Corridor Doors Have to Be Fire-Rated?

Q: We have an engineer who is telling us that the 2012 Life Safety Code requires our corridor doors to be fire-rated. He is referencing Table which says exit-access corridor walls that are either 1-hour rated or ½-hour rated require a 20-minute fire-rate door. He says the healthcare occupancy chapter sections and support this as well. Is this true?

A: Well… it appears your engineer is reading the Life Safety Code wrong. When you want to learn what the Life Safety Code requires pertaining to any subject, you start with the occupancy chapter first, not the core chapters (chapters 1 – 11). Section of the 2012 LSC says corridor walls in healthcare occupancies are ½-hour fire-rated and extend from the floor to the deck above. However, in smoke compartments that are protected throughout with approved sprinklers, the corridor walls are permitted to be non-fire-rated, but only resist the passage of smoke and extend from the floor to the ceiling provided the ceiling also resists the passage of smoke.

And according to section, doors in corridor walls in healthcare occupancies are only required to resist the passage of smoke, be 1¾-inches thick, solid bonded, wood core, or made of materials that resists fire for a minimum of 20 minutes. This does not mean the door has to be 20-minute rated… just constructed to resist fire for a minimum of 20-minutes.

According to section, whenever there is a conflict between the occupancy chapters and the core chapters, the information in the occupancy chapter governs. The information your engineer saw in Table is general information and applies to all occupancies. However, the existing healthcare occupancy chapter differs with information in Table, which means the information in the occupancy chapter governs.

I don’t see what you are referring to regarding It does not say doors have to be 20-minute rated. It says doors do not have to be 1¾-inches thick, solid bonded, wood core, and resists fire for 20-minutes for certain areas such as toilets rooms, bathrooms, and shower rooms. It is giving you a break for being an existing healthcare occupancy. In some very old hospitals, they installed doors that were not 1¾-inches thick, and this section is permitting them to remain.

And section is stating what I’ve already mentioned: Corridor walls in smoke compartments that are fully protected with sprinklers are permitted to be non-fire-rated smoke resistant partitions that extend from the floor to the ceiling, provided the ceiling also resists the passage of smoke.

Strange Observations – Combustible Materials in Structural Support

Continuing in a series of strange things that I have seen while consulting at hospitals…

So… I’m above a ceiling in a pre-assessment testing area and I see in the corner what appears to be a wood 2×4.

According to NFPA 220, construction types I and II cannot have combustible material in the structural components. (This hospital was a Type II (222).

This wood 2×4 is supporting an interior wall and the suspended ceiling.

You have to keep an eye on contractors while they are renovating your departments… they will do things like this that will eventually get you in trouble.

Fire Damper Removal

Q: I have a building that is fully sprinklered and has full protection from the fire alarm system, with multiple floors. The age of the building is 40+ years and when it was constructed it was not fully sprinklered and had fire and smoke dampers (some still pneumatic) to control the spread of fire and smoke. Our last damper inspection revealed that we have 44 dampers that are not functioning or they are inaccessible to inspect. My question is, since we are now fully protected by sprinklers and are using the rule for smoke compartments on the floors, are all the dampers we have are necessary or can we possible take some out of service? What is the rule on this situation?

A: That’s tough question to answer without actually seeing the facility, but I’ll take a stab at it: If the smoke compartment layout has been re-designed, and you find that some existing smoke barriers are no longer required, then the smoke dampers located in those smoke barriers could be removed, pending approval from your state and local authorities on hospital construction. However, if existing smoke barriers remain in use but you would like to remove the smoke dampers because section (2) of the 2012 LSC says smoke dampers are not required in new construction smoke barrier where the HVAC duct is fully ducted and the adjoining zones are fully sprinklered…. That may not happen because the IBC codes do not allow this. If you are required to comply with the IBC codes, then this will be a problem. Check with your state and local authorities to see if they require compliance with the IBC codes.

Alcohol Disinfectant Wipes

Q: What is your opinion on alcohol based disinfectant wipes and their inclusion in the aggregate amount of flammable liquids in a smoke compartment?  We are considering a product that contains 55% isopropyl alcohol and would be 857ml.  There is one opinion posted online that includes these products in the NFPA 30 standard compliance.

A: I would agree with the concept that any alcohol product would contribute to the aggregate total of ABHR liquids or aerosols to not exceed 10 gallons in dispensers per smoke compartment. Therefore, if you had one 857 ml dispenser of alcohol-based disinfectant wipes, then you would be limited to 36 one-liter ABHR dispensers per smoke compartment so you would not exceed 10 gallons of product in dispensers per smoke compartment. This would be consistent with section (5) of the 2012 LSC.

