Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2
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Observations: Name: MAIN BUILDING - Component: 01 - Tag: 0225 Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within the allowed gap margins, on four of thirteen stairtowers within the component.
Findings include:
1. Observation on January 10, 2024, between 10:50 AM and 12:15 PM, revealed gaps on stairtower doors exceeded one eighth of an inch, at the following locations:
a. 10:50 AM, 1st floor, Clinic, Stairtower South, top of door; b. 11:20 AM, 2nd floor, Clinic, Stairtower West, top of door; c. 11:25 AM, 3rd floor, Clinic, Stairtower South, top and latch side of door; d. 12:15 AM, 1st floor, Ben Franklin, Stairtower South, top of door.
Interview at the time of the exit conference with the Administrator, Asst. Director of Facilities, Director of Safety and Security and Maintenance Supervisor on January 10, 2024, at 2:00 PM, confirmed the stairtower doors exceeded the allowed gap margins.
| | Plan of Correction - To be completed: 02/16/2024
Tag 1. a. The gap exceeding 1/8" at the top of the 1st floor, Clinic, Stairtower South, door was corrected with approved Fire Door hardware. b. The gap exceeding 1/8" at the top of the 2nd floor, Clinic, Stairtower West, door was corrected with approved Fire Door hardware. c. The gap exceeding 1/8" at the top and latch side of the 3rd floor, Clinic, Stairtower South, door was corrected with approved Fire Door hardware. d. The gap exceeding 1/8" at the top of the 1st floor, Ben Franklin, Stairtower South, door will be corrected with door adjustment.
Maintenance staff will be educated about using an approved fire rated door system to prevent a gap of more than 1/8".
The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to assure that the approved fire rated door system is being used to prevent a gap of more than 1/8". The results of the audit will be forwarded monthly to the Quality Assurance Committee for review and comment and need for further audit.
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