Aug 31 2017

Existing Mechanical Equipment Spaces Opening onto Exit Enclosures

Category: Mechanical Rooms,Questions and Answers,StairwellsBKeyes @ 12:00 am

Q: With the elimination of the CMS Waivers, I was trying to clarify what now applies for mechanical room combustibles storage (i.e. mechanical areas with only stairway and elevator access vs. hallway access and stairway access, or just hallway access). Does it mean no combustible storage without a “buffer room” to a stairway still applies as described in the old waiver? I was confused with NFPA 101-2012, Separation of Occupancies in Healthcare (Table which appears to show 2-hour separation for all Storage, normal to hazardous. Confused with their footnote: ‡The 1-hour reduction due to the presence of sprinklers in accordance with the single-dagger footnote is not permitted.

A: Let me clear up some of the issues that may be confusing you. First of all, CMS did not eliminate any waivers. Healthcare organizations may still submit waiver requests provided the non-compliance that is being requested to be waived has been cited first during an accreditation survey or state survey on behalf of CMS. Since CMS adopted the 2012 Life Safety Code all of the Categorical Waivers that they issued over the past few years have not been eliminated, but rather they have been completed. The Categorical Waivers (for the most part) allowed healthcare facilities to use certain sections of the 2012 LSC early, before CMS formally adopted the 2012 Life Safety Code. Since CMS did adopt the 2012 LSC on May 4, 2016, with an effective date of July 5, 2016, there is no need for the Categorical Waivers. They were not eliminated or deleted; they just were completed.

Under the 2000 Life Safety Code, openings in exit enclosures (i.e. stairwells) were limited from normally occupied spaces and corridors. This means unoccupied mechanical rooms that had their only access through a stairwell were non-compliant with the 2000 Life Safety Code. The Life Safety Code Technical Committee recognized that was a problem in many hospitals, so they changed the code in the 2012 edition, to allow existing openings into exit enclosures from mechanical equipment spaces to remain, provided the following conditions occur [see section]:

  • The door assemblies between the exit enclosure and the mechanical space are properly rated
  • The space is used for non-fuel-fired equipment
  • The space contains no storage of combustible materials
  • The building is fully protected by automatic sprinklers

So… if you are attempting to use the above section for mechanical rooms that open onto a stairwell, then you are not permitted to have any combustibles stored in the mechanical space. This means no boxes of filters; no cardboard boxes containing repair parts; no storage of anything that could burn. And the entire building has to be protected with sprinklers. However, if you do have a vestibule separating the mechanical space from the stairwell, then you do not have to comply with the above requirements since you are compliant with section

Table that you referenced is a table to identify the separation between differing occupancies… not a separation involving storage rooms within the same occupancy. There are many different occupancies that a healthcare facility may have: Healthcare occupancy, business occupancy, and even a storage occupancy are just a few. Anytime there are different occupancies that are contiguous and one of the occupancies is a healthcare occupancy, then the barrier separating the two occupancies must be 2-hour fire rated. This table has nothing to do with the separation required around a storage room inside a healthcare occupancy.

Jun 15 2017

Locked Mechanical Room

Category: Door Locks,Mechanical Rooms,Questions and AnswersBKeyes @ 12:00 am

Q: The computer server is located in the mechanical room. IT wants the room locked for HIPAA compliance. Is it permissible to lock a mechanical room? Doesn’t locking compromise access to electrical panels, fire panel, water shutoff, etc. in an emergency?

A: Yes… you can lock a door into a mechanical room, as far as NFPA is concerned; you just can’t lock the door in the path of egress. Does a locked door to a mechanical room restrict access to electrical distribution panels? Yes it does, but that is a good thing. According to NFPA 99-2012, section access to overcurrent protective devices (i.e. circuit breakers) serving Category 1 or Category 2 rooms must be secured to allow access for authorized individuals only. So, having these distribution panels inside a locked mechanical room meets the requirement of NFPA 99.

It is expected that authorized individuals will have a key or device to access this room in the event of an emergency. Make sure any locks that are installed on the door does not lock the door for those individuals exiting the mechanical room. It is not uncommon for Information Technology to place intermediate distribution frames containing servers in various locations around the facility. The challenge is to meet all of the requirements for limiting access for HIPAA compliance and still allow regular access for other items in the room.