Batteries in the Fire Alarm System

Q: We have a difference of opinion in our organization that I hope you can settle for us. I believe the sealed lead-acid batteries in our fire alarm system are supposed to be tested per the requirements of NFPA 72 (Charger Test and Discharge Test annually and Load Voltage Test Semiannually). However, another point of view is that, since they’re a stored emergency power supply, they’re supposed to be tested the same as our Emergency Lights (30-seconds a month and 90 minutes annually). We want to be sure we’re in compliance, but we’ve reached the point where we’re turning in circles trying to figure out what we’re supposed to comply with. What are your thoughts on this question?

A: Based on NFPA 110-2010, section, the definition of a stored emergency power supply system is a system consisting of a UPS or a motor generator, powered by a stored electrical energy source, together with a transfer switch designed to monitor preferred and alternate load power source and provide desired switching of the load, and all necessary control equipment to make the system functional. That does not sound like batteries for a fire alarm system.

The Life Safety Code is the document that governs whenever there is a conflict or a disagreement. Section of the 2012 LSC requires compliance with section 9.6 in regards with the fire alarm system. Section says the fire alarm system must be installed, tested and maintained in accordance with NFPA 72. Table 14.4.5 of NFPA 72-2010 says sealed lead acid batteries used on fire alarm systems must have a charger test and a discharge test conducted annually, and a load voltage test conducted semi-annually. This eliminates any thought that the batteries must be tested monthly.

The requirement to test battery powered emergency lights on a monthly basis is found in section of the 2012 LSC, and this applies to emergency lighting systems… Not fire alarm systems. In this situation, you are clearly correct. Tell the others they owe you an ice cream cone for being right.

Strange Observations – Oxygen Cylinder Storage

Continuing in a series of strange things that I have seen while consulting at hospitals…

Yes… we are looking at oxygen cylinder storage issues again… Yuck.

The sad thing is, scenes like this are not that uncommon in my line of work as a consultant. That means it is not as strange as I would like it to be.

NFPA 99-2012, does require all compressed gas cylinders to be secured at all times. Presumably, those of you who are reading this realize this, and are as frustrated as I am when you find situations like this.

But put yourself in the position of the healthcare provider: Their number 1 priority is taking care of patients. Complying with Life Safety Codes, or other NFPA standards and regulations is not high on their list, and quite honestly, with everything they have to do, I’m okay with that. I’d rather they be concentrating on taking good care of me or my loved-one, rather than concentrating on making sure the corridor is not cluttered, or other basic LSC requirements.

So it is important for you to make compliance with the LSC as easy and simple as possible for those nurses, therapists, and technicians. That means, you need to do frequent rounding looking for basic violations as the one in the picture reveals. When you find these violations, you can do remedial training, but perhaps more importantly, make changes to eliminate the problem from happening again. In this case, obtain more storage racks so staff does not leave cylinders on the floor or unsecured.

Locks on Bathroom Doors

Q: In a multi-tenant office building, can restrooms in the common areas have controlled card access and mag locks tied into the fire system on the entry/exit doors?

A: Well, as long as the locks are installed in accordance with section of the 2012 Life Safety Code, I believe it would be okay from an NFPA viewpoint. But you need to ask your state and local authorities to see if they have other restrictions that would prevent this from happening.

Boot Camp Group Photo

Here is a group photo of those individuals who attended the Keyes Life Safety Boot Camp this past week in Jackson, TN. Everyone seemed to have enjoyed themselves and based on the evaluation sheet comments, I would say it was a success.

Thank you to Compliance One staff Ali Rogers and Joe Humphries for coordinating the event, and a very special THANK YOU to the West Tennessee Healthcare, Jackson-Madison County General Hospital for hosting the event.

There will be additional Keyes Life Safety Boot Camps later this year so keep your eye on this website for announcements when those details become finalized.

Delayed Egress Locks

Q: Our hospital is not fully sprinklered and is not fully smoke detected, but we want to install an infant security locking system in our Mother/Baby unit. I discussed this with our vendor who wants to sell us the infant security locking system, and he says we qualify for delayed egress locks because being 100% fully sprinklered is not the only criterion for compliance. He says we comply because we demonstrate the existence of an approved, supervised automatic fire detection system by having an automatic fire detection system in our hospital, so that should allow the installation of the infant security locking system. The vendor also said as long as the local AHJ approves the installation, that’s all we need, because the local AHJ has the final word. What do you say?

