ES&H Manual

Fire Protection Supplement

Chapter 4:

Fire Protection System Inspection, Testing,

and Maintenance Procedure


1.0             Purpose


Jefferson Lab conducts regular inspections, periodic testing, and preventive maintenance of its fire protection systems to ensure their continuous, proper operation.


Inspection, testing, and maintenance (IT&M) are conducted in accordance with the National Fire Protection Association (NFPA) requirements supplemented by equipment manufacturers' recommendations. Fire protection IT&M requirements shown in this supplement are derived from the reference documents listed below.


2.0             Scope


This document describes the use of subcontracted service work, quality assurance, and corrective actions employed to inspect, test, and maintain installed fire protection equipment. Timing of these activities is influenced by accelerator operations and available access times.


Fire protection system maintenance is an element of the Facilities Management and Logistics Department (FM&L).


3.0             Responsibilities


3.1              Fire Marshal  

·         Functions as the Subcontracting Officers Technical Representative (SOTR) for fire protection contracts.

·         Maintains the IT&M documents to industry standards.

·         Ensures quality assurance activities are accomplished.

·         Analyzes reported deficiencies in fire protection systems to prioritize corrective actions or major maintenance.

·         Investigates malfunctioning fire protection equipment to determine corrective action needed.

·         Oversees the daily activities of subcontractors’ staff for inspections and tests in accordance with the procedures contained in this document.

·         Coordinates the required IT&M activities with area work coordinators using the regional electronic work control system for each area.


3.2              Fire and Security Technician

·         Investigates malfunctions in the NCC alarm monitoring network and coordinates corrective action.

·         Investigates malfunctions in the VESDA network and coordinates corrective action.

·         Assists the Fire Marshal with fire protection system modifications and additions as requested.


4.0             Expectations


4.1              General Fire Protection Information

Several documents are required to accomplish all aspects of inspection and testing. The following documents contain tables and lists of detection and suppression devices located throughout the Jefferson Lab Facilities.


·         Jefferson Lab Building Fire Protection Features

o   A comprehensive list of building and pertinent fire protection features. This document contains the following information for each Jefferson Lab building:

§  Building name and number

§  Building use, floor area, number of stories and construction type

§  Fire suppression systems general description

§  Fire detection and alarm systems general description

§  Estimated values of buildings and administrative contents

·         Building Device Matrix

o   Multiple comprehensive spreadsheets listing fire detection and fire suppression devices contained in each building.

·         Fire Extinguisher Locations

o   A list of portable fire extinguishers located throughout the site.

·         Hydrant Location

o   A site plan showing 32 fire hydrants located on the private service fire mains within Jefferson Lab.

·         Early Warning Smoke Detector List

o   A list of early warning smoke detection devices.


4.2              Inspection Requirements

Several documents convey the required inspections to be performed on each fire protection device.

·         Equipment Designator Codes

o   The naming convention for fire protection identifiers used in a computerized maintenance management system.

·         Maintenance Codes

o   A detailed list of periodic inspections and tests that apply to detection and suppression system devices.

·         Maintenance Reports

o   A tabulated list of specific fire protection devices using designator codes and PM inspection codes generated by the computerized maintenance management system.


4.3              Test Requirements

Several fire protection devices require periodic testing to demonstrate continued satisfactory performance. Each test requires data to be recorded. Testing procedures are written for.

·         Clean Agent Suppression System Control Panels

·         Radiant Energy Fire Detectors

·         Gas Detection Systems

·         Restorable Heat Detectors

·         Protectowire Heat Detectors

·         Duct Smoke Detectors

·         Ionization and Photoelectric Smoke Detector

·         Very Early Smoke Detector Apparatus (VESDA) Aspiring Smoke Detection

·         Fire Hydrant Flow Test

·         Full-Flow Trip Test of Preaction Water Sprinkler System


4.4              Subcontracted Service Work

IT&M of fire protection systems is performed by Jefferson Lab staff. Service work on sprinkler systems, alarm systems, and hand-held fire extinguishers is performed by subcontractors. Services normally include performance of maintenance inspections or tests, submittal of records, inspection forms or deficiency reports. The Fire Marshal, under the direction of the Facilities Management Director, specifies and approves vendor and staff qualifications before work begins. 


See the Performance Work Statement for additional information regarding subcontracted services.


4.5              Quality Assurance

Quality assurance for subcontracted fire-protection services is accomplished through the Quality Assurance Plan contained in the subcontract document. 


For quality assurance forms see either Inspection of Services (Contractor Performance Evaluation) or Quality Assurance Report and Quality Check List.


4.6              Deficiencies and Corrective Actions

Equipment found to be malfunctioning with respect to intended design, condition, and function in fire protection systems are considered a deficiency. The Fire Marshal promptly analyzes reported deficiencies and assigns an appropriate risk code, which governs the prioritization of corrective actions.


Deficiencies reported through inspection and testing activities are entered into the FM&L Work Order System for tracking through completion. An impairment action is implemented based on hazard analysis.


5.0             Inspection, Testing, and Maintenance


Fire protection maintenance activities are conducted in accordance with the FM&L subcontract for the identified IT&M work. Complete records of all testing, inspection, and maintenance activities are maintained by the Fire Marshal. The frequency of IT&M is based on NFPA requirements; however, during accelerator operations, many areas are inaccessible, and maintenance scheduling is predicated on access times. All contractually required inspections and tests are accomplished during available maintenance periods.


6.0             References

·         NFPA 10 Standard for Portable Fire Extinguishers, 2013 Edition

·         NFPA 12 Standard on Carbon Dioxide Extinguishing Systems, 2011 Edition

·         NFPA 17A Standard for Wet Chemical Extinguishing Systems, 2013 Edition

·         NFPA 25 Standard for the Inspection Testing, and Maintenance of Water-Based Fire Protection Systems, 2014 Edition

·         NFPA 72 National Fire Alarm and Signaling Code, 2013 Edition

·         NFPA 80 Standard for Fire Doors and other Opening Protectives, 2013 Edition

·         NFPA 105 Standard for the Installation of Smoke Door Assemblies and Other Opening Protectives, 2013 Edition

·         NFPA 291 Recommended Practice for Fire Flow Testing and Marking of Hydrants, 2013 Edition

·         Fire Protection Handbook 20th Edition, ©2008 National Fire Protection Association


7.0             Revision Summary


Periodic Review – 01/03/19 – No update per TPOC

Revision 0.2 – 06/02/16 – Periodic Review; updated TPOC from D.Kausch to T.Minga; deleted reference to IT&M subcontract in section 4.4

Revision 0.1 – 09/17/13 – Periodic Review; clarified Responsibilities and Expectations; updated links









Fire Protection Department

Tim Minga





This document is controlled as an on line file.  It may be printed but the print copy is not a controlled document.  It is the user’s responsibility to ensure that the document is the same revision as the current on line file.  This copy was printed on 1/10/2019.