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Fire Marshal’s Office
Interim Life Safety Measures Guidelines

  1. PURPOSE
    2.

    This procedure establishes a tool to help the Fire Marshal’s Office assess the loss or potential loss of a life safety feature during the course of construction, renovation, and alteration or during the time when a building life safety system is impaired for greater than 4 hours or a PFI is identified. As a result of the assessment, additional measures as deemed appropriate by the Fire Marshal’s Office may be implemented to ensure an equivalent level of protection is provided. This procedure does not replace or is not a substitute for the Planning Project Management Risk Assessment Plan

  2. PERSONNEL AFFECTED


    3. This procedure impacts individual’s involved with construction, renovations and alteration activities. The primary audiences are:
      Planning & Project Management
      Facilities Maintenance Shops
      Security
      Environmental Health & Safety
    This procedure only applies to the University of Rochester Medical Center patient care areas. Off-site buildings are not included in the scope of this procedure. Unoccupied or new buildings are not included in this procedure unless those activities affect the life safety systems/features of adjoining buildings or if the building will become partially occupied prior to the commissioning of the life safety systems.

  3. DEFINITIONS


    4. Interim Life Safety Measures – a series of eleven (11) administrative actions that guide Strong Memorial Hospital during Life Safety Code deficiencies or construction activities that impair life safety systems by temporarily compensating for the impairment

  4. RESPONSIBILITIES


    1. Planning and Project managers shall provide a formal risk assessment of planned and awarded construction and/or renovation projects.  The risk assessment will determine the risk priority and make a determination of Interim Life Safety Measures that will be required during a project. A copy of the risk assessment will be submitted to EH&S for ILSM file.
    2. Planning and Project Management will ensure the contractors are following all required ILSM
    3. The hospital Fire Safety Coordinator from Environmental Health & Safety (EH&S) will perform an Interim Life Safety Assessment for any active life safety system that is impaired for more than 4 hours in a 24 hour period and on any passive fire safety system that is impaired/inoperable for greater than 45 days.
    4. Medical Center Facilities will implement a prioritized safety work order system to ensure timely correction of Life Safety Code deficiencies.

  5. PROCEDURES


    1. For any construction project managed by PPM, Environmental Health & Safety (including the Fire Marshal’s Office) is involved in the design review and construction process. During the design review process the Fire Marshal’s Office performs an Interim Life Safety Assessment screening (see appendix 1)
    2. For any construction or renovation project managed through Medical Center Facilities Operations, Environmental Health & Safety (including the Fire Marshal’s Office) is involved in the design review and construction process.  During the design review process the Fire Marshal’s Office performs an Interim Life Safety Assessment screening (see appendix 1).
    3. This screening allows the Fire Marshal’s Office to assess the appropriate compensatory measures that might be required during the construction phase.
    4. PPM shall be responsible to ensure contractors comply with the Interim Life Safety Measures that are required, if any, for all construction activities.
    5. PPM shall initiate requests to EH&S for fire protection systems deactivations or for any work that may impair a Life Safety feature of the building.
    6. Environmental Health & Safety will authorize the deactivation of Life Safety Systems and assess the need for any ILSM if the system is expected to be impaired for greater than 4 hours in a 24-hour period or if there is a significant compromise of one or more life safety protection features.
    7. Since no construction process is stagnant and the process itself is dynamic, a representative from the Fire Marshal’s Office will inspect the job site at the beginning of the project and at a minimum of once per week. This installation is intended to verify the contractor’s compliance with good construction of a Fire Safety Practice. In addition, this inspection will monitor the contractor’s compliance with any ISLM’s.   This frequency can be altered as directed by the inspector as indicated by his findings, confidence and previous dealings with various contractors.
    8. The Fire Safety Coordinator will document his/her inspection tour and on the Construction & Renovation Projects Fire & Life Safety Survey Form (see appendix 2). Any item identified, as “no” shall have an explanation in the comments section.
    9. Security notifies the Fire Marshal’s Office for all fire suppression or detection system impairments. The Fire Safety Coordinator works with Security in understanding the scope of the impairment and ensuring restoration. Anytime a fire detection or suppression system is impaired for 4 hours or more in a 24-hour period the Fire Safety Coordinator will perform an Interim Life Safety Measures Assessment and implement the appropriate compensatory actions.
    10. Facilities shall notify the Fire Marshal’s Office anytime a passive fire protection system has a work order that cannot be repaired within 45 days. The Fire Safety Coordinator will perform an Interim Life Safety Measures Assessment and implement the appropriate compensatory actions.
    11. Once the compensatory actions are identified, the fire safety coordinator will develop an ILSM Alert form (see appendix 3) identifying the project area and what life safety measures are required to be implemented. Since this is not a stagnant process, the ILSM form and alert might be modified during the project.
    12. Environmental Health & Safety has written a Safety Analysis that accepts a tight friction fit ceramic fiber as a temporary penetration seal without any additional interim life safety measures. The intent is for these seals to remain in place while modification / maintenance is being completed and they are repaired with a permanent seal after all work on new or existing penetrations has been completed.
    13. It is the University’s practice to leave the existing fire alarm system and any suppression system in the area operable at all times, especially during construction.  It is also our policy to install the new system in parallel with the existing system.  This allows us to test and accept the new system prior to demolition of the old system.
    14. Records of Interim Life Safety Assessment’s and inspections shall be maintained to ensure that each construction site has been reviewed and inspected in accordance with this guideline.  These records shall be available for review for 3 years.

  6. REFERENCES


    7. National Fire Protection Association Life Safety Code 2000 Edition

  7. APPENDICES/FORMS


    8. Appendix 1 – Interim Life Safety Measures Assessment Form
    Appendix 2 – Construction & Renovation Projects Fire & Life Safety Survey Form
    Appendix 3 – Interim Life Safety Measures Alert I

  8. REVISION HISTORY


    9. Date

    Revision No.

    Description

    10/2/07

    New

    Converted document into new format

    12/7/07

    1

    Added clarification of purpose and responsibilities.

    1/11/08

    2

    Modified procedures section, updated appendices

    3/6/09

    3

    Modified procedures section, updated appendices


QUESTIONS? Contact the EH&S Fire Marshal's Office at (585) 275-3243 or e-mail EH&S Questions.

This page last updated 10/5/2009. Disclaimer.