Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
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Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in six instances, affecting 5 of 16 smoke compartments.
Findings include:
1. Observation on April 16, 2025, revealed the following automatic sprinkler system deficiencies:
a) 9:00 a.m., there was a gap in the ceiling tile in Storage Room 308, which would allow the passage of heat and smoke, and may affect operation of the automatic sprinklers;
b) 9:35 a.m., a sprinkler head was missing an escutcheon plate in the Soiled Utility Room E277;
c) 9:45 a.m., there were wires supported by a sprinkler branch line above the doors outside of the Employee Cafeteria, on the first floor;
d) 10:00 a.m., a sprinkler head was completely obstructed by fiberglass/aluminum insulation surrounding large duct work in the W138/Painters Room;
e) 10:05 a.m., there was a sprinkler head and escutcheon plate hanging low, causing a gap in the ceiling tile greater than 1/8 inch, in the Employee Dining room;
f) 10:10 a.m., there was a sprinkler head and escutcheon plate hanging low, causing a gap in the ceiling tile greater than 1/8 inch, in the Kitchen dry goods storage room.
Interview with the Facility Administrator and Maintenance Director on April 16, 2025, at 1:30 p.m., confirmed the above listed automatic sprinkler system deficiencies.
| | Plan of Correction - To be completed: 05/30/2025
Service requests will be placed with the Allegheny County Department of Facilities Management to remedy any deficiencies received with this tag.
A work order was submitted with the carpenter to rectify the following identified issues:
1. Gap in the ceiling tile in Room 308
2. Missing escutcheon plate in the soiled utility room E277
3. Two escutcheon plates that were hanging low causing a gap in the ceiling tile greater than 1/8in. in the employee dining room.
The ESM and Security Chief walked the building to ensure that there were no additional gaps or hanging/missing escutcheon plates in the ceiling tiles. A work order was submitted for the engineer to secure any wires resting on the sprinkler branch line above the doors outside of the employee cafeteria on the first floor. The ESM and Security Chief walked the building and checked above multiple ceiling tiles throughout the building to ensure that there were not any more occurrences like the one identified. The sprinkler head that was obstructed by fiberglass/aluminum insulation in room w138 is going to be repaired by S.A. Comunale. The repair was part of the initial estimate including the repair of the missing sprinkler heads (estimate attached). ESM will have maintenance staff and security staff in-serviced on how to properly identify a ceiling tile that has penetrations or gaps as well as escutcheons missing or not secured to the ceiling tile. The ESM or designee will inspect the facility for any ceiling tiles with gaps or penetrations as well as missing or hanging escutcheons that would cause us to fail the sprinkler system maintenance test 2 x month for 3 months. All findings will be documented on an audit sheet and reported at the QI meetings for review and recommendations.
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