Fire Door Inspections

Q: Other than the annual fire door inspection that is required in the 2012 Life Safety Code, are there other inspections required? Fire doors that are included are also single fire rated doors in places like store rooms and maintenance shops, correct?

A: I’m not sure I understand your question. When you ask ‘are there any other inspections required?’… are you asking if there are any other inspections required of the fire doors? If so…. I am not aware of any. But if you’re asking are there any other inspections required in the 2012 LSC… then the answer is yes. If you’re asking if there are any other new inspections required by the 2012 LSC then I’ve included a list of changes required by the 2012 LSC that include these new inspections. In summary, new inspections are:

  • Monthly inspections of sprinkler pressure gauges
  • A quarterly main drain test on one system riser if the sprinkler water is supplied through a backflow preventer
  • A quarterly inspection of all fire hose valves
  • An annual fire door inspection
  • An annual test on all 2.5 inch fire hose valves
  • A 3-year test on all 1.5 inch fire hose valves
  • A 5-year internal inspection on sprinkler pipe

All fire rated doors must be inspected annually, regardless what they serve. So fire doors on storage rooms and maintenance shops must be included.

Fire Door Testing

Q: Now that we have some clarification from CMS on annual door inspection [See CMS S&C memo 17-38, dated July 28, 2017], I wanted to see if there was any new interpretation on rated corridor doors (20 minute and up) that are installed in non-rated wall assemblies. In looking at most publications from different authorities, they have interpreted that all rated doors need to be annually inspected since it could be obvious to the public. Section 4.6.12.3 of the 2012 Life Safety Code says existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. However, section 4.4.2.3 says where specific requirements contained in Chapters 11 through 43 differ from general requirements contained in Chapters 1 through 4, and Chapters 6 through 10, the requirements of Chapters 11 through 43 shall govern. If the chapters 11-43 govern over chapters 1-10 why are the authorities not recognizing 19.3.6.3.3 where it states compliance with NFPA 80 shall not be required? Unfortunately, it doesn’t say this for “smoke barrier” doors, so the authority’s logic could still have reason. In my interpretation of 4.6.12.3 and reading the appendix it seems that NFPA is referring to first response Life Safety features, like a pull station, fire extinguisher, strobe lights, fire panels etc….. If Joe Public is seeing a fire door do its thing, it’s probably too late. Certainly, first response LS features should always work even if they are not required.

 A: You make many excellent points. But the way I see it (and interpretations by most of the AOs and CMS agree), section 8.3.3.1 of the 2012 LSC requires compliance with NFPA 80 for fire doors and windows. There are no exceptions in 8.3.3.1 that exclude fire-rated doors located in non-fire-rated barriers. Compliance with 8.3.3.1 is required by section 19.1.1.4.1.1. Where section 19.3.6.3.3 says compliance with NFPA 80 is not required, they are speaking about non-fire-rated corridor doors, which are in smoke partitions that separate a corridor from another area or room.

Smoke barrier doors are often not corridor doors; they are cross-corridor doors. But at times, a smoke barrier can (and does) include a corridor wall and what appears to be a corridor door is now also a smoke barrier door. In those situations, the hospital has to comply with the most restrictive requirements.

To me, it is plain: If you have a fire-rated door (regardless if it is located in a fire-rated barrier or not), then it must comply with NFPA 80 and you must test and inspect it on an annual basis.  I’ve been told that the opinions from the staff at NFPA do not agree with this, but NFPA does not enforce the LSC, so we need to comply with those interpretations made by the authorities who enforce the Life Safety Code, such as CMS and the AOs.

 

Testing of Smoke and Fire Doors

Q: With regards to the 2012 edition of the Life Safety Code and the requirement to perform annual inspections of smoke/fire doors, would it be safe to assume that annual for “year one” would be between August 2016 and August 2017 and even beyond if we apply the +/- days to the annual requirement? We are having trouble trying to get everything done am hoping we can push out the new annual door inspection tasks.

A: First of all, I do not believe that smoke doors in healthcare occupancies are required to be inspected. 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. 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, some authorities say 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, educational 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).

