This section has been reviewed and updated as needed: September 2016

Policy Statement

An impairment of a fire protection system poses a risk to students, faculty and staff. This policy describes required actions to be taken by the University if a required fire protection system is impaired or taken out of service due to construction, alteration, malfunction, a special event, or an emergency condition.

Definitions

Fire protection system
Approved devices, equipment and systems or combinations of systems used to detect a fire, activate an alarm, extinguish or control a fire, control or manage smoke and products of a fire or any combination thereof.
Fire watch
A temporary measure to ensure continuous and systematic surveillance of a building or portion thereof by one or more qualified individuals for the purposes of identifying and controlling fire hazards, detecting early signs of unwanted fire conditions, raising the alarm of fire and notifying the fire department via 911 as soon as possible.
Impairment
A shutdown, in whole or in part, of a fire protection system.

Audience

This policy applies to all employees of UNC-Chapel Hill and outside contractors who will be working on University property.

Roles and Responsibilities

University Fire Marshal
Shall be the University’s designated Impairment Coordinator as defined in the North Carolina Fire Prevention Code

Reason for Policy

The University has an obligation to provide a safe and healthful environment to all students, faculty, staff and visitors located in University buildings. Functioning fire protection systems play a key role in maintaining life safety for building occupants. This policy establishes procedures to mitigate life safety risk in the event of an impairment of a building fire protection system.

Compliance

Failure to implement actions required by the North Carolina Fire Code during fire protection system impairments could expose the University to liability or significant property loss in the event of a fire.

Procedures

Impairments of fire protection systems may be classified as planned or unplanned. A planned impairment is when a fire protection system is placed out of service due to work that has been planned in advance, such as construction or maintenance. Special events requiring the impairment of a fire protection system are also considered planned. Unplanned impairments include, but are not limited to, the malfunction of a fire protection system or the restoration of a fire protection system after an emergency. In any case, an impairment of a fire protection system requires the implementation of compensatory measures to maintain life safety during the period of impairments. Examples of compensatory measures include, but are not limited to:

  • Reduction of activities within the impaired area or building
  • Closure of the impaired area or building
  • Implementation of a fire watch
Planned impairments for special events will be approved by the University Fire Marshal or designee. Individuals or groups requesting planned impairments for a special event shall submit a “Special Event/Assembly Fire Safety Permit” (Appendix A) to the University Fire Marshal no less than seven days prior to the event. The individual or group requesting the impairment shall be responsible for any cost or charges associated for the provision of an approved fire watch. See Fire Watch Requirements, below, for further guidance. Planned impairments for special events shall not require the notifications described in Notifications, below.
Individuals requesting planned impairments for construction or maintenance shall coordinate directly with Facilities Services. If any impairment is planned for a building operated by the Department of Housing and Residential Education (DHRE), Facilities Services shall immediately notify the University Fire Marshal (See Appendix B for a list of buildings operated by DHRE). Planned impairments in other buildings exceeding four hours in duration for a fire alarm system or ten hours in duration for a water-based fire protection system require the notification of the University Fire Marshal by Facilities Services. A required notification shall include:

  • The extent and expected duration of the impairment
  • Whether the areas or buildings involved have been inspected
  • Whether the fire protection system has been tagged
  • Whether employees in the area have been notified of the impairment
  • Recommendations regarding the implementation of a fire watch or other compensatory measure

Upon notification, the University Fire Marshal or designee shall determine whether a fire watch is required, or if another compensatory measure is acceptable for the duration of the fire protection system impairment. The costs or charges associated with providing a fire watch under this section are to be determined at the time of initiation. See Fire Watch Requirements, below for further guidance. The University Fire Marshal shall also complete the notifications required in Notifications, below.

In general, an unplanned impairment occurs due to a malfunction that renders a fire protection system inoperable. Any unplanned impairments in a building operated by the Department of Housing and Residential Education require the immediate notification of the University Fire Marshal. Unplanned impairments in other buildings exceeding four hours in duration for a fire alarm system or ten hours in duration for a water-based fire protection system require the notification of the University Fire Marshal. A required notification shall include:

  • The extent and expected duration of the impairment
  • Whether the areas or buildings involved have been inspected
  • Whether the fire protection system has been tagged
  • Whether employees in the affected area have been notified of the impairment
  • Recommendations regarding the implementation of a fire watch or other compensatory measure

Upon notification, the University Fire Marshal or designee shall determine whether a fire watch is required, or if another compensatory measure is acceptable for the duration of the fire protection system impairment. The costs or charges associated with providing a fire watch under this section are to be determined at the time of initiation. See Fire Watch Requirements, below for further guidance. The University Fire Marshal shall also complete the notifications required in Notifications, below.

