Lockers in Corridors

Q: We have a behavioral health unit and our administration would like to install lockers for visitors. However, there is only one location for these lockers and that is in the egress corridor outside of the unit. I am telling them this not permitted. Am I correct?

A: Without looking at the situation myself, I would be inclined to say it is not permitted because of the following potential issues:

  • Obstruction of the required width of the corridor (6 feet)
  • When the doors to the lockers are left open they project more than 4 inches in to the corridor
  • Hazardous area open to the corridor (combustible material in the lockers are not separated from the corridor)

Now, there could be exceptions to the above, such as:

  • If the lockers are recessed into an alcove where they would not obstruct the required width of the corridor
  • If the lockers are recessed into an alcove where an open door would not project more than 4 inches into the corridor
  • If the grouping of the lockers was less than 50 square feet, then it does not constitute a hazardous area
  • If the locker doors did not have vents and had positive latching hardware, and the doors did resist the passage of smoke, then you could qualify under and for corridor separation.

Overall, I don’t think it is a good idea to start placing lockers in a corridor, but there are ways to accomplish it and still be compliant with the Life Safety Code.

Illuminated Pumpkin

Here’s a strange observation (on a Tuesday?) that I saw recently at a nurse station… An electric pumpkin powered by an extension cord. Even though the electric pumpkin was UL listed and presumably okay, NFPA 70-2011, Article 400.8 (1) says flexible electrical cords cannot be used as a substitute for fixed wiring. That means extension cords cannot be used for anything except temporary use.

CORRECTION: On November 6, 2018, a very thoughtful reader pointed out to me that I was incorrect in my posting above. According to NFPA 70-2011, Article 590.3(B), extension cords are permitted to be used for holiday decorations up to 90-days. But Article 590.2(A) does say all other requirements of the code would have to be met. implying the extension cord would have to be listed by a national listing agency (i.e. UL). Also, Article 590.2(B) says temporary wiring is acceptable if it is approved based on the conditions of use. So, you would not be able to abuse the concept of an extension cord used on holiday decorations.

This also means that individual organizations could have policies specific to their staff that limit or prohibit the use of extension cords on holiday decorations beyond what NFPA 70-2011 provides.

I apologize for this error, and appreciate the reader for bringing this to my attention.

Aluminum Astragals

Q: We used our recently updated Life Safety drawings to have our fire doors inspected. The inspector cited us for aluminum astragals on 13 doors. His report stated that they should be changed to steel. My boss asked me to confirm that this is fact. What are your thoughts?

A: The inspector may know something… All hardware installed on fire-rated door assemblies must be listed for use on fire-rated door assemblies, and this includes astragals. Do you have the specification sheets for the astragals that you installed? If not, can you obtain them?

Look on the specification sheets for anything that says the astragals are listed by an independent testing laboratory (UL, Intertek, ETL, etc.) for use on fire-rated door assemblies. If you find that they are listed for use on fire-rated door assemblies, then you are good to go. Photo-copy that information and send it to the inspector for his/her review.

If the specification sheets do not say the astragals are listed for use on fire-rated door assemblies, then the inspector is correct and you would have to remove them. The issue is not whether they are made with steel or aluminum, but whether they are listed for use on fire-rated door assemblies. Perhaps the inspector believes that aluminum astragals are not listed…?

Fire Drills in a High-Rise Hospital

Q: A question was brought up today about whether or not what we are doing for fire drills meets code. Currently, as a high-rise hospital (12 floors), we are conducting drills 1 per shift per quarter, so 3 drills per quarter. Each drill affects 3 floors, the floor of activation, the floor above, and the floor below. Does activating only 3 floors per drill meet the intent of code, or should we be performing drills 3 times a quarter for the entire tower? This would equate to 12 drills in all per quarter.

A: According to the 2012 LSC, section, drills are conducted quarterly on all shifts to familiarize staff with the signals and emergency action required. These drills must be conducted under varied conditions.

Section 4.7.2 says fire drills are held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills must include suitable procedures to ensure that all persons subject to the drill participate.

So, the intent of the fire drill is to help staff become familiar with the fire alarm signals and the emergency action required. And, drills must ensure that all persons (i.e. staff) participate in the drill. Under your current practice, how does your staff on the 2nd floor participate in the fire drill is it is initiated on the 8th floor? It appears that they cannot, since you are only activating the occupant notification signals on the 7th, 8th, and 9th floors.