A: NFPA 101 Life Safety Code, 2012, section is rather clear: Among other requirements, in order to have delayed egress locks, you need one of the following:

  • The building needs to be fully protected throughout by an automatic sprinkler system, or;
  • The building needs to be fully protected throughout by an automatic fire detection system.

Being fully protected throughout with automatic sprinklers is obvious – you need full sprinkler coverage everywhere in the building. But it appears the term ‘being fully protected throughout by an automatic fire detection system’ is not so obvious. If you are not fully protected with sprinklers, then section requires a smoke detector in all occupiable areas. This is explained in section of the 2012 LSC. This means a smoke detector must be inside every room, every sleeping room, every procedure room, every corridor, every office, every conference room, every utility room, every lounge, every classroom, every work-room, every mechanical room, etc. In my 40-years of doing this work, I’ve yet to see a hospital qualify for this in regards to installing smoke detectors in all occupiable areas. If you believe your hospital meets the requirements for being fully protected with smoke detectors, then I would like to schedule a visit and take a look, because I’ve never seen that before.

Please understand the way your vendor described it “demonstrate the existence of an approved, supervised automatic fire detection system”, does not meet the description of being fully protected throughout by an automatic fire detection system. All hospitals have an approved, supervised automatic fire detection system, because the LSC requires that. But no hospital (so far that I have seen) has a smoke detector in all occupiable areas. It’s not required and it is too costly to install. Sprinklers are far cheaper.

Your vendor is correct, though: Sprinklers are not the sole criterion for the installation of delayed egress locks. But, it is one of two criteria, and so far, no hospital is choosing to go with the other choice (smoke detectors). Even if you could afford to install smoke detectors in every occupiable areas, the hospital would likely not be able to afford the maintenance (testing & inspection) and all of the false alarms that go with it.

By the way… the phrase “the local AHJ has the final word” is not accurate. I appreciate the respect that the vendor is trying to say, but all AHJs have the final word, not just the local AHJ. The typical hospital has many (between 5 and 8) AHJs that they have to comply with regarding the Life Safety Code:

  • CMS (Federal)
  • Accreditation organization
  • State licensing agency
  • State agency in charge of hospital construction
  • State fire marshal
  • Local fire authority
  • Local building code authority
  • Insurance company

All AHJs are equal. No one AHJ can override the decision of another AHJ. Any AHJ can decide to interpret the LSC in the way they deem necessary and if it disagrees with another AHJ, then so be it. The hospital must comply with the most restrictive interpretation. So, saying the local AHJ has the final word is not accurate; all AHJs have the final word. For example: If the local AHJ said it is okay to install delayed egress locks for infant security (because nobody wants to see infants stolen), even though the building is not fully sprinklered and not fully smoke detected, that’s not okay with other AHJS like CMS, your accreditation agency and your state agency on hospital construction. So, the hospital cannot do that, because they have to follow the most restrictive interpretation.

I see other hospitals that are not fully sprinklered or fully smoke detected use infant security systems but they do not install the door locking hardware. So, it operates like a warning system. If the hospital does not want to invest in being fully protected with sprinklers (or smoke detectors), then that is their only option. It is an incentive to become fully protected with sprinklers.

Clean Linen Stored in a Corridor

Q: If I had a hallway (breezeway which connects two healthcare occupancies) which is greater than 8 feet wide (approximately 12ft) and carts of clean linen are being stored on one side of the breezeway for more than 30 minutes, would this be allowed as long as the width is maintained at 8ft or greater?

A: Let’s re-think this situation… You have a breezeway, and you want to store clean linen in this breezeway? Do you see anything wrong with this picture…?

Talk with your Infection Control people. It does not make sense to me to store clean linen in a breezeway. Clean linen must be stored in a clean environment, such as a designated storage room for clean linen. A breezeway is not a clean environment and is not a suitable place to store clean linen.

But… if you’re asking about storing items in the corridor and if it is okay with the Life Safety Code, the answer is…. It depends.

You may store non-combustible items in the corridor as long as the required width of the corridor remains clear. You indicate the required width of the corridor is 8-feet… is that because inpatients would be using this corridor?

However, you cannot store combustible items in the corridor even if they do not obstruct the required width of the corridor. Clean linen is combustible, so therefore, to answer your question: No, you cannot store clean linen in the corridor.

Strange Observations – Smoke Detectors

Continuing in a series of strange things that I have seen while consulting at hospitals…

According to NFPA 72-2012, Annex A. smoke detectors should not be located in direct airflow, or any closer than 36-inches from an air diffuser. This would include return-air diffusers, exhaust-air diffusers, as well as supply-air diffusers.

