Dec 26 2017

Fully Sprinklered Buildings

Category: Questions and Answers,Sprinklers,WaiversBKeyes @ 12:00 am

Q: Our facility is a four story facility, and is a combination of different structures built in different years. All of the different structures are protected with sprinklers except for our power plant. Our power plant is 24 hours manned and has Fire Alarm System devices installed or equipped. Do we need to ask for a waiver as per the new NFPA 101 2012 edition that is to be implemented this year?

A: Existing healthcare occupancy buildings are not required to be fully protected with sprinklers. There is no requirement with the new 2012 LSC to install sprinklers in existing buildings (unless the building is a high-rise) so there is no need to ask for waivers.

Now, it is very desirable for healthcare occupancy buildings to be fully sprinklered because if they are, it allows you to do many terrific things. Take a look at the following 2012 Life Safety Code references, which describes the many advantages of having a fully sprinklered building:

  • – Delayed egress locks are allowed only if the entire building is protected with sprinklers or smoke detectors
  • – Capacity factors for egress components improve if entire building is sprinklered
  • 7.7.2 – No more than 50% of required exits may discharge through the level of exit discharge if area is sprinklered
  • – A hazardous area may not have to have 1-hour fire rated walls if protected with sprinklers (Note: This does not supersede section 18/
  • – Class C interior finishes are permitted in locations where Class B is permitted, and Class B interior finishes are permitted in locations where Class A is permitted, provided the area is protected with sprinklers. (Note: This does not supersede section 18/
  • – Class II interior floor finish is permitted in locations where Class I is permitted providing the area is protected with sprinklers.
  • 10.3.3 – Upholstered furniture must meet the requirements in accordance with NFPA 260 and NFPA 261, unless the furniture is located in rooms protected by sprinklers.
  • 10.3.4 – Mattresses must meet the requirements in accordance with Part 1632 of the CFR 16, and NFPA 267, unless the mattresses are located in a room that is protected with sprinklers.
  • – Lesser levels of Construction Types are permitted if the entire building is protected with automatic sprinklers.
  • Travel distances between any point in a room and the exit increases by 50 feet if the entire building is protected with automatic sprinklers
  • Hazardous areas are not required to be 1-hour fire rated if the walls are smoke resistant and area is protected with automatic sprinklers
  • – No interior floor finish requirements apply in smoke compartment protected with automatic sprinklers
  • – Areas open to the corridor are afforded exceptions if the smoke compartment is protected with automatic sprinklers
  • – Corridor walls are not required to be ½ hour fire rated provided they resist the passage of smoke and the smoke compartment is protected with automatic sprinklers.
  • – Corridor doors do not have to be 1 ¾ inch thick, solid-bonded wood core or of construction that resists fire for not less than 20 minutes provided they resist the passage of smoke and the smoke compartment is protected with automatic sprinklers.
  • – Smoke dampers are not required in fully ducted penetrations of smoke barriers provided both smoke compartments served by the barrier is protected with automatic sprinklers.

By the way, CMS will not consider a waiver request until such time the Life Safety Code deficiency has been cited in a report. So, don’t plan on submitting a waiver request until after you have been cited.

Nov 29 2017

Removal of a Water-Flow Switch

Category: Questions and Answers,Sprinklers,Standpipe Flow TestsBKeyes @ 12:00 am

Q: We have a water-flow switch on the line that rises through a nursing wing stairwell and feeds the hose cabinets. There are no longer any hoses in the cabinets. Can we remove the flow switch? I don’t know if it’s relevant but our pump test manifold is also on this riser.  I am going on the fact that if the fire department hooks up to the hose riser hopefully we will know there is a fire!

A: I do not believe you are permitted to remove the waterflow alarm switches from the standpipes, and you still need to maintain them and test them. According to NFPA 14 (standard for the installation of standpipes), 2010 edition, says you must have waterflow alarms on standpipes required by the AHJ. The presumption here is the installation of the standpipe was required by some AHJ, or they would not have been installed. In hospitals, only high-rise buildings are required to have standpipe system, so if your facility qualifies as a high-rise, then I would say no. If you want to pursue this issue, you would need to have written approval from all the AHJs who govern your hospital, such as CMS, Joint Commission, the local AHJ, the state AHJ, and the insurance company. Not likely that they would all agree to let you remove the devices.

Oct 16 2017

Portable Storage Racks

Category: Questions and Answers,Sprinklers,StorageBKeyes @ 12:00 am

Q: We have a surveyor that says if we have portable storage racks against the perimeter walls and have items stored closer than 18 inches of the ceiling but the sprinkler is 4 feet away, we are in violation of the LSC. He states since the racks are not fixed to the wall, that this is the reason. Is he correct?

