The University of Chicago
Safety Manual
Fire Safety Programs

Please note that this program has a glossary.  The glossary contains the definitions for various terms used in the program.   These terms are highlighted in bold print the first time they appear in the body of the program.

Policy

All fixed fire suppression systems shall be inspected, maintained and tested in accordance with this policy and procedure.

Authority and Responsibility

Departments responsible for coordinating the fixed fire protection program are:

1. Environmental Health and Safety;
2. Facilities Services - Operations and Maintenance for areas of the campus served by Facilities Services;
3. The University Architect's Office for new construction;
4. Residence Halls and Commons for its buildings;
5. International House for its building; and
6. Real Estate Operations for all residential or commercial properties.

These departments are responsible for:

1. Scheduling and coordinating the required inspection, and the maintenance and testing of all fixed protection systems in accordance with this policy;
2. Restoring any fixed fire protection to its normal operating condition after any maintenance, testing or usage;  
3. Notifying Environmental Health and Safety during any scheduled (24 hours notice required) or unscheduled impairment for a Red Tag Permit;
4. Notifying Environmental Health and Safety when all impairment is corrected; and
5. Providing documentation to Environmental Health and Safety when the required inspection, maintenance and testing is performed.

Environmental Health and Safety is responsible for:

1. Reporting any questionable conditions discovered during the Annual Fire/General Safety Review to the responsible department;
2. Responding to requests for Red Tag Permits, in a timely manner;
3. Making periodic tours of the areas during the shutdown of a fixed system;
4. Placing a copy of a Red Tag Permit in the lock box whenever one is issued;
5. Responding to requests for removal of fire protection locks;
6. Conducting monthly inspections of fire protection to ensure all valves are secured in the open position with appropriate locks and chains;
7. Documenting Red Tag Permit issuances for review by University Insurer, City of Chicago Fire Department and City of Chicago Fire Alarm Center;  
8. Reviewing documentation from appropriate departments during the annual fire/general safety review;
9. Informing the City of Chicago's Office of Emergency Communications when a fire protection system is taken out of service;
10. Informing the University's Dispatch Center when a fire protection system is taken out of service;
11. Informing the University's insurer when a fire protection system is taken out of service;
12. Informing the University's insurer when an acceptance test will be performed on a fixed fire suppression system; and
13. Reviewing the policy and procedure to ensure compliance.

Licensed Contractors are responsible for:

1. Performing appropriate inspection and maintenance of fixed fire suppression systems when scheduled by appropriate department; and
2. Providing documentation for appropriate departments when inspections and maintenance are complete.

Contractors and sub-contractors are responsible for complying with these procedures.

Fixed Fire Protection Systems

This policy shall include all types and components of a fixed fire protection system including, but not limited to:

1. Sprinkler systems;
2. Standpipe and fire hose systems;
3. Fire pumps; and
4. Fixed chemical extinguishing systems.

All fixed fire suppression systems shall have the appropriate inspection and testing performed as outlined per this policy.  The following provides a description of what the inspections involve and the type of personnel required to conduct these inspections.  Responsible personnel shall utilize the following fixed fire suppression checklists:

• Appendix A - "Fire Pump Checklist"; and
• Appendix B - "Sprinkler System Checklist".

Sprinkler Systems

Inspections

All sprinkler systems shall have a monthly and annual inspection performed.  The following provides a description of what the inspection involves and the type of personnel required to conduct these inspections. 

Monthly Inspection

All sprinkler systems shall have a monthly inspection performed by the building engineers of the appropriate departments.

The monthly inspection shall consist of the following:

1. Ensuring all gauges on a dry pipe sprinkler system are in good condition and maintaining normal pressure;
2. Ensuring all valves greater than one and one-half inches are in the open and locked position;
3. Ensuring all gauges on a wet pipe sprinkler system are in good condition and maintaining normal pressure; and
4. Ensuring all alarm devices are free from damage and all electrical connections are secure.

Annual Inspection/Re-Inspection

All sprinkler systems shall have an annual inspection performed by a representative from Environmental Health and Safety. 

