Fixed Fire Suppression Systems

Policy

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

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Authority and Responsibility

Departments responsible for coordinating the fixed fire protection program are:

  1. Environmental Health and Safety;
  2. Facilities Services - Operations;
  3. Facilities Services - Capital Project Delivery; and
  4. Physical Plant (for University BSD buildings serviced by University of Chicago Medicine).

Environmental Health and Safety is responsible for:

  1. Reporting any questionable conditions discovered during the annual fire and general safety audit to the responsible department;
  2. Reviewing Red Tag Permit issuances on a quarterly basis; and
  3. Annually auditing  the policy, program, and associated procedures to ensure compliance.

Facilities Services - Operations is responsible for:

  1. Responding to Red Tag Permit requests in a timely manner;
  2. Placing Red Tag Permit notification signage on the fire pump controller, door to the fire pump room, and fire alarm panel/annunciator, where applicable;
  3. Responding to requests for the removal of valve locks from fixed fire suppression equipment;
  4. Conducting inspections of the fixed fire suppression system to ensure all valves are secured in the open position with appropriate locks and chains, as required by the University's insurance provider;
  5. Scheduling and coordinating the required inspection, maintenance, and testing of all fixed fire suppression systems in accordance with this policy;
  6. Restoring any fixed fire suppression equipment to its normal operating condition after any maintenance, testing, or usage;
  7. Maintaining documentation related to required maintenance, testing, and inspections; and
  8. Informing the following agencies when a fixed fire suppression system is taken out of service, as well as, when the system has been restored:
  • The City of Chicago Fire Department call center or the University's monitoring service
  • The University of Chicago Police Department dispatch center
  • The University's insurance provider

Facilities Services - Capital Project Delivery is responsible for:

  1. Notifying the Facilities Services Work Center, at 773.702.1414, during any scheduled (48-hour notice required) or unscheduled impairment for a project related Red Tag Permit;
  2. Informing the University's insurance provider when an acceptance test will be performed on a fixed fire suppression system during a capital project; and
  3. Scheduling any acceptance testing with the appropriate local agencies.

Physical Plant is responsible for:

  1. Scheduling and coordinating the required inspection, maintenance, and testing of all fixed fire suppression systems in accordance with this policy;
  2. Informing Environmental Health and Safety of any fixed fire suppression impairments;
  3. Completing a sprinkler system shutdown permit prior to removing fixed fire suppression from service; and
  4. Restoring any fixed fire suppression equipment to its normal operating condition after any maintenance, testing, or usage.

Licensed contractors and sub-contractors are responsible for:

  1. Performing appropriate inspections, investigations, and conducting maintenance of fixed fire suppression systems when scheduled by the appropriate department;
  2. Providing documentation for appropriate departments when inspections and maintenance are complete; and
  3. Complying with the procedures outlined in this policy.

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Fixed Fire Suppression Systems

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

  1. Sprinkler systems;
  2. Standpipe and fire hose systems (Class I, II, and III 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 an approved inspection checklist to document the process.

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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 an outside contractor licensed to conduct such inspections.

The inspections of the sprinkler system shall be documented on an approved inspection form and shall be filed in a binder that is kept in the same room as the fire pump, as well as, retained electronically.

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 during the upgrade of an existing system, shall have an acceptance test completed prior to being placed into service. The acceptance test shall be arranged for by the Facilities Services - Capital Project Delivery project manager, or in conjunction with the contractor installing the system. Upon scheduling of an acceptance test, the project manager shall notify the University’s insurance provider.

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

Quarterly Testing

All other required testing on sprinkler systems shall be conducted in accordance with the applicable City of Chicago or NFPA codes. Potential required testing could include, but is not limited to: quarterly testing, annual testing, five-year testing, twenty-year testing, and fifty-year testing.

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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.

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 Facilities Services - Operations.

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Testing

Acceptance Test

All standpipe and hose systems installed in new construction, or during the upgrade of an existing system, shall have an acceptance test completed prior to being placed into service. The acceptance test shall be arranged for by the Facilities Services - Capital Project Delivery project manager, or in conjunction with the contractor installing the system. Upon scheduling of an acceptance test, the project manager shall notify the University’s insurance provider.

