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Policies,Administrative,UWHC,Department Specific,Facilities & Engineering Services

Fire Barrier Inspection and Maintenance (F&E.05.20.01)

Fire Barrier Inspection and Maintenance (F&E.05.20.01) - Policies, Administrative, UWHC, Department Specific, Facilities & Engineering Services

F&E.05.20.01

FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE


Effective Date: X Administrative Manual Policy

July 2015 Computer Room Manual F&E.05.20.01
Original
Revision X
Page 1
of 3
Title: Fire Barrier Inspection
and Maintenance

PE.05.20.01 Fire Barrier Inspection and Maintenance
I PURPOSE
This policy defines procedures for inspection and maintenance of fire barriers
within UWHC owned or leased buildings. This policy also establishes methods
for recording and monitoring the effectiveness of these procedures as part of the
Building Maintenance program (BMP).

II POLICY
A. New Fire Barriers

During construction and remodeling of UWHC buildings, fire barriers constructed
are inspected as required by the appropriate version of the NFPA 101 Life Safety
Code. Plant Engineering or Planning, Design & Construction Project Managers
forward as built drawings of the projects to the BIM department for incorporation
into the fire barrier summary maintained as part of the Plant Engineering Basic
Building Information document.

B. Periodic Inspection and testing

Fire door inspection, including closing and latching, are part of the Building
Maintenance Program. The number of repair work orders is trended and
reviewed as part of the departmental BMP statistics.


Fire wall and floor inspections for unsealed penetrations are incorporated in the
Building Maintenance Program.

The BMP is reviewed by the Continual Readiness and Environment of Care (EC)
Safety Committees.

III PROCEDURE
A. New Construction and Remodeling

1. All construction and remodeling projects are reviewed and inspected by the
Department of Health Services (DHS) to insure design and construction
compliant with the appropriate version of NFPA 101 Life Safety Code. Life
Safety Code issues noted during review or inspection are corrected prior to
occupancy by UWHC patients and staff.




FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE


Effective Date: X Administrative Manual Policy

July 2015 Computer Room Manual F&E.05.20.01
Original
Revision X
Page 2
of 3
Title: Fire Barrier Inspection
and Maintenance

PE.05.20.01 Fire Barrier Inspection and Maintenance
2. As part of the project close out, the following certifications will be provided to
the project manager by the appropriate contractors as defined in the
specifications of each project: a) certification that fire door installation,
closing, and latching meet code requirements; b) certification that installation
and operation of fire and smoke dampers meet code requirements and c)
certification that fire wall tightness has been inspected and meets code
requirements.

3. After construction, as built drawings provided by the contractors will be
forwarded to the UWHC Planning, Design & Construction department and
any changes made during the project will be incorporated into the Plant
Engineering Life Safety drawings.

4. The hospital operates fire and smoke dampers one year after installation.
Faulty damper operation will be corrected immediately by the inspecting
crew.

B. Periodic Fire Barrier Inspections

1. Components of the fire barriers will be periodically inspected and maintained
as listed in this section.

2. Fire doors will be tested at least twice a year to ensure fit, closure, and
latching. Changes to the inspection interval are determined by the Continual
Readiness Committee. Faulty door operation will be corrected immediately by
the inspecting crew. If they cannot be immediately repaired, an LS45 work
order will be issued.

3. Fire dampers will be inspected every two years. The hospital operates fire
and smoke dampers at least every six years to verify that they fully close.
Faulty damper operation will be corrected immediately by the inspecting
crew. If they cannot be immediately repaired, an LS45 work order will be
issued.

4. Fire walls will be inspected using two different programs. Fire walls will be
randomly inspected annually as part of Life Safety Rounds. Monthly fire wall
inspections, managed by the Building Trades Supervisor, will also be
performed. Improperly sealed penetrations will be corrected by originating a
work order or immediately upon discovery as defined in section C.


FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE


Effective Date: X Administrative Manual Policy

July 2015 Computer Room Manual F&E.05.20.01
Original
Revision X
Page 3
of 3
Title: Fire Barrier Inspection
and Maintenance

PE.05.20.01 Fire Barrier Inspection and Maintenance


C. Continuous Fire Barrier Preventive Maintenance

In addition to the random inspections noted in the preceding section, fire walls
are maintained by a continuous program that conducts inspections and repairs
by a fire wall crew who closely surveys the assigned firewalls and immediately
repairs penetrations when faulty.

D. Fire Barrier Program Monitoring

1. Fire door testing and failures are reviewed by the Continual Readiness and
EC Safety Committees.

2. Fire damper testing and failures are reviewed by the Continual Readiness
and EC Safety Committees.

3. Fire wall penetrations are reviewed by the Continual Readiness and EC
Safety Committees.

IV COORDINATION Continual Readiness Committee
EC Safety Committee

V REFERENCES NFPA 101 Life Safety Code (appropriate edition)




Wayne Abbott
Director, Facilities & Engineering Services