The annual inspection of a sprinkler system shall consist of the following:

1. Visually inspecting all sprinkler system pipe hangers for damage or poor condition;
2. Visually inspecting all sprinkler piping to determine if it is in good condition and free from mechanical damage, leakage and corrosion; and
3. Visually inspecting all sprinkler heads within the building to ensure they are free from obstruction, corrosion, paint, foreign materials and any physical damage.

All concerns discovered shall be documented on the Fire/General Safety Review Report.  The Environmental Health and Safety representative shall forward a copy of the report to the responsible department as described under the "Authority and Responsibility" section in this policy.

Testing  

The following provides a description of the required testing for sprinkler systems.  All required testing shall be arranged by the responsible department.

Acceptance Testing/Upgrades

All sprinkler systems installed in new construction or upgrading of a system shall have an acceptance test completed prior to being placed into service.  The acceptance test shall be arranged by the project manager or in conjunction with the contractor installing the system.  Upon scheduling of an acceptance test, the project manager shall notify Environmental Health and Safety.  Environmental Health and Safety shall notify the University's insurer.  

The acceptance test procedures for sprinkler systems shall be conducted in accordance with the City of Chicago Fire Prevention Bureau.  The Bureau follows the criteria set forth in Chapter 13 “Installation of Sprinkler Systems" of the National Fire Protection Association code and standards.

Quarterly Testing

All sprinkler system alarm devices such as water flow alarms and pressure switches shall be tested every three months.  The testing shall be performed by a person knowledgeable in the operation and function (e.g., contractor, building engineer) of sprinkler systems.

Criteria for quarterly testing shall be in accordance with Chapter 25 "Inspection, Testing and Maintenance of Water- Based Fire Protection Systems" of the National Fire Protection Association code and standards.

Annual Testing

A main drain test shall be performed on sprinkler systems annually to determine if the system is free from obstruction.  This test shall be performed by a person knowledgeable in the operation and function (e.g., contractor, building engineer) of a sprinkler system.

Criteria for main drain testing shall be in accordance with Chapter 25 "Inspection, Testing and Maintenance of Water-Based Fire Protection Systems" of the National Fire Protection Association code and standards.

Five Year Test

Sprinkler system gauges shall be replaced or tested every five years.

The testing, calibration and replacement of sprinkler system gauges shall be performed by a person qualified in the calibration and certification of sprinkler system gauges.

Twenty-Year Test

Where fast response sprinkler heads have been in service for twenty years, they shall be replaced or representative samples shall be sent to a recognized testing laboratory.

Where the representative sample of the sprinkler heads fails to meet the test requirements, all sprinkler heads the sample represents shall be replaced by the facility's engineer or contractor.

Test procedures shall be repeated every ten years thereafter.

Fifty Year Test

Where sprinklers heads have been in service for fifty years, they shall be replaced or representative samples shall be sent to a recognized testing laboratory for operational testing.

If the sprinkler head is going to tested instead of replaced, testing shall be performed using the same sampling methodology as indicated in the previous section.

Obstruction Investigation

An obstruction investigation shall be conducted by the facility's engineer to ensure that sprinkler system piping remains clear of all obstructive foreign matter.  An obstruction investigation shall be conducted on sprinkler systems if one of the following conditions exists:

1. Defective intake screens on a fire pump taking suction from open bodies of water;
2. Discharge of obstructive material during routine water tests;
3. Foreign materials in fire pumps, dry valves or in check valves;
4. Heavy discoloration of water during drain tests or plugging of inspector's test connections;
5. Plugged sprinklers;
6. Plugged piping in sprinkler systems dismantled during building renovation projects;
7. Failure to flush yard piping or surrounding public mains following new installation or repairs;
8. A record of broken public mains in the vicinity;
9. Abnormally frequent false-tripping of dry pipe valve(s);
10. A system is returned to service after an extended period of downtime (greater than one year); and
11. There is reason to believe that the sprinkler system contains sodium silicate or its derivatives.

Flushing Procedures

If an obstruction investigation indicates the presence of sufficient material to obstruct sprinklers, conduct a complete flushing program every five years.  The work shall be performed by a person having knowledge in the operation and function (e.g. contractor, building engineer) of a sprinkler system.

