Fire Protection

There are many life safety systems in our campus buildings. These systems are designed to help you stay safe in the event of a fire emergency. These systems include fire detection and notification systems (fire alarms), water based fire protection systems (fire sprinkler and stand-pipes), kitchen hood suppression systems, and room specific suppression systems. You will also find gas detection systems to warn you of the release of toxic gases and smoke.

Life safety systems are to be tested and approved when installed. These life safety systems also need to be tested periodically in accordance with corresponding NFPA standard to ensure proper operation. Impairment procedures need to be followed when a system or part of a system is taken out of service.

Hot Work

“Hot work” is a term used to describe a task or operation that generates heat, sparks, or an open flame, such as welding, cutting, grinding, soldering, torch applied roofing, heat guns, and similar activities. Welders and others who are responsible for hot work operations may be required to attend a special class to learn about hot work safety procedures. At a bare minimum, hot work operators must always keep combustible materials at least 35 feet away, keep a fire extinguisher readily available, make sure the jobsite has a hot work permit posted, and maintain a fire watch for at least 30 minutes after all hot work operations have ended.

If hot work operations are performed within an area where you are present, you need to know that most hot work processes release large amounts of hazardous air contaminants, which may include lead, manganese, hexavalent chromium (known to cause cancer), nickel, and other hazardous air contaminants. Electric arc welding also generates hazardous ultraviolet (UV) radiation that can permanently damage your eyesight. Never look directly at a welding arc, except through a welder’s helmet. Proper personal protective equipment and good ventilation is required for hot work processes. Relocate to a different work area if you are not properly equipped to be in a hot work area.

Call EH&S and ask to speak to a fire safety specialist for more information about hot work.

Hot Work Permit Program

Hot Work Permit (GS-FRM-002)

Hot Work Permit Warning Sign (GS-DWG-001)

Hot Work Permit Schedule Form (GS-FRM-001)

Fire Protection Impairment Program

1.0 Purpose

There are times when it may be necessary to disable a fire alarm system, fire suppression system, or a water based fire protection system. The purpose of this policy is to properly manage the risks associated with impairing a fire protection system. Environment Health & Safety has established impairment procedures that shall be followed whenever a fire protection system is taken out of service.

2.0 Scope

This program will outline specific measures to be taken during fire protection impairment to ensure that increased risks are minimal and duration of the impairment is limited.

An effective fire protection impairment program will:

  • Supervise the safe shutdown of a fire protection system
  • Control potential fire hazards during the impairment
  • Restore the fire protection system to service as soon as possible

This program applies to all University of Wisconsin – Madison employees, outside contractors and their representatives, any company representative hired by the University of Wisconsin – Madison to provide service, or any other outside trade worker who will be working at or within a University of Wisconsin – Madison facility.

3.0 Related Documents

NFPA 25 Inspection, Testing and Maintenance of Water-Based Fire Protection Systems
NFPA 72 National Fire Alarm and Signaling Code
IFC International Fire Code Chapter 9

4.0 Definitions

Authority Having Jurisdiction (AHJ) is an organization, office, or individual responsible for enforcing the requirements of a code or standard, or for approving equipment, materials, an installation or a procedure.

Fire Protection System is a fire sprinkler system, fire standpipe system, underground fire service main, fire pump, water spray fire suppression system, carbon dioxide fire suppression system, halogenated fire suppression system, wet chemical fire suppression system, FM-200 fire suppression system, a special extinguishing fire suppression system, dry chemical fire suppression system, or a fire alarm system.

Fire Watch is a temporary measure intended to ensure continuous and systematic surveillance of a building or portion thereof by one or more qualified individuals for the purpose of identifying and controlling fire hazards, detecting early signs of unwanted fire, raising an alarm of fire and notifying the fire department. Person(s) doing the fire watch shall not be assigned any other task.

Impairment is the shutdown, in whole or part of a fire protection system.

Impairment Coordinator is the person who manages the impairment while the system work is being performed and has overall responsibility for proper implementation of the fire protection impairment program.


