Sep 05 2013

Changes with Sprinkler Testing When the New 2012 LSC is Adopted

Category: Blog,Life Safety Code UpdateBKeyes @ 5:00 am

There will be significant changes for facility managers to deal with when the Centers for Medicare & Medicaid Services (CMS) finally adopts the 2012 edition of the Life Safety Code. This excerpt from a new upcoming book by Brad Keyes and published by HCPro, titled “Preparing for the New Life Safety Code” discusses changes involving the life safety equipment.

Sprinkler_-_Quick_Response_Type_Sprinkler[1]According to the Life Safety Code, automatic sprinkler systems are required to be installed in agreement with NFPA 13 Standard for the Installation of Sprinklers. But NFPA 13 does not address how the sprinkler systems should be inspected, tested or maintained- just installed. Prior to 1992, NFPA attempted to identify the proper requirements for the inspection, testing and maintenance of the automatic sprinkler system in various publications, but at that time a decision was made to combine all the different NFPA standards on sprinkler inspection, testing and maintenance into one.  Thusly, NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems was born, which set standards for all sprinkler systems in all types of occupancies. NFPA 25 applies to hospitals, nursing homes, ambulatory care occupancies, business occupancies and all other types of facilities, regardless whether patients are treated in the building or not. Now, there may be a question whether or not NFPA 25 is enforced by authorities at all locations, but the standard does apply to all.

The 2012 edition of the LSC references the 2011 edition of NFPA 25. The changes with NFPA 25 since the 1998 edition (which was referenced by the 2000 edition of the LSC) that are considered significant are:

  • All deficiencies or impairments discovered during the inspection, testing or maintenance process must be corrected or repaired, and performed by qualified individuals
  • The location of shut-off valves must be identified
  • An informational sign must be placed at the system control riser supplying an anti-freeze loop, dry system, preaction system, or auxiliary system control valve. Each sign must indicate the following minimal information:
    • Location of the area served by the system
    • Location of auxiliary drains and low-point drains for dry pipe and preaction systems
    • The presence or location of anti-freeze or other auxiliary systems
    • The presence and location of heat tape
  • Components and systems are permitted to be inspected, tested and maintained under a performance-based program as an alternative means of compliance, subject to the approval of the AHJ
  • Vane and pressure type waterflow switches are permitted to be tested semi-annually, rather than quarterly. Other mechanical type waterflow switches must be tested quarterly
  • A main drain test must be performed quarterly downstream of a backflow preventer in systems were the sole water supply is through a backflow preventer or pressure reducing valve. This is in addition to the annual main drain tests required at each riser.
  • Dry sprinklers that have been in service for 10 years must be replaced, or a representative sample tested
  • All sprinklers that have been in service for 75 years must be replaced, or a representative sample tested
  • Standpipe hose valves (not Fire Department Connections) are required to be inspected quarterly for the following:
    • Ensure hose caps are in place and not damaged
    • Inspect hose threads for damage
    • Ensure valve handle is present and not damaged
    • Inspect gaskets for damage and deterioration
    • Ensure hose valve is not leaking
    • Ensure access to hose valves is not obstructed
  • Standpipe systems with 2½ inch hose valves must have their valves tested annually by opening and closing the valve
  • Standpipe systems with 1½ inch hose valves must have their valves tested every 3 years by opening and closing the valve
  • Standpipe water-flow tests every 5 years are for wet standpipes. Dry standpipes are required to have a hydrostatic pressure test every 5 years
  • Electric motor driven fire pumps are permitted to be tested monthly at no-flow conditions for 10 minutes. Engine driven fire pumps must continue to be tested weekly at no-flow conditions for 30 minutes.

The new requirement to identify the location of all shut-off valves in your sprinkler system may be accomplished many different ways: Plot them on your CAD drawings; Mark the suspended ceiling grids where the valves are located; List them on charts which are posted in conspicuous areas of the facilities department; Or do all three. Since the standard does not define how the valves are to be identified, you get to make that distinction until such time an AHJ interprets it for you.

