Fire Watch Guidance

Q: We are looking for guidance now that the language of “If a fire watch is required, fire/smoke detection or alarm system outage” has become a point of conversation with our local and state Fire Marshals. We can’t seem to get a straightforward answer from them as to when exactly we need to implement a fire watch. For large projects, we will definitely be bringing in a contractor to install upright heads. Our question is related to the small, 1-2 day projects that may only have 1-2 heads without a ceiling barrier, making them non-compliant. Would this scenario, in your eyes, require a fire watch assuming no upright head installation? We struggle with the feasibility of both situations: implementing a continuous fire watch and also bringing in a contractor for just a couple of heads for one or two days.

A: Let’s take our guidance from section 9.6.1.6 of the 2012 Life Safety Code, which says where a required fire alarm system is out of service for more than 4 hours in a 24 hour period, then an approved fire watch must be conducted. Now, if we go to the Annex section A.9.6.1.6 it says the term ‘out of service’ is intended to imply a significant portion of the fire alarm system is not in operation, such as an entire initiating device circuit, signaling line circuit, or notification appliance circuit. It is not the intent to require a fire watch for a single non-operating device or appliance.

Now, I know that is for fire alarm systems and your question was specific towards sprinkler impairments, but the problem is beginning with the 2012 LSC, the LSC discontinued to have a standard on sprinkler system impairments, but in turn referenced NFPA 25-2011. So, we go to section 15.5.2 (4) through (6) for guidance. This section basically says whenever the sprinkler system is out of service for more than 10 hours in a 24 hour period, then you do a fire watch, contact the fire department, and notify the insurance carrier and the state AHJ. But in this case, the Annex section does not offer any explanatory information as what constitutes ‘out of service’ like the Annex section in the LSC does for fir alarm systems.

So, this means the AHJ gets to decide what ‘out of service’ means. I know that CMS and the accreditation organizations interpret it to mean a circuit or zone has to be out of service before a fire watch is required, and a single device impaired does not warrant a fire watch. But in your case, you’ve asked your state AHJ to explain their position and so far they have not.

I suggest you decide for yourself, since your AHJ refuses to make a decision. Write a policy that states a single device out of service does not warrant a fire watch, but rather a zone or circuit that is impaired does, and reference Annex section A.9.6.1.6 of the 2012 LSC as a guidance.

If the AHJ won’t help you by informing you what they expect, then you do the next best thing and decide for yourself based on referenced standards.

Sprinklers in Construction Areas

Q: My question is about removing ceiling tiles in a construction area, and not having adequate fire protection in a 6′ to 8′ high ceiling plenum. The suggestion had been made to turn the sprinkler heads up, but the water spray still will not reach 12 inches below the deck since the deck is very high. What would be considered an adequate solution besides erecting fire rated walls surrounding a construction area? Also, where in NFPA 13 does it mention the requirement for 12 inches below deck, and is there is a requirement to turn the existing sprinkler heads up?

A: NFPA 13-2010, section 8.5.4.1.1 says the distance between the sprinkler deflector and the ceiling above must be based on the type of sprinkler and the type of construction. Section 8.6.4.1.1.1 of the same standard says for standard pendant and upright type sprinklers, the minimum distance is 1 inch and the maximum distance is 12 inches between the sprinkler deflector and the ceiling. In your case, when the suspended grid and acoustical tile ceiling is removed for construction, the deck above now becomes the ceiling. If you have 6 feet of interstitial space above the suspended ceiling, that is more than 12 inches so the piping needs to extend upwards so the sprinkler deflector are within 12 inches of the deck. Make sure you install upright sprinklers… you cannot use pendant sprinklers in an upright position. There are exceptions and added requirements for ductwork, piping and ceiling-mounted obstructions.

