Fire Alarm Systems

Q: Our hospital has an outpatient clinic attached via a hallway and connected to the hospital directly. When I am in the out-patient clinic you cannot hear the fire alarms going off in the hospital. Do the systems need to communicate? They are currently on 2 different systems.

A: No… the two systems are not required to communicate with each other unless the expectation is for staff at one location is to respond to fire alarms in the other location. However, it may be practical for the alarm to communicate in each other’s building, in some fashion. There may be key individuals (i.e. engineering staff, management staff, and executives) who may be in one location and if the alarm is activated in the other location, they should know about it. But this can also be accomplished using two-way radios or pagers.

Fire Alarm Audible Devices in Physician Sleep Rooms

Q: We have audible notification devices for the fire alarm system installed in our physician sleep rooms. We have a physician requesting the one in his area be removed. Are we permitted to remove the audible devices or do we have to have them?

A: Well…. I would certainly remove any audible alarm notification devices from a physician sleeping room, but there are some surveyors who are sticklers for them. Here is the reason why:

A physician sleeping room on a patient unit would be considered a mixed occupancy as the physician sleeping room would have to meet chapter 29 Existing Hotels & Dormitories. Section 29.3.4.5 of the 2012 Life Safety Code requires an approved single-station smoke alarm in every sleeping room. A smoke alarm is different than the typical smoke detector in the hospital. The smoke alarm is required to have an audible device when the smoke alarm is activated it will alert the individual in the room. So, technically, the audible device is required and some surveyors actually require it.

However, since the sleeping room is in a hospital, most accreditation organizations allow a hospital smoke detector to be installed in the sleeping room in lieu of a smoke alarm since there is staff on duty that would wake any sleeping physicians in the event of a fire. But, not all surveyors and AHJs see it that way and actually require the smoke alarms with audible devices to be installed.

But perhaps the saving grace for you is the smoke alarm in the physician sleeping room is not required to be connected to the building fire alarm system (a smoke detector would be, but not a smoke alarm) so you don’t have to have a building audible notification device in the sleeping room which would activate everytime the fire alarm system is activated. Just have a single-station smoke alarm that has an audible signal installed, which will only activates if the a fire develops in the sleeping room.

By the way, section 29.3.6.2.2 and 29.3.6.2.3 requires a fire-rated door to that room if the corridor is not sprinklered, and the door needs a closer.

ASC Fire Alarm Testing

Q: What section of NFPA 72 (the National Fire Alarm Code) requires ambulatory surgery centers to perform testing of their fire alarm system on a quarterly basis? Do devices that require annual testing have to be divided and have the service contractor do 25% of them each quarter? My organization would like to know the specific identifier so that the requirement may be referred to.

A: The quick answer is there is no requirement in NFPA 72 (or any other NFPA standard) that requires quarterly testing of the fire alarm system for ASC classified as ambulatory care occupancies. Section 20.3.4.1 of the 2000 edition of the LSC requires compliance with section 9.6. Section 9.6.1.4 requires compliance with NFPA 72 (1999 edition) for testing and maintenance. NFPA 72, Table 7-3.2 discusses the frequency of testing and inspection for each component and device of the fire alarm system. While there are a few items that require quarterly testing (such as water-flow switches on sprinklers system, which actually comes from NFPA 25, and off-premises emergency notification transmission equipment), for the most part, annual testing is required on all initiating devices, notification devices, and interface devices. You do not have to divide the components that require annual testing into four groups and have your service contractor perform testing on 25% of the devices on a quarterly basis. Actually, this can be troublesome for larger organizations if the service contractor fails to test the devices during the same quarter each year. Most accreditation organizations require the annual test to be performed 12 months from the previous test, plus or minus 30 days.

Fire Alarm Test Report

Q: Does NFPA 72-1999 edition specifically state that annual fire system inspection documentation include an itemized inventory of each system device as passed or fail? Does a report stating that (i.e. 20 pull stations passed, 72 smoke detectors passed, 19 duct detectors passed) satisfy the requirement?

A: Specifically? I would say it does, but if you want to see the words: “Every annual fire alarm system documentation must include an itemized inventory of each device as passed or failed” … you will not find those words in NFPA 72, 1999 edition.

What it does say is this: Section 7-5.2.2 requires documentation of the fire alarm test to comply with all the applicable information found in Figure 7-5.2.2. On page 3 (of 4) of figure 7-5.2.2, the documentation required by NFPA 72 includes:

    • Location of the device
    • Serial number of device
    • Device type
    • Visual check
    • Functional test
    • Factory setting
    • Measured setting
    • Pass of Fail

In addition to that requirement for annual testing, section 7-1.6.2.1 requires all components affected by a change to the system to be 100% tested. This is in regards to a change to the system, like the addition of an initiating device all the devices on the circuit for the new device must be tested.

