the resulting vulnerabilities that have been identified. Contingency plans for failures Brainstorm for all potential failures. What can go wrong? Have a contingency plan for each. Equipment failures Generator Transfer switch; panel; circuit it breaker Include (older) breaker failures Update call lists for emergency suppliers All Rights Reserved 20

Simplest contingency plan very basic info can be too simplistic for many failures UTILITY FAILURE Normal Electrical Power Failure EMERGENCY CONDITIONS and BASIC STAFF RESPONSE BUILDING UTILITY FAILURES WHAT TO EXPECT WHAT TO DO OTHER RESPONSES Power only to emergency lights and RED plug outlets. Open Disaster Bin for flashlight, extension cords, batteries, etc. Know areas on emergency power. Ensure that Life Support Systems are attached to RED plugs; be prepared to handventilate. Report to Supervisor. Simplest contingency plan very basic info can be too simplistic for many failures UTILITY FAILURE Normal Electrical Power Failure EMERGENCY CONDITIONS and BASIC STAFF RESPONSE BUILDING UTILITY FAILURES WHAT TO EXPECT Power only to emergency lights and RED plug outlets. WHAT TO DO Open Disaster Bin for flashlight, extension cords, batteries, etc. Know areas on emergency power. EMERGENCY CLINICAL INTERVENTIONS Ensure that Life Support Systems are attached to RED plugs; be prepared to handventilate. List clinical interventions Emergency Electrical Power Failure (only) Power only to normal lighting, and gray or white plug outlets Open Disaster Bin for flashlight, extension cords, batteries, etc. Check all patient care equipment and patient task lighting. Ensure that Life Support Systems are attached to gray/white plugs or to BACKUP red plugs if available; be prepared to hand ventilate. List clinical interventions All Rights Reserved 21

Preparedness for power failures Recognize that t failures will occur Plan appropriate responses ahead of time Response will be different for each failure It is too late to formulate a response after the failure occurs Detailed emergency procedures help us to keep cool under pressure All Rights Reserved 22

A helpful resource from ASHE Shutdown preparation Similar to planning for internal electrical outages Critical Operations Power Systems Article 708, starting in 2008 NEC Article 708 probably does NOT apply to you; consider it as an example of best practices. Risk assessment: ID hazards, mitigation strategies Documented load testing & maintenance Commissioning Surge protection, selective coordination, bypassisolation ATS s, selective load pickup & shedding, 2 levels GF if req d. 72 hours onsite fuel, means to connect portable genset Physical security, physical protection, separation, 1 hr & 2 hr FRR, location limitations, 100 year floodplain considered, labeling, fire protection etc. NEC and National Electrical Code are registered trademarks of the National Fire Protection Association, All Rights Reserved 23

Thank you. Questions anyone? David Stymiest, P.E. CHFM CHSP FASHE (P.E. in LA, MS, MA) Cell 504.232.1113 DStymiest@ssr-inc.com (References follow this slide.) References 1 After the Storm - Expanding the concept of emergency power reliability by David Stymiest. Original content published in the January 2013 issue of HFM magazine, Vol. 26, No. 1, 2013 by Health Forum Inc. All rights reserved. Permission granted to SSR for digital use only. http://tinyurl.com/hfmafterthestorm ASHE White Paper: NFPA 110 / 111 Changes for 2013 originally presented at the 2012 ASHE Annual Conference. https://www.softconference.com/ashe/sessiondetail.asp?sid=280670 NFPA 110-2013 Edition Addresses Generator Fuel Oil Management in SSR Compliance News, Sep-Oct 2012 edition, http://ssr-cfmarticles.blogspot.com/2012/10/compliance-news-nfpa-110-2013-edition.html ASHE White Paper: Planning for Power Failures originally i presented at the 2007 ASHE Annual Conference. http://www.ssrinc.com/pdfs/planning%20for%20power%20failures_david%20stymiest_ashe %20Paper.pdf Response to a Partial Power Failure in the Operating Room, Tammy Carpenter, M.D., and Stephen T. Robinson, M.D., Anesthesia & Analgesia, vol. 110, no. 6 (June 2010) 1644 46: www.anesth-analg.com/content/110/6/1644.full.pdf+html All Rights Reserved 24

