Qualified Technicians

Q: We recently found out that our own maintenance staff is not qualified to service our fire alarm system. What other systems or items in the hospital requires our own technicians to be qualified in order for them to perform the required service?

A: As you mentioned, technicians who test, inspect or maintain the fire alarm system are required to be qualified and experienced, according to NFPA 72 National Fire Alarm Code, 1999 edition. Section 7-1.2.2 list examples of qualified personnel, and includes, but does not limit individuals with the following qualifications:

  • Factory trained and certified
  • National Institute for Certification in Engineering Technologies (NICET), fire alarm certified
  • International Municipal Signal Association (IMSA), fire alarm certified
  • Certified by a state or local authority
  • Trained and qualified personnel employed by an organization listed by a national testing laboratory for the servicing of fire alarm systems.

Other fire safety systems typically found in hospitals where some type of qualification is required, would be:

  • According to NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition, section 4-1.4, maintenance, servicing and recharging of portable fire extinguishers must be performed by trained persons having available the appropriate servicing manuals, the proper types of tools, recharge materials, lubricants, and manufacturer’s recommended replacement parts for the use of the extinguishers. Also, according to section 5-1.2 of the same standard, hydrostatic testing on portable fire extinguishers must be performed by persons trained in pressure testing procedures and safeguards, who have suitable testing equipment, facilities and appropriate servicing manuals available. The standard does not list any examples of what ‘trained persons’ mean.
  • Backflow preventers: Persons performing testing and inspection on backflow preventers are typically required to be licensed by the state or local authorities.
  • NFPA 12A, Standard on Halon 1301 Fire Extinguishing Systems, 1997 edition, section 4-1.1 and NFPA 2001, Standard on Clean Agent Fire Extinguishing Systems, 2000 edition (for FM-200 fire suppression systems), section 4-1.1, both say all systems must be thoroughly inspected, tested, and documented for proper operation by trained competent personnel. These standards do not describe what ‘trained competent personnel’ means.
  • NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 1998 edition (for kitchen hood fire suppression systems), section 5-3.1 says a trained person who has undergone the instructions necessary to perform the maintenance and recharge service reliably and has the applicable manufacturer’s listed installation and maintenance manual and service bulletins must service the wet chemical fire extinguishing system 6 months apart.

Where the above standards do not specify what training or qualifications are required, then that determination is left up to the authority having jurisdiction. So far, I have only seen the accreditation organizations request documentation for qualifications of the technicians for fire alarm testing, inspection and maintenance, but that does not mean they couldn’t request documentation on the other issues. As always it is best that you check with your state and local authorities to determine if they have additional requirements or interpretations that you will need to comply with.

Sprinkler Main Drain Test

Q: Where is the main drain test supposed to be conducted? Is it supposed to be at the sprinkler riser or low point drain?

A: According to NFPA 25 Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (1998 edition), the main drain test of the sprinkler system is to be conducted at the sprinkler system riser. The purpose of the main drain test is to determine whether there has been any change in the condition of the water supply piping and control valves. There has been some confusion about main drain tests, as one accreditation organization permits their hospitals to conduct the main drain test at the low point drain where the supply main enters the building. But they are confusing the NFPA 25 standard which does allow the main drain test to be conducted at low point drains on standpipe systems, only when standpipe systems are separated from sprinkler system risers. Main drain tests for sprinkler systems must be conducted annually, and after every time a control valve has been closed. A successful main drain test will record the static pressure of the water, the residual pressure after the main drain valve is opened, and the time to restore to static pressure after the main drain valve has been closed. The results of each test must be compared to previous test results to determine if there is any change in the water supply.

Monthly Elevator Recall Test

Elevator RecallOne of the requirements that CMS and Joint Commission surveyors is requesting from hospitals and nursing homes is documentation that the elevators have been tested  for ‘Recall’. Elevator recall is a test that the Life Safety Code requires to be accomplished on a monthly basis. Section 9.4.6 of the 2000 edition of the LSC says all elevators equipped with Fire Fighter Service shall be subject to a monthly operation. Now, the phrase ‘elevator recall’ is a bit of a misnomer, as the monthly test requires activating all of the Fire Fighter Service functions, not just the recall portion.

