Duct Detector Test

Q: During our inspection our surveyor was looking for 3/8″ holes, 3 feet upstream, before the smoke detectors in the ductwork. He requested testing procedures for the duct detectors from the tester who stated the test was performed by putting smoke onto the duct detector, which shut down the air-handler unit. The surveyor says the smoke must be inserted 3 feet prior to duct detector to test the actual tube for blockages. Can you tell me the actual regulation that states this requirement?

A: According to NFPA 72-2010, section 14.4.2.2, the method to conduct testing of fire alarm systems must comply with Table 14.4.2.2:

14(g) Smoke detectors

1) Smoke detectors/smoke alarms shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol, acceptable to the manufacturer of the aerosol or the manufacturer of the smoke detector/smoke alarm and identified in their published instructions, shall be permitted as acceptable test methods. Other methods listed in the manufacturer’s published instructions that ensure smoke entry from the protected area, through the vents, into the sensing chamber shall be permitted.

6) Duct detectors

In addition to the testing required in Table 14(g)(1), duct smoke detectors utilizing sampling tubes shall be tested by verifying the correct pressure differential (within the manufacturer’s published ranges) between the inlet and exhaust tubes using a method acceptable to the manufacturer to ensure that the device will properly sample the airstream. These tests shall be made in accordance with the manufacturer’s published instructions for the device installed.

Here is a summary on how to test duct detectors:

  1. The test must ensure smoke/aerosol enters the sensing chamber and an alarm responds.
  2. You must verify the correct air pressure differential between the inlet and exhaust tubes, in accordance with the manufacturer’s instructions.

So, while the vendor appears to be testing the detector, it does not appear he is testing the air pressure differential of the inlet and outlet tubes. I don’t see anything in NFPA 72-2010 that requires putting smoke/aerosol in the actual air tube for duct detectors. I do see where that is required for air sampling smoke detectors, but duct detectors are not the same as air sampling smoke detectors.

Qualifications of Personnel

Q: We recently acquired a hospital that has been performing segments of their own fire system testing. What are the specific requirements or qualifications for an individual conducting testing or inspections on fire alarm systems and sprinkler systems?

A: NFPA 72-2010, section 10.4.3.1 requires a certified individual to perform service, testing, inspection and maintenance on fire alarm systems and components. The certification must be one (not all) of the following:

  • Factory trained and certified for the specific type and brand of systems being serviced
  • Persons who are certified by a nationally recognized certification organization (NICET, IMSA, etc.)
  • Persons who are registered, licensed or certified by the state
  • Persons who are employed and qualified by an organization listed by a national recognized testing laboratory for servicing fire alarm systems.

I have seen some larger hospitals that do employ people who meet one of the above requirements, but most hospitals contract this work to a qualified vendor who has these credentials. When it comes to sprinkler system testing/inspecting, NFPA does not require certification of the individuals performing the test/inspection. However, please check with your state and local AHJ to determine if they have additional requirements.

Testing of Smoke and Fire Doors

Q: With regards to the 2012 edition of the Life Safety Code and the requirement to perform annual inspections of smoke/fire doors, would it be safe to assume that annual for “year one” would be between August 2016 and August 2017 and even beyond if we apply the +/- days to the annual requirement? We are having trouble trying to get everything done am hoping we can push out the new annual door inspection tasks.

A: First of all, I do not believe that smoke doors in healthcare occupancies are required to be inspected. Yes… section 7.2.1.15.2 of the 2012 LSC says (in part) smoke door assemblies need to be tested. But that conflicts with the occupancy chapter for healthcare and section 4.4.2.3 says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section 19.3.7.8 says doors in smoke barriers shall comply with section 8.5.4. Section 8.5.4.2 says where required by chapters 11 – 43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section 8.2.2.4 (which requires testing). Chapters 18 & 19 (healthcare occupancies) do not require smoke doors to be smoke leakaged-rated: Therefore, smoke barrier doors do not have to be tested in healthcare occupancies.