References 2 Electrical Power Failure in the Operating Room: A Neglected Topic in Anesthesia Safety, John H. Eichhorn, M.D., and Eugene A. Hessel II, M.D., Anesthesia & Analgesia, vol. 110, no. 6 June 2010) 1519 21: www.anesthesiaanalgesia.org/content/110/6/1519 Preventing adverse events caused by emergency electrical power system failures, The Joint Commission Sentinel Event Alert, Issue 37, Sept. 6, 2006: www.jointcommission.org/sentinel_event_alert_issue_37_preventing_adverse_ events_caused_by_emergency_electrical_power_system_failures/ Sounding a Sentinel Event Alert on Emergency Electrical Power Systems Environment of Care News September 2007: www.jcrinc.com Averting Common Causes of Generator Failure (Part 1), Darren Dembski and Sarah Escalante, Facilities Engineering Journal, September/ October 2009: www.afe.org/publications/genfailure09.09.pdf Problems Encountered During Hurricane Sandy by Dan Chisholm, MGI Systems, Inc., 3/4/13. http://mgisys.com/problems-encountered-during-hurricane-sandy/ References 3 Averting Common Causes of Generator Failure (Part 2), Darren Dembski and Sarah Escalante, Facilities Engineering Journal, November/December 2009: www.afe.org/publications/journal/generatorfailure2.pdf Generator Fan Failure Triggered AWS Outage, Rich Miller, Data Center Knowledge blog June 21, 2012: www.datacenterknowledge.com/archives/2012/06/21/aws-outage/ Multiple Generator Failures Caused Amazon Outage, Rich Miller, Data Center Knowledge blog July 3, 2012: www.datacenterknowledge.com/archives/2012/07/03/multiplegenerator-failures-causedamazonoutage/ Managing Hospital Emergency Power Systems Testing, Operation, Maintenance and Power Failure Planning, ASHE management monograph, 2006: www.ashe.org/resources/management_monographs/mg2009stymiest.html NFPA 110-1999, NFPA 110-2010, and NFPA 110-2013 Standard for Emergency and Standby Power Systems, NFPA; www.nfpa.org/110 All Rights Reserved 25

VO L.10 I S S U E 5 S E P T E M B E R / O C TO B E R 2 012 N F P A 1 1 0-2 0 1 3 E D I T I O N A D D R E S S E S G E N E R A T O R F U E L O I L M A N A G E M E N T By David L. Stymiest, PE, CHFM, CHSP, FASHE dstymiest@ssr- Inc.c om NFPA Disclaimer: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents. NFPA members can obtain NFPA staff interpretations at www.nfpa.org. The 2013 edition of NFPA 110 was recently released by the NFPA Standards Council. Chief among the changes in this edition were several changes, including informational Annex recommendations, intended to improve emergency power supply system (EPSS) reliability through better fuel oil management processes. The excerpts below are only partial excerpts, and readers should review the full text of the updated standard, which is available at www.nfpa.org/110. In the discussion below, note that all Annex language is not mandatory, rather it is advisory only and contains recommendations for user consideration. Paragraph 7.9.1.3 was modified to stipulate that tanks shall be sized so that the fuel is consumed within the storage life, or provisions shall be made to remediate fuel that is stale or contaminated or to replace stale or contaminated fuel with clean fuel. Although these are not in NFPA 110, some popular remediation techniques incorporate filtering of the stored fuel through a series of water separators and media filters, periodic centrifuge cleaning/polishing with high pressure tank agitation and/or mechanical tank cleaning with auxiliary filtration. Chapter 8 (Routine Maintenance and Operational Testing) applies to both new and existing systems and equipment. Paragraph 8.3.8 was modified to clarify that A fuel quality test shall be performed at least annually using appropriate ASTM standards. Chapter 2 (Referenced Publications) does not list appropriate ASTM standards because they are not specifically referenced in the main body of the standard. Since there is no ASTM standard specification for natural or synthetic gas, the NFPA 110 Annex indicates that industry generally uses pipeline specifications for natural gas quality. However, the NFPA 110 Annex does list the following ASTM standards for fuel oil systems because they are specifically discussed in the Annex: ASTM D 975, Standard Specification for Diesel Fuel Oils ASTM D 1835, Standard Specification for Liquefied Petroleum (LP) Gases Because fuel oil contaminants (including water) in fuel oil storage tanks can be found in the bottoms of storage tanks, new Annex language now recommends that special attention should be paid to sampling the bottom of the storage tank to verify that the stored fuel is as clean and dry as practicable and that water, sediment, or microbial growth on the tank bottom is minimized. The new Annex language also states that ASTM D 975 contains test methods for existing diesel fuel. (Continued on page 2) w w w.ssr- inc.c om