Mar 24 2017

Emergency Illumination in Mechanical Rooms

Q: Is emergency lighting required for mechanical rooms?

A: The answer depends on whether the mechanical room has a designated aisle, the occupancy classification of the building, and whether it is an underground or widow-less structure. According to section 7.8 of the 2012 Life Safety Code the means of egress is required to be illuminated in the following locations in any occupancy:

  • Designated stairs
  • Designated aisles
  • Designated corridors
  • Designated ramps
  • Passageways leading to an exit.

As far as a mechanical room is concerned, if the room is large enough that there would be a designated aisle in the room, then it would require illumination.

But does the illumination in the mechanical room need to be connected to emergency power? According to section 7.9, emergency illumination room is dependent upon any one of the following:

  • If required by the occupancy chapter;
  • If the building is an underground or windowless structure;
  • If the building is a high-rise building;
  • At doors equipped with delayed egress locks;

Healthcare occupancies and ambulatory healthcare occupancies do require emergency illumination (see 18/19/20/, but business occupancies only require emergency illumination if the building is two or more stories in height above the level of exit discharge; if the occupancy is subject to 100 or more persons above or below the level of exit discharge; and if the occupancy is subject to 1,000 or more persons.

If the mechanical room is located inside a healthcare occupancy, then it would have to be connected to a Type 1 essential electrical emergency power system, which means the emergency illumination must be provided by onsite generators.

So, it depends where the mechanical room is located. But if it is located inside a hospital, and the mechanical room is large enough to have an aisle, then yes, emergency illumination would be required.

Mar 10 2017

Portable Fire Extinguishers

Q: Are fire extinguishers required to be placed in mechanical rooms in our hospital? I’ve searched NFPA 10 and the Life Safety Code and haven’t found anything concrete. The mechanical rooms in our facility are strictly boiler rooms, electrical control panel rooms, and so on. They are considered restricted areas and are always kept locked, with access granted to just the facilities staff and the security staff. Any help you can provide is greatly appreciated.

A: Yes, according to sections and of the 2012 Life Safety Code, you must be in full compliance with NFPA 10 (2010 edition) for maximum travel distance to the location of a portable fire extinguisher, in all areas of your facility. Each classification of extinguishers has their own different requirements, as follows:

Class A Extinguishers

Maximum travel distance to extinguisher:                  75 feet

Maximum floor area for each extinguisher:               11,250 sq. ft.

Maximum floor rating per unit of ‘A’:                       3,000 sq. ft. for Light (Low) Hazard

1,500 sq. ft. for Ordinary (Moderate) Hazard

1,000 sq. ft. for Extra (High) Hazard


Class B Extinguishers

Light (Low) Hazard:

5-B                  30 feet maximum travel distance

10-B                50 feet maximum travel distance

Ordinary (Moderate) Hazard:

10-B                30 feet maximum travel distance

20-B                50 feet maximum travel distance

Extra (High) Hazard:

40-B                30 feet maximum travel distance

80-B                50 feet maximum travel distance

Class C Extinguishers

Class C fires are started with electrical current, but the actual fuel that burns is either a Class A or a Class B hazard. Therefore, Class C extinguishers should be mounted and located according to either Class A or Class B requirements, depending on the potential fire.

Class K Extinguishers

Maximum travel distance is 30 feet.

Even mechanical rooms where very few people have access are required to be protected with portable fire extinguishers, so make an assessment of what the potential fuel that could catch on fire, and obtain the classification of extinguisher(s) that meets that potential fuel, and space them out accordingly.

Apr 25 2016

Entrance Door to Mechanical Room

Category: Mechanical Rooms,Questions and AnswersBKeyes @ 12:00 am

Q: We have an old dark room that was converted into an air handler room. What’s the requirement for a door to this room?