If you are not already performing these inspections and tests, the new requirement for a quarterly main drain test downstream from the backflow preventer; and the quarterly inspections of the fire hose valves; and the annual (or 3-year) test of the fire hose valves may catch you by surprise. Make sure you begin a routine on these new inspections and tests, as the surveyors and inspectors will be fully aware of the requirements and won’t be bashful asking you for documentation.

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Apr 04 2013

Why The Life Safety Code?

Category: BlogBKeyes @ 6:00 am

10100[1]Why do we need the Life Safety Code? This is a question that I am frequently asked by individuals who do not understand what all the fuss is about that is placed on compliance with a code when the nation hasn’t had a fatality in a hospital due to fire in a long time. The answer to that question is simple: Without the Life Safety Code, our hospitals would return to a condition where tragic results will occur from fires and other emergencies.

 It wasn’t until 1970 that a national organization adopted the NFPA 101 Life Safety Code and required hospitals to be in compliant with it. The Health Care Financing Administration (HCFA), the fore-runner of the Centers for Medicare & Medicaid Services (CMS) chose the Life Safety Code over other codes and standards because it addresses the building and staff preparedness to cope with fires and emergencies. Prior to HCFA adopting the Life Safety Code, compliance with it was only regulated on a local or state level, and in many situations, compliance with the Life Safety Code was only a recommendation, not a requirement. As a result, there were significant losses of life with fires in hospitals prior to this time period.

 Cleveland Clinic, Cleveland, OH

In May, 1929, a fire in a lower level storage area, which contained nitrocellulose X-ray film killed more than 120 people, mainly due to the toxic and explosive gas which was a result of the combustion of the film. There were no sprinklers in the storage area and unsealed openings between the floors allowed the toxic and explosive gas to travel upward.

 Saint Anthony Hospital, Effingham, IL

In April, 1949, at least 74 people died in this 100-bed hospital located in the small rural community in central Illinois. The fire apparently started in the lower level where the laundry chute discharged the soiled linens, and spread upward via the open chute and through the building. The building was constructed with combustible materials, and did not have any smoke compartment barriers, nor any smoke detection or fire suppression systems.

 St. Elizabeth’s Mercy Hospital, Davenport, IA

41 people lost their lives in a 1950 fire in the female psychopathic hospital, caused by a deranged patient. The windows were barred and the doors were locked and staff was unable to quickly evacuate the patients. The building was constructed with combustible materials, and was not protected with sprinklers.

 Hartford Hospital, Hartford, CT

In December, 1961, 16 people died as a result of a fire that started in the trash chute at the Hartford Hospital. The building was constructed with non-combustible materials, but had interior finishes which were combustible. When the fire erupted through the chute door on the 9th floor, combustible ceiling tiles, wall coverings and flooring ignited, trapping many patients and staff in dead-end corridors. Sprinklers were present in other areas of the hospital, but not on the 9th floor where all the victims were located.  

 With the requirement starting in 1970, that all hospitals receiving Medicare reimbursement have to comply with the Life Safety Code, deaths in hospitals fires began to diminish, but were not all eliminated all-together.

 SAC-Osage Hospital, Osceola, MO

In December, 1974, 8 patients died as a result of a fire at the SAC-Osage Hospital. 6 patients died of smoke inhalation, and 2 patients died when a supply valve to their oxygen tent was inadvertently shut off. The facility was only 5 years old at the time, and was constructed to federal and state fire prevention codes in affect at the time. The fire was thought to have started from smoking materials igniting combustibles in a patient’s room.

 Hospice of Southeastern Michigan

In December, 1985, a fire that started in a recliner in a patient’s room led to the death of 8 people in this hospice facility. All of the fatalities were in rooms were the doors to these rooms had not been fully closed and latched.  Smoke spread through the bathroom ventilation system from room to room.

