Q: We have a building adjacent to our main hospital (separated by a two hour fire wall) that is a mixed occupancy. There are three stairwells that serve this building, but one has been taken out of service for emergency egress due to a large construction project outside. I have been conducting two fire drills per shift per quarter in this particular building for almost two years now and I fear I have fire drilled our employees in that building to the point that they have become desensitized to the fire alarms. It’s my understanding that the fire drill frequency can be specified in our ILSM policy. Here’s my thought – I’d like to state in our ILSM policy that any project lasting longer than a year will no longer require additional fire drills. That is; a whole year’s worth of additional drills is plenty and more drills can actually have a negative impact instead of a helpful one for our fire response efforts.
A: I think your thought process is valid and sound. Conducting too many fire drills does in fact desensitize one to an actual event. Since the accreditation organizations do not specify exactly what your ILSM policy must say, then I agree that you can reduce the number of ‘additional’ drills based on the length of time that the deficiency exists.
However, the accreditation organization will be somewhat suspicious of this action so you need to be prepared. Do a risk assessment identifying the pros and cons of doing additional fire drills for an extended period of time. Have the risk assessment draw a conclusion. Present this risk assessment to the Safety Committee and ask them to review and approve it. Make sure you get the committee’s response into the minutes. If challenged by a surveyor about doing less than the traditional amount of fire drills for ILSMs, then present the risk assessment and a copy of the Safety Committee’s minutes as evidenced of a thoughtful and considerate decision. The surveyor may accept your position and he/she may not. It’s a crap shoot.
On another point… is the stairwell that has been removed from service a ‘required’ means of egress? If there is a chance you can get your architect to deem the affected stairwell is not a required means of egress, then you can declare the stairwell is no longer a required means of egress and ILSM would not be needed. That means since the stairwell is not a required means of egress then blocking off the discharge is not a Life Safety Code deficiency. If you go that route, make sure you get a decision in writing by the architect and run that through your Safety Committee.