NIST S 7401-02_ITM of Fire Protection and Life Safety Systems_042221.pdf

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 1

INSPECTION, TESTING, AND MAINTENANCE OF 3

FIRE PROTECTION & LIFE SAFETY SYSTEMS 4

NIST S 7401.02 Approval Date: 07/21/2023

Effective Date:1 04/01/2019 9

1. PURPOSE12

The purpose of this suborder is to establish requirements and associated roles and responsibilities related to 13 inspection, testing, and maintenance (ITM) of fire protection and life safety systems on NIST-owned and 14 operated sites. 15

2. BACKGROUND18

a. NIST Policy (P) 7400.00: Fire and Life Safety, articulates NIST’s commitment to making fire and life19 safety an integral core value and vital part of the NIST culture, in part by complying with applicable 20 laws, regulations, and other promulgated fire and life safety requirements. 21

b. NIST Order (O) 7401.00: Fire and Life Safety, details the duties and powers of the NIST Authority23

Having Jurisdiction (AHJ)2 with respect to inspection, testing, and maintenance of fire protection and 24 life safety systems. 25

3. APPLICABILITY28

a. The provisions of this suborder apply to the following fire protection and life safety systems on NIST-29 owned and operated sites: 30

i. Fire alarm systems;32

ii. Fixed fire suppression systems;34

iii. Handheld fire extinguishing systems;36

1 For revision history, see Appendix A.

2 The NIST AHJ may delegate the authority to carry out any AHJ responsibilities to other Fire Protection Engineers in the Office of Safety, Health, and Environment.

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 2

iv. Fire and smoke control (and compartmentation) systems; 38

v. Emergency and standby power systems; 40

vi. Explosion prevention and control systems; 42

vii. Commercial cooking suppression systems; 44

viii. Elevator emergency operation systems; 46

ix. Means of egress and associated systems; 48

x. Monitored life safety systems; and 50

xi. Local (non-monitored) life safety systems. 52

4. REFERENCES 55

a. International Building Code- Chapter 17: Special Inspections and Tests 56

b. American Society of Mechanical Engineers (ASME) A17.1, Safety Code for Elevators and Escalators 58

c. National Fire Protection Association (NFPA) 3, Recommended Practice for Commissioning of Fire 60

Protection and Life Safety Systems. 61

d. NFPA 4, Standard for Integrated Fire Protection and Life Safety System Testing. 63

e. NFPA 10, Standard for Portable Fire Extinguishers. 65

f. NFPA 11, Low, Medium, and High-Expansion Foam. 67

g. NFPA 12, Standard for Carbon Dioxide Extinguishing Systems. 69

h. NFPA 13, Standard for Installation of Sprinkler Systems. 71

i. NFPA 15, Water Spray Fixed Systems for Fire Protection. 73

j. NFPA 16, Installation of Foam-Water Sprinkler and Foam-Water Spray Systems. 75

k. NFPA 17, Standard for Dry Chemical Extinguishing Systems. 77

l. NFPA 17A, Wet Chemical Extinguishing Systems. 79

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m. NFPA 20, Standard for the Installation of Stationary Pumps for Fire Protection. 80

n. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection 82 Systems. 83

o. NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. 85

p. NFPA 68, Standard on Explosion Protection by Deflagration Venting. 87

q. NFPA 69, Standard on Explosion Prevention Systems. 89

r. NFPA 72, National Fire Alarm and Signaling Code. 91

s. NFPA 80, Standard for Fire Doors and Other Opening Protectives. 93

t. NFPA 90A, Standard for Installation of Air-Conditioning and Ventilating Systems. 95

u. NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems. 97

v. NFPA 92, Standard for Smoke Control Systems. 99

w. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. 101

x. NFPA 101, Life Safety Code. 103

y. NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 105

z. NFPA 110, Standard for Emergency and Standby Power Systems. 107

aa. NFPA 111, Standard for Stored Electrical Energy Emergency and Standby Power Systems. 109

bb. NFPA 204, Standard for Smoke and Heat Venting. 111

cc. NFPA 291, Recommended Practice for Fire Flow Testing and Marking of Hydrants. 113

dd. NFPA 720, Standard for the Installation of Carbon Monoxide (CO) Detection and Warning Equipment. 115

ee. NFPA 750, Water Mist Fire Protection Systems. 117

ff. NFPA 2001, Clean Agent Fire Extinguishing Systems. 119

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5. APPLICABLE NIST DIRECTIVES 122

a. NIST P 7400.00: Fire and Life Safety 123

b. NIST O 7401.00: Fire and Life Safety 125

c. NIST S 7401.01: Fire Protection & Life Safety Systems for Design and Construction 127

d. NIST S 7401.03: Impairment of Fire Protection and Life Safety Systems 129

e. NIST S 7101.52: Cryogen Safety 131

f. NIST S 7101.60: Chemical Management 133

g. NIST S 7101.61: Compressed Gas Safety 135

6. REQUIREMENTS 138

a. System Commissioning (i.e., Acceptance Testing) 139

(1) Newly installed and modified existing fire protection and life safety systems shall undergo pre-141 functional testing in accordance with the relevant codes identified in Section 6b of this document, 142 prior to acceptance testing. 143

(2) Pre-testing documentation shall be provided to the NIST AHJ at least one (1) week prior to 145 scheduling final acceptance testing. 146

(a) Shorter notification periods are acceptable for projects lasting less than 30 days. 148

(3) Newly installed and modified existing fire protection and life safety systems shall undergo 150 acceptance testing in accordance with: 151

(a) NFPA 3, Recommended Practice for Commissioning of Fire Protection and Life Safety Systems; 153 and 154