The requirement to provide sprinkler fire-protection during a construction project comes from the NFPA 241-2009 standard on demolition and construction, required by 19.7.9.2 of the 2012 Life Safety Code. If your construction project is not protected with sprinklers during the construction phase, then you must construct 1-hour fire-rated barriers between the construction project and the occupied areas of the facility. A fire-rated barrier that is 1-hour is typically steel studs with one layer of 5/8 gypsum board on each side with all seams taped and covered with joint compound, and any openings would have to be 45-minute fire-rated door assemblies with closer and positive latching hardware. If the construction area is protected with sprinklers, then the barrier is not required to be 1-hour fire-rated, but construction tarps and flame-retardant plastic sheeting would not be permitted. Actual non-rated walls would be required.

Also, if an area of the healthcare facility is already protected with sprinklers, and the area is undergoing construction/remodeling that requires the removal of the suspended grid and acoustical tile ceiling, then a fire watch is required to be enacted until such time the sprinklers are no longer impaired. A fire watch is now based on the CMS Final Rule published on May 4, 2016. A fire watch must be performed by a trained individual who has no other duties to continuously patrol the impaired area looking for unsafe fire conditions, and must have the ability to immediately contact the fire department if they spot a fire. Continuous means this person is in the impaired area and does not leave to use the restroom, take a break or for any other reason. This is based on NFPA 25-2011, section A.15.2(4)(b). This goes on for 24-hours a day until the sprinklers are back in service. Even if you used minimum-wage individuals that would cost the hospital $3,500 to $4,000 per week, because you would need 5 individuals. This money could be better used to either turn sprinklers up to within 12 inches of the deck, or install sprinklers at the beginning of the project.

Sprinklers in Construction Areas

Q: We have a construction project in our cafeteria. We have an ILSM and additional measures in place. However, it was determined last week that we need to remove the sprinklers in the area for eight weeks. The construction is located on the lowest level and is unoccupied with no patient care in the area (but there’s patient care in the building). With the sprinklers out of service 24 hours a day, is a fire watch required? We also are looking at using 1 hour barriers and 3/4 hour doors during that time. Do the barriers change anything with a fire watch? Thank you

A: Can’t you re-install temporary sprinklers in this construction area for the duration of the project? You will need to turn the sprinkler lines upward to within 12 inches of the deck and install upright sprinklers. It is imperative that you have sprinkler protection, otherwise you will need to conduct a fire watch, continuously for the 8 weeks there are no sprinklers.

Yes… a fire watch is required because you have impaired sprinklers. It doesn’t matter where the impaired sprinklers are located… if you have impaired sprinklers, you must do a fire watch. NFPA 25-2011 section 15.5(4) says where the sprinkler system is out of service for more than 10 hours in a 24-hour period, you need to conduct a fire watch. CMS has said in their Final Rule to adopt the 2012 Life Safety Code published May 4, 2016, that a fire watch is conducted continuously, without interruption. The designated individual who performs no other function, continuously walks the impaired area looking for fire and the potential for a fire to occur, without leaving the area. This means the individual may not leave the impaired area to use the restroom, take a lunch break or any other function unless he is relieved by someone else.

This ‘continuous’ fire watch must be conducted for the duration that the sprinklers are impaired … 8 weeks. Can you afford to have that many FTEs designated to do nothing else but a fire watch for 8 weeks? I would believe it would be less expensive if you would turn up the sprinklers and install upright sprinkler heads in the construction area.

The fire watch does not affect the rated barrier, but the 1-hour fire rated barrier is required to separate the construction area from the occupied area if there are no sprinklers in the construction area.

Fire Watch Requirement

Q: When the code refers to a fire alarm system or sprinkler system being off-line for four or more hours in a 24 hour period (fire watch and fire department notification), does the entire system have to be off-line or just a portion to invoke the notification requirement?

A: The NFPA standards do not specifically address this issue, but I have seen The Joint Commission address this in one of their many publications, many years ago. I believe it was the EC News.

Essentially, the answer is no… the entire system does not have to be out of service before it qualifies for the fire watch and notification of the local fire department. Joint Commission said (and I’m paraphrasing here) that a single device out of service does not constitute the need for the fire watch and fire department notification, but an individual circuit or branch would. Many hospitals towers have two sprinkler zones per floor. If one of those zones were out of service for repairs for 4 or more hours in a 24 hour period, then a fire watch and fire department notification would be required.