 Riverside General Hospital, Riverside, CA

In November, 1986, 5 patients died in the Riverside General Hospital after a fire started in a patient room and spread out into the corridor. According to reports, the patient was smoking in his room and attempted to shut off his oxygen supply, but failed. Evacuation of the patients in the area of fire was not able to be completed due to heavy smoke from the fire.

 Maimonides Medical Center, Brooklyn, NY

3 patients died in a fire in September, 1993 at the Maimonides Medical Center, in Brooklyn, NY. According to a newspaper article, the fire started in a faulty respirator supplying oxygen to an elderly patient. The article said that hospital engineers had worked on the respirator hours before the fire, after nurses and other workers complained that it was giving electrical shocks. Investigators said that an electrical fault in the machine caused the fire, which was fuled by pure oxygen, and created a blast so fierce that witnesses said it sent a fireball through the 7th floor hospital window.

 Southside Regional Medical Center, Petersburg, VA

On December 31, 1994, a fire that started in a patient’s room in the Southside Regional Medical Center, in Petersburg, VA, resulted in the deaths of 5 patients. The fire apparently was started by smoking materials, which spread to bedding linens and mattress. Smoke spread into the corridor because the door to the room of origin was left open. According to reports, the fire alarm transmission to the fire department was delayed because the connection was taken out of service at the time of the fire. The room and the corridor were not protected with sprinklers.

 Great progress has been made over the years on fire safety in hospitals. In the five-year span between 1980 to 1984, fire departments in the United States responded to an estimated 7,100 hospital fires annually resulting in an average of 5 deaths per year. In a similar time span between 2006 to 2010, US fire departments responded to an average of only 1,400 fires per year that resulted in less than 1 death per year. The significant change in this statistic is attributed to the implementation of smoking bans in hospitals. In 1980 to 1984, 35% of the fires were started by smoking materials, as compared to only 7% of the fires were started by smoking materials during the period 2006 to 2010. During this same time period, 60% of the fires were started by cooking equipment.

 Fires will continue to occur in healthcare facilities, and we need to be prepared for them. While smoking bans have cut down the number of fires started by careless use of smoking materials, it hasn’t eliminated them. Most healthcare professionals will admit that patients are still sneaking cigarettes without the staff’s knowledge. Add in the factor of heat producing devices around high oxygen environments (such as cauterizing pens in surgery), fire will continue to happen.

 During the time period between 1980 to 1984, sprinklers were present in less than half of the reported fires in hospitals, while such fire suppression equipment was noted in 79% of the reported fires during the time period 2006 to 2010. During this same time period, damage from fire was limited to the room of origin in 97% of the reported fires.

 The lesson we have learned is sprinklers save lives. When coupled with early fire detection, and a capable, trained staff on fire response procedures, our hospitals are safer today than they have ever been. But we still average 3.8 fires per day in hospitals in the United States. We need to be prepared and ready to face that situation when it occurs. Without the Life Safety Code, we will have far more tragic results than we have today.

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Oct 11 2012

Why Do We Want to Know Where Our Quick Response Sprinklers are Located?

Category: BlogBKeyes @ 5:00 am

Frequently, I am asked why do healthcare organizations need to know where their quick response (QR) sprinkler heads are located? If you facility is similar to most, then you likely have a mixture of QR sprinkler heads and standard response (SR) sprinkler heads.

When conducting a Fire Safety Evaluation System (FSES) equivalency request, there is a question in the worksheet that inquires what level of protection does the healthcare facility have in regards to smoke detection. Very few hospitals install smoke detectors in all occupiable spaces. If you look at Safety Parameter #12 (Smoke Detection and Alarm) on the FSES worksheet 4.7.6, the value for ‘None’ is 0, and ‘Corridor Only’ is 2. According to the footnote, those values can be increased to 3 if the zone is protected with QR sprinklers. So, if that entire smoke compartment or zone is protected with QR sprinklers, then you can get extra points, which may prove to be handy.

