36C24919B0005-003.pdf

VA MEDICAL CENTER MEMORANDUM NO. 603-09-001-021

LOUISVILLE, KENTUCKY March 11, 2009

FIRE WALL AND SMOKE BARRIER PENETRATIONS

1. PURPOSE

To establish procedures regarding penetrations in ceilings, floors, pipe chases, fire walls, and smoke barriers for the purpose of maintaining the integrity of these structures as required by the National Fire Protection Agency (NFPA) 101 and Joint Commission to provide for the safety of occupants during fire incidents.

2. POLICY

All penetrations made in floors, ceilings, fire barriers, and smoke partitions for the purpose of installing/removing pipe, conduit, cable, or duct work, other modifications including incidental damage, or the removal of such items, will be repaired/sealed upon completion of the work and documented as repaired. Temporary methods of sealing or a temporary barrier shall be used at the end of a work period if the repairs have not been completed. This policy applies to all vertical and horizontal penetrations and to all Louisville Department of Veterans Affairs Medical Center (LVAMC) staff and contractors.

3. DEFINITIONS

a. Penetration: Any hole, opening or fault created in a fire barrier or smoke partition that compromises the integrity or fire rating of the penetrated structure.

b. Fire Stopping Material: Material used to replace or repair any penetrations. Material must meet specifications to ensure that the original integrity and rating of the penetrated surface is restored.

c. Fire Barriers: Floor, ceiling assemblies and walls, including supporting construction that meets the conditions of acceptance of NFPA 251. Fire barriers are designed to form fire compartments and are constructed to be continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through concealed spaces.

4. RESPONSIBILITIES

a. Service chiefs must be knowledgeable of the requirements of this guideline with respect to equipment installations or modifications that are coordinated within their assigned building spaces.

b. Safety Office or delegates from Project Engineer, Telecommunications Manager or Engineering will:

(1) Issue “Fire/Smoke Barrier Penetration” permits to LVAMC staff and contractors (see Attachment A); and

(2) Inspect and approve all completed work. This shall be done in conjunction with the Project Engineers and Maintenance Supervisors if indicated.

c. Project Engineers, Contracting Officer Technical Representatives (COTRs), Information Management Service (IMS), and other staff coordinating or performing such work are responsible for compliance with this guideline.

5. PROCEDURES

a. A Fire/Smoke Barrier Penetration Permit is obtained from the LVAMC's Safety Office or delegates from Project Engineer, Telecommunications Manager or Engineering and will be available for inspection at the designated site(s).

b. Prior to installation of equipment, cables, power connect, conduit, etc., all work, including IMS projects, will be approved by the Safety Office, Project Engineers, Telecommunication Manager, or Engineering. This will include a review of the location and scope of work with the individual(s) performing the project and the issuance of the permit.

c. The penetration, after installation or modification of the barrier, must be repaired (sealed) according to accepted practice and utilizing approved materials.

d. Upon completion of any penetration repair, a visual inspection for approval must be requested from the Safety Office, Project Engineer, Telecommunications Manager (if related to information technology,) or Engineering.

e. The completed permit will be signed by the user/responsible person(s) and Safety Office staff. Records shall be maintained in the Safety Office.

6. REFERENCES

NFPA Life Safety Code 101, Chapter 8; and NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction.

7. RESCISSION

Medical Center Memorandum No. 603-08-001-021, Fire Wall and Smoke Barrier Penetrations, dated June 6, 2008.

8. EXPIRATION/RESPONSIBILITY

This policy expires on March 11, 2012, and is the responsibility of Engineering Service.

/s/ Wayne L. Pfeffer, MHSA, FACHE Medical Center Director

Attachment

Dist. A

VA MEDICAL CENTER ATTACHMENT A

LOUISVILLE, KENTUCKY MEMORANDUM NO. 603-09-001-021

March 11, 2009

FIRE WALL/SMOKE BARRIER PENETRATION PERMIT

Permit Number Assigned: ______________________________________________________

Date Permit Issued: ___________________________________________________________

Contractor: __________________________________________________________________

VA Project Manager: __________________________________________________________

Telephone Number/E-Mail: _____________________________________________________

Pre-Inspection Completed by: ___________________________________________________

Pre-Inspection findings, Number of Existing Penetrations: _____________________________

If Existing Penetrations Exist, Explain Plan of Action to Seal: ___________________________

Number of Penetrations to be Created by Project: ___________________________________

Location of Work (building, floor, room number): ____________________________________

Scope of Work: ______________________________________________________________

Date Work is Expected to be Completed: __________________________________________

Materials Used:

Fire Stopping System Used: _____________________________________________________

Wall Board: __________________________________________________________________

Other: ______________________________________________________________________

Title of Approving Official Date

Upon completion of work, a representative from the LVAMC's Safety Office, Project Engineer, Telecommunications Manager or Engineering Manager will visually inspect the area to ensure compliance with requirements.

Inspected by: ____________________________________ Date: __________________

Contractor/VA Staff Signature: ___________________________________________________

Number of Penetrations Sealed: ________________

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VA MEDICAL CENTER MEMORANDUM NO. 603-09-001-021