Criteria for sprinkler system flushing shall be in accordance with Chapter 25 " Inspection, Testing and Maintenance of Water-Based Fire Protection Systems" of the National Fire Protection Association code and standards.

Standpipes and Hose Systems

Classifications

There are three classifications of standpipe systems.  These classifications are based on whether the fire department or the building occupants are expected to use the standpipe hose.  The following describes the three classifications of standpipe systems.

Class I:  A Class I standpipe system provides a two and one-half inch hose connection to supply water for use by the fire department and those trained in handling heavy water streams.

Class II:  A Class II standpipe system provides a one and one-half inch fire hose connection to supply water for use primarily by the building occupants or by the fire department during initial response.

Class III:  A Class III standpipe system provides a one and one-half inch hose station to supply water for use by building occupants and a two and one-half inch hose connection to supply a larger volume of water for use by the fire department.

All Class II and III standpipe and hose systems installed after January 1981 shall be equipped with lined hose.  Unlined hose can remain in use on systems installed prior to 1981, but replaced with lined hosed when existing hose becomes unserviceable.

All fire hose used on standpipe and hose systems shall be protected from dirt or other physical agents.  The protection shall consist of placing the fire hose in a cabinet or by providing a protective cover over the hose.

When the control valve for the standpipe system is located within a stairwell, the maximum length of hose shall not exceed 100 feet.  If the control valve is located in areas other than the stairwell, the length of hose shall not exceed 75 feet.

All fire hose on Class II and Class III standpipe systems shall be equipped with a shut-off type nozzle.

Inspections

Annual Inspection/Re-Inspection  

All standpipe and hose systems shall be inspected annually by a representative from Environmental Health and Safety during the annual Fire/General Safety Review.  The inspection shall consist of checking the standpipe and hose system to ensure they are free of:

1. Damage;
2. Corrosion;
3. Foreign material; and
4. Tampering.

The inspection shall also ensure that all valves greater than one and one-half inches are locked in the open position with a chain and sturdy lock.  The removal of such locks shall be under the direction of the shop supervisor.

All concerns discovered shall be documented on the Fire/General Safety Review Report.  The Environmental Health and Safety representative shall forward a copy of the report to the responsible department as described under the "Authority and Responsibility" section in this policy.

Upon being notified of a concern, the responsible department shall initiate an evaluation of the concern and, if necessary, take steps to resolve the concern.

Testing

Acceptance Test

All standpipe and hose systems installed in new construction or upgrading of a system shall have an acceptance test completed prior to being placed into service.  The acceptance test shall be arranged by the project manager or in conjunction with the contractor installing the system.  Upon scheduling of an acceptance test, the project manager shall notify Environmental Health and Safety.  Environmental Health and Safety shall notify the University's insurer.  

The acceptance test procedures for standpipe systems shall be conducted in accordance with the City of Chicago Fire Prevention Bureau.  The Bureau follows the criteria set forth in Chapter 14 "Installation of Standpipe and Hose Systems" of the National Fire Protection Association code and standards.

Hose Testing

All fire hose shall have an annual maintenance check completed by a contractor or by an in-house service that is licensed by the City of Chicago Fire Prevention Bureau and/or the State of Illinois.  All maintenance and hydrostatic testing performed by the service shall be in accordance with Chapter 1962 "Care, Use, and Service Testing of Fire Hose including Connections and Nozzles" of the National Fire Protection Association code and standards.

Fire Pumps

Inspection

All fire pumps shall have a monthly and annual inspection performed on them.  The following provides a description of what the inspection involves and the type of personnel required to conduct these inspections. 

Monthly Inspection

All fire pumps shall have a monthly inspection.  The work shall be performed by a person having knowledge in the operation and function (e.g., contractor, building engineer) of a fire pump.

The monthly inspection shall consist of:

1. Ensuring adequate heat is within the room or area in which the fire pump is located during the cold weather months;
2. Ensuring the pump suction and discharge valves are fully open;
3. Ensuring the pump gauges read normal operating pressures;
4. Ensuring the fuel tank is at least two-thirds full on diesel driven pumps;
5. Checking for leaks around piping;
6. Ensuring the controller selector switch is in the "on" position and illuminated; and
7. Ensuring that water supply valves to the fire pump are secured in the open position with a sturdy chain and padlock.

