Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9
Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)
|
Observations: Name: BUILDING 03 (1998 BRIDGE LINK BUILDING) - Component: 03 - Tag: 0321
Based on observation and interview, it was determined the facility failed to maintain the fire resistance of hazardous area enclosures, affecting one of five level in the facility.
Findings include:
Observation on February 21, 2024, between 9:45 a.m. and 9:48 a.m., revealed, in the basement, open penetrations in the following locations:
a. 9:45 a.m., Electrical Storage Room, by data wires to the right of the door into the room; b. 9:48 a.m., Data Closet, by a return duct above the door to the room.
Exit interview with the Director of Facilities on February 21, 2024, at 12:15 p.m., confirmed the open penetrations.
| | Plan of Correction - To be completed: 04/15/2024
# 1a, 1b The penetrations will both be sealed with a UL approved through penetration fire stop system (Hilti figure # W-L-1464 to maintain the fire and smoke resistance rating of the wall. Maintenance staff and the contractors involved will be re-educated on the proper procedure for sealing all fire/smoke rated penetrations and documented. Construction / renovation projects will be monitored on a continual basis for compliance also. Holy Redeemer Health System has implemented a Fire & Smoke Barrier Penetration Policy in 2012 that provides a comprehensive means of verifying that above ceiling work within Holy Redeemer Health System is accomplished in accordance with applicable building codes, standards, and related hospital policies. This policy applies to any work done in the buildings owned and or rented by the Holy Redeemer Health System. Permit forms are available in the Engineering & Maintenance office. All Smoke and Fire barriers will be inspected Quarterly for compliance as part of our preventative maintenance program and policy. The Director of Maintenance will be responsible for maintaining compliance of this inspection
|
|