Secondly, CMS has stated that they require the first test/inspection of the fire doors to be completed by July 5, 2017. This date is based on the effective date of the 2012 Life Safety Code (which was July 5, 2016), and the fact that the fire door testing is an annual event. So, the first annual inspection is not due until July 5, 2017. I know the Accreditation Organizations will follow suit.

By the way… CMS has stated they do not approve of the ‘+’ portion of due dates. In other words, if the accreditation organization says annual means 12 months from the previous test, plus or minus 30 days, CMS is saying they do not approve of the ‘plus 30 days’. They don’t mind the ‘minus 30 days’ but they do not approve of any test/inspection going beyond what is required for a due date.

Fire Door Annual Test & Inspection

Q: I’d like some clarification concerning the new requirement for annual fire door inspections: NFPA 101 2012, Chapter 7.2.1.15 States “Where required by Chapters 11 through 43, the following door assemblies shall be inspected ….”. I haven’t found anything in Chapters 18 or 19 that specifically require the annual inspection. Additionally, the NFPA 101 Handbook specifically states that only occupancies requiring inspections are Assembly, Educational, Day-Care and Residential board and care. My question is where is the specific reference that is requiring hospitals to conduct annual fire door testing?

A: What you stated was actually section 7.2.1.15.1 which does not refer to fire-rated doors, but to certain doors in high-traffic areas, or doors of high importance, such as doors equipped with panic hardware, doors in exit enclosures, electrically controlled doors, or doors with special locking arrangements. Now some of these doors may be fire-rated, but section 7.2.1.15.1 does not specifically refer to fire-rated doors. Therefore, that is why this section is only required if the occupancy chapter requires it and you’re correct in saying the healthcare occupancies do not require it.

And you’re correct: These doors are only required to be tested in occupancies where the occupancy chapter specifically requires it. The healthcare occupancy chapters and the ambulatory healthcare occupancy chapters and the business occupancy chapters do NOT require it, so the test and inspection identified in 7.2.1.15.1 are not required in healthcare, ambulatory healthcare, and business occupancies. Now, if you have mixed occupancies in your hospital and have areas that could qualify as assembly occupancy (i.e. dining areas, auditoriums, large conference rooms, etc.) then you would have to make sure the doors identified in 7.2.1.15.1 are tested and inspected in those areas.

But look at section 19.1.1.4.1.1 which refers to fire-rated doors and at the end of this section, it says “See also Section 8.3.3.1”. Section 8.3.3.1 requires openings that are required to have a fire-protective rating (i.e. fire-rated doors) shall be protected, by approved, listed labeled fire door assemblies with the requirements of NFPA 80. Since NFPA 80 requires annual test and inspections of all fire doors, this is the section (not 7.2.1.15.2) that requires you to test and inspect your fire-rated doors.

The CMS S&C memo 17-38 which was issued on July 28, 2017, describes this issue as well. CMS re-adjusted their expected completion date for the first fire-door test and inspection from July 6, 2017 to January 1, 2018, but not all of the Accreditation Organizations followed suit. Check with your authorities having jurisdiction to confirm what date they are expecting you to complete your first fire-door test and inspection.

AHJ on Fire Door Inspections

Q:  Does the authority having jurisdiction have the final say whether or not an individual has the ‘knowledge and understanding’ required to perform fire door inspections?

A: Yes they do. Take a look at 4.6.1.1 of the 2012 LSC “The authority having jurisdiction shall determine whether the provisions of this Code are met.” That means the AHJ decides if the organization is compliant with the applicable NFPA codes and standards. But, keep in mind the typical hospital has 5 or 6 different AHJs that inspect their facility for compliance with the LSC:

  • CMS
  • Accreditation organization
  • State health department
  • State agency with over-sight on hospital construction
  • State fire marshal
  • Local fire inspector
  • Liability insurance company

Not one AHJ can over-ride another AHJ’s decision. All AHJs are equal… but different. If 5 AHJs say the qualifications of the person performing the fire door inspections are fine, but 1 AHJ says no, then the hospital must comply with the most restrictive requirements and comply with the latter AHJ’s desires. An AHJ may have rules and requirements that exceed NFPA standards, as well they should. NFPA standards are minimal standards, and most hospitals exceed the NFPA standards in some capacity, often due to local ordinances or state regulations (and sometimes at the whim of the design professional). But, if the AHJ decides to have standards that exceed the minimal NFPA requirements, they need to be able to justify that decision.

