Marked Fire/Smoke Doors

Q: We are reviewing fire policy, and are wondering if it is a Life Safety Code requirement to have fire and smoke barrier doors labeled as such? By this I mean a sign or sticker on the face of the door stating: “smoke barrier” or “fire barrier”?

A: No… there is no Life Safety Code requirement to post signage on smoke barrier doors or fire-rated door assemblies, identifying them as such. I do not see any CMS or Accreditation Organization requirement to do so, either. However, it’s not a bad idea as long as the signage meets the limitation of NFPA 80 for fire-rated door assemblies. I have seen hospitals identify their smoke barrier doors, that helps their staff be aware of the smoke compartment locations. I think that works well for many organizations. Please check with your state and local authorities to determine if they have any requirements.

 

Strange Observations – Signs on Fire-Rated Doors

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

Doors to medical gas storage rooms are required to be fire-rated.

Fire-rated doors cannot have signs applied that cover more than 5% of the total surface of the door.

A sign that does not exceed 5% surface of the fire-rated door is approximately 8.5″ x 11″. This door has signs that exceed the 5% surface amount.

Also, the signs cannot be attached to the door using screws or nails, but must use adhesive.

Home-Made Bumpers on Doors

Q: We have metal “bumpers” (for lack of a better term) that were fabricated onsite at our hospital, that are used to keep carts and beds for damaging the doors. These bumpers are installed on fire-rated door assemblies and protrude out past the push pad of the horizontal crash bar on the door. Are these bumpers allowed?

A: No… According to NFPA 80- 2010, section 4.6.1, all devices mounted to a fire-rated door assembly must be listed by an independent laboratory (i.e. UL, Intertek, FM Approval) for use on a fire-rated door assembly. Home-made devices are not permitted. Also, the bumpers may stick out more than the maximum 7 inches allowed by section 7.2.1.4.3.1 of the 2012 LSC, when the door is fully opened.

Fire Pins

Q: I have a concern regarding the use of fire pins in fire rated door leaves: Since the latching feature of these devices is not testable (that I’m aware of, anyway), and as these doors are prone to abuse and sometimes require adjustment for clearance issues and so forth, how do we ensure the alignment of the fire pin assembly when adjustments are made or even during normal expansion/contraction due to temperature/humidity changes?

(The reply for this question comes from Lori Greene, Manager of Codes & Resources at Allegion. Visit Lori’s website on doors and hardware at www.idighardware.com)

 A: You’re right – there’s no way to test the pin.  But the pin and the hole that it will project into (typically filled with a plastic cap) should be visible on the door edge so you can ensure that they’re aligned.  On most pins there is a fair amount of tolerance so the alignment doesn’t have to be perfect.  Since the pins operate only when there’s a fire, and only when the temperature reaches >1000 degrees in the vicinity of the door (approx. 450 degrees at the pin), only a very small percentage of the pins will ever be activated.  The pin doesn’t have much of an impact on life safety – by the time the pin projects, it’s mostly about compartmentalizing the building and protecting property.

Aluminum Astragals

Q: We used our recently updated Life Safety drawings to have our fire doors inspected. The inspector cited us for aluminum astragals on 13 doors. His report stated that they should be changed to steel. My boss asked me to confirm that this is fact. What are your thoughts?

A: The inspector may know something… All hardware installed on fire-rated door assemblies must be listed for use on fire-rated door assemblies, and this includes astragals. Do you have the specification sheets for the astragals that you installed? If not, can you obtain them?

Look on the specification sheets for anything that says the astragals are listed by an independent testing laboratory (UL, Intertek, ETL, etc.) for use on fire-rated door assemblies. If you find that they are listed for use on fire-rated door assemblies, then you are good to go. Photo-copy that information and send it to the inspector for his/her review.

If the specification sheets do not say the astragals are listed for use on fire-rated door assemblies, then the inspector is correct and you would have to remove them. The issue is not whether they are made with steel or aluminum, but whether they are listed for use on fire-rated door assemblies. Perhaps the inspector believes that aluminum astragals are not listed…?

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.