Protecting penetrations: Tips to maintain your fire and smoke barriers

Transcription

1 Protecting penetrations: Tips to maintain your fire and smoke barriers A supplement to Opus Communications publications

2 Dear reader, The lesson of the day: Don t ignore unprotected breaches in your barriers. This is something we ve all learned after hearing countless stories of construction workers who bust a hole into a smoke or fire barrier, drag a pipe through the penetration, and then don t seal the gap. We ve also winced at the subsequent tales of inspectors or surveyors who took close looks at barriers for evidence of poorly handled penetrations. With a health care facility s reliance on the protections provided by barriers, it s clear all sides have a role in ensuring that penetrations don t compromise safety. We invite you to share this special report with your safety committee, project directors, contractors, staff members, and any others whose work may lead them to a smoke or fire barrier. We d like to thank the following people for their help and information in writing this report: Michael Crowley, PE, vice president and engineering manager at Rolf Jensen & Associates Inc. in Houston, who spoke during the NFPA s World Safety Conference in May John Hurley, managing director of Firestop Solutions Group in Olympia, WA, who also spoke during the NFPA conference. Firestop Solutions Group is a division of Specified Technologies Inc., a firestopping manufacturer. Pamela O Malley, RA, senior project manager and director of Children s Hospital of Philadelphia s main expansion project, who spoke at an American Society for Healthcare Engineering conference in Orlando, FL, in March Dean Samet, CHSP, associate director of standards for the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. Richard Walke, engineering group leader in the fire protection division at Underwriters Laboratories in Northbrook, IL. Robert Westenberger, MCO, CHFM, corporate director of safety and regulatory compliance at Saint Clare s Health Services in Denville, NJ. We welcome any comments or further tips on how to successfully battle this persistent problem. Sincerely, Scott Wallask Senior Managing Editor swallask@hcpro.com 781/ , ext Table of contents Health care presents tough challenges for barriers What does UL mean by a firestopping system? The Life Safety Code s take on penetrations Seven tips to help you tackle barrier penetrations Sample barrier work permit Discovering penetrations should be a constant goal Protecting penetrations

3 Health care presents tough challenges for barriers It may sometimes seem overkill to worry so much about smoke and fire barrier penetrations, particularly if sprinklers protect your health care facility. Don t be fooled, though. Linear openings such as construction joints create problems, as do penetrations from computer cabling, plumbing, medical gas lines, and other assorted mechanical and electrical lines, all of which can poke through a barrier. It s a pervasive problem, says Dean Samet, CHSP, of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Why? Primarily because of the communication age we re in. We re running phone lines and data cables... constantly and [they re] being modified. If staff members, vendors, or contractors don t seal these openings properly with firestopping, the dependability of the barrier suffers. In a worst-case scenario, fire or smoke that the barrier should resist instead escapes through the hole, subverting an important protection measure. Certain items that go through penetrations, like cables in plastic jackets, insulated pipe, or plastic pipe, can make matters worse. These items are combustible and provide a source of fuel to feed a fire and spread it through a barrier. Firestopping is often a vexing problem for many [facilities], says John Hurley. It s more than just the red stuff you shoot in an opening. Technically, firestopping involves restoring hourly fire integrity rating to a barrier, based on recognized testing from Underwriters Laboratories (UL), a product safety testing group headquartered in Northbrook, IL. You restore this reliability by filling the hole with a material classifed by UL that will reestablish the rating. This material comes in various forms, such as Firestopping is often a vexing problem for many [facilities]. caulks, putties, or foams. They mainly have two properties: the ability to expand rapidly when exposed to heat and the ability to absorb heat at higher temperatures. Divide and defend Why do you need to guard against barrier penetrations to begin with? It s all part of a three-tier protection plan within the building s design that allows health care facilities to not rely individually on prevention, detection, or suppression for fire safety. John Hurley, FSG Solutions That s where the common idea of smoke compartments comes in. Dividing floors in a health care facility into compartments helps to control fire in some cases stop the spread of smoke, which sprinklers can t do protect exit routes ensure that the facility can defend in place (a strategy that allows staff members to relocate patients to a safe area on the floor rather than evacuate the building) Compartments also serve as a last resort if a fire breaks out and the sprinkler or alarm systems fails. Sprinklers and barriers work hand-in-hand and serve as backups for each other in a facility, says Michael Crowley, PE. Look for locations So where do you typically use firestopping? The following areas are common spots: Areas known as through penetrations, usually holes into and out of a barrier for pipe or cable Membrane penetrations, where the hole goes through a single layer of the barrier but not out the other side, such as a P-trap under a sink (many contractors don t think they have to seal these) continued on p. 4 Protecting penetrations 3