Normal business hours
are Monday through Friday from 7:45 A.M. to 4:30 P.M., excluding University approved holidays.

Off business hours are all other times not defined as Normal Business Hours.

5.0 Roles and Responsibilities

Impairment Coordinator- The International Fire Code (IFC) requires the assignment of an impairment coordinator by the property owner. The impairment coordinator for UW-Madison is Jeff Schiller (608)-265-9080 from Environment Health & Safety. The impairment coordinator:
  • Authorizes the shutdown of the fire protection system
  • Ensures that the impairment procedures are being followed and completed
  • Verifies that steps to restore system to service have been followed and that the system(s) are restored to service as soon as possible.

University of Wisconsin - FP&M shops- UW shops fall within the requirements and need to follow the instructions outlined within this impairment policy. If deviation of this policy is needed, a call to EH&S is needed to discuss alternatives.

Outside Contractors- Any contracted person or organization shall follow the instructions outlined within this impairment policy. If deviation of this policy is needed, a call to EH&S is needed to discuss alterations.

6.0 Impairment Program Requirements

When a fire protection system is impaired (i.e. taken out of service), EH&S, UWPD dispatch, and MFD shall be notified immediately. If required, the building shall either be evacuated or an approved fire watch shall be provided for all occupants left unprotected by the impairment until the fire protection system has been returned to normal service.

During any impairment, Hot Work is prohibited, including cutting and welding. A discussion is needed in advance with EH&S if Hot Work is essential to complete the work.

7.0 Procedures

PROCEDURES: Water Based Fire Protection System

Pre-Planned Impairment

  • Determine the expected length and duration of the impairment
  • Survey and inspect the area of the building that will be affected by the impairment
  • Consult with the facility manager about the area in question and potential inconveniences
  • Get approval from the impairment coordinator (IC) to allow the impairment to happen
  • Complete the impairment worksheet.

Day of Planned Impairment – Water Based Fire Protection System

  • Survey area to ensure work area has not changed
  • Notify affected building occupants of the planned impairment
  • Notify EH&S, UWPD dispatch, and MFD of impairment
  • Ensure no Hot Work is being done in conjunction with a planned water-based fire protection impairment
  • Ensure hazardous operations (i.e. flammable and combustible liquid use) is not conducted during an impairment
  • Tag all applicable devices.
  • FDC, Control valves, FACP, FA annunciator

Impairment – Water Based Fire Protection System

  • Expedite work to ensure the water-based fire protection system is impaired for the shortest period of time
  • Perform a fire watch for the affected area (if needed)
  • Prohibit any Hot Work activities including cutting and welding. If Hot Work is needed in order to facilitate work, a Hot Work permit shall be on-site and posted.

After Impairment – Water Based Fire Protection System

  • Open all valves that were closed during impairment.
  • Remove tags from all components.
  • If a fire alarm system is involved make sure the fire alarm system is restored to normal operating condition
  • Perform necessary inspection and testing of the impaired water-based fire protection system to ensure the system is normal. At minimum a main drain test is required to ensure values are in their proper position(s)
  • Make the necessary calls to EH&S, UWPD dispatch, and MFD to notify the water-based fire protection system is back in service
  • Notify the facility manager the impairment and work is complete

Emergency or Unplanned Impairment – Water Based Fire Protection System

  • Stabilize the situation and control water flow to prevent a major loss of equipment or damage to the area
  • Notify EH&S, UWPD dispatch and MFD of the situation
  • Follow steps outlined under During Water-Based Impairment and After Water-Based Impairment.

PROCEDURES – Fire Alarm System

Pre-Planned Impairment

  • Determine the expected length and duration of the impairment
  • Survey and inspect the area of the building that will be affected by the impairment
  • Consult with the facility manager about the area in question and potential inconveniences
  • Get approval from the impairment coordinator (IC) to allow the impairment to happen
  • Complete the impairment worksheet.