S E P T E M B E R / O C TO B E R 2 012 VO L.10 I S S U E 5 N FPA 110-2013 EDITION ADDRES S ES G EN ER ATO R FU EL O I L M A N AG EM ENT (C o n t i n u e d f r o m p a g e 1 ) As a caution excessive water or other contaminants in a fuel oil storage tank or elsewhere within the fuel oil system can cause emergency generators to fail. This and other fuel oil system issues have been recognized as the second leading cause of EPSS failures. Starting system issues are recognized as the primary cause of EPSS failures. The NFPA 110 recommendations on sampling can help to minimize the potential for this fuel systemrelated failure mode. Annex paragraph A.7.9.1.2 contains more recommendations concerning water contamination-related failures and management techniques Fuel storage tanks should be kept as dry as possible and have provisions for water drainage on a regular basis. The presence of water can lead to microbiological contamination and growth, which in turn can lead to general or pitting corrosion of steel tanks and components, possibly resulting in filter plugging, operational issues, or a hydrocarbon release to the environment. Annex paragraph A.7.9.1.2 also discusses the importance of broader inspection techniques Regularly scheduled surveillance of the fuel allows the operator(s) to evaluate the condition of the fuel and make important decisions regarding the quality of the fuel dedicated to reliable operation of the prime mover. Although it is not a requirement, Annex Figure A.8.3.1(a) Suggested Maintenance Schedule for EPSSs, has recommended weekly checks for water in the Level 1 EPSS fuel oil systems for several editions. Annex paragraph A.5.1.1(1) contains explanatory material and recommendations regarding EPSS diesel fuel. It now states that the grade of diesel fuel used in an EPSS diesel engine should be based on recommendations from the diesel engine manufacturer and ASTM D 975. Annex paragraph A.5.1.1(1) also discusses special precautions recommended for outside storage tanks If diesel fuel is stored outside for long-term storage, it may be necessary to use a winter or arctic grade of diesel fuel or to take precautions such as insulating and heat-tracing fuel tanks and lines to ensure that fuel will flow to the prime mover under the coldest possible conditions. The NFPA 110-2013 Annex also goes on to warn against the use of certain biodiesel fuels in EPSS applications, such as in A.5.1.1(1) Where possible, the purchaser of fuel for the prime mover should specify a diesel fuel that does not contain biodiesel, which can accelerate the degradation of the diesel fuel if stored longer than 6 months. Further related discussion is in Annex paragraph A.5.5.3 biodiesel blends up to B5 (ASTM D 975, Standard Specification for Diesel Fuel Oils) have much shorter shelf lives than conventional diesel fuel [ultra-low sulfur diesel (ULSD)] and can accelerate degradation processes, endangering the entire diesel fuel supply. Annex paragraph A.5.5.3 also contains recommendations regarding fuel oil storage tank sizing Consideration should be given to sizing tanks in order to meet minimum fuel supplier delivery requirements, particularly for small tanks. Consideration also should be given to oversizing tanks. Annex paragraph A.5.5.3 also contains recommendations and explanatory material regarding fuel storage management Where fuel is stored for extended periods of time (e.g., more than 12 months), it is recommended that fuels be periodically pumped out and used in other services and replaced with fresh fuel. The NFPA 110-2013 Annex also recommends additional fuel oil system management techniques in paragraph A.7.9.1.2 To optimize the long-term storage of fuels for prime movers, the fuel tanks should be kept cool and dry, and the tank as full as possible. Tanks that are subject to temperature variations can experience accelerated fuel degradation, especially if the tanks are outside and above ground or close to an extreme heat source if stored inside a structure. The more constant and cooler the tank temperatures, the less likely temperature-related fuel degradation will occur. (Continued on page 3) w w w.ssr- inc.c om