(b) System specific codes identified in Section 6.b of this document. 156

(4) The NIST AHJ shall witness acceptance testing of all newly installed and modified existing fire 158 protection and life safety systems. 159

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(a) A written (including electronic) notice of the acceptance testing shall be provided to the NIST 161 AHJ and should be sent at least two (2) weeks3 prior to the scheduled date. 162

i. The acceptance testing notice shall include an updated set of as-built drawings of the 163 system(s) to be tested. 164

(b) Where feasible, acceptance testing shall be conducted during normal business hours (8:00 am to 166

5:00 pm), Monday through Friday. 167

b. Fire Protection and Life Safety System Inspection, Testing, and Maintenance (see Appendix B for a 169 consolidated list of ITM requirements from the NIST adopted codes and standards4). 170

(1) Fire Alarm Systems 172

(a) Fire alarm systems (e.g., smoke detectors, heat detectors, UV/IR detectors, beam detectors, 174 strobes, horns, speakers, control panels) shall be inspected, tested, and maintained in accordance 175 with NFPA 72, National Fire Alarm and Signaling Code. 176

i. The following requirements shall apply for acceptance testing of fire alarm systems: 178

(i) Pre-functional testing shall include 100% of new devices and the accuracy of 180 graphics and labels shall be verified. 181

(ii) Final graphics and device labels shall be completed and provided to the NIST 183 AHJ prior to acceptance testing. 184

(iii) Graphics and labels at all three (3) NIST Graphical Command Centers in 186

Gaithersburg shall be verified during acceptance testing when new fire alarm 187 panels are placed onto the system. 188

(iv) The fire alarm control panel(s) shall be free and clear of trouble conditions for 7-190 days prior to NIST network connection. 191

(v) The Fire Alarm Control Panel batteries shall undergo standby testing to ensure 193 that they are capable of supporting the system for the standby duration 194 requirements set forth in NIST S 7401.01: Fire Protection & Life Safety Systems 195 for Design and Construction. 196

3 Where necessary and feasible, a shorter notification period may be approved by the NIST AHJ.

4 Some ITM frequencies, as specified within the codes, have been modified by the NIST AHJ; 24/7 remote monitoring of system trouble, supervisory, and alarm statuses replaces the need for high frequency inspection cycles .

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(vi) All smoke detectors shall be field tested using either a listed canned aerosol 198 smoke approved by the manufacturer or other method approved by the 199 manufacturer. Detectors shall not be tested using magnets. 200

(vii) All duct-mounted smoke detectors shall be field tested by introducing smoke 202 directly into the sampling tube within the ductwork or according to 203 manufacturer’s recommendations. Detectors shall not be tested using magnets. 204

(viii) All heat detectors shall be tested using a heat gun for rate-of-rise following 206 manufacturer’s recommended temperature setting and distance between the heat 207 gun and detector head. Detectors shall not be tested using magnets. 208

(ix) Prerecorded messages and voice announcements shall be verified as intelligible 210 per the testing methods outlined in Annex D of NFPA 72. 211

ii. Modifications to the programming of fire alarm systems shall meet the requirements set 213 forth in Section 14.4.2.5 of NFPA 72, National Fire Alarm and Signaling Code, which 214 states “Changes to the system executive software shall require a 10 percent functional 215 test of the system, including a test of at least one device on each input and output circuit 216 to verify critical system functions such as notification appliances, control functions, and 217 off-premises reporting.” 218

(b) Life safety systems monitored on the fire alarm system shall be inspected, tested, and 220 maintained in accordance with NFPA 4, Standard for Integrated Fire Protection and Life Safety 221 System Testing, as well as the requirements listed below for each specific device. 222

i. Carbon monoxide detectors shall be inspected, tested, maintained in accordance with: 224

(i) NFPA 72, National Fire Alarm and Signaling Code; and 226

(ii) NFPA 720, Standard for the Installation of Carbon Monoxide (CO) Detection 228 and Warning Equipment. 229

ii. Combustible gas detectors (e.g., hydrogen, natural gas, propane) shall be inspected, 231 tested, and maintained in accordance with: 232

(i) NFPA 72, National Fire Alarm and Signaling Code; and 234

(ii) Manufacturer instructions. 236

iii. Oxygen depletion sensors shall be inspected, tested, and maintained in accordance with: 238

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(i) NFPA 72, National Fire Alarm and Signaling Code; and 240

(ii) Manufacturer instructions. 242

iv. Toxic gas detectors shall be inspected, tested, and maintained in accordance with: 245

(i) NFPA 72, National Fire Alarm and Signaling Code; and 247

(ii) Manufacturer instructions. 249

v. Automated external defibrillator (AED) cabinet alarms shall be inspected, tested, and 251 maintained in accordance with NFPA 72, National Fire Alarm and Signaling Code. 252

(c) Mechanical and electrical devices monitored on the fire alarm system (e.g., water detection, 254 freeze stat, pumps, heaters, fans, breakers) shall be inspected, tested, and maintained in 255 accordance with manufacturer instructions and shall be maintained in such a manner that the 256 fire alarm system is kept free of reoccurring or standing trouble conditions and nuisance alarms 257 resulting from a failure of the device. 258

i. Only mechanical and electrical devices that are deemed “critical” for monitoring shall be 260 approved by the NIST AHJ to be added to the fire alarm system. 261

(2) Fixed Fire Suppression Systems 263

(a) Water-Based Fire Protection Systems 265

i. Sprinkler systems shall be inspected, tested, and maintained in accordance with: 267