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 NFPA 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 NFPA code and standards.

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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 and the work shall be performed by a person having knowledge in the operation and function (e.g., contractor) of a fire pump.

The monthly inspections shall be documented on an approved inspection form and shall be filed in a binder that is kept in the same room as the fire pump, as well as, retained electronically.

Testing

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) of a fire pump.

The monthly testing shall be documented on an approved inspection form and shall be filed in a binder that is kept in the same room as the fire pump, as well as, retained electronically.

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 Facilities Services - Operations. The responsible department shall maintain all of the required documentation in the event that the University's insurance provider requests a review.

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 NFPA code and standards.

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 Facilities Services - Capital Project Delivery project manager, or in conjunction with the contractor performing the work. Upon scheduling of an acceptance test, the project manager shall notify the University's insurance provider.

The criteria for acceptance testing shall be in accordance with Chapter 20 “Installation of Centrifugal Fire Pumps” of the NFPA code and standards.

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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) 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 NFPA code and standards:

  • Chapter 12 - Carbon Dioxide Extinguishing Systems
  • Chapter 12A - Halogenated Agent Extinguishing Systems
  • Chapter 17 - Dry Chemical Extinguishing Systems
  • Chapter 17A - Wet Chemical Extinguishing Systems

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Impairment Procedures

Before Shutdown

Shutting down fixed fire suppression systems shall be planned in advance. 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 request the shutdown by submitting a work order to the Facilities Services Work Center, at 773.702.1414, at least 48 hours in advance.

Notification

Before the shutdown of the fixed fire suppression system, a representative from Facilities Services - Operations shall:

  1. Ensure that proper steps are taken to shut down any fire alarm systems. Refer to the Fire Detection Systems Policy;
  2. Notify the following agencies as to the reason of the impairment and the approximate amount of time the system will be impaired:
  • The City of Chicago Fire Department call center or the University's monitoring service
  • The University of Chicago Police Department dispatch center
  • The University's insurance provider

If requested by Facilities Services – Operations or Facilities Services – Capital Project Delivery, a representative of Environmental Health and Safety can tour the site. The purpose of the tour is to ensure that proper precautions are taken and hazardous processes are restricted. If necessary, Environmental Health and Safety will coordinate with the supervisor or project manager to arrange for temporary protection such as charged hose lines, the setting up of temporary sprinkler protection, extra extinguishers, or to establish a fire watch for the building or area.

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 Management Policy. Please note that certain types of hot work may be prohibited in areas where the fixed fire suppression system has been impaired.

Permit Posting

When all precautions are taken, the representative from Facilities Services - Operations shall issue a Red Tag Permit. The permit shall be posted as follows:

  1. On the fire pump controller;
  2. On the door leading into the fire pump room; and
  3. On the main fire panel, or annunciator, for the equipment which has been impaired.

During the Shutdown

During the shutdown of the fixed fire suppression equipment, the supervisor of the employee performing the work shall maintain the following restrictions:

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

Fire Watch

All University employees performing the fire watch shall be trained by Environmental Health and Safety in Fire Safety and Evacuation. Outside contractors are performing the fire watch, shall have 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, Facilities Services - Operations shall be responsible for:

  1. Ensuring that all components of the fixed fire suppression system are placed back into automatic service; and
  2. Notifying the following agencies that the system has been restored:
  • The City of Chicago Fire Department call center or the University's monitoring service
  • The University of Chicago Police Department dispatch center
  • The University's insurance provider

If sprinkler protection was impaired, Facilities Services - Operations is responsible for;

  1. Ensuring that sprinkler control valves are locked in the open position;
  2. Resetting the fire alarm system in normal operating condition;
  3. Removing the Red Tag Permit from the equipment, fire pump room door, and fire alarm panel/annunciator.

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.

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Documentation

All monthly and annual testing reports of fire suppression systems shall be maintained by Facilities Services - Operations.

Reviewed: March 2016

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