LSC sections 18/19.5.3 requires compliance with section 9.4, which in turn requires all existing elevators that travel a distance of 25 feet or more above or below the level that bests serves the needs of the emergency personnel, to comply with the Fire Fighter Service Requirements found in ASME/ANSI A17.3 Safety Code for Existing Elevators and Escalators. This code references other ASME/ANSI publications which describes the specific requirements for the installation of Fire Fighter Service for the elevators. Furthermore, LSC section 9.4.6 requires the Fire Fighter Service in each elevator to be tested once a month with a written record of the test and findings maintained on the premises. The elevator recall portion is commonly referred to as “Phase 1” and the in-car manual control system for fire-fighters is commonly referred to as “Phase 2”. Both phases, if equipped, must be tested for each car. Please check with your local and state authorities on the qualifications to conduct this test, as some AHJs only permit trained or certified individuals to conduct this test.

If you have never performed this Fire Fighter Service test, then I suggest you have your elevator maintenance company show you how it is done the first time, then you can continue to do it on a  monthly test. But, in lieu of that, here is how a monthly elevator recall test is performed:

  1. Take a copy of the elevator recall key, insert it in the corridor keyed switch on the level best used by the responding fire department, and turn it to the “Test” position. This key should be available from the elevator service company.
  2. This will recall all the elevators in that bank of elevators to the floor that you are on. The elevator will ‘recall’ to that floor and open the doors. The controls inside the elevator will not respond and the elevator car will sit there waiting for a fire fight to take control. The elevators will be “out of service” during this test, so plan on doing this test when it will least impact your operations.
  3. Remove the key from the recall corridor switch (leave it still in the “Test” position) and enter one of the elevator cars. Take the key and insert it in the keyed switched labeled “Fire Fighter Service”, and turn it to the “Test” position (I think it will say “Test”, but if not, turn the switch anyway). Now you have manual control on the elevator buttons inside the car.
  4. Push a button to another floor, holding it until the doors closed. The elevator will travel to that floor, but the doors will not open. If you push the “Door Open” button, then the doors will open, and stay that way until another floor button is pressed.
  5. While in the elevator car, test the function of the emergency telephone in the car.
  6. Return the elevator car to the recall floor, and test any other cars in that bank. Remove the key and go back to the corridor switch and return the switch to the normal setting.

That is a monthly ‘Elevator Recall’ test, which must be done each month to all elevators. You may find that the fire alarm system will become alerted during this test and before the elevators return to normal service you may have to reset the fire alarm system.


Generator Load Tests

Q: Is it allowed to combine the 3-year 4-hour generator load test along with the annual 2-hour load test? Our generator test company plans on running the generator at 50% load for the first two hours and then elevate to 75% load for the last two hours. In your opinion would this satisfy both the 2 hour and the 4 hour load test?

A: You are allowed to combine the 2-hour load test and the 4-hour load test. The 2-hour load test is required to be conducted once per year when the generator cannot meet the load test of 30% of nameplate rating every month. When this occurs, you still conduct the monthly load tests but once per year you need to conduct a 2-hour load test (usually by connecting the generator to a resistive load bank) that consists of the following sequences:

  • 25% load for 30 minutes, then
  • 50% load for 30 minutes, then
  • 75% load for 60 minutes for 2 continuous hours.

The scenario that you described allowed 50% load for the first two hours and then a 75% load for the last two hours. This would be acceptable in meeting both test requirements since the percentages listed in the standards are minimum settings, and you are permitted to exceed them. But you need to be careful, because if you combine these two tests and start out at 25% load (as required for the 2-hour load test) for the first 30 minutes, then you are out of compliance with the 4-hour test, unless you run an extra 30 minutes after you reach or exceed 30%.


Fire Pump Annual Flow Test

Q: My sprinkler testing contractor is questioning the requirement that fire pumps are to be flow-tested annually at 150% load on emergency power. It’s the emergency power requirement in question. Quite frankly, I do not remember a Joint Commission surveyor ever asking to see this information, either. What are the actual requirements?

A: Section 19.3.5 of the 2000 edition of the NFPA 101 Life Safety Code (LSC) requires healthcare facilities that have sprinkler systems, to be in compliance with section 9.7. Section 9.7.5 requires all automatic sprinkler systems to be inspected, tested and maintained in accordance with NFPA 25 (1998 edition).  Among other requirements in NFPA 25, section 5-3 discusses what is required for annual water-flow testing of fire pumps. For those fire pumps that are equipped with an Automatic Transfer Switch (ATS), a loss of normal power is to be simulated when the pump is operating at peak capacity (150% of nameplate capacity) to cause a transfer to generator power. Another set of readings need to be documented to ensure the pump is still operating at peak flow capacity (150%) while operating under generator power. Then the power needs to be restored to the normal source to ensure the breakers do not trip. The above testing requirements are compulsory by the LSC, and if an authority having jurisdiction (AHJ) chooses not to ask for this documentation, then that is their prerogative. However, since the typical hospital has 5 or 6 different AHJs inspecting them in accordance with the NFPA requirements, you can bet one of them will be asking to see these test results. It is better to be in compliance with the LSC and be prepared for that moment in time when you are asked to prove you did the annual flow test correctly, than to be embarrassed and say you didn’t do it because another AHJ did not ask to see the documentation.  Besides, it is a requirement, and if your testing contractor is not aware of these requirements, then perhaps the hospital may want to reconsider doing business with them.

