Fire Rated Door Assemblies

Q: I recently attended a conference where the speaker in the Life Safety session talked about the fire rating of the doors. She spoke of having the fire information labels on the doors. When I returned to the hospital, I found I only have about half the doors in my facility with the fire-rating labels. What do I need to do about this? Do I assume that all the doors are rated the same?

A: Fire-rated doors assemblies are required to have labels on the doors and on the door frames identifying that they are indeed fire-rated. The labels can be located on the side of the door or on the top of the door. Non-fire-rated door assemblies are not required to have any labels since there is no requirement for them to be fire-rated. In your case, it is reasonable to assume that not all door assemblies in your facility are actually required to be fire-rated and therefore do not have labels. You need to refer to your Life Safety drawings (or your original construction documents if your LS drawings are not accurate) to determine the location of the fire-rated doors assemblies in your facility, and then examine those door assemblies for compliance with the labeling requirements.

As a side note, I’ve been told by Mr. Jerry Rice, VP of DH Pace Company, Inc., that there is one exception to having labels on both the door and the frame. This would be on a ‘fire door assembly’ that comes from the factory as a complete assembly. These types of fire doors only have one label (none on the frame), and it is located under the top cap. The only sticker on the door is on the top cap that reads something like “Fire label under cap – Remove to view”. So, you would need to get on a ladder and take the cap off with a screwdriver if you want to see the label. Some AHJs deem that process is ‘not readily visible’ and push back, but most know of the door manufacturing process and accept the practice.

I personally have not seen these types of door assemblies in hospitals, but you need to be aware that they may be part of your facility.

 

Fire Door Maintenance

Q: If a door is a fire-rated door is it required to be maintained as a rated door in compliance with NFPA 80, regardless if its location doesn’t require a rated door? I was told by a facilities employee that there isn’t any information that he can find that states this. Really my fight with him is simple that a fire rated door regardless of location and function needs to meet the standards at all times i.e. door closer, holes in door and frame etc.

A: According to the 2012 Life Safety Code, section 8.3.3.1, openings required to have a fire protection rating must meet the requirements of NFPA 80. So, based on this passage, if the fire door is installed in a non-rated barrier, one could assume that testing the fire doors would not be required.

But one would be wrong. According to section 19.2.2.2.1 of the 2012 LSC, doors must be in compliance with section 7.2.1 of the same code. Section 7.2.1.15.2 says fire rated doors assemblies must be inspected and tested in accordance with NFPA 80. This section does not differentiate whether the door is in a fire-rated barrier or not. Therefore, all fire rated doors must be inspected and tested (and maintained) in accordance with NFPA 80.

The requirements of the occupancy chapter always over-rule the requirements of a core chapter when the two chapters conflict. So, in this case, section 19.2.2.2.1 has precedence over section 8.3.3.1, and requires all fire rated door assemblies, regardless if the door is installed in a fire-rated barrier or not, to be tested and inspected in accordance with NFPA 80.

You win… your friend loses… Start planning on testing all of the fire doors and have your first test completed by July 5, 2017.

Fire Rated Door Frames

Q: We have a mechanical room door that is ¾-hour rated. The mechanical room is a 10 foot x 10 foot room with two electrical panels and a small gas fired heating unit. The metal door frame does not have a rating label on it. Does the frame need to be ¾-hour rated?

A: Anytime you have a fire-rated door assembly, the frame needs to be labeled as a fire-rated frame. Door frames typically (but not always) just have a label that says it is a fire-rated frame without any time associated with it. Those frames that are just labeled as being fire-rated are good for 3-hours, according to information that I seen on the manufacturer’s website. After 3-hours, then the frame needs to be labeled with the specific fire-rating needed.

The room that you are describing is required to be classified as a hazardous room since there is a fuel-fired heating appliance in the room. A hazardous room in a healthcare occupancy under existing conditions is required to have 1-hour fire rated walls with a ¾-hour fire-rated self-closing and positively latching door if the room is not sprinklered. However if the existing room is protected with sprinklers then the Life Safety Code allows you to have smoke resistant walls with a non-rated smoke resistant self-closing positively latching door.