Other AHJs have taken on the same interpretation as well.

Walking Surfaces

Walking surfaces in the means of egress are required to be even. This is one situation in the NFPA codes and standards where they clearly defined what ‘even walking’ surface actually is required to be. Take a look at section 7.1.6.2 of the 2000 edition of the Life Safety Code, which says:

Abrupt changes in elevation of walking surfaces shall not exceed 1/4 inch. Changes in elevation exceeding 1/4 inch but not exceeding 1/2 inch shall be beveled 1 to 2. Changes in elevation exceeding 1/2 inch shall be considered a change in level and shall be subject to the requirements of 7.1.7.

 

Section 7.1.7 defines the walking surface for a ramp not to exceed 1 and 20 slope.

So, it is pretty clear that the LSC does not want abrupt changes in the walking surface to exceed 1/4 inch or 1/2 inch if it is beveled. This is logical as most people only lift their feet the minimum amount to walk safely through the path of egress. I remember a maintenance man in the hospital where I worked who ‘shuffled’ his feet as he walked, never really lifting his shoes. This eventually caught up to him as one time he caught the leading edge of his shoe on the transition where the  PVC floor tile met the concrete floor, and down he went. The edge of the PVC floor tile was 1/8 inch above the concrete floor, which by section 7.1.6.2 definition, met the requirements of the LSC. But unfortunately, that 1/8 inch was enough to trip this poor individual, and cause him to fall.

In the picture above, the very nice throw rug was measured to be about 3/4 inch thick, which exceeds the limitations of 7.1.6.2. Not knowing whose office the rug was located in, I informed the staff that it was a violation and needed to be removed. I found out later that the office belonged to the Chief Nurse Officer of the hospitals and she was very upset to learn that her rug was not permitted.

The picture to the left shows a more common problem. The exit is an emergency fire exit and is not used as an entrance into the hospital, which is quite common. While there is no NFPA standard that says the exit discharge (the path from the exit door to the public way) is required to be paved with concrete, crushed stone, bricks or asphalt, we revert back to section 7.1.6.2 which requires a level walking surface in the means of egress. Make no doubt about it, the means of egress includes not only corridors, but aisles in rooms, and the discharge from the exit.

The common position by most (if not all) AHJs who inspect hospitals is the grassy walkway shown in this picture, between the exit door and the public way does not qualify with section 7.1.6.2 for abrupt changes no more than 1/4 inch. Therefore, an improved level walking surface is required between the exit door and the public way, which is usually poured concrete. Another factor about grassy walking surfaces in the cold weather states is the lack of snow and ice removal during the winter time. With a concrete walkway, the path is likely to be cleared of snow and ice, but without a designated path, it is not as likley that the snow and ice would be removed.

Hot Work in Construction

In the last post that I made, I mentioned ‘Hot Work’ in construction sites in a hospital require special fire barrier protection, which is a 1-hour fire rated barrier from the floor to the deck above, between the construction and any occupied areas. This is found in NFPA 241 Standard for Safeguarding Construction, Alterations, and Demolition Operations (2000 edition), section 8.6.2. Now, Joint Commission does not enforce this level of protection, and all they require is flame resistant smoke-tight barriers that extend from the floor to the ceiling, mainly because the 2000 edition of the Life Safety Code only references the 1996 edition of NFPA 241, and not the 2000 edition of NFPA 241. The 1996 edition of NFPA 241 did not require the 1-hour barriers around ‘Hot Work’, only flame resistant smoke-tight barriers.

As a hospital facility manager, you need to be aware of this difference because many of the state agencies who survey on behalf of CMS will enforce NFPA 241 (2000) requirements. Here are examples of what ‘Hot Work’ can be:

  • Welding
  • Brazing
  • Soldering
  • Cutting with a torch
  • Grinding

It is suggested that you review your own policies on construction barriers and consider having 1-hour fire rated barriers whenever any ‘Hot Work’ is being done on a demolition, renovation, construction or remodel project.