S E P T E M B E R / O C TO B E R 2 012 VO L.10 I S S U E 5 N FPA 110-2013 EDITION ADDRES S ES G EN ER ATO R FU EL O I L M A N AG EM ENT (C o n t i n u e d f r o m p a g e 2 ) Annex paragraph A.7.9.1.2 also makes recommendations concerning the air space above the fuel oil within the storage tank, which can be influenced by the size of the tank, the rate of fuel oil usage, the emergency management requirements, the age of the fuel, etc. Tank ullage (air space) should be kept to a minimum. Excess air space allows for warm, humid air to enter the tank and condense moisture during the cool evening. Also, prolonged exposure to ambient air, which is 20 percent oxygen, can facilitate oxidative degradation of the fuel. And finally, in Annex paragraph A.7.9.1.2, NFPA 110 advises that Fuel maintenance and testing should begin the day of installation and first fill in order to establish a benchmark guideline for future comparison. Laboratory testing services should always be sought from a qualified or certified petroleum laboratory. TJ C PROVIDES M O R E CORRIDOR CLUT T ER G UIDA N C E By David L. Stymiest, PE, CHFM, CHSP, FASHE dstymiest@ssr- Inc.com TJC continued providing corridor clutter clarifications and expectations in the September 2012 edition of The Joint Commission Perspectives, which is TJC s official newsletter. In this issue TJC Department of Engineering Director George Mills followed up on his August 2012 column by addressing several additional issues including latching patient room doors, corridor walls, corridors and air supply, corridor projections. He also provided additional guidance related to the CMS waiver policy regarding certain provisions of the 2012 Life Safety Code. Mr. Mills discussed the differences between the required patient room door latches and the self-closing or automatic closing devices that are not required for patient room doors. He discussed TJC s expectation that accredited organizations are required to have in their fire response plans a process to ensure that patient room doors close and latch in a fire emergency. Because this requirement must be in the facility fire response plan, staff are accountable for checking patient room doors and closing the open ones during both fire drills and non-drill fire events. Mr. Mills discussed Life Safety Code differences in corridor wall requirements between fully-sprinklered buildings and unsprinklered buildings. Basically, the article summarized the Life Safety Code provision that corridors walls in fully-sprinklered compartments are permitted to be non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. In unsprinklered buildings however Mr. Mills stated that the corridor wall should have a 30-minute fire rating and walls that extend from the floor to the underside of the floor or roof above. Of course as with any other fire rated partition, corridor walls in unsprinklered buildings would not be permitted to have unsealed penetrations. The TJC Perspectives article also reminded accredited organizations that TJC does not allow corridors to be used as a part of an air supply, air return, or air plenum. This prohibition is based upon the concern that a corridor air flow usage such as that prohibited could also spread a fire. We recommend that accredited organizations read the entire referenced TJC article since it contains additional information not presented here. w w w.ssr- inc.c om

