Contractor’s Fire Extinguishers

Q: Is the hospital responsible for the fire extinguishers supplied by the contractors while they are performing work in our hospital? We had a surveyor cite us for not performing monthly inspections on a fire extinguisher that did not belong to us, but was on a construction site in the hospital.

A: Yes, the hospital is responsible for all fire extinguishers in your facility or on your property, regardless who owns the first-aid devices. According to section 19.3.5.6 of the 2000 edition of the LSC, compliance with section 9.7.4.1 is required. Section 9.7.4.1 in turn requires compliance with NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition for installation, inspections and maintenance. Section 1-2 states that NFPA 10 is prepared for the use and guidance of persons charged with selecting, purchasing, installing, approving, listing, designing and maintaining portable fire extinguishers. The Annex section of 1-2 continues to say that the owner or occupant of a property in which a fire extinguisher is located has an obligation for the care and use of the extinguishers at all times. This standard does not differentiate as to who owns the extinguishers, it simply states the owner of the building is responsible. When an accreditation organization surveys the hospital for compliance with the LSC, they are surveying the hospital, not the contractors. The actions and operations of contractors are your responsibility as long as they are on your property, therefore you are responsible for the extinguishers. This is why I always prohibited contractors from bringing their own extinguishers into the hospital where I worked. I insisted that the hospital provide adequate extinguisher coverage, and I supervised where they were located and when they were inspected. My advice is to never rely on a contractor to comply with a LSC requirement.

Contract for Maintenance of Portable Fire Extinguishers

Q:  Is there any formal requirement to have a “contract” with a fire extinguisher company for extinguisher maintenance? I have a copy of their credentials but recently was I lead to believe that we needed a formal contract.

A:  The 2000 edition of the LSC requires compliance with NFPA 10 Standard for Portable Fire Extinguishers, (1998 edition) which does not require any special type of contract with the agency performing the extinguisher maintenance. Also, the 1998 edition of NFPA 10 does not require any certification or licensure for the person or entity that performs the annual maintenance. The Joint Commission standards and the CMS Conditions of Participation do not have any language that requires a contract. So, unless your local or state authority has any special requirements regarding fire extinguisher maintenance, I believe it is safe to say there is no requirement for a contract on fire extinguisher maintenance.

Fire Extinguisher Inspection Tag

The picture of the inspection tag on the fire extinguisher to the left is not the greatest quality and I apologize for it being out-of-focus. I took the picture because the technicians at the hospital where the extinguisher was at only entered the month and year on the tag, rather than the month and day.

Section 19.3.5.6 of the 2000 edition of the Life Safety Code requires compliance with section 9.7.4.1, which in turn requires compliance with NFPA 10 (1998 edition) Standard for Portable Fire Extinguishers.  NFPA 10 (1998 edition), section 4-3.4.2 requires the monthly inspection to be recorded including the date and the initials of the person performing the inspection. The ‘date’ includes the month and day of the month.

 

The annual maintenance is required to be recorded which includes the date (this time the month, day, and year is required) and the initials of the person performing the maintenance. Many fire extinguisher contractors are just stamping the technicians name on the card, which is not what NFPA 10 requires.

Most AHJs are now enforcing this type of month/day documentation for the fire extinguisher inspection and annual inspection. Just punching a hole in the month and year on the inspection tag for the annual inspection is no longer enough. The month, day, and year needs to be clearly listed.

Travel Distance Requirement to Fire Extingushers

 

Hazard Classification

Hazard Type

Minimum Fire

Extinguisher Rating

Travel Distance

Class A

Low

2-A

75   ft

Class A

Moderate

2-A

75   ft

Class A

High

4-A

75   ft

Class B

Low

5-B

30   ft

10-B

50   ft

Class B

Moderate

10-B

30   ft

20-B

50   ft

Class B

High

40-B

30   ft

80-B

50   ft

Class C

A Class C fire is started by an electrical means, but the fire itself is either a Class A or a Class B fire. Therefore, the travel distance and the size and type of extinguisher must be sized and located on the basis of the anticipated Class A or Class B hazard.

Class K

A   Class K extinguisher must be provided where hazards exists involving combustible cooking oils or fat.

30   ft

Source: NFPA 10 (1998 edition)

Carbon dioxide fire extinguishers

Q: Can you direct me to the standard that states we must have a CO2 fire extinguisher in the operating rooms of our surgery department? Our operations chief insists a CO2 fire extinguisher must be installed in every operating room, and our director of surgery is resistant to the idea.

A: There is no Life Safety Code® (LSC) requirement that says you have to have a CO2 fire extinguisher (or any other type of fire extinguisher, for that matter) inside the operating rooms. Section 19.3.5.1 of the LSC refers to section 9.7.4.1, which requires you to follow NFPA 10 Standard for Portable Fire Extinguishers (1998 edition) as far as placement, classification, and capacity.