Testing

Acceptance Testing

All fire pumps shall have an acceptance test completed prior to placing the pump into service.  The test shall be arranged by the project manager in conjunction with the contractor.

The criteria for acceptance testing shall be in accordance with Chapter 20 "Installation of Centrifugal Fire Pumps" of the National Fire Protection Association code and standards.

The Architect's Office shall contact Environmental Health and Safety upon scheduling the acceptance test.  Environmental Health and Safety shall inform the University's insurer of the date and time of the acceptance test.  All test results shall be submitted to Environmental Health and Safety.

Monthly Testing

All fire pumps shall have a monthly test.  The work shall be performed by a person having knowledge in the operation and function (e.g., contractor, building engineer) of a fire pump.

The monthly testing of fire pumps shall consist of the following:

1. Automatically start the fire pump or booster pump in the same manner in which it would start in a fire situation;
2. If the drive unit for the fire pump is an internal combustion engine, run the engine for at least 20 minutes at its rated speed;
3. If the drive unit for the fire pump is electric motor driven, run the pump for at least five minutes;
4. If the fire pump is equipped with relief valve, ensure they are operating properly; and
5. Ensure that packings for the fire pump are not being overheated.

Annual Testing

All fire pumps shall have an annual test of the system performed by a private contractor knowledgeable in the operations and functions of a fire pump.  This inspection and test shall be scheduled by the responsible department as noted under the "Authority and Responsibility" section within this policy.  Environmental Health and Safety shall be notified upon all annual fire pump scheduling.

The annual inspection and testing of fire pumps shall be in accordance with Chapter 25 "Inspection, Testing and Maintenance of Water-Based Fire Protection Systems" of the National Fire Protection Association code and standards.

Chemical Extinguishing Systems

Inspections

Monthly Inspection

A monthly inspection shall be performed on all fixed chemical extinguishing systems by a person knowledgeable in the operation and function (e.g., contractor, building engineer) of the extinguishing system.

The monthly inspection shall consist of:

1. Ensuring that tamper indicators and seals are in place;
2. Ensuring the pressure gauge shows pressure in the operable range;
3. Ensuring there are no physical signs of damage;
4. Ensuring nozzle blow-off caps are intact and undamaged on wet chemical extinguishing systems;
5. Ensuring all hose assemblies are connected on carbon dioxide extinguishing systems;
6. Ensuring all detection devices are in place and free from foreign matter;
7. Ensuring manual actuators are unobstructed; and
8. Ensuring the system has a current service tag.

Upon completion of the monthly review, the person performing the review shall place his or her initials and the date the review was performed on the service tag.

If a questionable condition is discovered that would prohibit proper operation of the device, the person performing the review shall immediately contact the responsible department as described under the section "Authority and Responsibility" in this policy.  The responsible department shall contact a trained private contractor to perform the proper maintenance on the system and Environmental Health and Safety for any such fixed fire suppression repairs.

Maintenance

Semi-Annual Maintenance

The semi-annual maintenance of a chemical extinguishing system shall be performed by a private contractor trained in the knowledge and operation of the system.

Criteria for semi-annual maintenance of fixed extinguishing systems shall be in accordance with the following Chapters of the National Fire Protection Associations code and standards:

• Chapter 17 " Dry Chemical Extinguishing Systems";

• Chapter 17 " Wet Chemical Extinguishing Systems";

• Chapter 12 "Carbon Dioxide Extinguishing Systems"; and

• Chapter 12A "Halogenated Agent Extinguishing Systems".

A copy of the semi-annual maintenance criteria can be obtained by contacting Environmental Health and Safety at 702-9999.

Impairment Procedures

Before Shutdown

Shutting down fire protection equipment shall be planned.  All equipment such as excavating, pipe plugs, repair parts and personnel shall be ready prior to taking the system out of service. 

Before the shutdown of the fire protection equipment, the supervisor of the employee performing the work shall follow these procedures:

1. Notify Environmental Health and Safety of the shutdown at least 24 hours in advance; and
2. Obtain a Red Tag Permit and request removal of locks from Environmental Health and Safety.