S E P T E M B E R / O C TO B E R 2 012 VO L.10 I S S U E 5 ASHE Publishes New Management Monograph Managing Hospital Electrical Shutdowns By David L. Stymiest, PE, CHFM, CHSP, FASHE ASHE recently published a new management monograph that provides guidance for managing safe electrical shutdowns. It is available free of charge as a downloaded protected PDF to all ASHE members at http://www.ashe.org/resources/management_monographs/mg2012stymiest.html. Hard copies are also available to both ASHE members and non-members in the ASHE Online Store as ASHE catalog # 055978. This 55-page monograph covers the following major topics in depth: Why electrical shutdowns should be planned Things to consider before planning a shutdown Planning a shutdown Electrical system considerations during a shutdown After the shutdown Planning for future shutdowns Numerous appendices with samples and templates to assist hospitals in their shutdown management activities Our Compliance News readers are welcome to submit comments, suggestions and questions by email to: DStymiest@ssr-inc.com. dstymiest@ssr- Inc.com PU B LICATIONS AND SEMINARS Publications Risk and Reward - Assessing the need for electrical system shutdowns, Health Facilities Management, August 2012 Managing Hospital Electrical Shutdowns, ASHE Monograph, July 2012 Seminars October 4 New England Healthcare Engineering Society Annual Conference, Springfield, MA, Emergency Power Challenges in 2012 and Beyond October 8 Florida AHCA Fall Seminar, Orlando, FL, Managing Hospital Electrical Shutdowns and IPD Case Studies October 30-31 Tennessee Hospital Engineers Association Annual Meeting, Nashville, TN, Code Update: FGI Guidelines 2010 Edition and Impact to Hospital Construction in Tennessee, TJC and Enforcement of Surgery Room Relative Humidity Limits, HVAC System Selection Processes in an Integrated Delivery Methodology, and Continuous Commissioning and Energy Cost Management in Existing Healthcare Facilities November 7-9 Midwest Healthcare Engineering Conference, Indianapolis, IN, Continuous Compliance - Maintaining Constant Survey Readiness and NFPA 110/111 Update - Paying More Attention to EP Reliability November 16 Louisiana Society for Healthcare Facilities Management Meeting, Eunice, LA, NFPA 110/111 Changes for 2013 w w w.ssr- inc.c om Compliance News is a news let ter dedicated to accreditation, regulator y compliance and fac ility management issues for healthcare executives and fac ility managers. For more information, please contact David Stymiest, PE, CHFM, CHSP, FASHE, 800-545 - 6732; dstymiest@ssr- inc.com.

Major differences between NFPA 110-1999 (referenced by 2000 Life Safety Code ) and NFPA 110-2010 (referenced by 2012 Life Safety Code ) DStymiest@ssr inc.com Major differences between NFPA 110 1999 and NFPA 110 2010 (Not all differences are included within this table; refer to the standards for more information.] NFPA Disclaimer: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this document are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents. 1999 Edition 2010 Edition Category / Topic 2013 Edition (Ref. by 2000 LSC) (Ref. by 2012 LSC) Loading percentages and testing time frames Testing after repairs Absolute units (25%, 30%, 50%; 30 minutes, etc.) Required Not less than (NLT) clarification language added throughout Required; detailed instructions included, transfer all ATS s for NLT 30 minutes Major rewrites for clarification Immediately after passing acceptance tests Installation Acceptance Difficult to follow time Test sequencing First routine test Not really stipulated, could be next monthly Types of records Written record Permanent record None stated. Stipulated generator All EPSS per manufacturer. maintenance Suggest Annex if no mfr. Stipulated ATS maintenance Stipulated paralleling gear maintenance Stipulated battery maintenance Who may test & maintain EPSS Fuel quality testing, storage, other reliability issues [This item was changed from the ASHE White Paper] Basic All EPSS per manufacturer. None stated. All EPSS per manufacturer. Per manufacturer. Weekly inspections; follow manufacturer s specs Overseen by a properly instructed individual None. Annex notes discussed fuel storage and fuel shelflife issues No change; Major annual PM in Annex Similar to ATS stipulated maintenance Also permits battery conductance testing in lieu of specific gravity testing Overseen by a properly instructed individual Annually using tests approved by ASTM standards this language resulted in many questions, but also references NFPA 70B for info, but also references NFPA 70B for info, but also references NFPA 70B for info, but also references NFPA 70B for info Qualified Persons Annually using appropriate ASTM standards. Standards are listed. 2013 edition has many new improvements & clarifications for reliability (tanks, piping, quality, storage, sampling, testing, maintenance) in Annex A.7.9.1.2. and A.8.3.8 This document was first presented at the 2012 ASHE Annual Conference as a portion of the ASHE White Paper NFPA 110 / 111 Changes for 2013. Copyright 2012 ASHE; contact ASHE at www.ashe.org for reprint restrictions and permission. Full copies of referenced standards are available at www.nfpa.org/110 and www.nfpa.org/111.

