Eugene A. Cable, P.E.
Life Safety Consultants
NEHES NFPA Liaison
412 Horse Heaven Road
Averill Park, New York 12018
(518) 794-7237
Eugene.Cable@Fairpoint.Net

 Background and “Code Creep”
 Real World Life Safety Factors
 ILSM Standards and Policy

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– “Code Creep”: When codes and standards are enforced beyond their true intent.

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– “
The organization develops and implements activities to protect occupants during periods when a building does not meet the applicable provisions of the Life Safety Code®.
– EP 1. Each organization develops a policy for using interim life safety measures (ILSMs).
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– EP 3. “The organization has a written interim life safety measure
(ILSM) policy that covers situations when LSC deficiencies cannot be immediately corrected or during periods of construction”

 George Mills and Joint Commission presenters:
– Try to stop creep by emphasizing your policy
– “The ILSM review is driven by your policy”
– “
An ILSM policy should be in force during any situation in which a
LSC violation cannot be immediately corrected” (2011 Essentials)
 Rest of EP #3, “The policy includes criteria for evaluating when and to what extent the organization follows special measures to compensate for increased life safety risk.”
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Reason: Easy to just copy the standard into a policy
Reason: Ghost standard spreads quickly

 NFPA 101 addresses non-compliance
– Section 4.6.4 Time allowed for compliance
– Section 4.6.9.1 Conditions for occupancy
» No serious life safety hazard exists as judged by the AHJ.
– Section 4.6.10.1 Occupied during construction
» “Buildings. . . shall be permitted to be occupied during construction, repair,… only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place.
 The Life Safety Code acknowledges that deficiencies occur all the time.

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Redundant requirements
 Total Concept (Section 18.1.1.3)
 Multiple Safeguards
- Prevent Ignition
- Detection of Fire
- Inhibit fire growth
- Confinement of fire and smoke
- Extinguishment of fire
- Fire Dept actions
- Staff action – refuge
- Staff action - evacuate

 Unattended patient bunches up linen on patient bed and slips hand under the pile
Series of failures

 Multiple Safeguards:
Prevent Ignition
- Detection of Fire
- Inhibit fire growth
- Confinement of fire and smoke
- Extinguishment of fire
- Fire Dept actions
- Staff action – refuge
- Staff action - evacuate

1.

2.

3.

4.

5.

 ILSM is really an effort at temporary equivalency, to introduce a non-required safety element to make up for one that is required but missing.
 Difficult to decide appropriate alternative measures
 FSES Equivalency methodology outlines THE major factors/parameters for life safety.

 Patient mobility/ density/ location/staff ratio
– Called the “occupancy risks”
 Building safety parameters
– Construction
– Room Interior finish
- Hazardous areas
- Smoke control/ barriers
– Corridor interior finish
- Emergency movement routes
– Corridor walls
– Corridor doors
- manual fire alarm FD connection
- smoke detection and alarm
– Smoke zone dimensions - automatic sprinklers – coverage/QR
– Vertical openings
 Fire Safety Requirements – no choice
– Exit signs
– Evacuation plan/ drills
– HVAC comply 90A
- emergency lighting
- furnishings combustibility
- fire extinguishers comply NFPA 10
Gene Cable (518) 794-7237

Time
Fire
Time to
Detection
Ignition
Time to
Notify
Occupants
Time for Smoke To Block Egress Path
Fire Development - fire growth curve
Detection
Egress
Route
Blocked
Occupants
Alerted
Time Needed To Get Out
Response
Delay
To
Prepare
To Travel
Occupants
Safely Out
Safety
Margin
Gene Cable
(518) 794-7237

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– 1. Self-closer broken Y: 28 N: 23
– 2. Stair pipe penetrations Y: 41 N: 10
– 3. Ceiling tiles missing Y: 12 N: 39
– 4. Wall missing (trick) Y: 29 N: 22
– 5. Electrical Transformer rm door Y: 41 N: 10

The five quiz examples
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Would not even evaluate for ILSMS – No
 2. Do the ILSM evaluation and likely yes needed
 3. No evaluation needed and NO ILSMs
 4. (trick) corridor wall not required in the first place, QR sprinkler and smoke detector in the open space – Yes Evaluation, but No ILSMs
 5. Gave a hint, electrical room, 20,000 F arc flame potential, yes do evaluation and likely Yes

 Immediate Threat to Health or Safety
– Rule:
Preliminary Denial of Accreditation
 Failure to make sufficient progress on previously accepted PFIs (LS.01.01.01 EP 2)
– Rule: Accreditation with Follow-up Survey
 Failure to develop an acceptable ILSM policy
– Rule: Accreditation with Follow-up Survey

 Failure to implement appropriate ILSMs
(LS.01.02.01 EP 4 – 14) Direct or an Indirect finding – no rule; less serious
– For EP # 4 -14, 5 are “directs”
– Example: Provide additional firefighting equipment – D
Conducts one additional fire drill - ID

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Actual standard: “
The Organization protects occupants during periods when the LSC is not met or during periods of construction.”
 Order of Standards (LS.01.02.01)
– EP 1 & 2: regardless of ILSM policy
– EP 3: must clearly define the ILSM policy including
» Both construction related and non-compliance with the LSC
» When to implement
» What to do to protect occupants
– EPs 4 – 14 align with policy and implementation strategies

 An organization experiencing a compromising situation (4 out of 24 hours) must implement a fire watch until the fire alarm system or sprinkler system has been returned to service or is stable.
– In many situations, this distinction comes down to whether an event or activity is scheduled or unscheduled.
 A scheduled activity would be an event known to and under the knowledge of and control of organization staff
– a construction project
– servicing or upgrading the fire alarm system or sprinkler system.