Since you mentioned a CO2 fire extinguisher, I will discuss the required placement for those. A CO2 fire extinguisher is a Class B:C type fire extinguisher, meaning it is rated to extinguish fire involving flammable liquids and energized electrical sources.

A risk assessment is required to determine if in fact you actually have flammable liquids in the particular operating room that you are interested in. If you don’t, then a Class B:C fire extinguisher is not required in that area. If you do, then your assessment needs to identify if the quantities of the flammable liquids are low, moderate, or high (it had better not be moderate or high…that’s plain weird for an OR).

Assuming it is low, you then need to place a Class B:C fire extinguisher (which could include but is not limited to a CO2 extinguisher) either 30 feet from the flammable liquids or 50 feet, depending on the capacity rating of the Class B:C extinguisher. All fire extinguishers are labeled with their approved capacity rating, such as 5-B:C, or 10-B:C rating. A 5-lb. CO2 fire extinguisher is typically (but not always) rated as 5-B:C, which would make the travel distance from the flammable liquid hazard to the extinguisher no more than 30 feet. If the Class B fire extinguisher is rated at 10-B:C (typically a 10-lb CO2 extinguisher, but not always) then the travel distance is allowed to be 50 feet, but not more. [Refer to the sidebar on page 11 for travel distances].

When flammable liquids are present in the operating rooms many hospitals decide to include a Class B:C CO2 fire extinguisher to provide a safer environment for their patients and staff. Other hospitals decide to place them outside the operating rooms but within the allotted travel distance. Either is fine and permissible.

CO2 Fire Extinguishers in Operating Rooms

Q: Can you tell me if there is a requirement for the operating rooms to have a CO2 fire extinguisher inside the rooms themselves? Our hospital received a citation by the physician surveyor on this issue for not having them in the operating rooms. Our local fire marshal has told us to place the sterile water-mist extinguishers in each room, which we did. What do you think?

A: There is no Joint Commission, CMS or NFPA requirement to have a CO2 fire extinguisher inside the operating room. The Joint Commission standards refer to NFPA 10-1998 Standard for Portable Fire Extinguishers on placement, inspection, maintenance and testing of fire extinguishers. CO2 extinguishers are used on Class B fires which are for flammable liquids. If there is a potential of flammable liquids in the operating room, then you would have to have an extinguisher with a Class B rating within either 30 feet or 50 feet of the hazard, depending on the level of hazard and the rating of the extinguisher. This can be accomplished by having a Class B extinguisher in the hallway outside of the operating rooms. There is no requirement for extinguishers to be located inside the operating room. However, since your local authority having jurisdiction (AHJ) has requested that sterile water-mist extinguishers be placed in every operating room, this constitutes a risk assessment and is a valid course of action to take when the standards and codes do not have a direct requirement. Therefore, the surveyor cannot cite you for not having CO2 extinguishers inside the operating rooms. [NOTE: Water-mist extinguishers are not Class B extinguishers, but are Class A/C. If flammable liquids are present in the operating rooms, then a Class B extinguisher would have to be located with the appropriate travel distance of the hazard.]  One last thing: The issue of a CO2 extinguisher placed inside the operating room is the surveyor’s opinion and it’s a good one. Surveyors are taught to be consultative and make suggestions on “best practice”. In this case though, it sounds like the surveyor crossed the line and confused “best practice” with a standard requirement.

Travel Distance to Fire Extinguisher on a Helipad

Q:  Is there a maximum distance that a fire extinguisher needs to be located from a helipad? Where would I find the fire extinguisher requirements for a helipad?

A: NFPA 418 (1995 edition) addresses the classification of fire extinguishers for helipads, Table 5-1 lists the size according to the length of the helicopter, including the tail boom and rotors. For helicopters up to 50 feet long, a 4-A:80-B fire extinguisher is required. For helicopters from 50 feet up to 80 feet, a 10-A:120-B is required, and for helicopters from 80 feet up to 120 feet in length, a 30-A:240-B is required.

NFPA 10 (1998 edition) addresses the appropriate travel distances for fire extinguishers from the source of ignition. For Class B (flammable liquid) fires, the maximum travel distance of a fire extinguisher with a classification of 80-B is 50 feet. However, since there is a spreading property of aviation fuel, and it may be considered a three-dimensional fire (pouring, running, and dripping flammable liquid), section 2-3 consider this a special hazard and placement of fire extinguishers should be in collaboration with the local authority having jurisdiction. A risk assessment that considers the source of fuel, and the hazard that a large fire extinguisher may present when placed in locations that could interfere with the safe operation of the aircraft should be conducted and reviewed by the organization’s Safety Committee.