It is not at all uncommon for a healthcare organization to seek permission from a state or local AHJ (i.e. state fire marshal) to install a particular device or have a particular feature, only to find out later that their accreditation organization does not agree, and cites the issue. Both the state or local AHJ and the accreditation organization are correct; they are interpreting the Life Safety Code as they see fit. Whatever was approved by the state or local AHJ is just an approval for the state or local regulations. What was cited by the accreditation organization was cited based on the accreditation organization’s regulations and understanding of the Life Safety Code.

This is why healthcare organizations need to obtain permission and interpretations from all of their AHJs… not just one or two.

Fire Rated Doors in Non-Fire-Rated Walls

Q: If a fire door is in a wall that is not a fire-rated wall, will the wall need to be brought to be a fire-rated wall?

A: No… not typically. The location of fire-rated barriers (i.e. walls) are determined by the design professional (i.e. architect) when the facility is designed and constructed. Often times, after the facility is built and operating for a few years, new locations that require fire rated barriers are identified. These could include rooms that are newly designated as hazardous areas, or perhaps a building separation from a new addition.

It is not uncommon for some design professionals to specify fire-rated door assemblies in barriers that are not fire-rated. This may be due to a building code requirement, or it may be due to a misunderstanding of the codes and standards. For whatever reason, once these fire-rated door assemblies are installed, you must maintain them in accordance with NFPA 80 which includes annual fire-door testing and inspections. But there is no requirement to designate a barrier to be labeled as a fire-rated barrier simply because it has a fire-rated door assembly installed in it. To be sure where the fire-rated barriers are actually located, refer to the Life Safety drawings and/or original construction documents of the facility.

Fire Door Inspection Qualifications

Q: In regards to fire door inspections, what are the qualifications of the person to perform the inspection?

A: NFPA 80-2010, section 5.2.3.1 says fire doors must be tested by individuals with knowledge and understating of the operating components of the door assembly, but NFPA 80 does not identify or describe what ‘knowledge and understanding’ actually means. The word ‘qualified’ is not found in this context of describing the individual who performs this inspection. When the codes or standards are vague (as they often are), then it is up to the authorities having jurisdiction to decide how to interpret the code or standard (see 4.6.1.1 of the 2012 LSC). When the AHJ does not make an interpretation of the code or standard, then it is up to the individual facility to decide what’s right.

In this case, no national AHJ has published an interpretation for hospitals on what ‘knowledge and understanding’ is required to test and inspect fire door assemblies. Therefore, hospitals and other healthcare organizations have the right to decide what that means. However, during a survey or an inspection, the AHJ surveyor has the right to question how the hospital determined their individual has the ‘knowledge and understanding’ and if it is not satisfactory to the AHJ surveyor, then a citing may be in order.

My advice to healthcare organizations on this issue is to document why they believe their individual has the ‘knowledge and understanding’ to perform the inspections. If their maintenance person has worked on fire doors for 20 years then that may be sufficient evidence.

I also recommend healthcare organizations to sign their people up for an online course on fire door inspections, by using the link and coupon code located at the right-hand side of this web-page, to the International Fire Door Inspector Association (IFDIA).

Door Undercuts

Q: What is the maximum you can have between the bottom of door and the thresholds for a fire-rated door assembly? I have some stairwell doors with 1 inch to 1 ¼ inch gap between the bottom of the door and the threshold.

A: That will be a problem. According to section 8.3.3.1 of the 2012 Life Safety Code, you must install fire-rated door assemblies in accordance with NFPA 80-2010. Section 4.8.4.1 of NFPA 80-2010 says the clearance under the bottom of the door shall be a maximum of ¾ inch. Also, section 7.2.1.15.2 of the 2012 Life Safety Code says you must maintain the fire rated door assemblies in accordance with NFPA 80.

Any clearance under the bottom of the door (while it is in the closed position) that exceeds ¾ inch will be considered non-compliant. There are after-market devices available that you can install on the door to fill that gap, but you must be very careful as you can only install devices that have been listed by an independent testing laboratory (i.e. UL, FM Approval, Intertek) that have been approved for that purpose.