I fully understand compartmentalizing the fire alarm signals to the floor where the alarm is initiated, the floor above and the floor below. This is permitted in NFPA 72-2010. However, by doing so, you are unknowingly violating the Life Safety Code, because you are preventing ¾ of the rest of the staff from participating. So, compartmentalizing the alarm signal on an actual fire alarm is permitted, but I don’t see where doing so is permitted for fire drills.

Now, one may ask what the 2nd floor staff should do if the alarm is initiated on the 8th floor? While it is understood there is not a lot to do, there is basic fire response procedures that must be followed:

  • Close all doors
  • Clear corridors of clutter
  • Be prepared to receive evacuating patients from other floors
  • Send staff to scene of fire with extinguishers (if that is part of your fire plan).

Strange Observations – Part 48

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

I apologize for the photo being out of focus. I only had my new smart phone for a few days when I took this and I was having difficulty adjusting to the technology (okay… so I’m an old guy… deal with it).

The yellow sign is flexible, and is mounted on a magnet. Yet it projects more than 4 inches into the corridor.

Should I write it up …?

I did.

Fixed Seating vs. Seating Open to the Corridor

Q: I have a CEO that wants furnishings (seating) in the corridor. I informed her that would be acceptable if we maintained five feet and the furnishings are bolted to floor and follow the 2012 Life Safety Code. Well, this action would not make the furnishings aesthetically appealing, according to her. So, if the required width of the corridor is maintained and the furnishings are kept to one side of corridor and are not fixed to the wall or floor, will that meet the requirements of the Life Safety Code?

A: Assuming the seating arrangement is located in an area where inpatients would egress, and if the seating arrangement is in a wide spot in the corridor that does not obstruct the required 8-foot width of the corridor, then you do not have to meet the more restrictive requirements of (5) of the 2012 LSC, that does require the seating to be secured to the wall or floor. However, you do have to meet one of the nine (9) subsections of for corridor separation, most likely subsection eight (8) that requires:

  • Each area does not exceed 600 square feet
  • The area is equipped with smoke detectors
  • The area does not obstruct access to required exits.

But the problem with seating that is not secured to the floor or wall, is the chairs get moved around by un-informed individuals (i.e. visitors), and eventually they obstruct the required width of the corridor, or they obstruct access to required exits (such as an egress from a mechanical room). If you choose to go the route of, make sure you perform frequent walk-throughs of the area to ensure nobody is rearranging the furniture.

Christmas Decorations – Part 2

Q: I enjoyed your recent post regarding Christmas decorations. However, can you please simplify for me the rules on Christmas decorations in hospitals? The percentages are a little confusing, I think. Thank you very much.

A: Not to be a smarty-pants, but here is a simple interpretation:


I know that would not be very popular, but that would be the safest and easiest. But here is another way of looking at decorations:

  • If your building is fully sprinklered, the LSC permits up to 30% of the walls and ceilings to be covered with combustible decorations.
  • Combustible decorations that are not mounted to the walls or ceilings are not permitted (i.e. Christmas trees)
  • Decorations that are not attached to the walls or ceilings must be flame retardant
  • You cannot use an extension cord (or a power strip) to power electrical decorations
  • All electrical decorations must be UL listed

Christmas Decorations

Q: I notified our administration that Christmas decorations are basically forbidden in a healthcare occupancy. We do have a few floors that are business occupancy and they were wondering what the restrictions of decorating are within a business occupancy (we are fully sprinkled). I do not see anything about this in the Life Safety Code pertaining to business or mixed occupancy. Do you mind sharing any advice?

A: Well…. Actually, the Life Safety Code does address this issue and there is a difference between occupancies. Section of the 2012 LSC prohibits combustible decorations in a Healthcare Occupancy (i.e. hospital), with the exception (and this is a rather generous exception) of wall and/or ceiling mounted combustible decorations that cover 20% of the wall and ceiling surface in non-sprinklered smoke compartments, 30% of the wall and ceiling surface in a sprinklered smoke compartment, and 50% of the wall and ceiling surface in patient sleeping rooms that have a capacity of no more than 4 persons in smoke compartments that are full protected with sprinklers.

In chapter 39 for Business Occupancies, there are no restrictions, so decorations are not restricted. However, you cannot have non-UL listed electrical decorations, and the National Electrical Code prevents you from using extension cords to power electrical decorations.

