Fire Rated Door in a Non-Rated Barrier

Q: If I replace a smoke barrier door with a fire door, does the wall now have to be brought up to fire-rated wall code or will it still be considered the same smoke barrier code? We were told by an inspector that now the wall would have to be a fire-rated wall even though it’s not needed to be.

A: This issue is becoming a sticky wicket. I’ve had this question raised numerous times recently. I kind-of see where the surveyor is coming from: If the fire-rated door assembly is obvious to the public as a fire door, then the public could conclude that the barrier is also a fire-rated barrier. Kind-of makes sense. But that’s not what the Life Safety Code says. It is clear to me that the LSC does require all fire-rated doors to be tested regardless if they are located in a fire-rated barrier or not.

Section 4.6.12.3 says existing features of life safety obvious to the public, if not required by the LSC must be maintained or removed. Most AHJs will say a fire-rated label on the door is obvious to the public, although an unofficial NFPA interpretation is saying a fire rated label is not obvious to the public. In this situation, we have to go by what the AHJ says. Section 8.3.3.1 says fire-rated doors must comply with NFPA 80-2010, so all fire rated doors must be tested and inspected regardless if they are located in a fire-rated barrier.

But there is nothing in this section of the LSC or any other section that clearly says a fire-rated door assembly located in a barrier requires the barrier to be a fire-rated barrier. The AHJ has the right to interpret the Life Safety Code, but in my opinion this interpretation is way over the top. But, if you do get cited for this, it really is an easy solution: Just pop the fire-rated labels off the door.

 

Fire Door Inspection Records

Q: Do fire door inspection records need to be maintained for 3 years?

A: I would say at least 3-years, and longer as needed. NFPA 80-2010 section 5.2.1 says fire door assemblies must be inspected and tested not less than annually, and a written record of the inspection must be signed and kept for inspection by the AHJ. Since your routine accreditation surveys are once every 3-years, and since the purpose of the accreditation survey is to determine compliance with the standards since the last survey, then I would say you need to retain all records at least 3 years so the surveyor can confirm your level of compliance during that 3-year period. Now, it is my position that you should never throw away any document confirming regulatory compliance as you may need it someday, for other AHJs or maybe even litigation purposes. You can purge your files of test reports older than 3 years but make sure you box them up and store them somewhere safe and dry.

Fire Door Inspector

Q: My accreditation organization has a standard that says “testing and inspection of fire door assemblies needs to be conducted by a qualified person.” By what specifically do they mean when they say “qualified” and where are we able to find where they define their interpretation of what qualified is?

A: You will find the interpretation of what ‘qualified’ means under section 5.2.3.1 of NFPA 80-2010, which says functional testing of fire doors and window assemblies must be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. You may hire this responsibility out to a contractor with this knowledge and understanding, or you may assign the responsibility to test the fire doors to one of your own staff individuals, provided you ‘qualify’ them by determining they have the knowledge and understanding to perform this test.

If you decide on the latter, you need to document this decision by describing why you believe this individual has this knowledge and understanding of fire door operating components, and retain that document in case the surveyor asks to see how you qualified that individual. Your own staff individual could be qualified based on a certification course they may have taken (please understand there is no requirement that the person conducting the fire door inspections be certified, but it can be a good source of education), or the individual may be qualified simply because they have worked on doors for years and have accumulated this knowledge and understanding. The key is you may need to defend this decision, so it is best to document the decision and retain that to show to a surveyor.

Door to Compressed Gas Storage Rooms

Q: I have an oxygen/med gas storage room that is attached to the hospital, and can only gain access to the room by way of the exterior of building. Does the room have to have a fire-rated door assembly?

A: Well… that depends. If the storage room contains 3,000 cubic feet or more of compressed medical gases, and the room is located indoors, then the room must be constructed with 1-hour fire-rated construction and the door to the room is required to be 1-hour fire rated if new construction, and 3/4-hour rated if existing conditions. (See 5.1.3.3.2(4) of NFPA 99-2012).

However, the intent of 5.1.3.3.2 is to separate the compressed gas storage room from the rest of the facility by requiring 1-hour fire rated barriers, and if the door opening to the storage room opens into the facility, one could easily understand why a fire-rated door is required. However, if the door to the storage room opens to the outdoors (i.e. receiving dock) then one could make a point that the door is not required to be fire-rated, because there is no separation between the storage room and the rest of the facility at that point.

But the problem is, NFPA 99-2012 section 5.1.3.3.2 does not say that and does not appear to have any exception for a door to the storage room that opens to the outdoors. I think a rational, smart, understanding surveyor would agree with that point and not cite you for not having a fire-rated door that opens to the outdoors.