(i) NFPA 13, Standard for Installation of Sprinkler Systems; and 269

(ii) NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-271

Based Fire Protection Systems. 272

ii. Standpipe and hose systems shall be inspected, tested, and maintained in accordance 274 with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based 275 Fire Protection Systems. 276

iii. Private fire service mains shall be inspected, tested, and maintained in accordance with: 278

(i) NFPA 291, Recommended Practice for Fire Flow Testing and Marking of 280

Hydrants; and 281

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(ii) NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-283

Based Fire Protection Systems. 284

iv. Fire pumps shall be inspected, tested, and maintained in accordance with: 287

(i) NFPA 20, Standard for the Installation of Stationary Pumps for Fire Protection; 289 and 290

(ii) NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-292

Based Fire Protection Systems. 293

v. Water spray fixed systems shall be inspected, tested, and maintained in accordance with: 295

(i) NFPA 15, Water Spray Fixed Systems for Fire Protection; and 297

(ii) NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-299 Based Fire Protection Systems. 300

vi. Foam-water sprinkler systems shall be inspected, tested, and maintained in accordance 302 with: 303

(i) NFPA 11, Standard for Low-, Medium-, and High-Expansion Foam; or 305

(ii) NFPA 16, Installation of Foam-Water Sprinkler and Foam-Water Spray 307 Systems; and 308

(iii) NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-310

Based Fire Protection Systems. 311

vii. Water mist systems shall be inspected, tested, and maintained in accordance with: 313

(i) NFPA 750, Water Mist Fire Protection Systems; and 315

(ii) NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-317 Based Fire Protection Systems. 318

viii. Valves (e.g., control, alarm, check, pre-action, deluge, dry pipe, relief, backflow, fire 320 department connections), valve components, trim, and piping shall be inspected, tested, 321 and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and 322 Maintenance of Water-Based Fire Protection Systems. 323

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(b) Non-Water-Based Fire Protection Systems 324

i. Carbon dioxide extinguishing systems shall be inspected, tested, and maintained in 326 accordance with NFPA 12, Standard for Carbon Dioxide Extinguishing Systems. 327

ii. Dry chemical extinguishing systems shall be inspected, tested, and maintained in 328 accordance with NFPA 17, Standard for Dry Chemical Extinguishing Systems. 329

iii. Wet chemical extinguishing systems shall be inspected, tested, and maintained in 331 accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems. 332

iv. Clean agent extinguishing systems shall be inspected, tested, and maintained in 334 accordance with NFPA 2001, Standard for Clean Agent Fire Extinguishing Systems. 335

(c) Commercial Cooking Suppression Systems 337

i. Commercial cooking systems shall be inspected, tested, and maintained in accordance 339 with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial 340 Cooking Operations. 341

(3) Handheld Fire Extinguishing Systems 343

(a) Handheld fire extinguishers (e.g., water-type, dry chemical, wet chemical, carbon dioxide, 345 halogen agent) shall be maintained in accordance with NFPA 10, Standard for Portable Fire 346 Extinguishers. 347

(4) Fire and Smoke Control (and Compartmentation) Systems 349

(a) Fire doors shall be inspected, tested, and maintained in accordance with NFPA 80, Standard for 351

Fire Doors and Other Opening Protectives. 352

(b) Air-conditioning, heating, ventilating ductwork, and related equipment, including smoke 354 dampers and combination fire and smoke dampers shall be inspected, tested, and maintained in 355 accordance with: 356

i. NFPA 90A, Standard for Installation of Air-Conditioning and Ventilating Systems; and 358

ii. NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning 360

Systems. 361

(c) Smoke control systems shall be inspected, tested, and maintained in accordance with NFPA 92, 363 Standard for Smoke Control Systems. 364

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(d) Smoke dampers and combination fire and smoke dampers shall be inspected, tested, and 366 maintained in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other 367 Opening Protectives. 368

(e) Smoke and heat venting systems shall be inspected, tested, and maintained in accordance with 370 NFPA 204, Standard for Smoke and Heat Venting. 371

(5) Emergency and Standby Power Systems 373

(a) Emergency and standby power systems providing secondary power to fire protection and life 375 safety systems shall be inspected, tested, and maintained in accordance with: 376

i. NFPA 110, Standard for Emergency and Standby Power Systems; or 378

ii. NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power 380 Systems. 381

(6) Explosion Prevention and Control Systems 383

(a) Deflagration vents shall be inspected, tested, and maintained in accordance with NFPA 68, 385

Standard on Explosion Protection by Deflagration Venting. 386

(b) Explosion prevention systems shall be inspected, tested, and maintained in accordance with 388 NFPA 69, Standard on Explosion Prevention Systems. 389

(7) Elevator Emergency Operation Systems 391

(a) Elevator emergency operations (e.g., firefighter operation, recall, and shunt trip) shall be 393 inspected, tested, and maintained in accordance with: 394

i. NFPA 101, Life Safety Code; and 396

ii. ASME A17.1, Safety Code for Elevators and Escalators. 398

(8) Means of Egress and Associated Systems 400

(a) Means of egress (e.g., corridors5, hallways, stairwells, vestibules, walkways) and associated 402 systems (e.g., doors, turnstiles, locks, latches, stairs, railings, exit signs, emergency lights, 403 elevators) shall be inspected, tested, maintained in accordance with Chapter 7 of NFPA 101, 404 Life Safety Code, as interpreted by the NIST AHJ, and in accordance with the following (All 405

5 Laboratory Service Galleys are not considered a corridor, but a support space for the labs, thus the requirements of 6.b.(8) do not apply to these spaces.