Notification

To obtain a Red Tag Permit, contact a representative from Environmental Health and Safety at 702-9999 at least 24 hours prior to the start of the project.

Before the shutdown of the fire protection equipment, a representative from Environmental Health and Safety shall:

1. Tour the area or building prior to shutting down the fire protection system; 
2. Ensure that proper steps are taken to shut down any fire alarm systems.  Refer to the Fire Detection Systems policy, Section 4.3 of the University’s Safety Manual;
3. Notify the City of Chicago Fire Department as to the reason for impairment and the approximate amount of time the system will be impaired;
4. Notify the University's Police Dispatch Center as to the reason for impairment and the approximate amount of time the system will be impaired; and
5. Notify the University’s insurer as to the reason for impairment and the approximate amount of time the system will be impaired.

The purpose of the tour is to ensure that proper precautions are taken and hazardous processes are restricted.  If necessary, the Safety Officer shall coordinate with the supervisor to arrange for temporary protection such as charged hose lines, the setting up of temporary sprinkler protection and/or extra extinguishers. 

If the project involves any type of cutting, welding or brazing, the supervisor or his/her designee shall obtain a Hot Work Permit.  Refer to the Hot Work policy, Section 4.5 of the University's Safety Manual.

Permit Posting

When all precautions are taken, the Environmental Health and Safety representative shall issue a Red Tag Permit.  The permit consists of three parts and shall be posted as follows:

1. Part 1 shall be documented in the Environmental Health and Safety database;
2. Part 2 shall be placed in the affected building's Lock Box; and
3. Part 3 shall be placed directly on the fire protection equipment that is impaired.

During the Shutdown

During the shutdown of the fire protection equipment, the supervisor of the employee performing the work and the Environmental Health and Safety representative shall maintain the following restrictions:

1. Limit the practice of hazardous processes (e.g., usage of open flame, mixing and transferring of chemicals);
2. Restrict smoking within the building; and
3. Restrict cutting, welding or brazing within the building.

Fire Watch

All University employees performing the fire watch shall be trained by Environmental Health and Safety in Fire Safety and Evacuation.  When outside contractors are performing the fire watch, Environmental Health and Safety shall ensure their knowledge of the following:

1. Portable fire extinguisher procedures;
2. Procedures for reporting an emergency;
3. Evacuation procedures; and
4. Hazard recognition.

The fire watch shall conduct the following during the impairment:

1. Periodically inspecting the areas and rooms within the affected building(s) to ensure hazards do not exist;
2. Ensuring adequate fire protection equipment is available and in working condition; and
3. Limiting hazardous work practices such as welding, cutting, brazing or the usage of open flame.

Restoring the System

Upon completion of the work, the supervisor of the employee performing the work or his/her designee shall be responsible for:

1. Notifying Environmental Health and Safety that the system has been restored;
2. Ensuring that all fire protection is placed back into automatic service;
3. If sprinkler protection was impaired, conducting a two-inch drain test at the sprinkler riser;
4. Ensuring that sprinkler control valves are locked in the open position;
5. Resetting the fire alarm system in normal operating condition;
6. Removing the Red Tag Permit from the equipment and completing the remaining information; and
7. Forwarding the Red Tag Permit to Environmental Health and Safety.

Upon notification of restored impairment, Environmental Health and Safety shall:

1. Remove the Red Tag Permit from the building’s Lock Box;
2. Notify the University’s insurer that the impairment is complete;
3. Notify the University's Police Dispatch Center that the impairment is complete; and
4. Notify the City of Chicago Fire Department that the impairment is complete.

Emergency Shutdown

When a system is taken out of service unexpectedly, such as sprinkler pipes breaking or otherwise physically damaged, stabilize the situation and initiate the "Before the Shutdown" precautions outlined in the previous section.

Documentation

All monthly and annual testing reports of fire suppression systems shall be maintained by Environmental Health and Safety.  The appropriate department shall forward all monthly and annual testing, maintenance and inspection reports to Environmental Health and Safety.

Section 4 Index 

 Table of Contents

Environmental Health and Safety
Issued: 01/24/96
Revised: 10/08/08