Sprinklers in Patient Room Lockers

Q: Are sprinklers required in patient room lockers for existing facilities?

A: No… Section 8.1.1 (7) of NFPA 13-2010 says furniture not intended for occupancy is not required to be sprinklered.

Fire Hose Valves

Q: We recently had our fire sprinkler inspection and was informed by the vendor that with the new 2012 LSC updates, every fire hose connection valve weather it is 1½ inch or 2½ inch needs to be tested and operated annually to verify they are in working order. We have had our fire hoses removed quite some time ago per recommendation from our local fire department. Are these fire hose valves (which are not used) still required to be tested?

A: Yes… but not as you say. First of all, removing the occupant use fire hoses does not mean the fire hose valves will not be used. The fire department will bring their own hoses in to hook up to your standpipe system. Secondly, the fire hose valves must be inspected quarterly, and the fire hose valves that are 2½ inches are required to be tested annually, and the fire hose valves that are 1½ inches are required to be tested once every 3-years.

Take a look at NFPA 25-2011, section 13.5.6.1 for quarterly inspections and section 13.5.6.2 for annual/3-year testing requirements. Just because you removed your occupant use fire-hoses does not relieve you of the responsibility of testing, inspecting and maintaining your fire hose valves. You have them – then you must maintain them.

Mechanical Room Fire Extinguishers

Q: What are your thoughts on using CO2 extinguishers in an HVAC mechanical room, instead of an ABC type?

A: It likely would be a situation where you would be non-compliant with NFPA 10-2010, and therefore you would not be compliant with the 2012 LSC. A CO2 extinguisher carries a BC rating, meaning it is classified for use on flammable liquid fires and electrical fires. But what about fires in your mechanical room that are caused by normal combustibles (paper, cardboard, plastic, linen, etc.)? I’ve yet to see a mechanical room that did not have some level of combustibles stored in the room (filters, boxes of spare parts, trash bags, etc.).

I would recommend ABC fire extinguishers for all mechanical rooms, and the dry powder type is the most common and affordable to use. However, if the mechanical room has sensitive electronic equipment, then perhaps a Clean Agent ABC type extinguisher would be more appropriate.

CO2 extinguishers have a limited value, and should only be used in areas where you have flammable liquids in use and storage, such as laboratories, pharmacies, and perhaps a grounds garage.

Fire Extinguishers in Vehicles

Q: What is the standard on fire extinguishers in work vehicles? We have them in our transit vans to our home health nurses. Do we need them inspected and retagged every year like our buildings? Also do they need a monthly check as well?

A: I am not aware of any NFPA code or standard that requires portable fire extinguishers inside vehicles used/owned/leased by healthcare organizations. If there is a requirement to have them, it may come from your insurance provider.

However, the expectation is once you have them, you must maintain them. So that would mean you need to inspect them monthly, and provide maintenance service on an annual basis.

Missing Ceiling Tiles

Q: Do missing ceiling tiles in a suspended ceiling create a Life Safety Code deficiency in an existing business occupancy? Should section 4.6.12.2 of the 2012 Life Safety Code apply to require the maintenance of broken or missing ceiling tiles in a business occupancy?

A: The complete membrane that the ceiling forms is required if sprinklers or smoke (or heat) detectors are installed in the room or area served by the ceiling. The ceiling acts to trap the heat and smoke and allows the sprinklers or detectors to operate. Otherwise, if a ceiling tile is missing, or has excessive gaps around penetrations, or the ceiling tiles have holes, then heat and smoke can continue up into the interstitial space above and the operation of the sprinklers and/or detectors would be delayed, thus causing an impairment.

If there are no sprinklers or smoke (or heat) detectors in the room or area, then there may not be any Life Safety Code reason for the ceiling system, unless it serves as part of the fire-rated floor/ceiling system, such as UL-G227 or UL-G235. Section 4.6.12.2 would not apply if the ceiling is not serving a purpose of life safety. Now, the suspended grid and tile ceiling may serve an Infection Control purpose, and you would have to maintain it for that reason, but that is not a Life Safety Code purpose.

Yes… this would apply to business occupancies. It is not dependent on any particular occupancy.

Quarterly Test of Main Drain

Q: Has the frequency for the main drain testing changed from annually to quarterly?

A: Yes… but not for all the main drain test locations. The new 2012 LSC now references the 2011 edition of NFPA 25, and section 13.2.5.1 of NFPA 25-2011 requires once per quarter, one (not all) main drain test must be conducted on a system riser located downstream of the backflow preventer when the sole water supply is through a backflow preventer. This test must record the static water pressure, the residual water pressure, and the time required to restore water pressure to static pressure. This test is conducted with the fire pump off (if so equipped) and the jockey pump on.

You still must conduct an annual main drain test on all of the system risers.

Strange Observations – Part 35

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

This is pretty easy to spot… A sprinkler hanger used to support copper medical gas pipe.

Not permitted….

Fire Extinguishers

Q: Are portable fire extinguishers required in business occupancies?

A: Yes… Section 38.3.5 of the 2012 Life Safety Code says portable fire extinguishers must be provided in every business occupancy in accordance with 9.7.4.1. Section 9.7.4.1 references NFPA 10 for installation, inspection, and maintenance of portable fire extinguishers.

Strange Observations – Part 33

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

Equipment rooms can be a major source of findings for surveyors.

Mostly because equipment rooms are often out-of-sight / out-of-mind. And because often times no-one is assigned to maintain the equipment rooms in safe condition.

Here we have a trash cart and a water machine obstructing access to electrical panels and a fire extinguisher.

Fire Extinguisher Signs

Q: I was wondering if there was a specific regulation that states exactly where fire extinguisher signs need to be located. Is there a difference between patient area and staff area? Looking over the new Life Safety Code regulations I have not been able to get a specific answer on where signage location is mandatory.

A: The only thing I can find is section 6.1.3.3.2 of NFPA 10-2010, which says where visual obstructions of fire extinguishers cannot be completely avoided, means shall be provided to indicate the extinguisher location. The Annex section says acceptable means of identifying the fire extinguisher locations include arrows, lights, signs, or coding of the wall or column.

 So, while there is no direct requirement to install signs over fire extinguishers, you may do so. However, be aware: Some AHJs will expect signs identifying the locations of all extinguishers once you start using signs. Their logic is, if you use signs to identify the location of some extinguishers, then your staff will expect to see signs for all extinguishers.

The AHJs do have the right to interpret the code as they see fit. I suggest you ask your AHJs to see if they would require all of the extinguishers have signs.