The provisions of this section shall only apply to impairments exceeding four hours in duration for a fire alarm system or ten hours in duration for a water-based fire protection system.

Tags indicating that a fire protection system, or portion thereof, has been impaired or placed out of service shall be located at each fire department connection, system control valve, fire alarm control unit, fire alarm annunciator and fire command center indicating which system, or part thereof, is impaired.

Additionally, when a fire alarm system is impaired for more than four hours, a sign shall be placed at each entrance of the building advising occupants of the impairment and directing them to contact 911 in the event of an emergency.

Once a fire protection system has been restored to complete operation, Facilities Services shall notify the University Fire Marshal. This notification shall include:

  • Verification that any necessary inspections and tests have been conducted to ensure that all fire protection systems are operational.
  • Whether employees in the affected area have been notified of the restoration of the fire protection system.
  • Whether the impairment tags have been removed from the fire protection system.

Upon receiving confirmation that the fire protection system has been restored, the University Fire Marshal shall also complete the notifications required in Notifications, below.

Chapter Nine of the North Carolina Fire Prevention Code states that fire watches shall “be provided with at least one approved means for notification of the fire department, and their only duty shall be to perform constant patrols of the premises and keep watch for fires.” All persons assigned to a fire watch under this policy must be approved by the University Fire Marshal and must be dedicated exclusively to the duties described in this section. Fire watch personnel for all planned impairments associated with maintenance and construction or for unplanned impairments will be contract security guards coordinated and vetted through UNC Police.

Individuals conducting a fire watch under this policy shall:

  • Be trained in the University’s fire watch procedure and fire reporting procedure.
  • Be responsible, non-impaired, alert and awake at all times.
  • Know the location of fire protection devices, including the fire alarm panel, pull stations and fire extinguishers.
  • Have a reliable means to contact 911 available at all times. For the purposes of this policy, a cellular telephone is an approved means for notification of the fire department.
  • Have access to all areas of the building with keys to all secured areas.
  • Have a functioning flashlight.
  • For buildings operated by the Department of Housing and Residential Education: Continuously and systematically patrol all affected, common areas of the building throughout the fire watch.
  • For all other buildings: Systematically patrol all affected areas of the building every 30 minutes.
  • Maintain a log indicating the times and areas of patrol within the building and conditions observed. Each entry shall have a time, date and signature. An approved log is in Appendix C of this policy.
Where a notification to the University Fire Marshal is required under this policy, the University Fire Marshal shall also notify the following individuals/groups:

  • Chapel Hill Fire Department
  • UNC-Chapel Hill E-911 Center
  • Director, Environment, Health and Safety
  • Assistant Director, Environment, Health and Safety
  • Risk Management Division, Office of the State Fire Marshal

Notifications shall include all information provided to the University Fire Marshal. Additionally, notifications shall include the nature of any required compensatory measures.

Applicable Regulations, Statutes, and Related Policies

  • North Carolina Fire Prevention Code
  • NFPA 25: Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems
  • NFPA 72: National Fire Alarm and Signaling Code
  • NFPA 101: Life Safety Code

Policy Contacts

Mary Beth Koza, Director
Department of Environment, Health & Safety
Phone: 919-843-5913
Email: mbkoza@ehs.unc.edu
David Guynn, Fire Safety and Emergency Response Manager
Department of Environment, Health & Safety
Phone: 919-962-5708
Email: dtguynn@ehs.unc.edu
Anna Wu, Associate Vice Chancellor
Facilities Services
Phone: 919-962-7248
Email: annaw@fac.unc.edu
David Sharpe, Alarm Shop Supervisor
Facilities Services
Phone: 919-904-0839
Email: David.Sharpe@facilities.unc.edu

Appendices

Back to Chapter 4-17: Open Flame Policy
Proceed to Chapter Five: Occupational Safety Policies