Strange Observations – Part 18

Continuing in a series of strange things that I have seen when consulting at hospitals…

It’s thoughtful that they put a protective bar infront of the fire alarm pull station, but the box (and my notepad) is blocking access to the pull station.

Positive Alarm Sequence

I was reviewing some new standards and came across the Positive Alarm Sequence (PAS) issue for fire alarm systems, that the 2012 LSC now permits in fully sprinklered healthcare occupancies (see 18/ and of the 2012 Life Safety Code), provided it is in accordance with NFPA 72-2010.

The PAS (section of NFPA 72-2010) is designed to allow the facility a 3-minute delay in annunciation of the fire alarm signal, to allow them time to investigate whether the alarm is a nuisance alarm. The PAS option first became available for use on non-healthcare occupancies in the 2003 edition of the LSC, and then became available for use in healthcare occupancies in the 2006 edition. It is now available to all healthcare occupancies, ambulatory healthcare occupancies, and business occupancies since CMS adopted the 2012 Life Safety Code on July 5, 2016. So, this is something that may be a new concept to many facility managers.

The sequence of operation for the PAS is as follows:

  1. The fire alarm control panel must have the PAS feature an integral part of the programmable control system of the panel. The PAS is not a feature that can be used on older systems that were not originally equipped with it.
  2. To initiate the PAS operation, the signal from an automatic fire detection device selected for PAS operation shall be acknowledged at the fire alarm control unit by trained personnel within 15 seconds of annunciation. Usually any general alarm fire alarm initiating device would activate the PAS operation.  Supervisory or “off normal” conditions wouldn’t activate the PAS.  The only time you wouldn’t have an alarm event activate the PAS would be a general evacuation device, like a key switch monitored by the fire alarm system, that’s intended to signal an immediate evacuation of the hospital.
  3. If the signal is not acknowledged within 15 seconds, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  4. If the PAS operation is initiated in accordance with, trained personnel shall have an alarm investigation phase of up to 3-minutes to evaluate the fire condition and reset the system. The term ‘trained individuals’ means you need to have individuals who are trained to respond properly and immediately. No certifications or licenses are required for this function. The training includes in-house procedures that involve investigation within a certain timeframe, as well as training on use of the fire alarm annunciator and how the PAS is programmed to operate.
  5. If the system is not reset during the alarm investigation phase, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  6. If a second automatic fire detection device selected for PAS is actuated during the alarm investigation phase, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  7. If any other fire alarm initiating device is actuated, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  8.  The system shall provide means for bypassing the PAS.

Obviously, in order for the PAS operation to function properly, someone needs to be near the fire alarm control panel or a remote annunciator, so the trained individual who’s monitoring the system may take the appropriate action. If your fire alarm control panel or a remote annunciator is not continuously monitored, then the PAS function would not be suitable for your facility.

The 3-minute phase of investigation to evaluate the alarm condition, can be done with multiple individuals. An example may be one individual at the control panel and one in the field, communicating via walkie-talkies in order to make a decision to reset the panel before the 3-minutes expire, or to allow the alarm annunciation to continue.

Although the PAS function is permitted, caution is recommended before you implement this operation. The PAS can devolve into an automatic reset by the staff to give them more time to investigate, with the intent of pulling a manual station if there is indeed a problem, or worse, to let it go back into alarm as a means of verification.

If you are wondering whether or not CMS allows PAS operation the answer is yes, they do. Although CMS has not officially commented on this issue, they have to allow it since it is permitted by the 2012 LSC. Unless they specifically dis-allow something that is permitted by the LSC, then it is permitted, as long as it applies to the applicable occupancy. Unless they say otherwise, they follow NFPA to the letter. Examples of them saying otherwise involved the 4-inch corridor projection issue (vs. 6-inch what LSC allows); roller latches in certain corridor doors (2012 LSC still allows roller latches in certain corridor doors); and 1 or more patients incapable of self-preservation in Ambulatory Health Care Occupancies (vs. 4 or more). They have published S&C memos or addressed these issues in the Final Rule to adopt the 2012 LSC.

This means your accreditation organizations will allow PAS operations as well, unless of course they specifically have said they dis-allow it. For Joint Commission accredited organizations, their new EP 4 under LS.02.01.34 (2018 CAMH manual) specifically does permit PAS operation, in buildings that are fully protected by sprinklers.

Before you make plans or changes to implement PAS operation, check with your state and local authorities to determine if they have any restrictions on the use of PAS operation.

Gene Rowe, Director of Business Development for Affiliated Fire Systems, Inc., Downers Grove, IL, contributed to this article. You may reach Gene at


AEM Program for Fire Alarm and Sprinklers

Q: Are sprinklers, smoke detectors, etc. considered to be operating components of the utility systems? If so, our inspections are based on the pertinent NFPA references. I think that the fire system inspections could be considered preventive maintenance or at least the means to determine what maintenance needs to be completed. Can we use the CMS AEM program to alter our PM activities on the fire alarm and sprinkler systems?