While the Annex section is not part of the enforceable code, it is explanatory information provided to give the reader direction on how the Technical Committee viewed certain standards. Any authority having jurisdiction (AHJ) may use this Annex information in determining compliance with the standard, and most AHJs do. Therefore, the 36-inch rule is widely enforced in all surveys.

But some smoke detectors have UL listings for use in high-velocity airflow areas and are recommended by the manufacturer to be mounted close to air-diffusers. This would lead one to believe they would be permitted within close proximity to an air-diffuser, such as the one in the picture indicates. But I have read reports where surveyors still cite the organization for installing the special high-velocity smoke detectors too close to air-diffusers because of the perception that the airflow would prevent ambient smoke from being detected by the smoke detector.

Rather than fighting this battle with over-zealous surveyors, it is best to just make sure all smoke (and heat) detectors are at least 36-inches from all air-diffusers.

Ambulatory Healthcare Occupancy Fire Drills

Q: My question is with an ambulatory healthcare occupancy classification. Do you need just one fire drill per quarter or do you need one fire drill per shift per quarter? The ambulatory healthcare occupancy has a 24hr ED and also has some departments that have three shifts, ie: EVS, Security and Medical Imaging.

A: According to section of the 2012 Life Safety Code, fire drills are to be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and the emergency action required under varied conditions. So, the answer is once per shift per quarter.

Fire Pump Phase Reversal

Q: On our fire pump, we monitor the “Fire Pump Run” and “Fire Pump Loss of Power” on our supervisor points, but the fire pump control panel has a point which could be monitored for “Phase Reversal”. My question is, are we required to monitor “Phase Reversal” as a supervisory point?

A: That answer depends on the version of NFPA 20 “Standard for the Installation of Stationary Pumps for Fire Protection” that was enforced when the pump was installed or renovated (upgraded).

According to NFPA 20-2010, section 10.4.7, where the fire pump room is not constantly attended, audible or visual signals powered by a source not exceeding 125 volts must be provided at a point of constant attendance, for each of the following points:

  • Pump running
  • Loss of power
  • Phase reversal
  • Connected to EM power

According to NFPA 72-2010, section, the building fire alarm system is to be used for fire pump monitoring.

There was a time when NFPA only required the points for “Pump running” and “Loss of power” to be monitored, so you may not have to connect “Phase reversal” to the building fire alarm system. According to section 1.4.1 of NFPA 72-2010, the NFPA 72 code/standard is not retroactive to existing equipment.

When was this fire pump controller installed? I checked the 1999 edition of NFPA 20, and that edition required all four points to be monitored. If the controller was installed or updated since March 11, 2003 (the date CMS adopted the 2000 Life Safety Code) then I would say “Phase reversal” is required to be monitored.

Fire-Rated Doors in Fire-Rated Barriers?

Q: If the health care facility is fully sprinklered do doors in a corridor, where the walls are fire rated, do the doors have to be fire rated? I read in NFPA 101 that they do not….

A: Where do you read that…? I would like to know what you’re reading to be able to provide you with a better answer.

Generally speaking, where you have a fire-rated barrier, you usually need to have fire-rated doors in openings in the fire-rated barriers. But there are some exceptions:

  • Fire-rated barriers that separate an atrium from the rest of the facility are not required to have fire-rated doors.
  • Corridor walls in existing healthcare occupancies located in a smoke compartment that is not fully sprinklered, are required to be 30-minute fire-rated and the corridor doors are permitted to be non-fire-rated, but must limit the passage of smoke.
  • Some building codes that require fire-rated corridor walls do not require fire-rated doors in the openings. But this is not a LSC issue.
  • Smoke barriers that separate smoke compartments are required to be rated (1-hour for new construction) but doors in smoke barriers are not required to be fire-rated.


Strange Observations – Oxygen Cylinder Storage

Continuing in a series of strange things that I have seen while consulting at hospitals…

This room contained more than 300 cubic feet of compressed medical gases (but less than 3,000 cubic feet). And even though the picture does not show the whole room, what I wanted to capture is the fact that the oxygen cylinders in storage are not separated from combustibles by at least 20-feet, or 5-feet if the room is protected with sprinklers.

According to NFPA 99-2012, section you must store oxidizing gases at least 5-feet from combustibles if the room is sprinklered, or at least 20-feet if the room is not.

It is obvious in this picture that some sort of plastic items are stored right next to the oxygen cylinders. Another option is to store the oxidizing gas cylinders in a fire-rated storage cabinet, then you do not need to maintain the 5-feet or 20-feet clearance.