HospitalInspections.org

NFPA 90A Standard for installation of Air Conditioning and Ventilating Systems 1999 Edition
Chapter 3 Integration of Air Conditioning and Ventilation System(s) with Building Construction
3-3* Penetrations - Protection of Openings.
3-3.1 Fire-Rated Walls and Partitions.
3-3.1.1*
Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
Exception*: Fire dampers shall not be required where other openings through the wall are not required to be protected.
3-3.1.2
Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.
3-4.5 Damper Closure.
3-4.5.1
All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.
3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
This Standard is not met as evidenced by:

Based on observation and staff interview, it was determined the hospital failed to continuously maintain fire dampers in reliable operating condition with inspections and periodic testing in accordance with National Fire Protection Association (NFPA) 90A.

Findings include:

1. On 06/05/12 at approximately 12:47 p.m., an inspection of the hospitals third floor fire dampers located above the drop ceiling near the chapel was conducted. At this time, there was no evidence that a four (4) year maintenance inspection had been conducted to the fire dampers.

2. On 06/05/12 at approximately 12:50 p.m., an inspection of the hospitals fourth floor fire dampers located above the drop ceiling near room 417 was conducted. At this time, there was no evidence that a four (4) year maintenance inspection had been conducted to the fire dampers.

3. These findings were discussed with the hospital maintenance director on 06/05/12 at approximately 1:00 p.m. and he agreed that a four (4) year inspection and maintenance had not been conducted for the fire dampers.

NFPA 90A Standard for installation of Air Conditioning and Ventilating Systems 1999 Edition
Chapter 3 Integration of Air Conditioning and Ventilation System(s) with Building Construction
3-3* Penetrations - Protection of Openings.
3-3.1 Fire-Rated Walls and Partitions.
3-3.1.1*
Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.
Exception*: Fire dampers shall not be required where other openings through the wall are not required to be protected.
3-3.1.2
Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.
3-4.5 Damper Closure.
3-4.5.1
All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.
3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
This Standard is not met as evidenced by:

Based on observation and staff interview, it was determined the hospital failed to continuously maintain fire dampers in reliable operating condition with inspections and periodic testing in accordance with National Fire Protection Association (NFPA) 90A.

Findings include:

1. On 06/05/12 at approximately 12:47 p.m., an inspection of the hospitals third floor fire dampers located above the drop ceiling near the chapel was conducted. At this time, there was no evidence that a four (4) year maintenance inspection had been conducted to the fire dampers.

2. On 06/05/12 at approximately 12:50 p.m., an inspection of the hospitals fourth floor fire dampers located above the drop ceiling near room 417 was conducted. At this time, there was no evidence that a four (4) year maintenance inspection had been conducted to the fire dampers.

3. These findings were discussed with the hospital maintenance director on 06/05/12 at approximately 1:00 p.m. and he agreed that a four (4) year inspection and maintenance had not been conducted for the fire dampers.