A: You cannot use the CMS AEM program for Fire Alarm inspection and testing requirements. The CMS S&C letter 14-07 that describes the AEM program says the following regarding when the AEM program is not appropriate: “Other CoPs require adherence to manufacturer’s recommendations and/or set specific standards. For example: The National Fire Protection Association Life Safety Code (LSC) requirements incorporated by reference at 42 CFR 482.41(b) has some provisions that are pertinent to equipment maintenance, and compliance with these requirements are assessed on Federal surveys.”

So… you must follow the NFPA requirements specified for sprinkler and fire alarm testing and inspection, and the AEM program is not applicable.

Batteries for Fire Alarm Systems

Q: Can you tell me where I could find the code reference for how often batteries serving fire alarm panels (booster panels, control panels, etc.) need to be replaced based on how old they are?

A: Currently, we are on the 2010 edition of NFPA 72, and Table 14.4.5 (6) (d) says sealed lead acid type batteries used on fire alarm systems need to be replaced 5 years after date of manufacturer, or more often as needed.

So, for now it is every 5 years after date of manufacturer.

Silencing Audible Fire Alarm Signals

Q: Recently we had an actual fire that set off our fire alarm. Our operators did not silence the audible horns, which are very loud, before announcing the code and location, thus the location was not known to most of the hospital staff. At our recent Safety Committee meeting this was discussed and it seems that some people believe that the audible should either not be silenced or delayed until after the code is announced overhead, then be activated. I have always instructed the operators to let the audible signals go for about 30 seconds then silence the audibles, and announce the location of the fire. The strobes do remain on until the alarm is cleared, and then only the safety officer or designee can reset the panel. If the panel is reset then the all clear is announced. So the question is, can the audible signals be silenced during an activation?

A: I’m concerned by your comment that the audible notification devices are ‘very loud’. I think you need to first address this issue to make sure you’re compliant with the intent of the National Fire Alarm Code (NFPA 72-2010). Section 18.4.4 of the 2010 edition of NFPA 72 discusses the requirement for Private Mode audible requirements. Most hospitals are designed to meet the requirements of ‘Private Mode’ rather than ‘Public Mode’ when it comes to fire alarm occupant notification. There are significant differences not only in the location of audible devices, but in the decibel requirements as well. Section (for Private Mode) of NFPA 72-2010 says the audible signals must have a sound level of 10dB above the average ambient sound level, or 5 dB above the maximum sound level, measured 5 feet off the floor. This signal is required to annunciate for at least 60 seconds, so cutting off the audible alarm signal before 60 seconds would not be permitted. However, section of NFPA 72-2010 does say with the permission of the authority having jurisdiction (AHJ), you can reduce these requirements. But be careful with the AHJ issue, as the typical hospital has 5 or 6 different AHJs who evaluate for compliance with NFPA codes and standards:

  • CMS
  • Accreditation organization
  • State health department
  • State agency with authority over hospital design and construction
  • State fire marshal
  • Local fire inspector
  • Liability insurance company

Typically, the accreditation organizations do not approve design issues in hospitals, but the state and local authorities do. If you want to reduce the duration of the fire alarm audible signal, you would need to receive the approval of all the AHJs… not just one or two. That is not likely to happen. I could see more than one of your AHJs not wanting to put in writing that you can reduce a minimum level of life safety for your hospital. So, my advice is to do the following:

  • Take a look at the dB ratings and see if they exceed the required levels for Private Mode notification as described in; adjust them as needed to meet the dB rating listed.
  • Program your fire alarm panel to pause after 60 seconds of audible signal, to allow the operators to announce the location of the alarm.
  • Develop a coded notification system using chimes to provide a general location or area of the alarm. Most modern fire alarm control panels are capable of this style of notification, rather than a general alarm style. This way your staff can begin to respond to the general area of the alarm and within 60 seconds they will hear the overhead page where the alarm is precisely located.

Supervising Stations for Fire Alarm Systems

Q: What code states that quarterly communication between our fire panel and our local fire department must be completed?

A: What used to be called the off-site monitoring transmission equipment has been changed to be called the “Supervising Station Alarm Systems – Transmitters” as defined in NFPA 72-2010. But they also changed the frequency of the test from requiring it to be conducted quarterly to be required annually, as described in Table 14.4.5, section 22 of the 2010 edition of NFPA 72. It also refers to Table, section 18 for test methods. So, the answer you are seeking is Table 14.4.5 section 22 of NFPA 72-2010.