Day of Planned Impairment – Fire Alarm System

  • Survey area to ensure work area has not changed
  • Notify affected building occupants of the planned impairment
  • Notify EH&S and UWPD dispatch of impairment
  • Ensure no Hot Work is being done in conjunction with a planned impairment
  • Ensure hazardous operations (i.e. flammable and combustible liquid use) is not conducted during an impairment

Impairment – Fire Alarm System

  • Expedite work to ensure the fire alarm system is impaired for the shortest period of time
  • Perform a fire watch for the affected area
  • Prohibit any Hot Work activities including cutting and welding. If Hot Work is needed in order to facilitate work, a Hot Work permit shall be on-site and posted.

After Impairment – Fire Alarm System

  • Ensure the Fire alarm panel is normal.
  • Remove tags from all components.
  • Make the necessary calls to EH&S and UWPD dispatch to notify them the fire alarm system is back in service
  • Notify the facility manager the impairment and work is complete

Emergency or Unplanned Impairment – Fire Alarm System

  • As soon as the situation is under control, begin following the steps outlined under Day of Planned Impairment, Impairment and After Impairment.

PROCEDURES – Fire Suppression Systems

Pre-Planned Impairment

  • Determine the expected length and duration of the impairment
  • Survey and inspect the area of the building that will be affected by the impairment
  • Consult with the facility manager about the area in question and potential inconveniences
  • Get approval from the impairment coordinator (IC) to allow the impairment to happen
  • Complete the impairment worksheet.

Day of Planned Impairment – Fire Suppression System

  • Survey area to ensure work area has not changed
  • Notify affected building occupants of the planned impairment
  • Notify EH&S and UWPD dispatch of impairment
  • Ensure no Hot Work is being done in conjunction with a planned impairment
  • Ensure hazardous operations (i.e. flammable and combustible liquid use) is not conducted during an impairment

Impairment – Fire Suppression System

  • Expedite work to ensure the fire alarm system is impaired for the shortest period of time
  • Perform a fire watch for the affected area
  • Prohibit any Hot Work activities including cutting and welding. If Hot Work is needed in order to facilitate work, a Hot Work permit shall be on-site and posted.

After Impairment – Fire Suppression System

  • Ensure the Fire alarm panel is normal.
  • Remove tags from all components.
  • Make the necessary calls to EH&S and UWPD dispatch to notify them the fire alarm system is back in service
  • Notify the facility manager the impairment and work is complete

Emergency or Unplanned Impairment – Fire Suppression System

  • As soon as the situation is under control, begin following the steps outlined under Day of Planned Impairment, Impairment and After Impairment.

8.0 Fire Watch

A fire watch is utilized for a fire alarm or automatic fire protection system shutdown. A fire watch will be comprised of individuals beyond normal staffing that are assigned to walk the area affected. Fire watch personnel must be trained in use of fire extinguishers. Fire watch personnel must only be tasked with the duties of fire watch. Fire watchers shall be provided with at least one approved means of notification of the fire department and their only duty shall be to perform constant patrols of the premises and keep watch for fires. Fire watchers shall document their fire watches by using the fire watch log sheet (Appendix C).

APPENDIX A: IMPAIRMENT WORKSHEET

APPENDIX B: IMPAIRMENT TAG

APPENDIX C: FIRE WATCH LOG SHEET

Kitchen Hood Requirements

Hood Systems are located above fryers and grills and are used for exhausting cooking odors and grease. They are a good place to install fire suppression nozzles because of their location above the fire hazard. The fire suppression nozzles can discharge either a wet or dry fire suppression agent in case one of the fryers or grills should catch on fire. Also, this area is usually protected with fire suppression nozzles because there is a heavy buildup of grease in the area above the hood, called the plenum. A specially formulated fire suppression agent is stored in pressurized vessels in close proximity to the hazard.

This type of system works in local application by chemically reacting and smothering the fire. Proper inspection and constant evaluation of the hazard should make sure this type of system will work when needed.

