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Policy

  1. 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 – Facilities Operations;
  3. Facilities Services – Capital Project Delivery;
  4. Biological Sciences Division Facilities Planning, Design, and Construction; and
  5. 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 Permits 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 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;
  6. Restoring any fixed fire protection to its normal operating condition after any maintenance, testing, or usage;
  7. Maintaining documentation related to required inspections, maintenance, and testing;
  8. Displaying a schematic of normally open and closed valves in the fire pump room for fire department use; and
  9. Informing the following agencies when a fixed fire suppression system is taken out of service and 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 dispatch center
  • The University’s insurance provider
  • Environmental Safety and Health
  • Facility manager or building point of contact

Facilities Services - Capital Project Delivery and the Biological Sciences Facilities Planning, Design, and Construction 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 and EHS 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. Completing a Sprinkler System Shutdown Permit prior to removing fixed fire suppression from service;
  2. 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;
  3. Scheduling and coordinating the required inspection, maintenance, and testing of all fixed fire protection systems;
  4. Restoring any fixed fire protection to its normal operating condition after any maintenance, testing, or usage;
  5. Maintaining documentation related to required inspections, maintenance, and testing;
  6. Displaying a schematic of normally open and closed valves in the fire pump room for fire department use; and
  7. Informing the following agencies when a fixed fire suppression system is taken out of service and 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 dispatch center
  • The University’s insurance provider
  • Environmental Safety and Health
  • Facility Manager or Building Point of Contact

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.

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 valves greater than one and one-half inches are locked in the open position with a chain and lock. The removal of such locks shall be under the direction of Facilities Services – Facilities Operations or Physical Plant.

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Inspection/Testing/Maintenance

All fixed fire suppression systems shall have the appropriate inspection, testing, and maintenance performed by an outside licensed contractor in accordance with the City of Chicago Fire Prevention Bureau and National Fire Protection Association. Documentation shall be kept and available for review for all inspections, testing, and maintenance of fixed fire protection systems.

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 testing shall be arranged for by the project manager or in conjunction with the contractor installing the system. Upon scheduling of the testing, the project manager shall notify the University’s insurance provider and EHS.

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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 or Physical Plant Work Center at 773.702.6295 at least 48 hours in advance.

Notification                                                                              

Before the shutdown of the fixed fire suppression system, a representative from Facilities Services – Facilities Operations or Physical Plant shall:

  1. Ensure 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
  • UCPD Dispatch Center
  • The University’s insurance provider
  • Environmental Safety and Health
  • Facility Manager or Building Point of Contact

If requested, a representative of EHS can tour the site. The purpose of the tour is to ensure that proper precautions are taken and hazardous processes are restricted. If necessary, EHS 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.

Permit Posting

When all precautions are taken, the representative from Facilities Services – Facilities 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.

For BSD campus buildings serviced by University of Chicago Medicine, Physical Plant shall complete a Sprinkler System Shutdown Permit prior to removing fixed fire suppression from service.

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.

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Fire Watch

All University or University of Chicago Medicine employees performing the fire watch shall be trained in Fire Safety and Evacuation. Outside contractors performing 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.

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Restoring the System

Upon completion of the work, Facilities Services – Facilities Operations or Physical Plant shall be responsible for:

  1. Notifying the following agencies that the system has been restored:
  • University’s insurance provider
  • University of Chicago Police dispatch center
  • City of Chicago Fire Department or the University’s monitoring service
  • Environmental Health and Safety

      2. Ensuring that all components of the fixed fire suppression system are placed back into automatic service.

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; and,
  3. Removing the Red Tag Permit or Sprinkler System Shutdown Permit from the equipment, fire pump room door, and fire panel/annunciator.  

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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 inspection, testing, and maintenance reports of fixed fire suppression systems shall be maintained by Facilities Services – Facilities Operations or Physical Plant.

Reviewed: October 2022

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