Another reason to know where your QR sprinklers, is the 20-year maintenance requirement. 20 years after installation, QR sprinklers have to be tested (10% removed and sent to a testing lab) to make sure they are still operable, then they have to be tested every 10 years thereafter. Most organizations find it more cost effective to just remove all the QR sprinklers and replace them with new ones every 20 years. QR sprinklers became very popular in the early 1990’s in the healthcare industry, so many of them may already be beyond their 20-year maintenance requirement.

QR sprinklers and SR sprinklers are not allowed to be installed within the same four walls (room, area, hallway). You cannot ‘mix’ QR with SR sprinklers, because they will not respond the same in the event of a fire. The QR sprinklers may discharge quicker than the SR sprinklers, which may actually prevent the SR sprinklers from actuating at all. Surprisingly, I find this problem frequently. By identifying where the QR heads are located, this will help identify if they are mixed with any SR heads.

The top picture is a pendent QR sprinkler with a glass bulb filled with a secrete liquid. I don’t know if the liquid is actually a trade secrete, but I don’t know what it is, so it is a secrete to me. The diameter of the glass bulb will tell you if it is QR or SR: A QR head will have a 3 mm bulb, while the SR head will have a 5 mm bulb.

But there are QR sprinklers that do not have glass bulbs, like the second picture, which is a concealed head. In situations like this, the letters ‘QR’ will be printed (embossed) on the deflector and if you get close enough to the head you will be able to read the ‘QR’ letters. You can also review the contractors certification test records to see if they identified QR heads were installed, but sometimes the contractors fail to accurately identify what heads were installed, so a visual examination is usually the best method.


Aug 30 2012

Main Drain Test- Part 2: Where Are They Required to be Conducted?

Category: BlogBKeyes @ 5:00 am

According to the 2000 edition of the Life Safety Code, main drain tests are regulated by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition. Section 1-5 of NFPA 25 defines a main drain as the primary drain connection on the system riser and also is utilized as a flow test connection. Section 9-2.6 requires a main drain test must be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.

NFPA 25 does not adequately define what a ‘system riser’ is, so we turn to the Handbook for NFPA 13 Standard for the Installation of Sprinkler Systems which identifies a ‘system riser’ as follows:

“The above ground horizontal or vertical pipe between the water supply and the mains (cross or feed) that contains a control valve (either directly or within its supply pipe) and a waterflow alarm device. A system riser is more than just a subset of the term riser, which is broadly defined as any vertical piping within the sprinkler system. As indicated by the definition, a system riser can be any aboveground pipe in a vertical or horizontal orientation installed between the water supply and the system mains that contain specific devices.”

By the above definition, it appears one could loosely define the locations of a main drain test to be conducted wherever there is a control valve and waterflow alarm switch. In a large multi-story facility, that would most likely require a main drain test at least on every floor, possibly more. The Accreditation Organizations (AOs, such as Joint Commission, HFAP and DNV) typically do not seek this level of compliance. Most of the AOs only expect main drain tests to be conducted at the base of the risers of the sprinkler system, not at every floor. However, depending on the state agency surveyors who conduct CMS validation surveys, it is very reasonable and possible that they will expect the main drain tests to be conducted at every floor.

It is my experience that many of the AOs do not really know what to look for in a main drain test. One AO has confused the main drain requirements of standpipe systems with the main drain requirements of sprinkler systems and placed it in their standards that is is acceptable to conduct the main drain test at the low point drain at the point where the water supply enters the building, which is not consistent with what the NFPA standards requires. I know that CMS state agency surveyors are better educated and prepared to expect stricter compliance with the NFPA standards, as compared with the AOs.

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Aug 28 2012

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

Category: BlogBKeyes @ 5:00 am

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.