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 11 allowances provided in this Suborder are subject to review and approval by the NIST AHJ): 406

i. Building corridors shall be inspected semi-annually for compliance with the 408 requirements identified in this section. 409

ii. Minimum Corridor Width 411

(i) A minimum 44-inch width of clear and unobstructed egress must be maintained 413 in all corridors that serve an occupant load of 50 or more in all NIST buildings. 414 Corridors serving less than 50 occupants are permitted to have a minimum width 415 of 36 inches. 416

a. In some corridors, the minimum clear width of 44-inches may not be 418 sufficient for emergency egress due to the existing occupant load of the 419 building. In these cases, the NIST AHJ has the authority to require a 420 greater corridor clear width to be maintained 421

(ii) The use of the required clear width for temporary storage of construction 423 material, equipment scheduled for installation, supplies pending movement into 424 labs or offices, surplus materials or similar items which would jeopardize area 425 occupants is prohibited. 426

(iii) Bulletin or chalkboards or similar items attached to the wall may extend into the 428 clear space; however, displays which extend into the clear space by more than 4 429 inches are not permitted. 430

(iv) Temporary parking of an occasional utility cart, which may be quickly moved by 432 the occupants to provide full access, is permitted. Locations for such equipment 433 shall be provided on the side of the corridor authorized for equipment or storage. 434

iii. Allowances, Restrictions and Requirements for Corridor Use6 436

(i) All items permitted to be stored in the corridor must be noncombustible or 438 located in a noncombustible cabinet. 439

a. This requirement permits storage in standard file cabinets and similar 441 metal furnishings. Combustible materials (e.g., paper, wood, plastic or 442 similar materials) are to be stored within the cabinets. Storage on top of 443 cabinets is not allowed in order to eliminate potential injury from material 444

6 The requirements of this section do not apply to vestibules or lobbies that are clearly distinctive from the corridor.

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 12 or equipment that may become accidentally dislodged. 445

(ii) Any storage permitted in corridors by this document is restricted to one side of 447 the corridor. The same side should be utilized in all corridors on the same floor. 448

a. In general, the side of the corridor designated for storage or equipment 450 use shall be the side of the corridor opposite the stairwell door to ensure 451 that, under emergency conditions, there will be no impediments to 452 reaching the stairwell. However, in some corridors, projections may 453 already exist due to structural building elements such as columns 454 projecting from the side of the corridor normally preferred as the "clear" 455 side. Where this condition exists, utilization is limited to the side with the 456 permanent existing projections. 457

b. In buildings where access to a stairwell or horizontal exit is in the end 459 wall of the corridor, the OU which owns the spaces served by the corridor 460 shall establish which side will be used for materials or equipment. The 461 selected side shall be uniform throughout all connecting corridors on the 462 same floor. Where multiple OUs own spaces served by these corridors, a 463 mutual agreement should be made. If necessary, OSHE may be consulted 464 to make the determination. 465

(iii) Location of material or equipment shall not prevent emergency access to exit 467 doorways. 468

a. A 60-inch clear space shall be provided on both sides of all exit doors, 470 including stairwell doors. A 12-inch clear space shall be provided on both 471 sides of all non-exit doors serving an occupied space. All doors must be 472 provided with adequate clear space to open the door to full swing. 473

(iv) Location of material or equipment shall not prevent emergency access to 475 emergency equipment. 476

a. All emergency equipment; including safety showers, eyewashes, 478 sprinkler valves, fire alarm pull stations, fire alarm panels, and fire 479 extinguishers, must be maintained with full and unobstructed access at all 480 times. 481

b. Storage or equipment placement shall not visually block fire alarm 483 devices or exit signage. 484

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(v) Location of material or equipment shall not impede upon clear spaces for 486 electrical panels established by OSHA in 29 CFR 1910.303(g). 487

(vi) Storage and use, as specified, of the items listed below is prohibited in 489 corridors. Nothing in this section prohibits the incidental use of the corridor for 490 delivery of restricted materials, the movement of such items from room to room, 491 or similar activities. 492

a. Combustible Furniture: Combustible furniture shall not be stored or used 494 in the corridor. Furniture constructed of noncombustible or factory-495 applied fire retardant treated materials are permitted. Temporary storage 496 of combustible furniture during office or lab renovations may be 497 permitted with prior approval by NIST Fire and Facilities Safety Group 498

(FFSG). 499

b. Flammable or combustible liquids: Flammable or combustible liquids 501 shall not be stored or used in the corridor. This includes flammable or 502 combustible liquids located within a flammable liquid storage cabinet. 503

c. Hazardous chemicals: The manipulation or storage of the following types 505 of chemicals in the corridor is prohibited: (1) chemicals that are reactive 506 or may become reactive; (2) explosive compounds; (3) compounds that 507 are capable of creating a single, acute toxic exposure if released; (4) 508 highly corrosive or strong oxidizers that may react violently with other 509 materials; (5) known chemical carcinogens that could easily contaminate 510 an area or unnecessarily expose personnel; (6) temperature sensitive; and 511

(7) waste chemicals of any nature. The NIST Chemical/Regulated Waste 512 Pickup Request System describes specific disposal procedures for the 513 following types of waste: chemical, biohazardous, and battery. 514

d. Compressed gas cylinders (all sizes): Compressed gas cylinders shall not 516 be stored or used in the corridor. 517

e. Liquefied gases: Liquified gases shall not be stored or used in the 519 corridor. 520

f. Radioactive materials: Use or storage of radioactive materials in corridors 522 is specifically prohibited. Radioactive wastes are not to be placed in 523 corridors in preparation for pick up by disposal personnel. Nothing in this 524 section would preclude the transportation of sources or radioactive 525 specimens through the corridors; however, such activities are to be 526 conducted in a manner which minimizes the chances of contamination 527 https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.303 https://nistsafety.nist.gov/CWP/PickupRequest/ https://nistsafety.nist.gov/CWP/PickupRequest/