Now… you may have a state agency that believes differently. Ultimately, they are an authority and if they say you have to test smoke doors, then you have to test smoke doors. But it is not required in healthcare occupancies according to the 2012 LSC. Also, some authorities say that healthcare occupancy doors in 7.2.1.15.1 must be tested, even if they are not fire-rated doors. This also is incorrect. The doors identified in 7.2.1.15.1 do not apply to healthcare occupancies so they are exempt from having to be tested. Only doors in assembly occupancies, educational occupancies, and residential board & care occupancies need to comply with 7.2.1.15.1.

But be aware: If you have areas of your healthcare facility that qualify as assembly occupancy, even if you do not declare that area as assembly occupancy, then you must comply with 7.2.1.15.1 and test those doors. This would include doors in assembly occupancies that:

  • Have panic hardware or fire-rated hardware;
  • Are located in an exit enclosure;
  • Are electrically controlled egress doors;
  • Delayed egress, access-control, and elevator lobby locked (per 7.2.1.6).

Secondly, CMS has stated that they require the first test/inspection of the fire doors to be completed by July 5, 2017. This date is based on the effective date of the 2012 Life Safety Code (which was July 5, 2016), and the fact that the fire door testing is an annual event. So, the first annual inspection is not due until July 5, 2017. I know the Accreditation Organizations will follow suit.

By the way… CMS has stated they do not approve of the ‘+’ portion of due dates. In other words, if the accreditation organization says annual means 12 months from the previous test, plus or minus 30 days, CMS is saying they do not approve of the ‘plus 30 days’. They don’t mind the ‘minus 30 days’ but they do not approve of any test/inspection going beyond what is required for a due date.

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.

 

Qualified Technicians

Q: We recently found out that our own maintenance staff is not qualified to service our fire alarm system. What other systems or items in the hospital requires our own technicians to be qualified in order for them to perform the required service?

A: As you mentioned, technicians who test, inspect or maintain the fire alarm system are required to be qualified and experienced, according to NFPA 72 National Fire Alarm Code, 1999 edition. Section 7-1.2.2 list examples of qualified personnel, and includes, but does not limit individuals with the following qualifications:

  • Factory trained and certified
  • National Institute for Certification in Engineering Technologies (NICET), fire alarm certified
  • International Municipal Signal Association (IMSA), fire alarm certified
  • Certified by a state or local authority
  • Trained and qualified personnel employed by an organization listed by a national testing laboratory for the servicing of fire alarm systems.

Other fire safety systems typically found in hospitals where some type of qualification is required, would be:

  • According to NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition, section 4-1.4, maintenance, servicing and recharging of portable fire extinguishers must be performed by trained persons having available the appropriate servicing manuals, the proper types of tools, recharge materials, lubricants, and manufacturer’s recommended replacement parts for the use of the extinguishers. Also, according to section 5-1.2 of the same standard, hydrostatic testing on portable fire extinguishers must be performed by persons trained in pressure testing procedures and safeguards, who have suitable testing equipment, facilities and appropriate servicing manuals available. The standard does not list any examples of what ‘trained persons’ mean.
  • Backflow preventers: Persons performing testing and inspection on backflow preventers are typically required to be licensed by the state or local authorities.
  • NFPA 12A, Standard on Halon 1301 Fire Extinguishing Systems, 1997 edition, section 4-1.1 and NFPA 2001, Standard on Clean Agent Fire Extinguishing Systems, 2000 edition (for FM-200 fire suppression systems), section 4-1.1, both say all systems must be thoroughly inspected, tested, and documented for proper operation by trained competent personnel. These standards do not describe what ‘trained competent personnel’ means.
  • NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 1998 edition (for kitchen hood fire suppression systems), section 5-3.1 says a trained person who has undergone the instructions necessary to perform the maintenance and recharge service reliably and has the applicable manufacturer’s listed installation and maintenance manual and service bulletins must service the wet chemical fire extinguishing system 6 months apart.

Where the above standards do not specify what training or qualifications are required, then that determination is left up to the authority having jurisdiction. So far, I have only seen the accreditation organizations request documentation for qualifications of the technicians for fire alarm testing, inspection and maintenance, but that does not mean they couldn’t request documentation on the other issues. As always it is best that you check with your state and local authorities to determine if they have additional requirements or interpretations that you will need to comply with.