Fire Suppression Systems

Environment Health & Safety's Fire Extinguisher Shop is responsible for the maintenance and inspection of 60 fixed fire suppression systems located in solvent rooms and computer areas on campus and the University Hospital. All systems are inspected bi-annually according to the NFPA code.

The four different types of suppression agents used are Dry Chemical, Wet Chemical, Carbon Dioxide, and Halon. Different agents are used for different fire hazards.

  1. Carbon Dioxide systems are used to protect most solvent rooms. This type of system is a total flooding system and requires that the door and vents to the room remain shut during actuation of the system. This system is extremely effective but is dangerous if a person is trapped in the room, as it displaces oxygen, during a discharge. For this reason all CO2 suppression systems have a pre-discharge alarm which gives anyone working in the space time to get out before Co2 is released.
  2. Halon systems are used to protect high tech areas, such as computer rooms, and high tech areas where minimal collateral damage from the firefighting agent can be tolerated because Halon is a totally clean agent. Another nice feature of Halon is that life can be supported at the concentrations used to extinguish the fire. Even though you can remain in a room during a Halon discharge, all Halon system are equipped with a pre-discharge alarm to give occupants time to leave the area before Halon is discharged. Halon's main drawbacks are that it has ozone depletion potential and is extremely expensive to recharge.
  3. A dry chemical system uses powder, sodium or potassium bicarbonate, to extinguish a fire. The system operates much like a hand-held dry chemical fire extinguisher. The dry chemical powder is discharged from the system and covers the entire room in a fine powder. Upon coating everything in the room, the discharged extinguishing agent essentially separates the fuel source from the oxygen supply, smothering the fire.
  4. A wet chemical system is ideal for grease laden cooking facilities. The wet chemical agent used is a potassium carbonate solution. When the potassium carbonate solution is discharged, the solution is released in a fine mist or droplet spray pattern. The discharged solution combines with the fuel source (i.e. grease) separating itself from the oxygen source. The reaction of combining the grease and potassium carbonate is called saponification. Saponification is a process that produces soap by combining fats with a basic ingredient. For our purposes, animal grease is our fat and potassium carbonate extinguishing agent is our base.

Activation of any suppression system can happen by a number of methods. These methods include fusible link, thermo detection, flame detection, or by pulling manual pull station.

Water-Based Fire Protection Systems

Water based fire protection systems are installed to contain a fire until the fire department arrives on scene. These systems are designed to deal with specific hazards. Sprinkler heads come in various sizes and shapes and have various temperature settings. The bulb ruptures when the colored sprinkler head element reaches its temperature setting. Once ruptured, water is released from the sprinkler head. The number of sprinkler heads activated will depend on the amount of heat being generated by a fire. In most cases, not all sprinkler heads activate at the same time like you see in the movies. There are systems designed to operate like you see in the movies but those systems are few and far between.

Fire Alarm Detection System

Fire detection and notification systems more commonly referred to as fire alarm system. Fire alarm systems are installed to provide building occupants an early warning of a fire.

Fire alarm systems are comprised of pull stations, smoke detectors, heat detectors, duct detectors, speaker/strobes, and/or horns and strobes. A fire alarm system can be activated in many ways. Some examples include pulling a fire alarm pull station or detection of smoke or heat. A fire alarm system can also be activated by flow and tamper switches connected to a fire sprinkler system that detect water flow.

When a fire alarm system is activated, speaker/strobes flash at a given flash rate and an audible noise notification will be heard with possible voice instructions on what building occupants shall do. Audible noise levels will be at least 70 dba.

It is extremely important to evacuate a building upon hearing the fire alarm. Proceed to the buildings’ nearest exit in an orderly fashion. Once outside get at least 100 feet away from the building and assemble at your facility’s designated assembly point.

NFPA 72 is the national standard for fire alarm installation and maintenance. Fire alarm systems shall be tested based on standard set within NFPA and IFC. Inspection and testing records shall be kept and maintained by the University.