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 14 through spillage or breakage and maintains radiation levels within 528 acceptable limits. 529

g. Materials or equipment which present a significant physical, mechanical, 531 or electrical hazard to occupants using the corridor shall not be stored or 532 used in the corridor. 533

h. Construction Materials: Construction materials may be 535 stored temporarily in the corridor during the workday, as long as the 536 minimum prescribed clear corridor width is maintained. Construction 537 materials shall not remain in the corridor overnight. Equipment and 538 supplies shall not, under any circumstances, be stored in stairwells. 539

i. Excess Property: Equipment and supplies cannot be abandoned in 541 corridors or stairwells. Transfer or dispose of unneeded property by 542 notifying the organization’s designated Property Custodian of the desired 543 action. Refer to NIST’s Personal Property Disposal Office’s (PPDO) 544 procedure for guidance on reporting excess property. Per PPDO policy, 545 all excess property that is scheduled for removal must be placed in a 546 secured area. 547

(1) In cases where a corridor is considered a “secured area”, the 549 following shall apply: Combustible excess property shall not be 550 stored in the corridor while awaiting removal, except on the day 551 of scheduled pick up. Noncombustible excess property is 552 permitted to be stored in the corridor for a maximum of 3 days. 553 The property should be labeled with the scheduled date of pick up 554 and the owner’s contact information. Any property that is not 555 labeled will be assumed to have been in the corridor for more than 556 3 days and the owner will be requested to immediately remove the 557 item(s). In all cases, the minimum required width of the corridor 558 shall be maintained at all times. 559

j. Trash and Recycling Bins: Large containers for the storage/disposal of 561 trash or recyclable materials, other than those provided by OFPM, shall 562 not be stored in the corridor. Rolling trash bins or carts are permitted 563 temporarily in corridors. Trash or recycling bins that have a capacity of 7 564 gallons or less may be temporarily placed in corridors outside of offices 565 and labs for pick-up by NIST custodial staff. 566

k. Combustible Crates and Boxes: Empty combustible crates and boxes, 568 assembled or disassembled, shall not be stored in the corridor. Equipment 569 https://inet.nist.gov/ofpm/report-excess-property https://inet.nist.gov/ofpm/report-excess-property

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 15 located in crates or boxes and pending movement into labs is permitted to 570 be stored temporarily in corridors for a maximum of 7 days, provided the 571 minimum corridor width is not reduced. Each individual crate or box 572 should be labeled with the date it was received and the owner’s contact 573 information. Any crate or box that is not labelled will be assumed to have 574 been in the corridor for more than 7 days and the owner will be requested 575 to immediately remove the crate or box. 576

l. Combustible Pallets: Empty combustible pallets shall not be stored in the 578 corridor. Items pending movement into labs or offices may be located on 579 pallets, provided the items are not prohibited by other sections of this 580 document. 581

m. Items that encourage the congregation of people, such as food or vendor 583 tables, are prohibited in corridors, unless the corridor has been 584 specifically designed for this purpose. The corridors adjacent to Building 585 101’s Red and Green auditoriums are examples of areas that have been 586 designed to support the use of the auditoriums and are therefore exempt 587 from this requirement. 588

(vii) Combustible items are permitted in break areas, provided these items serve the 590 purpose of the break area. Break areas are permitted to be open to a corridor, 591 within alcoves, within recessed areas, or within rooms with cased openings. 592

(viii) Printers, scanners, and copy machines which do not utilize flammable liquids are 594 permitted within recessed areas of a corridor. Replacement paper supply in 595 excess of two full printer replacements shall not be stored at these locations. 596

iv. Organizational Unit Guides and Restrictions 598

(i) An Organizational Unit (OU) that occupies an entire building, or an entire floor 600 of a building may establish additional guides and restrictions for corridor use in 601 buildings or areas under its control, providing such guides and restrictions do not 602 conflict with this NIST suborder. Local guides and restrictions must be reviewed 603 and approved by NIST FFSG prior to becoming effective. 604

(9) Local (Non-Monitored) Life Safety Systems 606

(a) The following local (non-monitored) detectors/sensors shall be inspected, tested, and 608 maintained in accordance with manufacturer instructions: 609

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i. Carbon monoxide detectors; 612

ii. Combustible gas detectors (e.g., hydrogen, natural gas, propane); 614

iii. Oxygen depletion sensors; and 616

iv. Toxic gas detectors 618

(i) The criteria set forth in Section 7.9.6.3 of NFPA 55, Compressed Gases and 620 Cryogenic Fluids, must be met for a locally monitored systems to be deemed 621 acceptable. 622

(10) Equipment Safety Systems and Interlocks 624

(a) Equipment safety systems and interlocks designed to stop the flow of hazard chemicals to 626 equipment or tools upon detection of smoke or fire shall be inspected, tested, and maintained in 627 accordance with manufacturer instructions. 628

(b) Systems providing inputs to the fire alarm systems shall also be inspected, tested, and 630 maintained in accordance with: 631

i. NFPA 4, Standard for Integrated Fire Protection and Life Safety System Testing; and 633

ii. NFPA 72, National Fire Alarm and Signaling Code. 635

(11) Fire-Resistant and Firestop Systems 637

(a) Newly installed intumescent fire-resistant coatings, mastic fire-resistant coatings, sprayed fire-639 resistant materials shall be inspected and tested in accordance with Chapter 17 of the 640 International Building Code. 641