If the hazardous room qualifies as new construction (or renovation), then the room must be constructed with 1-hour fire rated walls with a ¾-hour fire-rated self-closing positively latching door and the room must be protected with automatic sprinklers.

Even if the fire rated door that you refer to is not required, you must maintain it as such, which means the frame must also be labeled as being a fire-rated frame.

Incorrect Interpretations on Smoke Door and Fire Door Testing

I just found out yesterday that CMS is teaching their state agency LS surveyors that smoke barrier doors need to be tested in healthcare occupancies. This interpretation of the 2012 Life Safety Code from CMS is incorrect, but your state agency on behalf of CMS may be expecting you to do this.

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. You may show them this code trail and perhaps they will allow you to not test your smoke doors, but 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, CMS has instructed their state agency LS surveyors 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 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).

New Fire Door Inspection Requirements

Cross Corridor door web 2When the new 2012 Life Safety Code becomes effective July 5, 2016, CMS will expect all healthcare organizations to be compliant with the requirements of the new 2012 Life Safety Code. One of the more challenging changes that the new 2012 Life Safety Code will require is compliance with NFPA 80-2010 edition, which requires all fire-rated door assemblies to be inspected annually.

This includes all of the side-hinged swinging fire-rated doors in your facility. And it applies to any fire rated door assembly, whether it is located in a required fire rated barrier or not.

The requirements for the annual inspection include the following:

  • Is the door and frame free from holes and breaks in all surfaces?
  • Are all the glazing, vision light frames and glazing beads intact and securely fastened?
  • Are the doors, hinges, frame, hardware and threshold secure, aligned and in working order with no visible signs of damage?
  • Are there any missing or broken parts?
  • Is the clearance from the door edge to the frame no more than 1/8 inch?
  • Is the door undercut no more than ¾ inch?
  • Does the active door leaf completely closes when operated from the full open position?
  • Does the inactive leaf close before the active leaf when a coordinator is used?
  • Does the latching hardware operate and secure the door in the closed position?
  • Is the door assembly free from are auxiliary hardware items which could interfere with its operation?
  • Has the door been modified since it was originally installed?
  • If gasketing and edge seals are installed, have they been verified for integrity and operation?

Anyone can do this inspection… there is no requirement that the inspector has to be certified. But the standard does require that the individual inspecting the door assembly is knowledgeable, so if you plan on using in-house people, make sure they have some sort of training. The IFDIA certification (see side panel) is one of many on-line courses to become trained for fire door inspections.

There is a Fire Door Inspection form you may down-load for free from this website. Just click on “Tools” and scroll down to the bottom to find it.

Fire and Smoke Door Clearances

Q: I have a question concerning clearances on fire rated doors and smoke compartment barrier doors. The way I read the 1999 Edition of NFPA 80 and the information in the 2000 Life Safety Code (LSC) is that a maximum gap of 1/8 inches is permitted between “meeting edges of door pairs”. In terms of 2000 LSC compliance would you agree that the 1/8 inch clearance on smoke barrier doors and fire rated doors is regulated at the “meeting edge of door pairs”?

A: According to the Annex section of 8.3.4.1 of the 2000 LSC, it says the clearance for the proper operation of smoke doors is defined as 1/8 inch. While the Annex section is not part of the enforceable code, it does provide a guide for authorities to use in making their own interpretations. The Annex does not limit the 1/8 clearance to just the meeting edges of a pair of doors and could be construed as meaning the edges of the door that meets with the jamb of the frame.

Section 2-3.1.7 of the 1999 edition of NFPA 80 says the clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 inch + 1/16 inch for steel doors and shall not exceed 1/8 inch for wood doors.

So, to answer your question: “In terms of 2000 LSC compliance would you agree that the 1/8 inch clearance on smoke barrier doors and fire barrier doors is regulated at the meeting edge of door pairs,?”, I would say yes it is regulated at the meeting edges of door pairs, but section 2-3.1.7 of NFPA 80 says the clearance between the edge of the door and the frame is included in the 1/8 inch limitation. So the clearance between the edges of the door and the frame are also included in the 1/8 inch requirement.