Corridor Doors

Q: I have a healthcare occupancy under existing construction. The building was built back in the 50’s and 60’s, with a major renovation in 1992. The available plans have indicated the fire-rated walls and doors, but there are other doors not specifically designated as smoke doors or fire-rated doors. My question is, what doors would fall under the description of corridor doors? Would it be all doors that exit directly into the egress corridor? Some of these doors are to normally occupied offices, some are to patient rooms, and some are to conference rooms that are only occupied during meetings.

A: Corridor doors are those that separate the corridor from a room, suite, or area. They are not cross-corridor doors that separate a corridor from another corridor. Do not be fooled by a double set of doors, as they can be either corridor doors (an entrance to a room, or suite), or cross-corridor doors (smoke barrier doors, or privacy doors in a corridor).

Here is a summary of the Life Safety Code requirements for corridor doors:

  • Corridor doors must comply with section of the 2012 LSC, and have certain requirements that they must meet, such as:
    • They must resist the passage of smoke (no holes in them)
    • They must be 1¾-inch thick, solid-bonded wood core
    • Constructed with materials that resist fire for a minimum of 20 minutes (NOTE: This does not mean the corridor doors must be 20-minute fire rated).
  • Corridor doors to toilet rooms, bathrooms, shower rooms, sink closets and similar auxiliary spaces that do not contain flammable or combustible materials are not required to comply with the above requirements.
  • In smoke compartments protected throughout by automatic sprinklers the corridor door construction requirements listed above are not mandatory, but the corridor doors must resist the passage of smoke (no holes).
  • Corridor doors are not required to meet the NFPA 80 standards for fire-rated door assemblies, unless the door also serves a fire-rated barrier.
  • The clearance between the bottom of the corridor door and the floor (i.e. undercuts) must not exceed 1 inch.
  • The corridor doors must have positive latching hardware.
  • Corridor doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials are not required to have positive latching hardware.

You will notice section does not say anything about self-closing devices for corridor doors, because they are not required on corridor doors, unless the corridor serves another purpose, such as a smoke barrier, horizontal exit, or hazardous area.

Check with your state and local authorities before you make any modifications, to determine if they have other regulations or requirements regarding corridor doors.

Battery Powered Emergency Lights

Q: NFPA 101-2012, section 7.9.3 requires 1½-hour testing of battery powered emergency lights annually. The Joint Commissions wording of EC.02.05.07 EP-2 states to do that OR the hospital replaces all batteries every 12 months and performs a random test of 10% of all batteries for 1½-hours. Because NFPA 101 does not give that second option, can we really do that (the second option) and be compliant? We’ve felt it’s easier to replace the batteries annually and test a random 10% during that time period than to test all of the over 100 battery powered emergency lights we have. Secondly, NFPA 101-2012, section 7.9.3 does not mention egress vs. task battery powered emergency lighting. Seeing it is located in chapter 7 ‘Means of Egress’, is it implied it only means battery powered emergency lights used for egress? Joint Commission specifically says egress lighting. Several of our battery powered emergency lights are task lights and this would allow us to cut down on monthly and annual testing. Do we need to be as stringent on task lighting as we are on egress lighting to remain compliant?

A: First of all, Joint Commission dropped the option of replacing the batteries and testing 10% of the battery powered emergency lights, in the 2018 CAMH manual, standard EC.02.05.07, EP 2. Starting January 1, 2018, you need to conduct monthly tests and annual tests of all battery powered emergency lights.

I am aware that Joint Commission tries to give the hospitals a break by saying only the battery powered emergency lights used for egress and Exit signs need to be tested. And in their 2018 manual, standard EC.02.05.07, EP 2 they inserted a new section that says battery powered emergency lights in new construction/renovated sedation and anesthetizing areas are tested for 30 minutes annually. But please understand that Joint Commission’s standards are not compliant with the 2012 Life Safety Code, section (3) which requires 90-minute annual test. If you follow Joint Commission’s standards on this issue, you may be cited by a state surveyor for not complying with the annual testing requirements of section (3).

Section of the 2012 LSC says if you have an existing feature of life safety that is not required by the LSC but is obvious to the public then you must maintain it or remove it. I think we’d all agree that battery powered emergency lights would be obvious to the public whether they are used to supplement the EM powered egress lighting or if they are used for task lighting in certain areas. According to the 2012 LSC, section 7.9.3, maintaining it includes the monthly 30-second test and the annual 90-minute test.

To be compliant with the 2012 LSC, you need to test the battery powered emergency lights monthly and annually. I suggest you re-evaluate the need for all of the battery powered emergency lights that you have, and invest into self-diagnostic units to eliminate the monthly test requirements.