Atch 13 Fire-Smoke Barrier Permit.doc
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This is a Department of Veterans Affairs memorandum establishing procedures for fire wall and smoke barrier penetrations at the Tennessee Valley Healthcare System (TVHS). The memo outlines the policy and responsibilities for managing penetrations in floors, ceilings, fire barriers, and smoke partitions created during installation, removal, or modification of pipes, conduit, cable, ductwork, and other building systems. All penetrations must be repaired and sealed upon completion of work using fire-stopping materials that restore the original integrity and fire rating of the penetrated structure, in compliance with National Fire Protection Agency (NFPA) 101 and The Joint Commission safety standards. Temporary sealing methods must be employed if repairs are not completed by the end of a work period.
The memorandum assigns specific responsibilities to VA TVHS staff, safety and occupational health personnel, project engineers, and contractors. A Fire/Smoke Barrier Penetration permit must be obtained from the Safety Section prior to any work, with a unique case number assigned. Project Engineers or Safety personnel must approve the work location and scope before installation begins, and visual inspection and approval from a Project Engineer or Safety staff member is required upon completion of the penetration repair. The completed permit must be signed by both the responsible person and Safety staff, with records maintained in the Engineering Service. The memorandum was issued on June 17, 2013, rescinded a previous 2010 version, and required annual review with reissuance by April 30, 2016. Attachment A provides a blank Fire Wall/Smoke Barrier Penetration Permit template for use.
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Department of Veterans Affairs
Memorandum 626-13-138-73 VA Tennessee Valley Healthcare System March 31, 2013
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 National Fire Protection Agency (NFPA) 101 and The 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 ductwork, 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 Department of Veterans Affairs Tennessee Valley Healthcare System (VA TVHS) 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 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 and Occupational Health Staff will:
(1) Issue “Fire/Smoke Barrier Penetration” permits to VA TVHS staff and contractors.
(See Attachment A)
(2) Inspect and approve all completed work. This shall be done in conjunction with the Project Engineers, if indicated.
c. Project Engineers, Contracting Officer’s Representatives (CORs), Information Management Service 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 VA TVHS Safety Section; the permit will be assigned a specific case number. The permit shall be available for inspection at the designated site(s).
b. Prior to installation of equipment, cables, power connect, conduit, etc., all work, including Information Resource Management projects, will be approved by the Safety Section, Project Engineers, or delegates. This will include a review of the location and scope of work with the individual(s) performing the project.
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 Project Engineer (if related to an Engineering project) or Safety personnel.
e. The completed permit will be signed by the user/responsible person(s) and Safety staff. Records shall be maintained in Engineering Service.
6. REFERENCES:
a. NFPA Life Safety Code 101, Chapter 8
b. NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction
c. VA Tennessee Valley Healthcare System, Memorandum 626-10-138-29 "Fire Safety/Life Safety Management Program"
7. RESCISSION: TVHS Memorandum 626-10-138-73 dated April 26, 2010.
8. RESPONSIBILITY AND REVIEW DATE: This memorandum will be reviewed annually by the Chief, Engineering Service and will be reissued no later than April 30, 2016.
/s/ Juan A. Morales, RN, MSN 6/17/2013
Juan A. Morales, RN, MSN Health System Director Attachment: A Distribution: Safety Manual
ATTACHMENT A
FIRE WALL/SMOKE BARRIER PENETRATION PERMIT
Contractor/VA Service _________________________________________________
Responsible Person ___________________________________________________
Telephone number/Email ______________________________________________ Case # Assigned __________
Location of work (building, floor, room number) ____________________________
Scope of work ________________________________________________________
Materials used:
Firestopping __________________________________________________________
Wall board ____________________________________________________________
Other ________________________________________________________________
Approving Official and Title
Date
Upon completion of work, a representative from TVHS Safety staff will visually inspect the area to ensure compliance with requirements.
Inspected by _____________________________ Date ______________________
Contractor/VA staff signature ___________________________________________ Comments ___________________________________________________________
PAGE
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