Circuit Breaker Testing

Q: During a recent survey, the inspector cited us for not exercising our circuit breakers downstream of our generator. Does the LSC require annual exercising of all circuit breakers between the generator and the connected load?

A: The LSC section 9.1.3 does require emergency power generators to comply with NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition. Section 6-4.6 of NFPA 110 requires the main and feed circuit breakers between the generator and the transfer switch terminals to be exercised annually with the generator in the off position. This appears to me that all emergency source circuit breakers are required to be exercised annually.  This would include the generator output breaker and all downstream distribution breakers, up to and including any breakers that feed the emergency feed side of the automatic transfer switch (ATS).  I believe that would exclude any loads connected to the load side of the ATS such as motors, lights, pumps, etc.  The process is a simple one because all affected breakers are normally in a de-energized state. I do not recall ever seeing a reason for this procedure published, although I’m sure there is a good reason.  In my experience though, breakers that are not exercised regularly can be extremely (if not impossible) to reset, even though the internal trip mechanism may work perfectly. This may lead an organization to not conduct this annual test, which may result in them being cited for noncompliance. Some organizations will purchase replacement circuit breakers and have them available on a shelf in case the breaker will not reset. While this is a very proactive approach to testing and a quick response to potential repairs, it can be rather costly as the large current breakers are a bit pricey. While this issue may not come up very often during a survey, it is a LSC requirement and the surveyor has the obligation to cite the issue if he or she sees it as being noncompliant.

Main Drain Tests- Part 1: Why Are They Required?

Main drain tests are required by section 9.7.5 of the 2000 edition of the Life Safety Code, which requires sprinklers systems to be tested and maintained according to NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition.  The purpose of a main drain test is covered in the Annex section A-9-2.6, of NFPA 25, which says:

“…(main) drains also are used to determine whether there is a major reduction in waterflow to the system, such as might be caused by major obstruction, a dropped gate, a valve that is almost fully closed, or a check valve clapper stuck to the valve seat. A large drop in the full flow pressure of the main drain (as compared to previous tests) normally is indicative of a dangerously reduced water supply caused by a valve in an almost fully closed position or other type of severe obstruction. After closing the drain, a slow return to normal static pressure is confirmation of the suspicion of a major obstruction in the waterway and should be considered sufficient reason to determine the cause of the variation. A satisfactory drain test (i.e., one that reflects the results of previous tests) does not necessarily indicate an unobstructed passage, nor does it prove that all valves in the upstream flow of water are fully opened. The performance of drain tests is not a substitute for a valve check on 100 percent of the fire protection valving.”

The Annex section A-9-2.6 also continues to describe what a main drain test is:

The main drain test is conducted in the following manner:

  1. Record the pressure indicated by the supply water gauge [Static Pressure]
  2. Close the alarm control valve on alarm valves
  3. Fully open the main drain valve
  4. After the flow has stabilized, record the residual (flowing) pressure indicated by the water supply gauge
  5. Close the main drain valve slowly
  6. Record the time taken for the supply water pressure to return to the original static (nonflowing) pressure
  7. Open the alarm control valve”

I find that many hospitals, especially the older hospitals, do not have the requisite pressure gauge, drain valve and a suitable drain to collect the substantial flow of water to properly conduct a main drain test. Also, I always recommend to my clients to shut off the fire pump and leave on the jockey pump during the main drain tests. Shutting off the fire pump for this test constitutes an impairment, and appropriate interim life safety measures must be considered, according to the organization’s policy.

Please be aware that a main drain test is required downstream of any control valve that has been closed, then opened. Also starting with the 2002 edition of NFPA 25, a single quarterly main drain test is required downstream of all backflow preventers in the system. This will be a requirement once the 2012 edition of the Life Safety Code is finally adopted.