But will you always have a rational, smart, and understanding surveyor?

Fire Rated Door Assemblies

Q: You have stated in previous Q&As that all fire-rated door assemblies must be tested and inspected. I don’t think that is true on fire-rated door assemblies that are not located in a fire-rated barrier. I was under the impression that the hospital’s current Life Safety drawings would be the determining factor on what barriers the hospital was responsible for maintaining. For example, if the building had rated doors on a wall that was not denoted as a fire rated barrier on the LS drawings, one could justify why there were not maintained. I run into the installation of unnecessary rated doors in many facilities, both old and new.

A: You make an interesting case. However, the Life Safety Code always trumps everything else, and in this case it would trump the hospital’s LS drawings. According to section 4.6.12.3 of the 2012 LSC, it clearly says all existing features of life safety that are obvious to the public, if not required by the LSC, must be maintained or removed. And section 8.3.3.1 says openings (i.e. doors) required to have fire protection must be maintained in accordance with NFPA 80 which requires annual testing and inspection.

Now, there’s a lot going on with this statement… For example: NFPA has said via informal comments that a fire-rated label on the edge of the door is not considered ‘obvious to the public’. But other AHJs disagree, and have stated that the fire-rating label on the door constitutes the need to maintain it as a fire-rated door. Most surveyors will go by the fire-rating label on the door, since a high percentage of Life Safety drawings are inaccurate to some degree.

I don’t disagree with your logic. If it were up to me, I would not require fire-rated doors that are not in fire-rated barriers to require testing and inspections. But think of it the way a surveyor does… Who is to say the fire-rated doors are not located in a fire-rated barrier? Just because the Life Safety drawings say it is not in a fire-rate barrier, what about building code requirements? Life Safety drawings do not always represent the rated wall requirements of building codes. There is too much ambiguity for a surveyor to take the word of the hospital that a certain fire-rated door is not located in a fire-rated  barrier.

My advice is to remove the fire-rated label from the door and frame if the facility is sure the door assembly is not located in a fire-rated barrier.

Fire-Rated Doors

Q: My hospital is a behavioral health hospital converted from an acute hospital. The doors on patient rooms and mostly all doors in this building are solid core doors….which are fire rated. My office door and most in this wing are also lead lined. We need the solid core doors for the patient rooms due to their behavior….regular doors would be torn up quickly. How do I comply with the new ruling on fire-rated door inspections in this situation?

A: You can do one of two actions:

  1. You can test and inspect the fire-rated door assemblies on an annual basis in accordance with sections 4.6.12.3 and 8.3.3.1; or
  2. You can remove the fire-rated label on the door assemblies if the door is not required to be a fire-rated door assembly.

Even if the door is a labeled fire-rated door assembly but is located in a barrier that is not required to be a fire-rated barrier, you must still maintain the door in accordance with NFPA 80, which requires annual test and inspection. However, if the barrier is not required to be a fire-rated barrier, and you remove the labels (on the door and on the frame) then the door is no longer a fire-rated door assembly and you do not have to maintain it as such.

Office Door Holiday Decorations

Q: Staff members at our behavioral healthcare facility enjoy decorating their corridor office doors (business occupancy, 20-minute fire-rated doors, multiple floors) with wrapping paper, bows, etc. affixed with scotch tape for the holidays. Are there specific prohibitions against this? We don’t want to be a Grinch unless necessary. thanks!

A: Section 7.1.10.2.1 of the 2012 LSC says decorations cannot obstruct the function of the door or the visibility of the egress components. So, the decorations cannot obstruct the door in any way.

Section 4.1.4.1 of NFPA 80-2010 says signage on fire-rated doors cannot be more than 5% of the door surface. Now decorations may not be considered signage by most individuals, but the intent is to keep the fire-load on the door to a minimum so it can function properly in the event of a fire. I can see where a surveyor would have a serious issue with decorating fire-rated doors with wrapping paper and bows, because it adds fuel to the door that was not present during the UL testing of the doors.

Sorry, but I suggest you be the Grinch and tell them to remove wrapping paper and bows from the fire-rated doors.

Fire Rated Door Assembly

Q: We are planning to install double egress doors within the corridor for the purpose of separating the clean OR area from the dirty side. The doors and frame that were ordered happen to be rated for 45-minutes. This will not be a smoke or fire barrier and the doors/frame will only extend up to the drop ceiling. Since the doors are rated for 45 minutes, do we need to maintain these doors as fire rated doors and inspect them on an annual basis?