Service Situation
Fire Watch
Required?
ILSM
Evaluation
Required?
Putting a shield over one smoke detector to prevent dust/false alarms for more than 4 hours
No Recommended
Rationale : Other features of fire protection are not compromised during the event, such as additional smoke detectors or sprinkler heads in the affected area.
Covering all smoke detectors during a controlled event, such as only during the time contractors are working in an affected area, although after hours, the entire area is fully operational
No Yes
Rationale: During a controlled event the organization is managing the deficiency. The area would be continually monitored, and ILSM should be implemented as per policy.
Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than 4 hours
● Scheduled event (that is, working on, servicing, or upgrading fire alarm system or sprinkler system)
Not in all cases
Yes (emphasis on occupant notification)
Rationale : During a controlled event, the organization is managing the deficiency. The area would be continually monitored, and ILSM would be implemented as per policy.
● Unscheduled event (that is, shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than 4 hours in response to a system failure)
Yes Yes

 Can do fire watch for less than 4 hour impairment
 Can be normal staffing for small scale impairment
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“involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected.”

 Post signage to ID alternate exits and way to get there.

» Have one
» Both construction related and non-compliance LSC
» When to implement
EP 3: “The organization has a written interim life safety measure (ILSM) policy that covers situations when LSC deficiencies cannot be immediately corrected or during periods of construction.” “The policy includes criteria for evaluating when and to what extent the organization follows special measures to compensate for increased life safety risk.”

SUBJECT:
EP 3 Policy Example # 1
INTERIM LIFE SAFETY POLICY
The XX Medical Center recognizes that construction and/or renovation activities have the potential to increase the risk of injury to staff, patients and/or visitors. Because of this potential, a program of risk evaluation and mitigation strategies has been developed to minimize these risks. The following procedures will be followed during all construction and/or renovation activities that have this potential.
At the completion of the preliminary design phase and prior to beginning construction or renovation, an Interim Life Safety Measures, (ILSM), Review Checklist will be completed by the Construction Projects Manager or his designee.
Identified Life Safety Deficiencies
In addition to construction and renovation activities, interim life safety measures must be considered whenever there is an identified life safety deficiency . This could occur as a result of a periodic life safety assessment or as an item identified during a scheduled hazardous surveillance tour. Whenever a life safety code deficiency is identified a review will be conducted to determine the need for interim life safety measures.
CRITIQUE: Covers the two major bases CONCERN: Boxed self in, all defs.
Take OUT

Example # 2
Policy # 6602 Interim Life Safety Measures
It is the policy of XX Memorial Medical Center to assess the need for Interim
Life Safety Measures (ILSM) to ensure the safety of all building occupants during periods of construction or when significant deficiencies or impairments compromise the level of life safety protection provided by building Life Safety Features .
ILSM apply to all personnel, (including construction workers) working in
Health Care, Ambulatory Care Buildings, and any other occupancy classifications deemed appropriate by the Life Safety Officer or designee.
ILSM must be assessed whenever a significant deficiency is identified or prior to the start of any construction project where ILSM are required as part of the Pre-Construction Risk Assessment (PCRA). ILSM shall not be warranted for incidental short-term deficiencies .
CRITIQUE: Covers the two major bases; does avoid the “all deficiencies”
Concern: Who decides: “significant” and what is “short-term” .
Add IN

Example # 2 addendum
Policy # 6602 Interim Life Safety Measures
(Same policy as Example # 2 with definitions)
II. Definitions:
Incidental short-term deficiencies : Minor transient deficiencies that only effect local areas, do not pose any systemic risks and will be corrected by the
Maintenance department. Examples include the failure of one corridor smoke sensor which is flanked by other working sensors, dirty sprinkler heads and other deficiencies of similar magnitude.
Significant Deficiencies: Life Safety Code deficiencies that pose systemic risks. Examples include blocking of egress corridors due to construction, impairments to smoke and/or fire barriers and impairments to suppression and detection systems greater than 4 hours.
GOOD

Example # 3
Policy # 6602 Interim Life Safety Measures with definitions
It is the policy of XX Memorial Medical Center to assess the need for Interim Life Safety
Measures (ILSM) to ensure the safety of all building occupants during periods of construction or when significant deficiencies or impairments compromise the level of life safety protection provided by building Life Safety Features .
ILSM apply to all personnel, (including construction workers) working in Health Care,
Ambulatory Care Buildings, and any other occupancy classifications deemed appropriate by the Life Safety Officer or designee. ILSM must be assessed whenever a significant deficiency is identified or prior to the start of any construction project where ILSM are required as part of the Pre-Construction Risk Assessment (PCRA).
ILSM shall not be warranted for incidental short-term deficiencies .
The surveyor/ evaluator identifying the deficiency determines whether or not it is a significant or incidental short-term deficiency. The Life Safety Officer should be consulted in questionable situations and can ultimately overrule .
CRITIQUE: Covers the two major bases; does avoid the “all deficiencies” aspect
Concern: None Add IN

» Have one
» Both construction related and noncompliance LSC
» When to implement

» What to do to protect occupants –EP 4 – 14
Policy example # 1
EP 3:
“The organization has a written interim life safety measure (ILSM) policy that covers situations when LSC deficiencies cannot be immediately corrected or during periods of construction.” “The policy includes criteria for evaluating when and to what extent the organization follows special measures to compensate for increased life safety risk.”
Prior to the start of the project, the project details and the
ISLM Review Checklist will be reviewed with the Safety
Officer, an Engineering Services Representative, the XX
Construction Representative and the Contractor representative. Any additions or revisions to the checklist will be noted and will be added to the project procedures.

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– If not available – Indirect finding

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