VHA DIRECTIVE 2005-007
February 15, 2005
4. ACTION
a. Network Director. Each Network Director is responsible for:
(1) Establishing a network policy on fire protection and life safety code reviews which must
ensure that all delegated construction projects are designed, constructed, and reviewed to meet
all applicable VA fire code requirements.
(2) Ensuring that each facility implements the requirements of VHA policy.
b. Facility Director. Each facility Director is responsible for ensuring that:
(1) A special fire protection and life safety code review is conducted on all delegated Major
and Minor projects and any NRM project where the scope of work is primarily (greater than 50
percent of the total project cost) fire protection (i.e., fire alarm or sprinkler systems, etc.) or
includes significant renovation and construction where specific fire code and standard
requirements would be applicable.
(2) For these special fire protection and life safety reviews, a qualified individual conducts
the review. A Network VHA safety and fire protection engineer would be a qualified individual.
Other qualified individuals would be an external third-party Fire Protection Engineer
knowledgeable of the National Fire Protection Association (NFPA) National Fire Codes and
knowledgeable of exit calculations, sprinkler system and fire alarm system requirements, Life
Safety Code requirements, etc.
(3) For all other delegated projects other than as described, fire code reviews are conducted
at the facility by the facility safety officer and others, as needed.
(4) Sufficient reviews are conducted as needed at various stages of design and construction
to ensure fire code compliance, but a minimum of one review is required prior to construction
contract award.
(5) A fire protection engineering firm or expertise is part of the design and construction of
selected projects as part of the A/E team. All delegated Major and Minor projects, unless
exempted by the Network Director, and any NRM projects where the scope of work is primarily
(greater than 50 percent of the total project cost) fire protection (i.e., fire alarm or sprinkler
systems, etc.) must use a fire protection engineer (see subpar. 5e for specific qualifications).
(6) A local policy is established in accordance with VHA policy and in compliance with
appropriate Network policies. Policies must include requirements that individuals have specific
responsibility for conducting fire code plan reviews.
(7) A facility Chief Engineer, or comparable qualified position, is responsible for:
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