A: Yes, you do. Section 4.6.12.3 of the 2012 Life Safety Code says existing life safety features obvious to the public, if not required by the Life Safety Code, shall be ether maintained or removed. A door and frame that are labeled that identifies the door assembly as a fire-rated door assembly is interpreted by CMS and the AOs as being “obvious to the public”. Therefore, a fire rated door assembly that is not located in a fire-barrier (as you described) would have to be maintained as such and be tested and inspected on an annual basis, because the label is ‘obvious to the public’.

However, if the label is not obvious to the public (meaning it is on top of the door) then it would not have to be maintained as a fire-rated door assembly. Also, if you wanted to delete this door from the list of fire-rated doors that are tested and inspected on an annual basis, then you may remove the fire-rated label and it is no longer obvious to the public.

I’ve been told by reliable individuals that NFPA does not believe that a fire-rated label is obvious to the public, and I would not disagree with them. But they are not the AHJs. CMS and the AOs are AHJs, and the informal interpretations from them says the label is obvious to the public.

If you don’t want to test the door every year, take the label off. But be advised, you can never place that label back on if you change your mind. You would have to have it re-inspected by a UL listed company who inspects doors for re-labeling.

 

Fire Door Inspections

Q: Other than the annual fire door inspection that is required in the 2012 Life Safety Code, are there other inspections required? Fire doors that are included are also single fire rated doors in places like store rooms and maintenance shops, correct?

A: I’m not sure I understand your question. When you ask ‘are there any other inspections required?’… are you asking if there are any other inspections required of the fire doors? If so…. I am not aware of any. But if you’re asking are there any other inspections required in the 2012 LSC… then the answer is yes. If you’re asking if there are any other new inspections required by the 2012 LSC then I’ve included a list of changes required by the 2012 LSC that include these new inspections. In summary, new inspections are:

  • Monthly inspections of sprinkler pressure gauges
  • A quarterly main drain test on one system riser if the sprinkler water is supplied through a backflow preventer
  • A quarterly inspection of all fire hose valves
  • An annual fire door inspection
  • An annual test on all 2.5 inch fire hose valves
  • A 3-year test on all 1.5 inch fire hose valves
  • A 5-year internal inspection on sprinkler pipe

All fire rated doors must be inspected annually, regardless what they serve. So fire doors on storage rooms and maintenance shops must be included.

Fire Door Testing

Q: Now that we have some clarification from CMS on annual door inspection [See CMS S&C memo 17-38, dated July 28, 2017], I wanted to see if there was any new interpretation on rated corridor doors (20 minute and up) that are installed in non-rated wall assemblies. In looking at most publications from different authorities, they have interpreted that all rated doors need to be annually inspected since it could be obvious to the public. Section 4.6.12.3 of the 2012 Life Safety Code says existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. However, section 4.4.2.3 says where specific requirements contained in Chapters 11 through 43 differ from general requirements contained in Chapters 1 through 4, and Chapters 6 through 10, the requirements of Chapters 11 through 43 shall govern. If the chapters 11-43 govern over chapters 1-10 why are the authorities not recognizing 19.3.6.3.3 where it states compliance with NFPA 80 shall not be required? Unfortunately, it doesn’t say this for “smoke barrier” doors, so the authority’s logic could still have reason. In my interpretation of 4.6.12.3 and reading the appendix it seems that NFPA is referring to first response Life Safety features, like a pull station, fire extinguisher, strobe lights, fire panels etc….. If Joe Public is seeing a fire door do its thing, it’s probably too late. Certainly, first response LS features should always work even if they are not required.

 A: You make many excellent points. But the way I see it (and interpretations by most of the AOs and CMS agree), section 8.3.3.1 of the 2012 LSC requires compliance with NFPA 80 for fire doors and windows. There are no exceptions in 8.3.3.1 that exclude fire-rated doors located in non-fire-rated barriers. Compliance with 8.3.3.1 is required by section 19.1.1.4.1.1. Where section 19.3.6.3.3 says compliance with NFPA 80 is not required, they are speaking about non-fire-rated corridor doors, which are in smoke partitions that separate a corridor from another area or room.

Smoke barrier doors are often not corridor doors; they are cross-corridor doors. But at times, a smoke barrier can (and does) include a corridor wall and what appears to be a corridor door is now also a smoke barrier door. In those situations, the hospital has to comply with the most restrictive requirements.

To me, it is plain: If you have a fire-rated door (regardless if it is located in a fire-rated barrier or not), then it must comply with NFPA 80 and you must test and inspect it on an annual basis.  I’ve been told that the opinions from the staff at NFPA do not agree with this, but NFPA does not enforce the LSC, so we need to comply with those interpretations made by the authorities who enforce the Life Safety Code, such as CMS and the AOs.