4 Barriers continued from p. 3 Construction joints, including wall-to-wall, floorto-floor, or wall-to-floor Blank openings in walls, usually from removed equipment The joint at the intersection of a floor slab and the exterior curtain wall of the building Half of the product sales in the firestopping industry end up in linear openings, such as the tops of wall joints, rather than in the more widely known penetrations, Hurley says. Check in the ducts, too Workers often overlook electrical ducts as another potential penetration problem, says Robert Westenberger, MCO, CHFM. Many times, once the duct is closed up and the penetration outside unsealed, people don t realize if there was a fire within the duct and there are large openings, fire and smoke can spread up the duct and into other areas, Westenberger says. At his facility, once a conduit is in place within a duct, crews install a sealant at the floor or ceiling penetrated by the duct and within the duct. Workers can later remove the sealant if additional work needs to be done in the duct, he says. Problems with firestopping Unlike other life safety materials and equipment, which specialized workers tend to install, firestopping is the only code-required product installed by virtually every trade, including including information technology workers, plumbers, electricians, and sprinkler crews. There is no quality control aspect right now that is nationally recognized, Crowley says. Unfortunately, that s where our problem is. People will grab anything. Firestopping material expands with heat, which helps seal a penetration as it burns away during a fire. But What does UL mean by a firestopping system? Underwriters Laboratories (UL) is an independent, not-for-profit organization that conducts safety tests on a wide variety of products. You can find the familiar UL circle symbol on many items, ranging from toasters to holiday light sets. When it comes to barrier penetration awareness, it s important to note that UL doesn t test firestopping material. We rate the system as a whole, as opposed to individual material, says Richard Walke of UL. What are the parts? The firestopping system includes the following components: The rated wall being penetrated The item that penetrates the wall The firestopping fill material As an example, you might use a rated firestopping caulk with a steel pipe penetration in a rated fire wall together, they provide a rated firestopping system. Take some of that caulk and put it with a plastic pipe, and you might not have a rated [system], says Walke. Lots of systems out there Designs and firestop installations must specifically follow UL guidelines to meet the organization s ratings. UL lists 3,500 firestopping systems in volume two of its Fire Resistance Directory, Walke says. Go to for more information. 4 Protecting penetrations