So, I would say NFPA 72 (1999 edition) does specifically require the documentation of whether or not each device passed or failed its test. Also, it is now an interpretation by many of the national AHJs for healthcare organizations that each test report has this information documented. The logic for this requirement is solid; how does the facility manager know that the fire alarm testing technician actually tested each and every device in their building, if you do not know where they are, and document the results of each test?

A report stating that 20 pull stations passed, 72 smoke detectors passed, 19 duct detectors passed their inspection would NOT satisfy the reporting requirement, as I understand it. There needs to be an inventory list showing each device location and whether or not it passed or failed its test.

 

It makes good sense.

 

Fire Alarm System in a Business Occupancy?

Q: We have a physician practice that currently has fire extinguishers and a “panic button” that contacts 911. We do not have fire alarms, smoke detectors or a sprinkler system. Are we required to have any of those in the practice?

A: The answer is… maybe yes and maybe no. Sorry; that’s not much of an answer, but not all offsite small business occupancies actually require a fire alarm system.

If the physician practice is truly a business occupancy, meaning there is no procedures being conducted where patients are rendered incapable of self-preservation, then section 39.3.4.1 of the 2000 Life Safety Code says this for existing conditions:

A fire alarm system in accordance with section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:

  • The building is two or more stories in height above the level of exit discharge
  • The occupancy is subject to 100 or more occupants above or below the level of exit discharge
  • The occupancy is subject to 1,000 or more total occupants.

For new construction in business occupancies (meaning new construction or renovation documents approved by local authorities after March 11, 2003), section 38.3.4.1 of the 2000 Life Safety Code says this:

A fire alarm system in accordance with section 9.6 shall be provided in any business occupancy where any one of the following conditions exists: 

  • The building is two or more stories in height above the level of exit discharge
  • The occupancy is subject to 50 or more occupants above or below the level of exit discharge
  • The occupancy is subject to 300 or more total occupants.

 

The occupant capacity is calculated by taking the total gross area of the floor (or building) in square feet, and dividing it by 100 square feet per person. So, a 5,000 square foot story would have an occupant load of 50 persons.

So, as you can see, if the physician practice is a business occupancy and meets the requirements for a new or existing occupancy, then a fire alarm system is not required, according to the Life Safety Code.

Sprinkler systems are not required in business occupancies, whether they are new construction or existing construction.

Now, there may be other codes or standards that you need to comply with, so please check with your local and state authorities to determine what their requirements are.

Visual Inspection of Fire Alarm Devices

Q: A question came up recently on the NFPA 72 semi-annual visual inspections required for fire alarm system devices. Would the printed records from an intelligent fire alarm system suffice for the visual inspections on devices such as smoke detectors, pull stations and heat detectors?

A: I would say no, the printed records from an intelligent fire alarm system would not suffice for a visual inspection on the fire alarm system devices. Items such as the following must be visually inspected twice a year on a semi-annual basis:

Initiating Devices

  1. Duct Detectors
  2. Electromechanical Releasing Devices
  3. Fire-Extinguishing System(s) or Suppression

System(s) Switches

  1. Fire Alarm Boxes
  2. Heat Detectors
  3. Radiant Energy Fire Detectors
  4. Smoke Detectors

The reasoning for this decision is found in the NFPA 72 handbook, which states: “The visual inspection is made to ensure that there are no changes that effect equipment performance. Equipment performance can be affected by building modifications, occupancy changes, changes in environmental conditions, device location, physical obstructions, device orientation, physical damage, improper installation, degree of cleanliness, or other obvious problems that might not be indicated through electrical supervision.”

It is not uncommon to find ancillary hospital equipment placed or installed in such a way as to affect or obstruct the normal operation of some of these devices. Semi-annual visual inspections will find these issues before they affect the performance of the fire alarm system.

Generally speaking, the printed records from an intelligent fire alarm system would only suffice for documentation on the 2-year sensitivity testing requirement. Everything else would have to be confirmed through direct observation.

Visual Inspection of Fire Alarm Devices

Q: A question came up recently on the NFPA 72 semi-annual visual inspections required for fire alarm system devices. Would the printed records from an intelligent fire alarm system suffice for the visual inspections on devices such as smoke detectors, pull stations and heat detectors?