A: It all depends where this former dark room is located. First of all, what is the occupancy designation for the building or area where this air handler is located? If it is business occupancy and the air handler does not include a gas-fired furnace, then it is very likely that no door is actually required to this room. However, if the building or area is designated as a healthcare occupancy, then it depends whether or not the room opens up onto a corridor. In healthcare occupancies, all corridors must be separated by walls and doors from all other areas. Now, there are some exceptions to this requirement, but an air handler room will not qualify for any of these exceptions. If the former dark room/air handler room does not open onto a corridor, but opens onto another room, then it is likely that a door would not be required, provided the air handler room does not contain anything to make it a hazardous room, such as fuel-fired equipment, or storage of combustibles of flammables. If the air handler room somehow qualifies as a hazardous room (see sections of the 2000 edition of the LSC) then the room will need to be protected with automatic sprinklers, and the walls will be required to be 1-hour fire rated, and the doors will be required to be ¾-hour rated, self-closing and positive latching. All of that would be required even if the room does not open onto the corridor. If the air handler room is not considered to be a hazardous area, and the room opens onto a corridor, then the door is only required to resist the passage of smoke, or if the corridor is located in a non-sprinklered smoke compartment then a substantial door such as 1¾ inch thick, solid-bonded, wood-core door, or be of such construction to resist fire for at least 20 minutes. Notice it did not say the door had to be 20-minute fire rated. That is a common misunderstanding.

Aug 03 2015

Sprinklers in an Air Handler Room

Category: Mechanical Rooms,Questions and Answers,SprinklersBKeyes @ 12:00 am

Q: Do air handler mechanical rooms located at the top of a hospital, and are healthcare occupancies, require sprinkler systems?

A: Yes… if the rest of the hospital is required to be sprinklered. There is nothing in the code or standards that allows the air handler mechanical room to not be sprinklered when the rest of the hospital is required to be sprinklered. But, the mechanical room is not required to be sprinklered if the hospital itself is not required to be sprinklered. This is dependent on the date when the hospital was constructed; the date of the most recent renovation in the mechanical air handler room; the construction type; and any approved equivalencies you may have.

Sep 15 2014

Equipment Room Storage

Category: Mechanical Rooms,Questions and Answers,StorageBKeyes @ 6:00 am

Q: I was always under the impression that no storage was allowed in mechanical rooms within hospitals. Now I work at a hospital that allows ladders and supplies to be stored in mechanical rooms. Is this allowed?

A: All I can say is it is not a NFPA violation to store items in mechanical rooms, as long as it is done properly. Obviously, storing combustible or flammable items must be accomplished in approved storage rooms, and the typical mechanical room may not qualify for these hazards. But then again, perhaps a mechanical room could qualify to store combustibles. Sections for new construction and for existing conditions of the 2000 edition of the LSC describe the requirements for storing combustibles. It does not make sense to store a bunch of cardboard boxes full of paper filters in a mechanical room that also houses fuel-fired equipment. But why can’t you store those same boxes of filters in a mechanical room for air handlers that does not have any fuel-fire equipment, and qualifies as a hazardous room under the code sections referenced? The NFPA codes and standards do not prohibit it. Where hospitals get ‘pinched’ on this issue, is they don’t do their homework. A mechanical room that was never designed to double up as a storage room may not qualify as a storage room for combustibles. If you alter (or change) the use of a room or area, the room or area must comply with the requirements for new construction. This means if a hospital decides to start storing combustibles in an AHU mechanical (with no fuel-fired equipment), now the room must be protected with 1-hour fire rated barriers, and also be protected with automatic sprinklers. If the room in question does not meet these requirements, then the hospital is exposed for a citation. Another issue is access. Even if the same AHU mechanical room described above qualifies as a hazardous room, if there are so many items stored in the mechanical room that obstructs access to the mechanical equipment, then that is a problem and the hospital could be cited as well

May 05 2014

Fire Protection of Equipment Rooms

Q: What is the fire rating supposed to be in the walls of the hospital equipment rooms, such as the generator room, boiler room, chiller rooms, and electrical rooms? We have a disagreement as to what is required and your answer decides who is correct.