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Aug 09 2012

Sprinklers in Existing Healthcare Occupancies

Category: BlogBKeyes @ 5:00 am

This may seem basic to some of you, but one of the problems in the healthcare facilities management industry is people don’t always have a good solid foundation of the basics. From time to time, I have a conversation with a client about challenges they are having in regards to installing sprinklers in their existing facilities. Frequently they ask me how they should enter their sprinkler project into the Joint Commission Statement of Conditions (SOC), Plan For Improvement (PFI) list. Eventually I get around to asking the question “Why are you installing sprinklers?” Now, don’t get me wrong, I’m a firm believer in sprinklers as they do save lives in the event of a fire, and I am all for hospitals and nursing homes retroactively installing them, but I want to make sure the client fully understands their options.

First of all, let’s make it very clear that the 2000 edition of the Life Safety Code (LSC) does not require existing healthcare occupancies to be protected with automatic sprinklers, unless the Construction Type or an approved equivalency requires it. Existing conditions is defined as the local authority having approved construction documents for new construction or renovation projects before March 11, 2003. Why March 11, 2003? Because that’s the date the Centers for Medicare & Medicaid Services (CMS) approved the 2000 edition of the LSC. There is a caveat to this issue, and that is the LSC has required new construction and renovation to be protected with automatic sprinklers since the 1991 edition, so if your organization was required to comply with the 1991 (and subsequent) edition(s), then new construction and renovation conducted since the time that edition was adopted by your authorities needs to be sprinklered. CMS went directly from the 1985 edition of the LSC to the 2000 edition on March 11, 2003. I know Joint Commission had adopted the 1994 and the 1997 editions prior to adopting the 2000 edition on March 1, 2003 (Yes, they adopted the 2000 edition 10 days earlier than CMS…), but I do not know if and when they ever adopted the 1991 edition.

Construction Type is a NFPA reference describing the general fire resistance of the construction materials used to build the facility, and the level of fire protection on key structural members of the building, as measured in hours. So, Construction Type II (222) which is the most common type  for hospitals, would be a building constructed with fire resistant materials (such as concrete, brick, stone, gypsum board, etc.) and has key structural members (such as load bearing walls, beams, joists, trusses, floor decks) with a 2-hour fire resistant rating. Generally speaking, the taller the building the greater the Construction Type must be. According to the existing healthcare occupancy chapter (19) in the LSC, some lessor Construction Types in existing constructions must be sprinklered. In some cases an equivalency will specify sprinklers in an existing condition in order to gain enough points to be successful. If you have any approved equivalencies, check them out to see if automatic sprinklers are a condition of their approval.

So, getting back to the client with the question about entering the sprinkler project into the SOC PFI list, I ask them “Why are you installing sprinklers?” If they say it is just a desire of theirs to have a fully sprinklered facility, then that is not a LSC deficiency, and they cannot enter that into their PFI list. The PFI list is reserved only for deficiencies with the Life Safety Code. Now, if they are installing sprinklers because they are renovating an area,or correcting a deficiency with their Construction Type, or need the points on an equivalency, then that is a life safety deficiency and the sprinkler project may be entered into the PFI list.

Confusing? That’s all-right, as it can be. Rome wasn’t built in a day, and everything a facility manager needs to know about the Life Safety Code is not learned by just reading a blog posting…. But it can help!


P.S. Be prepared for changes when the 2012 edition of the Life Safety Code is finally adopted (probably in 2014 or 2015). The new edition will require existing nursing homes to be fully protected with automatic sprinklers, and existing hospitals that are considered high-rise facilities to be fully protected with automatic sprinklers. A high-rise building is greater than 75 feet in height where the building height is measured from the lowest level of fire department vehicle access to the floor of the highest occupiable story. A penthouse mechanical room would not typically be considered an occupiable story.