Keep in mind that there are limitations on the door material, amount of clearance, and the rating.  Here are links to information on 3 products suggested to me by Lori Greene (see her website at www.idighardware.com), but there may be more:

Zero:  http://idighardware.com/2013/03/solution-for-oversized-undercuts/

NGP:  http://idighardware.com/2015/01/new-products-for-oversized-fire-door-clearances/

Crown:  http://idighardware.com/2014/06/a-fire-door-test-first-hand/

Doors Wedged Open

Q: It has been our practice to not allow door hold open wedges on any door within the hospital. As far as code requirements go is it rated doors only, or does it include any door with a closer?

A: It applies to any fire rated door assembly, any non-rated door assembly that is required to be self-closing, and all corridor doors regardless of their fire-rating and regardless if they are self-closing.

Look at section 19.3.6.3.10 of the 2012 LSC, which says doors shall not be held open by devices other than those that release when the door is pushed or pulled. This section is part of section 19.3.6.3 “Corridor Doors” so it is referring to corridor doors only. Approved ‘push or pull’ release devices to hold a door open are the friction-fit type hold open that are integral to the door closer, and magnets. The logic here is a person could quickly push or pull the door closed, but if the door was wedged open, then the closing of the door would be slower and more difficult; therefore, wedging a door open would not be permitted.

Section 19.3.7.8 (1) of the 2012 LSC says doors in smoke barriers must be self-closing. The term ‘self-closing’ means the door has to close by itself without assistance. A smoke barrier door that is wedged open will not close by itself. Section 3.3.238 of the 2012 LSC defines “Self-closing” as a door equipped with an approved device that ensures closing after opening. All doors in hazardous areas are required to be self-closing regardless if the door is fire-rated or just smoke resistant.

To further make the point, section 19.2.2.2.7 of the 2012 LSC says any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by automatic release device that complies with 7.2.1.8.2. The implication here is these doors must be self-closing and may only be held open by a device that releases the door (and allows the door to self-close) upon activation of the fire alarm system or sprinkler system.

And to finally address fire-rated door assemblies, section 8.3.3.1 requires all doors required to have a fire protection rating to comply with NFPA 80, which requires self-closing devices on the doors. So, any fire-rated door assembly may not be wedged open.

That applies to nearly all doors in a hospital. But there are some doors that you could actually wedge open, although you probably would not want to inform your staff. Doors located inside a suite of rooms that do not serve an exit or a hazardous area would be permitted to be wedged open because those rooms inside a suite are not required to have doors. But that’s about it.

Annual Test on Fire Rated Door Assemblies

Q: In regards to the new annual fire rated door assembly inspection, are we to inspect every door that has a fire rating or the doors that are located in fire-rated walls? I have noticed that not all fire doors in the building are located in fire rated walls, according to my Life Safety drawings. What do you say?

A: It is not uncommon for fire-rated door assemblies to be found in walls and barriers that are not fire-rated. This is often due to conflicting building codes that require 20-minute fire rated doors in all corridors, or a misunderstanding by the design professional. But make no mistake: You are required to test and inspect those doors on an annual basis.

My interpretation is based on section 7.2.1.15.2 of the 2012 LSC which says: “Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80…” This section of the LSC does not have any exceptions for fire-rated door assemblies that are located in walls and barriers that are not fire-rated.

Therefore, all fire-rated door assemblies must be inspected and tested in accordance with NFPA 80 on an annual basis, regardless where they are located.

Another way of looking at this issue is to review section 4.6.12.3 of the 2012 LSC which says existing life safety features that are obvious to the public, if not required by the LSC, must be either maintained or removed. The interpretation of what’s ‘obvious to the public’ is certainly open for discussion, but most fire-rated door assemblies can be determined by looking at a fire rating label on the hinge-side edge of the door, and that is viewable by the public. Whether it is obvious or not is a matter of opinion, but if you take the hardline on that, then all fire-rated doors (with a fire rating label) have to be maintained even if they are not located in a fire-rated barrier.

Either way… I think the LSC is pretty clear… you need to test and inspect all fire rated door assemblies regardless if they are located in a fire rated barrier. And by the way, the first test of the side-hinged swinging fire doors is due in a couple weeks: July 5, 2017. Better have it completed by then.