A: According to NFPA 110 (1999), section 5-2.1, generator rooms are required to have 2-hour fire rated barriers that protects the room from fire outside the room. Any 2-hour fire rated barrier is required to have 90-minute fire rated doors and frame and if there are any HVAC duct penetrations through the 2-hour barrier, then the HVAC duct opening needs to be protected in accordance with NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating System, which would require a 90-minute fire damper. A boiler room is considered a hazardous area, and according to the 2000 edition of the LSC, sections 18/, the hazardous area is required to be protected with 1-hour fire rated barriers if it is considered new construction, or 1-hour barriers if it is considered existing and is not protected with sprinklers. Existing boiler rooms that are protected with sprinklers only require smoke resistant walls. All door openings in a 1-hour barrier are required to be ¾ hour fire rated, with fire rated frames. However, unlike the 2-hour barrier, a 1-hour fire rated barrier for a hazardous area is not required to have any fire dampers in a HVAC duct penetration, unless the HVAC penetration is not fully ducted. Electrical rooms typically are not required by the LSC to have fire rated barriers (walls), however NFPA 13 (1999 edition) Standard for the Installation of Sprinkler Systems, section 5-13.11 does permit an electrical room to be protected with 2-hour fire rated barriers in lieu of being protected with sprinklers. Therefore if the room does have fire rated barriers for any reason (including local or state building codes) then it would need fire dampers in the HVAC duct penetration if it is 2-hour fire rated or greater. Chiller rooms typically do not require fire rated barriers, unless the chillers are fuel-fired, then they would require the same protection as the boilers. As always, please check with your local and state authorities to determine if there are other regulations that may affect this situation.

Good Luck!

Aug 13 2012

Equipment Room Sprinklers

Category: Mechanical Rooms,Questions and AnswersBKeyes @ 5:00 am

Q:  We have equipment rooms on the top floor of our hospital that contain mechanical equipment, but no boilers or generators. Are these equipment rooms required to be protected with sprinklers?

A: That depends on a couple of factors. When were the equipment rooms constructed or renovated? Since the 1991 edition of the Life Safety Code, all new construction associated with healthcare occupancies are required to be protected with automatic sprinklers. So any construction that fell under the purview of the 1991 edition (or any subsequent edition) would require the equipment rooms to be sprinklered. Likewise, if the equipment rooms were renovated since the 1991 edition was in force, then the renovation would be required to comply with the new construction requirements and be sprinklered. However, as mentioned in the previous Q&A, an electrical room that is separated by 2-hour fire resistant rated construction, and does not contain any storage or liquid-filled transformers is exempt from being protected with sprinklers, and yet the hospital can still take credit for that area being sprinklered.

Jul 22 2012

Mechanical Room Storage

Category: Mechanical Rooms,Questions and AnswersBKeyes @ 5:00 am

Q: I have a storage question for you that relates to storing beds and other hospital equipment in our mechanical rooms. Is this allowed or would I be cited for storing things in the mechanical room??

A: To be sure, mechanical rooms are designed to house mechanical equipment, and storage should not obstruct access to the mechanical equipment. According to the 2000 edition of the LSC, storage in mechanical rooms is not prohibited, however there are some requirements that you must meet. The mechanical room must not contain any open flame or fossil-fuel fired heating equipment. The items stored in the mechanical room must be orderly and neat. Storage cannot obstruct access to electrical panels, fire extinguishers, fire alarm pull stations, and must be clear of all sprinklers located on a horizontal plane 18 inches below the sprinkler deflector. If the items stored in the mechanical room are combustible (cardboard boxes, paper or plastic wrapping, linens, etc.) then the mechanical room must meet normal hazardous room requirements. If the room is new (meaning if the room has been designated for storage on or after March 11, 2003), then it must be protected with automatic sprinklers  and the walls constructed from the floor to the deck above with 1-hour fire rating, with a ¾ hour fire rated, self-closing, positive latching door. If the room is considered existing (meaning the room was designated as storage before March 11, 2003 and there have not been any major renovations since), then it must be protected with automatic sprinklers with walls that are smoke resistant and extend from the floor to the ceiling, and protected with a 1 ¾ inch solid bonded wood core door that is smoke resistant and self-closing and positive latching, or if not sprinklered, then the room is required to be protected with 1-hour fire rated barriers. However, please check with your state and local authorities as they may have other codes or standards that may prohibit storage in a mechanical room.

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