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Jun 13 2012

Spare Sprinkler Heads

Category: BlogBKeyes @ 5:00 am

Here’s a quick quiz: How many spare sprinkler heads are you required to have on hand at your facility? If you said 6, then you would be partially correct. The number of spare heads that you are required to have on hand is directly correlated to the type, rating and quantity of heads you have in the facility. The minimum required is 6 of each type and rating.

The differences in type would be the orientation of the head (pendant vs. upright vs sidewall), standard response vs. quick response, and recessed or surface mounted. While most heads in a typical healthcare setting would be rated for 155 degrees, you may find higher temperature heads in the boiler room, over the kitchen cooking appliances and other high temperature areas.

Also, NFPA 13 Standard for Installation of Sprinkler Systems (1999 edition), section 3-2.9 requires not fewer than 6 spare heads when the quantity of sprinkler in the building is less than 300. For systems that have between 300 and 1000 sprinklers in the building, then 12 spare heads of each type and rating are required to be in storage. For systems with more than 1000 sprinkler heads then you must have at least 24 spare heads for each type and rating. And the spare heads must be stored in a cabinet where the ambient temperature does not exceed 100 degrees F. A special wrench to install the heads is also required to be stored with the spare heads.

So, it may be useful for you to find the location where you keep the spare heads, and make sure you have the correct quantity in storage for each type and rating of heads installed in the facility. And don’t forget to look for the special installation wrenches.



May 16 2012

Ceiling Mounted Obstructions

Category: BlogBKeyes @ 5:00 am

Which came first: The chicken or the egg?

Yeah, I don’t know the answer to that one either, and it is a really weak attempt of a connection to today’s subject: Ceiling mounted obstructions. But it does illustrate that something did in fact come first, and careful planning is necessary for all things that follow.

If an area of the hospital is new or newly renovated where the suspended ceilings are removed and new sprinklers installed, then it is likely that the sprinkler head was installed before any ceiling mounted devices, such as the IV Pole Track as indicated in the picture. However, if the sprinklers are installed into an existing situation where sprinklers were not previously installed, then it is likely that the IV Pole Track was there first. Whatever the situation, some sort of coordination is needed to prevent  ceiling mounted obstructions from getting too close to the sprinkler head.

The track in the picture (above) is for an IV Pole that glides on the track and moves around the patient. It is not a privacy curtain track.  The sprinkler head deflector is about an inch below the suspended ceiling, and the IV Pole Track projects down about 2 1/2 inches below the suspended ceiling.  As the picture indicates, the sprinkler head is about 4 inches away from the IV Pole Track. This configuration is a violation of NFPA 13 (1999 edition), section 5-, which provides us with a Table that has the minimum distances required between a sprinkler head and a ceiling mounted obstruction. The amount that the ceiling mounted obstruction extends below the sprinkler head deflector is also a factor. So, according to Table 5-, nothing is permitted to extend below the sprinkler head deflector for the first 12 inches. But, then it starts to change, as a ceiling mounted obstruction that is 18 inches away from the sprinkler is allowed to extend down no more than 2 1/2 inches below the sprinkler deflector.

Take a look at Table 5- in NFPA 13 (1999 edition) and use it to evaluate the correct distance allowed for a ceiling mounted obstruction from a sprinkler head. You need to do an entire hospital search to find these problems before a surveyor does. Unless the area is under warranty from the general contractor, at this point it really doesn’t matter who is at fault: the person installing the sprinkler or the person installing the IV Pole Track. What’s important is it gets resolved.

Don’t forget to consider the ceiling mounted signs that are in the hospital. They frequently get installed with little (or no) regard for proper clearances from sprinklers.


Mar 29 2012

Sprinklers in Electrical Rooms

Category: BlogBKeyes @ 10:57 am

I was talking recently with a good friend of mine, Jeff Lehmann, concerning sprinkler installation in electrical equipment rooms. The topic of discussion was, if an electrical equipment room was not protected with automatic sprinklers, but the rest of the hospitals was, does that make the hospital to be classified as being nonsprinklered?