As far as smoke compartment barrier doors, I would also agree that the clearance between the meeting edges of door pairs are limited to 1/8 inch, but this is based on the current interpretation of the accreditation organizations and CMS state agencies. But I’m not so sure about the clearance between the door edge and the frame jamb as the 1/8 inch limitation is found in the Annex section, and it would have to be an interpretation by an authority since it is not written in the enforceable code. I personally do not have any experience on how accreditation organizations and CMS state agencies are surveying the issue of smoke compartment barrier door clearances between the door edge and the frame jamb. So, the clearances between a smoke compartment barrier door edge and the frame jamb is an issue that is not clearly defined at this time.

Temporary Signs on Fire Doors

Q: Are hand-made temporary directional signs permitted to be taped to fire doors? We had a surveyor tell us that nothing can be taped to a fire door.

A: Yes, temporary signs are permitted to be taped to a fire door, but they are limited in size. NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition, section 1-3.5, says informational signs installed on the surface of fire doors are permitted. The total area of the attached signs is not to exceed 5 percent of the area of the face of the fire door to which they are attached. Signs are required to be attached to fire doors using an adhesive. Mechanical attachments such as screws or nails are not permitted. Signs are not to be installed on glazing material in fire doors, and signs are not to be installed on the surface of fire doors so as to impair or otherwise interfere with the proper operation of the fire door. With a fire door size of 80” x 32” (approximate guess of the fire door in question), a single 8½ x 11 sheet of paper is well below the 5 percent maximum which the code permits. You state that the paper sign was observed to be attached to the door with adhesive, so it appears it meets the requirements for signage on fire doors. Sounds like a case for an appeal or clarification.     

Force to Open a Fire Door

Q: What is the permitted force to open a fire door? What kind of means can be used to test this onsite?

A: The answer to your question is found in section 7.2.1.4.5 of the 2000 edition of the Life Safety code, which says: “The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf to release the latch, 30 lbf to set the door in motion, and 15 lbf to open the door to the minimum required width. Opening forces for interior side-hinged or pivot-swinging doors without closers shall not exceed 5 lbf. These forces shall be applied at the latch stile. Exception #1: The opening force for existing doors in existing buildings shall not exceed 50 lbf applied to the latch side. Exception #2: The opening forces for horizontal sliding doors shall be as provided in Chapters 22 and 23. Exception #3: The opening forces for power-operated doors shall be a provided in 7.2.1.9.” I am not an expert in the available tools to measure lbs. of force, but a good-old fashion fish scale should do the job. Since you asked specifically for fire doors, I looked at NFPA 80 but did not find anything that would contradict the above section.

Frames for Fire Rated Door Assemblies

Label for Fire Door FrameDuring the building tour a surveyor observed a label on a frame for a fire rated door assembly that read “Fire Resistant Frame – This frame is identical in construction to a listed frame.  This frame does not bear a listing mark of a testing laboratory because of size, hardware preparation or other limiting factors specified by the user/owner”.  The surveyor initially decided to cite the organization for not having a frame that has  an hourly fire rating on the fire rated door assembly.

Before the survey report could be finalized, it was brought to the surveyor’s attention that NFPA 80 does not require an hourly rating on fire rated door assembly frames. According to NFPA 80, frames in a fire rated door assembly need to be identified that they are fire rated frames, but they do not have to be listed with a specific fire rating. NFPA 80 requires the door frame to be labeled as a fire rated frame, but it does not require the hourly rating to be on the label. It is apparent that a label that says it is a fire rated frame (but with no hourly rating) is good for up to and including 3-hour fire rated door assemblies. After that, the hourly rating needs to be inserted on the frame label.

In this situation the surveyor relented and the finding was not included in the survey report. Another example where a tactful approach explaining the codes and standards to the surveyor can lead to a successful outcome.