(b) Newly installed firestopping systems shall be inspected and tested in accordance with Chapter 643 17 of the International Building Code. 644

i. The NIST AHJ shall be consulted prior to the start of any work to determine the 646 percentage of witnessed installations or destructive testing required for the project. 647

(c) Existing fire-resistant or firestop systems shall not be disturbed or altered from their original 649 installed condition. If work requires removal of an existing fire-resistant or firestop system, the 650 NIST AHJ shall be consulted. 651

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(12) Other Safety Systems 654

(a) Chemical fume hoods, chemical fume hood exhaust systems, and laboratory special exhaust 656 systems shall be inspected, tested, and maintained in accordance with NFPA 45, Standard on 657 Fire Protection for Laboratories Using Chemicals, and NIST S 7101.60, Chemical 658 Management. 659

(b) The NIST AHJ shall be consulted for initial acceptance testing/commissioning requirements for 661 these systems. 662

c. Fire Protection and Life Safety System Impairments 664

(1) Impairment of any fire or life safety system shall comply with the requirements set forth in NIST S 666 7401.03: Impairment of Fire Protection and Life Safety Systems. 667

d. Performance of Inspection, Testing, and Maintenance 669

(1) Inspection, testing, and maintenance of fire protection and life safety systems shall be performed by 671 an individual that meets the requirements set forth in the system-specific codes and standards 672 referenced in Section 6b. 673

e. Recordkeeping 675

(1) ITM records shall be maintained per the requirements established within the relevant system-677 specific codes or for a minimum of two (2) years from the date of ITM completion where not 678 specified within the code. 679

(2) ITM records shall be readily available for review by the NIST AHJ upon request. 681

7. DEFINITIONS 684

a. Acceptance Testing – Testing performed on an installation to confirm compliance with applicable 685 manufacturers’ installation specifications, applicable codes and standards, and the project Basis of 686 Design and Owner’s Project Requirements (NFPA Glossary of Terms). 687

b. Alcove – A recessed space within a corridor that is of sufficient size to be used for the storage of 689 materials. 690

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 18

c. Authority Having Jurisdiction (AHJ) – A qualified Fire Protection Engineer7 in Office of Safety Health 692 and Environment designated by the NIST Chief Safety Officer to enforce8 the NIST-adopted codes and 693 standards relevant to fire, electrical, and life safety on NIST-owned and operated sites. 694

d. Combustible Material - A material that, in the form in which it is used and under the conditions 696 anticipated, will ignite and burn; a material that does not meet the definition of noncombustible or 697 limited-combustible. 698

e. Commissioning – A systematic process that provides documented confirmation that fire protection and 700 life safety systems function according to the intended design criteria set forth in the project documents 701 and satisfy the owner’s operational needs, including compliance with any applicable laws, regulations, 702 codes, and standards requiring fire protection and life safety systems (NFPA Glossary of Terms). 703

f. Commissioning Record – The complete set of commissioning documentation for a project that is turned 705 over to the owner at the end of the construction phase. 706

g. Compartmentation – The interposing of a physical barrier that is not required to be fire or explosion 708 resistant to limit combustible particulate solid migration and hence to control the size of a hazard area 709 (NFPA Glossary of Terms). 710

h. Compliance – Meeting or exceeding all applicable requirements of the NIST adopted code(s) and 712 standard(s). 713

i. Corridor - An enclosed exit access component that defines and provides a path of egress travel. 715

j. Delegated Authority Having Jurisdiction – A qualified engineer in Office of Safety Health and 717 Environment designated by the NIST AHJ to enforce the NIST-adopted codes and standards that fall 718 within their relevant discipline(s). 719

k. Emergency Power System – A system designed to provide secondary power to fire protection and life 721 safety systems. 722

l. Exit Access – That portion of a means of egress system that leads from any occupied portion of a 724 building or structure to an exit. 725

m. Fire Alarm System – A system or portion of a combination system that consists of components and 727 circuits arranged to monitor and annunciate the status of fire alarm or supervisory signal-initiating 728 devices and to initiate the appropriate response to those signals (NFPA Glossary of Terms). 729

7 See requirements for Office of Personnel Management Fire Protection Engineering Series 0804.

8 Nature of enforcement is dependent upon the severity of the violation, e.g. stop work order, revocation of work permit, denial of use and occupancy.

https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/0800/fire-protection-engineering-series-0804/

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 19

n. Fire and Life Safety – The protection of life and property by minimizing fire and related hazards 731 through the incorporation of and maintenance of building features, fire protection systems, and egress 732 components, and the implementation of safe work practices. 733

o. Fire Protection System – Any fire alarm device or system or fire-extinguishing device or system, or 735 combination thereof, that is designed and installed for detecting, controlling, or extinguishing a fire or 736 otherwise alerting occupants, or the fire department, or both, that a fire has occurred. 737

p. Fixed Fire Suppression System – A total flooding or local application system consisting of a fixed 739 supply of extinguishing agent permanently connected for fixed agent distribution to fixed nozzles that 740 are arranged to discharge an extinguishing agent into an enclosure (total flooding), directly onto a 741 hazard (local application), or a combination of both; or an automatic sprinkler system (NFPA Glossary 742 of Terms). 743

q. Impairment – Temporary shutdown (in whole or in part) of a Fire Protection System where the system 745 is damaged, disabled, or out of order. The resulting condition is that the Fire Protection System does 746 not function as intended in the event of a fire or other emergency. 747

r. Inspection – A visual examination of a system or portion thereof to verify that it appears to be in 749 operating condition and is free of physical damage (NFPA Glossary of Terms). 750

s. Life Safety Systems – Those systems that enhance or facilitate evacuation, smoke control, 752 compartmentalization, and/or isolation. 753

t. Local (Non-Monitored) Systems – Fire protection and life safety systems that, when a change of state 755 occurs, result in an audible and/or visual alarm at the device only; the change of state is not monitored 756 at a supervised central station. 757

u. Monitored Systems – Fire protection and life safety systems connected to the NIST fire alarm system 758 that, when a change of state occurs, result in a trouble, supervisory, and/or alarm signal at a supervised 759 central station. 760

v. Means of Egress – A continuous and unobstructed way of travel from any point in a building or 762 structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, 763 and (3) the exit discharge (NFPA Glossary of Terms). 764

w. Noncombustible Material- A material that complies with any of the following shall be considered a 766 noncombustible material: 767