5 that characteristic alone isn t sufficient protection; other factors include how much firestopping material you use and whether you install the correct hardware, such as firestopping collars. This combination of features makes it easy to inadvertently seal a penetration incorrectly (see the related story on p. 4 for more details on what UL expects for firestopping installations). Contractors tend to rush through firestopping during the wrap-up of a job, and worse, they may not understand the compartment system that a given health care facility uses, Hurley says. It s not realistic for health care facilities to automatically expect carpenters, plumbers, and technicians to be familiar with firestopping because that activity is not usually part of their jobs, Samet adds. Risks unfold in this setting There are other downfalls associated with firestopping that have little to do with the material you use and hinge more on health care settings. One trouble spot is that the director of engineering or maintenance is usually the person responsible for barrier integrity, yet often has little control of penetration threats. That s because workers who cause penetrations may not report to engineering for example, an information services employee installing fiber optic cable through a smoke barrier may deal with the director of information management. Adding to this dilemma is the fact that health care buildings have more compartments and penetrations than most non health care structures. Endless cable changes driven by information systems and medical technology, especially in large teaching hospitals, increase the chance of penetrations and the risk of substandard firestopping, Hurley says. See pp. 6 7 for a list of ideas to help you better handle penetrations. The Life Safety Code s take on penetrations The Life Safety Code s (LSC) requirements for barrier penetration protection appear in Chapter 6 of the 1997 edition (Chapter 8 in the 2000 edition). The two specific sections to check are the following: ( in the 2000 version), which covers penetrations in fire barriers ( ), which discusses penetrations in smoke barriers Filling the hole Both sections have similar requirements. You must fill the space between the penetrating item and the barrier with a material capable of maintaining the fire or smoke resistance, or install an approved device designed for this purpose. You can meet the latter option by using a firestop system, which includes specifically listed building materials or assemblies designed to prevent the spread of flames or smoke. The bulleted sections above also address items that use sleeves and vibration provisions. The health care chapters of the LSC refer back to the above sections on barrier penetrations. Newer requirements, too Also, in the 2000 LSC, there is a new section under that discusses smoke partitions. These partitions also require protection of any penetration, similar to the provisions for barriers. Finally, you can find further requirements on protecting duct penetrations in NFPA 90A, Installation of Air Conditioning and Ventilating Systems. Protecting penetrations 5

6 Seven tips to help you tackle barrier penetrations Use the following ideas to improve your facility s penetration vigilance: Label your barriers 1. A simple move is to stencil or paint the rating of your barrier on the wall. For example, you d stencil two-hour fire barrier onto the wall above a drop ceiling grid to warn staff members, vendors, and contractors who might poke a hole in it. Identifying these walls will help people penetrating the wall... and those of us inspecting them, says Michael Crowley, PE. It also may help contractors avoid sealing penetrations that don t need to be. Labeling barriers is a fairly easy action with new construction, he adds. However, it s a bit trickier with existing buildings, though if you re in the midst of a retrofit, stenciling the primary walls shouldn t be too tough. Either way, the effort will pay off with less penetration problems and perhaps even kudos from inspectors. You ll be sending a message to your [authorities] that you are ahead of your peers, because very few people do this, says John Hurley. Focus on problem areas 2. Look for the hot spots that always seem to have penetration problems or are high traffic areas for holes, such as computer cable trays and sleeves above doorways. Take an inventory of these openings and increase your inspections and preventive maintenance rounds. Keep a log of your visits so you can measure compliance, Hurley says. By the way, certain penetrations, such as cable trays and cable bundles through sleeves, require regular access. In such cases, installing items such as a firestop pillow or firestop putty, rather than traditional firestop caulking or mortar compound, will save time and money over the years, Hurley says. You can easily reopen and replace such products because of their easy access. 3. Talk to manufacturers Take note of whose firestopping products your facility uses and give those vendors a call. Almost all manufacturers provide instruction on installation and good ones will offer competency-based training to help ensure the contractors install the products properly, Hurley says. Also, some vendors like Firestop Solutions Group in Olympia, WA, ( sell videos that show people how to use firestopping material. Use tagout systems 4. This approach is similar to the Occupational Safety and Health Administration s lockout/tagout requirements for controlling hazardous energy. Basically, you install a lock or tag on penetration risk areas, such as utility closets or areas above the ceiling tiles. When contractors or workers see the lock or tag, it should warn them that they can t penetrate the barrier or, if they do, they must properly seal the hole, Crowley says. Issue barrier permits 5. You might consider requiring all contractors to obtain a special permit and badge for any penetration work in the facility (see the sample on p. 7). Such a move mirrors what many sites already mandate for hot work or projects in confined spaces, Hurley says. If you go with this idea, beef it up by having security officers challenge contractors to show them their badges or permits, or require them to display the permits in their immediate work area. Warn your vendors 6. In your penetration policies and contracts, add a clause that says the facility will conduct an inhouse firestopping inspection of any penetrations before you pay the vendor. And then make sure you tell the vendors about this. Chances are if they know your policy ahead of time, 6 Protecting penetrations