Multiple Sensor Detectors

Q: In regards to multi-sensor devices, such as rate of rise/fixed temp combo heat detectors; if the rate of rise portion of the device is testable, but the fixed temp portion of the device is not, then does the device fall into the replace after 15 years for non-restorable heat detectors? The same issue with smoke/fixed temp heat combo devices (older devices); do they have to be replaced for the fixed temp heat portion? There are many different ways to view this, as code states that they have to be tested independent of one another.

A: The short answer is no, combination devices do not fall into the 15 year replacement criteria.  Explanation: The replacement interval for fixed temperature heat detectors applies only to non-restorable detectors [NFPA 72 Table].  Both smoke/heat and rate of rise/fixed detectors are restorable.  Rate of rise/fixed heat detectors fall under the maintenance requirements of Table, which does not mandate a replacement interval.  If the rate of rise tests normally, that’s the primary sensor and does not have to be replaced as long as it passes inspection. Smoke/heat detectors fall under two maintenance criteria.  Table is for smoke detectors with thermal elements, which states that both elements must be tested & the failure of any element requires the replacement of the device.  However, since we’re talking about a smoke/heat detector with a fixed temperature element, Table for combination fire detectors is applicable.  It states that if individual sensors cannot be tested individually, the primary sensor shall be tested, in this case being the smoke detector.  As long as the primary sensor functions properly, it’s good to go and is the sole consideration regarding replacement.

Covers on Manual Pull Stations

Q: We are in the process of putting manual pull station covers on most if not all of our stations. Some of the stations are dual action. Will putting a cover on a dual action manual pull station convert it to a triple action? Is there a code which prevents this situation from being acceptable?

A: The installation of a protective cover over a double action manual station does constitute a triple action, but it’s not prohibited by code.  Prior to 2013 edition of NFPA 72, this wasn’t expressly addressed.  NFPA 72 (2010) Chapter 17.14.5 allows protective covers over manual stations, so long as they remain accessible.  There’s nothing prohibiting a certain amount of ‘actions’; it just doesn’t mention it.  However, it was addressed in the 2013 edition.  NFPA 72 (2013) Chapter 17.14.7 states a protective cover may be placed over a single or double action manual station.  The annex note explains that this does make it a triple action, but that it’s still code compliant. It should be noted that the 2012 Life Safety Code references the 2010 edition of NFAP 72, not the 2013 edition.

Class A Wiring for Fire Alarm Systems

Q: Is Class ‘A’ wiring required in new construction for new fire alarm systems?

A: Per NFPA 72-2010, chapter, unless a class of wiring is determined by a local AHJ or the owner, it’s a design decision, based on an evaluation of site specific conditions and the needs of the facility.  There’s nothing in NFPA 101, 72 or 70 that mandates a particular pathway class must be used in a particular occupancy for fire alarm systems.  The only mandates are what devices go in (based on the LSC); where they go in (based on NFPA72) and the physical attributes of the conduit & conductors, along with their mounting methods (based on NFPA 70).

Many times healthcare notification circuits are subject to survivability requirements because they do not have general evacuation, but the intent of survivability is to provide continuity of service through physical protection of the conductors from attack by fire rather than to ensure continuity of service due to any circuit break.  Some design engineers equate survivability with Class A wiring, but that’s a mistake.  Class A wiring may be used in conjunction with other factors such as sprinkler coverage as a performance means of achieving survivability in lieu of the prescriptive method, but it’s not required.

Fire Door Smoke Detectors

Q: I have a life safety consultant doing our annual inspection, and he keeps saying that I need to have individual smoke detectors for my corridor fire rated doors. The corridors on both sides of these doors are completely protected with smoke detectors, but he says regardless, that area smoke detectors are required next to the doors. Is this correct?

A: No, I don’t believe what the consultant is telling you is correct. Section of NFPA 72 (2010) allows for either area smoke detectors or complete corridor smoke detector protection to activate the release of a hold-open on a door serving a fire barrier or a smoke compartment barrier. So, in regards to the cross-corridor doors that are held open by magnets connected to the fire alarm system, you are permitted to have one of the following:

  • A smoke detector on either side of the door mounted within five feet of the door; or smoke detectors mounted on both sides of the door within five feet if the transom above the door is greater than 24 inches.
  • The entire corridor where the cross-corridor door is located is properly protected with smoke detectors. A smoke detector must then be located within 15 feet of the door. For mounting locations for an area protected with detectors, the detectors must be no more than 15 feet from the wall (this is based on one-half of the maximum spacing distance between detectors which is 30 feet). The cross-corridor doors must be considered ‘closed’ when designing the detector locations, so that constitutes a “wall” and a detector is required within 15 feet of that wall.

Where consultants and surveyors have problems is they see a cross-corridor door held open by a magnet, and then they do not see a detector within five feet, and they believe that is a violation of NFPA 72. What they don’t consider is the corridor is completely protected with smoke detectors and NFPA 72 (2010) (1) allows a detector to be one-half of the maximum spacing.