(1) A material that, in the form in which it is used and under the conditions anticipated, will not ignite, 769 burn, support combustion, or release flammable vapors when subjected to fire or heat 770

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 20

(2) A material that is reported as passing ASTM E 136, Standard Test Method for Behavior of 772 Materials in a Vertical Tube Furnace at 750 Degrees C, or 773

(3) A material that is reported as complying with the pass/fail criteria of ASTM E 136 when tested in 775 accordance with the test method and procedure in ASTM E 2652, Standard Test Method for 776 Behavior of Materials in a Tube Furnace with a Cone-shaped Airflow Stabilizer, at 750 Degrees C. 777

x. Pre-Functional Testing – Testing performed prior to acceptance testing to confirm compliance with 779 manufacturers’ specifications, applicable codes and standards, and the project documents (NFPA 780 Glossary of Terms). 781

y. Private Fire Service Main – Private fire service main is that pipe and its appurtenances on private 783 property: 784

(1) Between a source of water and the base of the system riser for water-based fire protection systems; 786

(2) Between a source of water and inlets to foam-making systems; 788

(3) Between a source of water and the base elbow of private hydrants or monitor nozzles; 790

(4) Used as fire pump suction and discharge piping; or 792

(5) Beginning at the inlet side of the check valve on a gravity or pressure tank (NFPA Glossary of 794 Terms). 795

z. Shall/Should/May – 797

• Shall (Must or Will): Indicates that the performance of an item is mandatory. 798

• Should: Indicates that the performance of an item is not mandatory, but the full implications of not 800 performing that item must be understood and either justified or carefully weighed before choosing a 801 different course. 802

• May: Indicates that the performance of an item is at the discretion of the individual responsible for 804 the action. 805

aa. Testing – A procedure used to determine the operational status of a component or system by conducting 807 periodic physical checks, such as water flow tests, fire pump tests, alarm tests, and trip tests of dry pipe, 808 deluge, or pre-action valves (NFPA Glossary of Terms). 809

bb. Underwriters Laboratories (UL) - Independent, non-profit product safety testing and certification 811 organization 812

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 21

8. ACRONYMS 814

a. AHJ – Authority Having Jurisdiction 815

b. BSHED –Boulder Safety Health and Environment Division 817

c. FFSG – Fire and Facilities Safety Group 819

d. GSHED – Gaithersburg Safety Health and Environment Division 821

e. ITM – Inspection, Testing, and Maintenance 823

f. NFPA – National Fire Protection Association 825

g. OFPM – Office of Facilities and Property Management 827

h. OSHE – Office of Safety Health and Environment 829

i. UL- Underwriters Laboratories 831

9. RESPONSIBILITIES 834

a. Organizational Unit (OU) Directors are responsible for: 835

(1) Ensuring that the Inspection, Testing, and Maintenance of Fire Protection and Life Safety Systems 837

Suborder is adapted and used in their spaces; and 838

(2) Ensuring that any fire protection and life safety systems owned by the OU are inspected, tested, and 840 maintained in accordance with Section 6. 841

(3) Ensuring that individuals performing the inspection, testing, and maintenance of any fire protection 843 and life safety systems owned by the OU are qualified per the requirements set forth in the system-844 specific codes and standards referenced in Section 6. 845

(4) Ensuring that all ITM records for any fire protection and life safety systems owned by the OU are 847 maintained per the requirements of Section 6d. 848

b. First-Level Supervisors 850

(1) Ensuring that the employees and covered associates they supervise comply with the corridor storage 852 requirements outlined in Section 6. 853

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 22

c. Chief Facilities Management Officer is responsible for: 856

(1) Ensuring that fire protection and life safety systems owned by NIST are inspected, tested, and 858 maintained in accordance with Section 6; 859

(2) Ensuring that individuals performing the inspection, testing, and maintenance of fire protection and 861 life safety systems owned by NIST are qualified per the requirements set forth in the system-862 specific codes and standards referenced in Section 6. 863

(3) Ensuring that new and modified fire protection and life safety systems owned by NIST undergo: 865

(a) Pre-functional testing; and 867

(b) Acceptance testing and commissioning; 869

(4) Ensuring that acceptance and commissioning records are: 871

(a) Received from the commissioning agent; 873

(b) Provided to the NIST AHJ in electronic or hard copy form; and 875

(c) Maintained by OFPM for the life of the system; and 877

(5) Ensuring that all ITM records for fire protection and life safety systems owned by NIST are 879 maintained per the requirements of Section 6e. 880

d. NIST-Gaithersburg Fire Protection Group (i.e., NIST Fire Department) is responsible for (Gaithersburg 882 only): 883

(1) Ensuring that handheld fire extinguishers are inspected, tested, and maintained in accordance with 885 the requirements of this suborder; 886

(a) Ensuring that all extinguishers are barcoded to allow for tracking of annual maintenance 888 requirements; and 889