A: It’s not an issue of being correct; it’s an issue of interpretation. I would agree with the surveyor’s interpretation. Even though the actual standard in NFPA 13 does not explain it in this detail, the interpretation makes sense. The rack against the wall which is secured (or at least it is not mobile) stays in place and can have items stored up to the ceiling and still be compliant. However, the rack that is mobile (i.e. it has wheels) can be moved around and can obstruct the spray pattern of the sprinkler.

It makes sense to me, but remember; it doesn’t matter what I think. The surveyor represents the AHJ and it matter what he thinks. You can try to appeal the decision if you want, and you might succeed. But the interpretation actually makes sense to me.

Oct 12 2017

AEM Program for Fire Alarm and Sprinklers

Category: AEM Program,Fire Alarm,Questions and Answers,SprinklersBKeyes @ 12:00 am

Q: Are sprinklers, smoke detectors, etc. considered to be operating components of the utility systems? If so, our inspections are based on the pertinent NFPA references. I think that the fire system inspections could be considered preventive maintenance or at least the means to determine what maintenance needs to be completed. Can we use the CMS AEM program to alter our PM activities on the fire alarm and sprinkler systems?

A: You cannot use the CMS AEM program for Fire Alarm inspection and testing requirements. The CMS S&C letter 14-07 that describes the AEM program says the following regarding when the AEM program is not appropriate: “Other CoPs require adherence to manufacturer’s recommendations and/or set specific standards. For example: The National Fire Protection Association Life Safety Code (LSC) requirements incorporated by reference at 42 CFR 482.41(b) has some provisions that are pertinent to equipment maintenance, and compliance with these requirements are assessed on Federal surveys.”

So… you must follow the NFPA requirements specified for sprinkler and fire alarm testing and inspection, and the AEM program is not applicable.

Aug 04 2017

Sprinkler Testing Certification

Category: Questions and Answers,Sprinklers,TestingBKeyes @ 12:00 am

Q: I reside in California. Do I need a special license or certificate to perform monthly and quarterly sprinkler systems tests and/or inspections? Primarily, I am interested in main drain tests. I am the fire alarm, technician at a large hospital, and have NICET Level II certification. I have over 20 years of hospital fire experience and I have a State of California weekly fire pump test certificate. From a NFPA standpoint, do I need a license or certificate to perform testing and inspections on water based fire protection equipment (sprinklers)?

A: No. NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems only requires ‘qualified’ people to perform the inspections and testing activities, and ‘qualified’ means being competent and capable, and having met any requirements and training that are acceptable to the AHJ. So, if the state of California has additional requirements for training, such as licensing and/or certification, then you would have to comply with that. But NFPA 25 does not require license or a certificate to perform inspections and testing.

Aug 03 2017

Spare Sprinkler Heads

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

Q: How many spare sprinkler heads are we required to keep on hand in our hospital? Some people have told us we need 6 of each kind of head we have, and some people have said we only need 6 total heads regardless how many types of heads. What do you say?

A: When it came to spare sprinkler heads, NFPA 13-1999 was misleading and it was often misinterpreted. At one time, accreditation organizations required 6 spare heads of each type, but that was not the intent of the technical committee. The 2010 edition of NFPA 13 has cleared this up. Section of NFPA 13-2010 says a supply of at least six spare sprinklers must be maintained on the premises, but to clarify, Annex section A. says a minimum of two sprinklers of each type and temperature rating should be provided. Also, section does say a supply of dry heads is not required. However, section requires an increase in spare heads if the facility has more than the following thresholds installed:

  • Under 300:         No fewer than 6 spare heads
  • 300 to 1000:        No fewer than 12 spare heads
  • Over 1000:         No fewer than 24 spare heads

Section says there must be a sprinkler wrench for each type of head stored with the spare sprinkler heads, although a single sprinkler wrench could be appropriate for use on multiple sprinklers. Section does require a list of all the sprinklers be included in the spare sprinkler cabinet. This list includes the following:

  • Sprinkler identification number (SIN) or the manufacturer, model orifice (size), deflector type, thermal sensitivity, and pressure rating
  • General description of each sprinkler type, such as:
    • Upright
    • Pendent
    • QR
    • SR
    • Sidewall
  • Temperature rating in °F
  • Quantity of each type of sprinklers maintained in spare cabinet
  • Issue or revision date of the spare sprinkler list.

Find your spare sprinkler cabinet and make sure you meet all of the above requirements.

May 19 2017

Dust on Sprinkler Heads

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

Q: I just had a survey and received a finding for dust on some of the sprinkler heads.  I understand that foreign material is not permitted, but minute amounts of dust? I think this is an unreasonable citation. What do you say?

A: Dust is a foreign material and foreign material is not permitted on sprinkler heads. I support the finding, since how much dust is too much? If you allow just a little dust, then at what point is too much dust? Besides, any foreign material, including dust, can change the reaction time of a sprinkler head.