A: I would say no, the printed records from an intelligent fire alarm system would not suffice for a visual inspection on the fire alarm system devices. Items such as the following must be visually inspected twice a year on a semi-annual basis:

Initiating Devices

  1. Duct Detectors
  2. Electromechanical Releasing Devices
  3. Fire-Extinguishing System(s) or Suppression

System(s) Switches

  1. Fire Alarm Boxes
  2. Heat Detectors
  3. Radiant Energy Fire Detectors
  4. Smoke Detectors

The reasoning for this decision is found in the NFPA 72 handbook, which states: “The visual inspection is made to ensure that there are no changes that effect equipment performance. Equipment performance can be affected by building modifications, occupancy changes, changes in environmental conditions, device location, physical obstructions, device orientation, physical damage, improper installation, degree of cleanliness, or other obvious problems that might not be indicated through electrical supervision.”

It is not uncommon to find ancillary hospital equipment placed or installed in such a way as to affect or obstruct the normal operation of some of these devices. Semi-annual visual inspections will find these issues before they affect the performance of the fire alarm system.

Generally speaking, the printed records from an intelligent fire alarm system would only suffice for documentation on the 2-year sensitivity testing requirement. Everything else would have to be confirmed through direct observation.

Fire Alarm System Upgrade

Q: I am doing a renovation project in our hospital and the area of renovation is 50% of the total building area. Part of the renovation scope is a fire alarm system upgrade. Is there any code or standard requirement that the fire alarm devices in the remaining 50% of existing building should be upgraded also before it can be occupied? 

A: Your question involves the fire alarm system in the existing area of the building which is not being renovated, and asks if the fire alarm system in that remaining 50% of the existing building should be upgraded as well, before the building can be occupied.

First let me say that this is a question that does not have a direct answer, from either the Life Safety Code (2000 edition), or the NFPA 72 National Fire Alarm Code (1999 edition). When there is not a direct reference to a question in the codes or standards, then the authorities having jurisdiction (AHJ) must be consulted for their interpretation. This means you need to contact the AHJs who have authority over the design of your fire alarm system and ask them how they interpret the issue. A hospital typically has 5 or 6 different AHJs that should be consulted:

  • State health department or agency on public health
  • State fire marshal
  • Local fire department
  • Local building authority
  • Insurance company

Having said that, it appears to me that you may not have to replace the devices in the existing area of the building that is not under renovation. Section 1-2.3 of NFPA 72 (1999 edition) says this: “Unless otherwise noted, it is not intended that the provisions of this document be applied to facilities, equipment, structures, or installations that were existing or approved for construction or installation prior to the effective date of the document. EXCEPTION: Those cases where it is determined by the authority having jurisdiction that the existing situation involves a distinct hazard to life or property.”

So, as long as the existing devices are still in good working order and do not pose a hazard to life or property, it appears to me that you do not have to upgrade them in your project. However, as I said, it really doesn’t matter what I think: All that matters is what the AHJ say. So, please consult with them for direction.

Obstructions to Fire Alarm Control Panel

Q: Where in the Life Safety Code does it require clearance in front of a fire alarm control panel? I have a situation in our hospital where we want to put a stanchion near the panel, but I thought we had to maintain a certain amount of clearance. Can you point me to the exact standard? 

A: The requirement to maintain a certain amount of clearance in front of all electrical panels (which includes the fire alarm panel) is found in NFPA 70 National Electrical Code (NEC), section 110-26(a), which says: “Sufficient access and workings pace shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.” The actual distance required for clearance is found in Table 110-26(a) and is required to be 36 inches.

Heat Detector Spacing From an Air Diffuser

Heat Detector imagesALEXIFM2A reader recently asked me where in NFPA 72 does it say that heat detectors have to be a minimum of 36 inches away from an air diffuser. He could not find the standard reference and asked if I could point him in the right direction.

Well…. I think he had a point, since there is no requirement in NFPA 72 that says heat detectors have to be 36 inches away from air diffusers. Section 2-3.5.1 and section A-2-3.5.1 of NFPA 72-1999 says spacing for detectors from air diffusers (supply and return) must be 3 feet. This section (NFPA 72 2-3) is referring specifically to smoke detectors, and section NFPA 72 2-2 refers specifically to heat detectors and there is no similar language in section 2-2 concerning minimum distance from air diffusers for heat detectors.

Therefore, one can conclude that heat detectors do not have to comply with the 3 foot spacing from air diffusers like smoke detectors. But that is not how all of the AHJs interpret this. The actual spacing (3 feet) for smoke detectors is found in the Annex section of the standard which is explanatory information and not part of the enforceable standard. But AHJs are free to use this information in the Annex section in determining compliance with the standard. Therefore, AHJs can interpret this section how they want, and many of the AHJs interpret that you need to maintain 3 feet from air diffusers for both smoke and heat detectors.

If you get cited, you can fight the finding by pointing out the reference in the Annex section is only for smoke detectors, but ultimately the AHJs get to interpret this the way they want, and you may end up losing anyway.