(2) Ensuring that all ITM records are maintained per the requirements of Section 6e. 891

e. NIST AHJ is responsible for: 893

(1) Ensuring that the requirements of this suborder are enforced; 895

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 23

(2) Providing additional guidance and interpretation of the provisions within this suborder and 897 applicable codes. 898

(3) Witnessing acceptance testing of all new and modified fire protection and life safety systems; and 900

(4) Annually auditing ITM records to ensure that program requirements are being met and records are 902 being appropriately maintained. 903

f. OSHE BSHED and GSHED Division Chiefs are responsible for: 905

(1) Assigning corridor inspection responsibilities to OSHE staff who meet the requirments of OU 907 Workplace Inspectors. 908

(2) Ensuring that building corridors are inspected in accordance with Section 6b. 910

g. OSHE Staff Who Meet the Requirements of OU Workplace Inspectors are responsible for: 912

(1) Conducting semi-annual inspections of building corridors. 914

(2) Advising each OU of conditions requiring corrective action; and 916

(3) Immediately notifying the appropriate OU personnel to bring about the removal of items that would 918 prevent safe egress of building occupants. 919

10. AUTHORITIES 922

a. The NIST AHJ may delegate the authority to carry out any AHJ responsibilities to Fire Protection 923

Engineers in the Office of Safety, Health, and Environment. 924

b. If a fire protection and life safety is owned by an OU, the OU is ultimately responsible for ITM of the 926 system(s). However, the OU may transfer the responsibilities for conducting ITM or managing a 927 contract for ITM to another entity, such as OFPM or OSHE, provided this agreement is formalized in 928 writing and a copy of this agreement is provided to the NIST AHJ. 929

c. As overseer of fire protection and life safety systems owned by NIST, OFPM is ultimately responsible 931 for ITM of those systems. However, OFPM may transfer a portion of these responsibilities to another 932 entity, such as the NIST-Gaithersburg Fire Protection Group (i.e., NIST Fire Department) or OSHE, 933 provided this agreement is formalized in writing and a copy of this agreement is provided to the NIST 934

AHJ. 935

. 937

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 24

11. DIRECTIVE OWNER 939

Chief Safety Officer 940

12. APPENDICES 943

A. Revision History 944

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 25

Appendix A. Revision History 948

Version No.

Approval Date

Effective Date Brief Description of Change; Rationale

1 03/28/18 04/01/19 • None – Initial document

2 04/22/21 TBD

• Removed references to specific code edition years in order to align with the F&LS Order

• Removed classifications of building systems and research-specific systems;

• Added NIST specific requirements for fire alarm acceptance testing;

• Added requirements for maintaining safe egress corridors;

• Added requirements for firestopping and fire-resistance systems;

• Assigned corridor inspection responsibilities to OSHE;

• Revised required inspection frequencies to align with the demands, resources, and infrastructure of NIST facilities.

3 07/21/23 TBD

• Section 9.d and Section 10.c – “NIST Fire Department” was added to clarify who the “NIST Fire Protection Group” is.

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 26

Appendix B. ITM Requirements Extracted from NIST Adopted Codes and Standards 955

Fire Alarm Systems

Component Periodic Frequency Method NFPA Reference

1. All equipment Annual Inspection NFPA 72- Chapter 14

2. Control equipment

(a) Fire alarm systems monitored for alarm, supervisory, and trouble signals

NFPA 72- Chapter 14

(1) Functions Annual Test

(2) Fuses Annual Inspection/Test

(3) Interfaced Equipment Annual Inspection/Test

(4) Lamps and LEDs Annual Inspection/Test

(5) Primary (main) power supply Annual Inspection/Test

(6) Trouble Signals Semiannual Inspection

i. Audible and visual Annual Test

ii. Disconnect switches Annual Test

iii. Ground-fault monitoring circuit Annual Test

iv. Transmission of signals to off-premises location Annual Test

(b) Fire alarm systems unmonitored for alarm, supervisory, and trouble signals

(1) Function Annual Test

(2) Fuses Annual Test

(3) Interfaced Equipment Annual Test

(4) Lamps and LEDs Annual Test

(5) Primary (main) power supply Annual Test

(6) Trouble Signals Annual Test

3. Supervising station alarm systems-transmitters

(a) All equipment

Annual

Inspection/Test

(b) Digital alarm communicator transmitter (DACT) Annual Inspection/Test

(c) Digital alarm radio transmitter (DART) Annual Inspection/Test

(d) McCulloh transmitter Annual Inspection/Test

(e) Radio alarm transmitter (RAT) Annual Inspection/Test

(f) All other types of communicators Annual Inspection/Test

4. In-building fire emergency voice/alarm communications equipment

Annual Inspection NFPA 72- Chapter 14

(a) Amplifier/tone generators Annual Test

(b) Call-in signal silence Annual Test

(c) Off-hook indicator (ring down) Annual Test

(d) Phone jacks Annual Test

(e) Phone set Annual Test

(f) System performance Annual Test

5. Engine-driven generator Annual Test NFPA 72-Chapter 14

6. Secondary (standby) power supply Annual Test NFPA 72-Chapter 14

7. Uninterruptible power supply (UPS) Annual Test NFPA 72-Chapter 14

8. Batteries NFPA 72-Chapter 14

(a) Lead-acid Annual Inspection

(1) Battery replacement Annual Test

(2) Charger test Annual Test

NIST S 7401.02 Ver. 2 (Uncontrolled Copy in Print) Page 27

(3) Discharge test Annual Test

(4) Load voltage test Annual Test

(5) Specific gravity Annual Test

(b) Nickel-cadmium Annual Inspection

(1) Battery replacement…