Sprinklers Under Canopies

Q: Does the Life Safety code require a sprinkler under a 4′ canopy? I find this hard to believe so I would like to know if you have a reference for this.

A: The LSC does not say how to install sprinklers, it just says that you do or you don’t need to install them. If you are required to install sprinklers (new construction, renovation, or construction type) then you must follow NFPA 13 (2010) edition on how to install them.

Section of NFPA 13 says sprinklers must be installed under exterior roofs or canopies exceeding 4 feet in width. An exception to this requirement is if canopy or roof is of noncombustible or limited combustible construction. Also, sprinklers must be installed under roofs or canopies over areas where combustibles are stored and handled. The annex portion of this standard says vehicles that are temporary parked are not considered to be in storage. And the Annex says limited combustibles such as newspaper vending machines do not constitute storage of combustibles.

So, if your canopy is 4 feet in width or less, then you are not required to install sprinklers, according to NFPA 13. Also, you need to install sprinklers where the local or state authorities tell you do so. I suggest you check with them to determine if your arrangement requires sprinklers.

Sprinkler System Pressure Gauges

Q: My question has to do with the pressure gauges for our fire sprinkler system. We just had some out of date pressure gauges replaced by a new sprinkler contractor. They removed the 3 1/2 inch gauges and replaced them with 2 inch gauges. Upon further inspection I noticed that the gauges had no UL or FM listing. They have on the back a CRN aka Canadian Registration Number. Can this type of gauge be used?

A: The Canadian Registration Number (CRN) is a number issued by each province or territory of Canada for the design of a boiler, pressure vessel or fitting. The CRN identifies the design has been accepted and registered for use in that province or territory. You are in Florida, so there is no requirement in the USA for a CRN. According to NFPA 13-2010, the standard on the installation of sprinkler systems, section says the pressure gauges must be listed and must have a maximum limit not less than twice the normal system working pressure at the point where installed. It is apparent that the Canadian Registration Number is not the same as a listing from an independent testing laboratory, so I would say the gauges that were installed at your facility would not be acceptable.

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 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 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 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.

Fully Sprinklered Buildings

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.

Removal of a Water-Flow Switch

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.

Portable Storage Racks

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.

AEM Program for Fire Alarm and Sprinklers

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.

Sprinkler Testing Certification

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.

Spare Sprinkler Heads

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.

Dust on Sprinkler Heads

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.