In the NFPA 13 Standard for the Installation of Sprinklers handbook (2010 edition), there is a comment concerning sprinkler installation in electrical rooms:

“Although sprinkler systems have been successfully installed in rooms containing electrical equipment for 100 years with no documented instances of a problem, NFPA 13 identifies certain conditions that, if followed, permit sprinklers to be omitted from electrical equipment rooms… Building owners need to police the areas. The building owner must control access to all such electrical equipment rooms to reduce the likelihood that storage of any type is present in these spaces.”

What the handbook is referring to is also found in NFPA 13 (1999 edition) section 5-13.11 which allows an exception to installing sprinklers in an electrical equipment room, provided you meet all of the following requirements:

  • The room is dedicated to electrical equipment only
  • Only dry-type electrical equipment is used
  • Equipment is installed in a 2-hour fire rated enclosure including protection for penetrations
  • No combustible storage is permitted to be stored in the room

As mentioned, the room must have a 2-hour fire rated barrier surrounding the room, including the floor and deck above. Any openings (doors) in the room must be properly fire rated at 90-minutes and must be self-closing and positive latching. Any ventilation ductwork which penetrates the 2-hour barrier must be equipped with the appropriate fire dampers, and all penetrations must be properly firestopped.

But we need to look at section in the 2000 edition of the Life Safety Code which also has an exception that says:

“In Type I and Type II construction, and where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.”

In the past, I have seen this exception applied to elevator equipment rooms as well as electrical equipment rooms, specifically where the lcoal AHJ did not want sprinklers in those rooms. But this exception is also accepted to allow FM-200, Halon, Inergen and CO2 fire protection systems to be installed in certain rooms, such as computer rooms, without the building being classified as nonsprinklered.

The 2-hour fire rated barrier exception in NFPA 13 (1999 edition) section 5-13.11 certainly qualifies as an ‘alternative protection’ system, therefore, if properly installed in Type I or Type II buildings, it would not make the hospital be classified as being nonsprinklered.


Mar 27 2012

Fire Department Connections

Category: BlogBKeyes @ 4:17 pm

In the pictures to the left, you will see damaged wall-mounted Fire Department Connections, or FDC for short. The FDC is an often over-looked important piece of fire protection, mainly because it is out-of-sight and out-of-mind.

The purpose of the FDC is to allow the fire department to be able to pump supplemental water into the sprinkler system, standpipe, or other system. This will provide additional water supply for fire extinguishment to supplement existing water supply.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998  edition is referenced by the Life Safety Code (2000 edition), and requires compliance with the testing methods and frequencies. Section 9-7 identifies the inspection requirements for the FDC:

 1. FDC must be inspected quarterly

2. The FDC must be visible and accessible

3. The FDC couplings or swivels must not be damaged, and they have to rotate smoothly

4. The FDC plugs or caps must be in place and undamaged

5. The FDC gaskets must be in place and undamaged

6. The FDC identification sign must be in place and readable

7. The check valves serving the FDC must not be leaking

8. The automatic drain valve serving the FDC must be in place and operating properly

Section 9-7 continues by saying if the FDC plugs or caps are not in place, then the interior of the FDC must be inspected for obstructions and you must verify that the valve clapper is operational over its full range. Additionally, all components must be repaired or replaced as necessary in accordance with the manufacurers’ instructions.

CMS, The Joint Commission, HFAP and DNV all require compliance with NFPA 25 in regards to FDC inspections. NFPA 25 does not require a specially trained or certified individual to conduct this inspoection, just someone who hasa been instructed on what to look for. Healthcare organizations must take appropriate action to ensure the quarterly inspections are conducted, even if they rely upon a contractor to do so. A simple preventative maintenance (PM) work order issued from the computerized maintenance management program, once every three months is the easiest way to remember to conduct this inspection.


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