There may be times when a service technician will need to use an open flame torch to solder or braze a fitting for a repair function. While this should be tracked and covered with your own ‘Hot Work Permit’ program, it is important to identify that it is not construction and 1-hour fire rated barriers are not required.

NFPA does not define ‘construction’ so I turned to the dictionary which says construction is: The act of putting together to form an assembly. So, remodeling something, or a renovation process appears to me to be construction and would require the 1-hour barriers for ‘Hot Work’. But repairs would not.

But my opinion does not count. Since NFPA does not clearly define what ‘construction’ is, the authorities having jurisdiction (AHJ) are the ones who get to make this determination. Don’t be caught by surprise: If you haven’t already done so, I suggest you contact you local and state AHJs and ask them what they require for fire barriers when you have ‘Hot Work’ in construction sites inside the hospital.

Fire Watch Frequency Requirements

Q: Do you know of any guidelines for the amount of time you have to conduct a fire watch during an Interim Life Safety Measures (ILSM) operation? Does it have to be every hour, or can it be every shift, or even once a day?

A: The requirement for Interim Life Safety Measures originates in section 4.6.10.1 of the LSC and is actually referred to as Alternative Life Safety Measures. This section of the code does not specify the frequency of any measure implemented to compensate for an impairment to life safety. Sections 9.6.1.8 and 9.7.6.1 requires a fire watch must be provided (or evacuate the facility which is not feasible in a hospital) whenever the fire alarm system or sprinkler system is out of service for 4 or more hours in a 24-hour period. Again, these sections do not specify how often the fire watches should occur. There are other NFPA documents that discuss fire watches such as NFPA 601 Standard For Security Services in Fire Loss Prevention (1996 edition) and NFPA 51B Standard for Fire Prevention During Welding, Cutting, and Other Hot Work (1999 edition) but none of these standards specifies a frequency that fire watches should be implemented. So, when the code and standards do not specific a specific frequency, then it is up to the authorities having jurisdiction (AHJ) to interpret what the frequency should be. Since the typical hospital has 5 or 6 AHJs inspecting their hospital according to NFPA codes and standards, then you must adhere to the most restrictive requirement. While the Joint Commission does not officially specify the frequency a fire watch occurs, their senior engineer in the Standards Interpretation Group has said during informal discussions that he would require hospitals to have fire watches twice per shift, based on an 8-hour shift.

However, I suggest that you contact your local and state AHJs and find out what they require. My experience shows that many localities have surprisingly restrictive requirements when it comes to fire watch frequencies.

Fire Watch Requirements

Q: What is actually required in order to perform a Fire Watch when the fire alarm system is inoperative? How often should a Fire Watch be performed?

A: The Life Safety Code (LSC) section 9.6.1.8 requires an approved fire watch be conducted whenever the fire alarm system is out of service for 4 or more hours in a 24 hour period. The Annex section A.9.6.1.8 explains that a fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard to walk the affected areas. These individuals should be specially trained in fire prevention and in occupant and fire department notification techniques.

NFPA 601 (1996 edition) Standard for Security Services in Fire Loss Prevention provides examples of procedures for fire loss prevention:

  • Check permits for hot work
  • Check for obstructed sprinkler heads or closed control valves
  • Check portable fire extinguishers for availability
  • Check temporary fire alarm equipment
  • Check affected area is clear of discarded packaging
  • Check affected area for clear path of egress
  • Check for any forms of ignition

While there is not a specific requirement that fire watches be performed by security personnel, it is strongly recommended that you do not leave this important responsibility to someone who does not have an active stake in the safe operation of your facility. There is not a prescribed frequency in any NFPA code or standard on how often a fire watch should be conducted, so it is left up to the authorities having jurisdiction (AHJ) to make this determination. Joint Commission has indicated that two fire watch rounds per 8 hour shift would be acceptable, however it is recommended that you contact your local and state authorities to determine what frequency they require.

NOTE: Whoever you choose to perform the fire watch, they will need to have basic training on what to look for and what action to take. The Fire Watch form under the “Forms” page can be used for not only documentaing that a fire watch has been initiated, but also serves as an education tool for just-in-time training for the individual who conducts the fire watch.