Major differences between NFPA 110 1999 and NFPA 110 2010 (Not all differences are included within this table; refer to the standards for more information.] NFPA Disclaimer: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this document are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents. 1999 Edition 2010 Edition Category / Topic 2013 Edition (Ref. by 2000 LSC) (Ref. by 2012 LSC) Monthly testing duration if using % loading criteria Monthly testing duration if using exhaust gas temp Annual load test criteria Spark ignited unit testing duration EPSS (Gen to ATS) circuit breaker exercising EPSS (Gen to ATS) M.V. circuit breaker exercising 3 year 4 hour load test Combining tests Optional standby systems Application Seismic Risk Areas Engine Temperature Battery temperature Engine room temperature 30 minutes minimum under operating temperature conditions or at not less than 30 % of the EPS nameplate rating 30 minutes minimum 2 hours: (25% 30min, 50% 30min, 75% 60min) Not mentioned (assumed to be same as DG) 30 minutes minimum under operating temperature conditions and at not less than 30 % of the EPS nameplate kw rating 30 minutes minimum [Less in 2005 Ed. for <30% but reverted back to 30 min. minimum in 2010 Ed.] 1.5 hours: (NLT 50% 30min, NLT 75% 60min) 30min or until water temp and oil pressure stabilize Annex clarification on prime vs. standby ratings Annually with EPS off Exercise @ 6 months + OL testing every 2 years NONE (Started in 2005 edition) NONE Not mentioned; many assumed to be Level 2 New installations unless a distinct hazard to life Minimum 96 hours without refueling if the need for EPS persists for this period of time Min. 90F jacket water Min. 50F Min. 70F indoors; Min. 32F outdoors 4 continuous hours, transfer all ATS s, NLT 30% or exhaust gas temp; use just available load if spark YES. Stipulates rules for combining annual & 3 yr Excluded when not Level 1 or Level 2 Chapter 8 applies to new and existing systems From 2005 Edition] ASCE 7 seismic design Category C, D, E or F require Class X = minimum 96 hours of fuel supply As determined by manufacturer for cold start and load acceptance Min. 40F indoors or outdoors Moved to Annex: ASCE 7 seismic design category C, D, E, or F should be minimum 96 hours without refueling if EPS operation is necessary for this period Clarified, moved around, redundancies eliminated; no significant changes This document was first presented at the 2012 ASHE Annual Conference as a portion of the ASHE White Paper NFPA 110 / 111 Changes for 2013. Copyright 2012 ASHE; contact ASHE at www.ashe.org for reprint restrictions and permission. Full copies of referenced standards are available at www.nfpa.org/110 and www.nfpa.org/111.