7 they ll be more careful when they install firestopping, Hurley says. Spot checks are one way to show you re serious about the work, adds Dean Samet, CHSP. Also, if in-house crews perform the firestopping, connect any failure to properly complete firestopping with supervisory action, he adds. 7. Get it in the bids Put any firestopping requirements in your project contracts when they go out to bid, says Pamela O Malley, RA. That helps get the word out early about what you expect from contractors. Also, if it s an option, use firestopping workers with whom you re familiar. You might have a list of required subcontractors who the main contractors must use, based on your experiences, O Malley says. A good source to check out is the Firestop Contractors International Association, which keeps a list of preferred firestopping contractors. Go to and then click the link on the left side for member lists. Sample barrier work permit (Facility name), employed by (Worker s name) (Contracting firm s name) has been granted permission to work on fire and smoke barriers. This work may involve penetrations to the barrier. The workers must properly seal all penetrations as outlined in this facility s policies and procedures. Dates of work: Location of work: Work to be performed: Area/floor supervisor: Contact person: Issued by: (Facility representative s signature and title) Date issued: Worker s signature: Please keep this permit with you at all times. You may need to show it. Source: Based on information in the guidebook to the video, Playing it Safe: Your Guide to Working in a Medical Facility, produced by The Greeley Company, Marblehead, MA. To order the video, go to or call 800/ Protecting penetrations 7

8 Discovering penetrations should be a constant goal Don t merely tie your barrier maintenance into the accreditation cycle If the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) surveys your facility, then you ve probably heard the advice not to think of accreditation as something you just do every three years. The same thing can be said about watching for penetrations, says John Hurley. Don t only inspect for penetrations just before a survey. Many facilities do just that, though. Hurley finds that barrier compliance hits its highest levels when the three-year survey cycle comes to a head, and, once the JCAHO bestows accreditation, compliance generally drops off. What happens if you get a random unannounced survey two years into the cycle? Hurley asks. Inspectors representing the Centers for Medicare & Medicaid Services may also stop by, and they notoriously hound facilities on Life Safety Code issues. The costs will chase you Beyond surveys, three-year maintenance of penetrations Online poll results During your last JCAHO, state, or Medicare inspection, did surveyors check your fire and smoke barriers for penetrations? Yes: 91% No: 9% Source: Survey results at complied in August turns into bad business, Hurley adds. Facilities already pay a lot of money during survey time, but buck up even more cash to catch up with earlier, shoddy repair work. He knows of a facility in New York state that spent close to $1 million repairing penetrations before a survey. Meanwhile, the JCAHO also requires 95% compliance with barrier maintenance if you choose to use the optional building maintenance program in the Statement of Conditions. This means facilities must show that the barriers were okay 95% of the time over the past three years. The JCAHO s emphasis on the 95% compliance rate is very important in trying to manage these penetrations, says Michael Crowley, PE. The magic recipe? Ha! There s no sole formula to figure out the tricky answer of 95% barrier compliance, says Dean Samet, CHSP, of the JCAHO. But one idea he suggests is to take the number of penetrations and divide that figure by the total number of barriers in your facility. Take the number you come up with and multiply it by 100 to get the percentage of barriers that are out of compliance. The example shows the vagueness that plagues the 95% issue, though. For example, do you count a trio of penetrations in one barrier as three separate instances of noncompliance or just one? And in fairness, what if one barrier has twice the wall area of another? 09/02 SR3702 This special report is published by Opus Communications, Inc., 200 Hoods Lane, Marblehead, MA Copyright 2002 Opus Communications, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of Opus Communications or the Copyright Clearance Center at 978/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For renewal or subscription information, call customer service at 800/ , fax 800/ , or customerservice@hcpro.com Opinions expressed are not necessarily those of the editors. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations which owns the trademark. 8 Protecting penetrations