Failure to Maintain Smoke Barriers as per NFPA 101
Penalty
Summary
The facility failed to maintain smoke barriers in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition. Specifically, the G-wing east smoke barrier wall in Building #1 was not continuous from the floor to the underside of the roof and through all concealed spaces, and the fire-resistance rating was not maintained as required. During observations, a 12-inch by 12-inch hole in the smoke barrier wall was found filled with insulation but not fire-protected. This deficiency was confirmed during an interview with the Maintenance Supervisor, who acknowledged the issue and stated that they would address the fire sealing of the space in the G-wing smoke barrier wall.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 1. G wing east smoke barrier wall penetration will be sealed using appropriate fire seal. Due to the location of this area, it is not accessible for hand-application and specialized equipment is required. NOTE – this penetration was from original construction and is located above a series of pipes and conduits offering no means of direct access. 2. All smoke barrier walls in building #1 (identified as G and D wings) will be inspected to identify any other penetrations lacking appropriate fire protection. 3. All maintenance staff will be informed of the requirements for smoke walls and fire protection sealant in written form, with signature attesting to receipt and understanding. Existing standards for new work resulting in penetrations will be included in education. 4. Director of Plant Operations will verify all smoke barrier walls have been visually inspected and report the findings to Quality Assurance/Performance Improvement committee. New work resulting in penetrations to smoke walls will be visually inspected at completion; any remaining penetrations will be reported through Safety Committee. Responsible: Director of Plant Operations