Major differences between NFPA 110 1999 and NFPA 110 2010 (Not all differences are included within this table; refer to the standards for more information.] NFPA Disclaimer: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this document are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents. 1999 Edition 2010 Edition Category / Topic 2013 Edition (Ref. by 2000 LSC) (Ref. by 2012 LSC) Combustion air & ventilation air Batteries EPSS equipment in NP rooms containing electrical service equipment? Other items in EPS rooms Lightning protection system Distribution ATS transfer time in monthly tests Provide portable when genset out of service Adequate; Proper Nickel cadmium or lead acid No No storage Adequately protected Applicable requirements; some details Not discussed Give consideration Level 1: directly from outside by exterior wall opening or 2 hour fire rated air transfer system. Fire dampers, shutters, or other self closing devices not permitted for supply or return/discharge air to EPS equipment Nickel cadmium or lead acid; differentiates VRLA vs. vented (flooded) Level 1: Not where service >150 V G and 1000 A Parts, tools, manuals for routine maintenance and repair are okay Use NFPA 780 where LPS is required Added NFPA 99 reference Not discussed Listed transfer switch Yes, where available Protection from hazards Rooms, shelters, or separate buildings located to minimize possibility of damage from flooding (fire fighting, sewer, similar) Rooms, shelters, or separate buildings designed and located to minimize the damage from flooding (fire fighting, sewer, similar) Clarified, moved around, redundancies eliminated; no significant changes 10 sec not required during monthly testing; if not met during monthly test, need process to annually confirm capability of system to comply when 10 sec cannot be met, except MV CP or mechanical (not LS/CB) may be electrically interlocked MV breakers Rooms, enclosures, or separate buildings designed and located to minimize the damage from flooding (fire fighting, sewer, other) This document was first presented at the 2012 ASHE Annual Conference as a portion of the ASHE White Paper NFPA 110 / 111 Changes for 2013. Copyright 2012 ASHE; contact ASHE at www.ashe.org for reprint restrictions and permission. Full copies of referenced standards are available at www.nfpa.org/110 and www.nfpa.org/111.

Major differences between NFPA 111 1999 and NFPA 111 2010 (Not all differences are included within this table; refer to the standards for more information.] NFPA Disclaimer: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents. 1996 Edition of 111 2010 Edition of 111 Category / Topic 2013 Edition of 111 (Ref. by 2000 LSC) (Ref. by 2012 LSC) SEPSS design and equipment SEPSS equipment in NP rooms containing electrical service equipment? Testing after repairs Installation Acceptance Test First routine test Types of records Stipulated SEPSS inspection Stipulated SEPSS maintenance Stipulated SEPSS exercising Stipulated battery maintenance Exclusions from NFPA 111 SEPSS requirements Who may operate, test & maintain Remote annunciation 1990 s era technology, now obsolete Not discussed Not discussed Time sequenced, includes full load test Immediately after acceptance test Written records Inspect monthly with detailed PM requirements maintained to ensure to a reasonable degree that the system is capable Exercise quarterly lesser of at least 5 min or class. Annual: full load for full duration of Class As part of quarterly inspection, includes load test <500 VA, <24v, <2 min, unit equip, nuclear, solar, wind, fuel cells Updated for modern technology, including fuel cells, flywheel systems, closecoupled hybrid rotary systems, ultracapacitor systems Not discussed After any repair or replacement, including battery replacement More detailed than previously, still includes full load test Reproducible written records, also documentation of postrepair/replacement test, added ohmic measurements maintained so that the system is capable Expanded operational testing requirements Annual: full load for 60% of Class Load test details added, expanded to include ohmic measurements & response to bad readings <500 VA, <24v, <2 min, unit equip, nuclear, solar, wind, UPS powered by an EPSS Adds DC rectifier plants Excludes Level 1 SEPSS from high energy normal power room Properly trained individual Qualified personnel 1990 s era practices Level 1 expanded to facility or network remote annunciation to reflect modern practices This document was first presented at the 2012 ASHE Annual Conference as a portion of the ASHE White Paper NFPA 110 / 111 Changes for 2013. Copyright 2012 ASHE; contact ASHE at www.ashe.org for reprint restrictions and permission. Full copies of referenced standards are available at www.nfpa.org/110 and www.nfpa.org/111.