It is similar to a communication cable hanging across a sprinkler pipe… One cable does not seem to make any difference with the added weight on the hanger. But when does it become too much? Since it is not defined, then the answer is one cable is too much.

Keep in mind, when the codes and standards are not definitive, the AHJ gets to decide what is definitive.

May 10 2017

5-Year Internal Inspection of Sprinkler Systems

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

Q: I listened in on your webinar when you introduced all of us to the changes with the new 2012 Life Safety Code. In regards to the section involving fire sprinklers you stated that we need to have a five-year internal inspection of the pipe at the end of the line and a branch to a sprinkler head. But you do not specify whether this applies to just wet systems or dry systems? Do we need to do this on both types of systems?

A: According to Section 14.2 (Internal Inspection of Piping) in NFPA 25-2011, here is what’s required:

  • An inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.

Brad’s comments: According to the NFPA handbook for this section, you must open up both locations (a flushing location and a sprinkler) and examine the condition of the pipe inside both of these locations. The standard specifically wants you to look for the presence of Micro-biologically Influenced Corrosion (MIC), zebra mussels, or inorganic materials such as rust and scale, as well as other items that may have been left in place by the installers such as gloves and cut-out coupons. You’re looking for these items because they can cause obstructions. According to the handbook, looking in just two locations once every 5 years is sufficient and provides a reasonable assurance that the entire system is acceptable. This internal inspection should be coordinated when the system is drained for other internal inspections, such as check valves. The handbook specifically says this 5-year inspection applies to wet, dry, pre-action, and deluge systems, as well as foam-water sprinkler systems.

  • Alternative non-destructive examination methods shall be permitted.

Alternative nondestructive examination methods includes the use of X-ray, ultrasound, and remote video techniques.  

  • Tubercules or slime, if found, shall be tested for MIC.

NFPA does not define what a tubercule is, but according to a dictionary, a tubercule (also spelled tubercle) is a nodule or small eminence, attached to the inside of the pipe. The reason NFPA wants tubercules and slime tested for MIC, is MIC is very destructive to the inside of a sprinkler pipe, and almost always leads to pinhole leaks. There is newer technology being used that injects nitrogen (taken from the atmosphere) into the sprinkler system when filling that lowers the level of oxygen to a point that prohibits MIC from growing.

  •  If the presence of sufficient foreign material is found to obstruct the pipe or sprinklers, then an obstruction investigation must be conducted as described in section 14.3.

NFPA does not say how much foreign material is sufficient to obstruct pipe or sprinklers, so this is a judgement call. It would be normal to observe small amounts of scale and rust inside sprinkler pipe and should not trigger an obstruction investigation.

  • Non-metallic pipe shall not be required to be inspected internally.

Corrosion is associated with metallic pipe so non-metallic pipe (i.e. plastic CPVC) is not subject to the 5-year internal inspection.

  • In dry systems and pre-action systems the sprinkler removed for inspection shall be from the most remote branch line from the source of water that is not equipped with the inspector’s test valve.

The dry system and pre-action system is required to have an inspector’s test valve, but NFPA does not want a sprinkler pulled on the branch line containing the inspector’s test valve. So, they want the sprinkler pulled on the next branch line closest to the branch line containing the inspector’s test valve.

If you haven’t already done so, obtain a copy of NFPA 25-2011 for your own reference. 

Apr 24 2017

Cable on Sprinkler Pipe

Category: ILSM,Questions and Answers,SprinklersBKeyes @ 12:00 am

Q: We have some sprinkler piping that runs the length of the hall with multiple wires wrapped around the pipe. There is no way of removing the wiring from the pipe unless we perform some major sprinkler pipe removal and reinstallation. This has been identified in a mock survey and we need to come up with a plan of action. How do you recommend we deal with this?

A: Well… you really need to remove the cables and wires from the sprinkler pipe. If you don’t, then you are non-compliant with NFPA 25-2011, section

However, here is one other possibility: Do a risk assessment; determine what risks there are to the sprinkler pipe that has cable surrounding it. (I suspect you will find there are no risks, or at least, minimal risks). If your risk assessment identifies any mitigating factors, then implement those mitigating factors. In other words, remove the cable from the sprinkler pipe the best that you can.

If you cannot remove all of the cable from the sprinkler pipe then I suggest you assess it for ILSMs and let it be. Wait for it to be cited during a survey, then submit a waiver request as part of your plan of correction. I suspect the accreditation organization would likely transfer the waiver request on to the respective CMS regional office and they would approve it, provided you demonstrated a significant hardship.

Apr 19 2017

Sprinklers in Construction Areas

Category: Construction,Fire Watch,Questions and Answers,SprinklersBKeyes @ 12:00 am

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.

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