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 18/22.214.171.124 and 126.96.36.199 of the 2012 Life Safety Code), provided it is in accordance with NFPA 72-2010.
The PAS (section 188.8.131.52.1.1 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:
- 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.
- 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.
- 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.
- If the PAS operation is initiated in accordance with 184.108.40.206.1.1, 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.
- 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.
- 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.
- 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.
- 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 firstname.lastname@example.org