Use of Fire and Smoke Doors During a Fire Drill

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I was recently asked if the Life Safety Code addresses the use of smoke and fire doors during a fire drill. Here is what I responded with:

The Life Safety Code (LSC) does address certain key actions required by staff during a fire drill, but it does not specifically restrict the use of doors in fire or smoke compartment barriers while the fire alarm is activated. Section 18/19.7.1.1 of the 2000 LSC requires the healthcare occupancy to have a written plan for the protection of all persons in the event of a fire; for the evacuation to areas of refuge; and for the evacuation of the building when necessary. Section 4.7 of the same code also makes similar statements regarding orderly evacuation during a fire drill. It makes sense that opening and closing doors in a fire or smoke compartment barrier would be necessary in order to evacuate patients to another smoke compartment, or to evacuate the building. It also makes sense that responding emergency personnel (both internal and external) would have to open and close doors in order to assist with the evacuation or address the fire.

But perhaps what you are referring to is the action of the people who are not responding to the fire alarm, and they are going about their regular activity. Doctors, nurses, technicians, visitors, volunteers, vendors, and others may be ignoring the fire alarm and just continue to walk through doors to other parts of the building. These may be the people who you are referring to that are opening and closing fire and smoke compartment barriers doors during a fire alarm.

The Joint Commission standard EC.02.03.03, EP 4 says staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan. This is a little bit more than is required by section 18/19.7.1.3 of the 2000 LSC, which says employees of healthcare occupancies shall be instructed in life safety procedures and devices. A fire drill is certainly one method of instruction in life safety procedures and devices. But neither the Joint Commission standards (and EP) and the LSC reference actually requires all staff to participate in every fire drill. It just wouldn’t be practical in a healthcare facility that is providing treatment and care to patients.

Therefore, hospitals get to decide for themselves how their staff should react during a fire alarm, as stipulated in their fire response plan (also known as the Fire Safety Management Plan). Most hospitals that I have had the pleasure of working with require staff in the immediate area of the fire emergency respond by following R.A.C.E. (Rescue; Alarm; Contain; and Evacuate or Extinguish) and staff away from the origin of the alarm simply close doors and be ready to receive patients. Some hospitals have staff away from the origin of the alarm to dispatch one individual with a fire extinguisher to the scene of the alarm.

You can write into your plan what you want your staff to do. If you want them to stop at each closed door and not traverse through it until the ‘all-clear’ is given, that is your decision, but I don’t think that is a very practical idea, or one that would be followed. When a fire alarm is activated, it represents a potential disaster and even though it may seem that a ‘all-hands-on-deck’ call is needed, that is not the practical thing to do as a first response. If your facility has 1200 workers on the average day shift, and the fire alarm is activated in the 4th floor ICU, you do not want all 1200 workers to rush up to the 4th floor ICU; that is not practical.

The concept of fire response in a healthcare occupancy is all healthcare workers are trained in the facility’s fire response plan. You count on the staff in the immediate vicinity of the fire to respond appropriately and quickly. Once the alarm is announced, certain trained individuals rush to the area where the alarm originates. The rest of the staff is supposed to reply in accordance with your fire response plan. Quite honestly, unless the staff has specific duties during a fire alarm, moving about the hospital performing their normal duties in areas away from the alarm would be considered appropriate. You actually need the hospital to continue to function even during a fire drill. Each fire drill will not asses every staff member’s response; it just is not practical in such a large setting. That is one reason why there are so many fire drills in a hospital each year: By sheer quantity you hope to get nearly all of the staff to participate in at least one drill.

Another issue is physicians. What should they do during a fire alarm? Many hospitals are writing into their fire response plan that physicians on a nursing unit that are not actively providing care or treatment to a patient, should report to the nurse’s station and await direction. In a Surgery department, unless the operating room is the scene of the fire, you pretty much want surgeons and nurses to remain in the operating rooms and continue with the business at hand, and wait for further instructions from the surgery nurse’s station.

I don’t know if I’ve helped you with your question, but if it were me, I would let people do what they normally do, unless they have specific responsibilities during a fire alarm. If you are really concerned about certain fire or smoke compartment barrier doors being opened in close proximity to a fire, then it would be practical to station one person at the door preventing unauthorized individuals from opening that door.