Unprotected Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls, which is a requirement for ensuring safety in the event of a fire. During an observation, it was found that there was an unprotected penetration in the smoke barrier wall located above the suspended ceiling, specifically above the East Hall smoke barrier cross-corridor doors. This penetration was around gray wires, compromising the integrity of the smoke barrier. The Maintenance Manager confirmed the presence of this unprotected penetration during an interview.
Plan Of Correction
The facility will maintain the rating of the smoke barrier walls. The identified penetration of the smoke barrier wall has been sealed using an approved through penetration fire stop system in order to maintain the rating of the smoke barrier. Other areas within the component shall be rechecked for penetrations and, if found, sealed with approved through penetration fire stop system in order to maintain the rating of the smoke barriers. Ongoing monitoring of penetrations have been added to the electronic task work order system, and shall be overseen by the director of maintenance/designee. Director of Maintenance shall report on any ongoing findings of penetrations and sealing performed to the QAPI committee for review/recommendation for a period of three months. Maintenance staff shall be educated by Administrator on the NFPA 101 Standard for maintaining smoke barrier walls.