Smoke Detectors in On-Call Physician Sleeping Rooms

Q: We recently had an inspection and we were cited for not having a smoke detector in the on-call sleeping room for physicians which is located on our Labor & Delivery nursing unit. We thought since the sleeping room is located in the healthcare occupancy a smoke detector would not be required. The inspector didn’t see it this way and wrote us up. Was he correct in doing so?

A: This is one of those “…it depends” answers. Since the on-call physician sleeping room is located on the nursing unit, the inspector probably assumed that you have a mixture of two different occupancies: Healthcare, and Hotels & Dormitories. When there is a mixture of occupancies that are not separated by 2-hour fire rated barriers, section of the 2000 edition of the Life Safety Code (LSC) requires the most restrictive life safety requirements be included for each occupancy. It appears the on-call physician sleeping room qualifies as Hotel & Dormitory occupancy, and single station smoke alarms are required in all sleeping rooms, according to section of the LSC. However, and this is where the “…it depends” issue enters, there is an exception to section that talks about incidental use. The incidental use of the Hotel & Dormitory occupancy is allowed within the larger, predominant Healthcare occupancy, without having to meet the requirements of the Hotel & Dormitory occupancy. The question is, what constitutes “incidental” use? That is up to the authority having jurisdiction (AHJ) and since the average hospital has 5 or more AHJs, it is likely that anyone one of those AHJs will require a smoke detector in the on-call sleeping room. A smoke detector that is connected to the building fire alarm system which transmits alarms through notification appliances to the staff in the building should be considered equivalent to a single-station smoke alarm. The LSC does not prohibit the use of devices of equivalent or superior safety. I would say the inspector’s finding is valid and pretty good advice.

Fire Alarm System Batteries

What’s the number one item that fire alarm testing contractors fail to properly test? Batteries. OK, I don’t keep statistics on these types of things, but based on the lack of a response when I ask to see the documentation that the fire alarm system batteries were tested, it sure seems like this is the most common item that is not properly tested.

And it really doesn’t have to be that way, if someone would only read NFPA 72 National Fire Alarm Code (1999 edition) and perform the test as required. Table 7-2.2 prescribes the methods on the selective testing, and Table 7-3.2 prescribes the testing frequency of the selected tests. Doesn’t get any simpler than that.

But reality demonstrates that batteries usually receive only a cursory effort at testing, and falls short of the NFPA 72 requirements. There are multiple reasons why this happens, and the most common one that I hear is “This is the way we’ve always done it”, and “Joint Commission doesn’t ask us for this information”. Whether or not Joint Commission asks to see this documentation (and they are now asking for that), you still have other authorities who may be asking to see that the batteries are properly tested.

I had the opportunity to ask a fire alarm testing contractor why he didn’t test the fire alarm system exactly as prescribed by NFPA 72. His answer was very logical: “Because the hospital wouldn’t pay me to do it that way”. He explained that he got the contract through a successful bid process, and he bid only what the hospital asked for. If he included additional work that was not in the bid request, he probably would not get the contract. This places the responsibility for compliance squarely on the head and shoulders of the hospital representative, typically the facility manager.

 So, let’s look at what is required for testing the batteries in a fire alarm system. Most batteries now days are sealed lead acid type batteries, such as the one in the picture to the left. According to NFPA 72, table 7-2.2, there are three tests that need to be conducted:

Charger Test:  With the batteries fully charged and connected to the charger, the voltage across the batteries shall be measured with a voltmeter. The voltage shall be 2.3 volts per cell plus or minus 0.02 volts at 77 degrees F, or as specified by the equipment manufacturer.

Discharge Test:  With the battery charger disconnected, the batteries shall be load tested for 30 minutes following the manufacturer’s recommendations. The voltage level shall not fall below the levels specified. [Note: An artificial load equal to the full fire alarm load connected to the battery shall be permitted to be used in conducting this test.]

Load Voltage Test:  With battery charger disconnected, the terminal voltage shall be measured while supplying the maximum load required by its application. The voltage level shall not fall below the levels specified for the specific type of battery. If the voltage falls below the level specified, corrective action shall be taken and the batteries shall be retested. [Note: An artificial load equal to the full fire alarm load connected to the battery shall be permitted to be used in conducting this test.]

So, those are the testing methods required by NFPA 72, but what about the frequencies? All three tests must be conducted when batteries are initially installed, but only the first two tests (Charger Test and Discharge Test) are required annually thereafter. The third test (Load Voltage Test) is required semi-annually after installation, and this is the test that frequently does not happen.

The testing requirement is for ALL batteries in the fire alarm system, not just the ones in the main fire panel. Don’t forget those NAC panels scattered throughout the hospital that serve as power boosters for the occupant notification devices. And, check out the remote annunciators, as there may be batteries in them as well.










Spot-Type Smoke Detectors Used in Air flow

I was recently at a hospital where I noticed the smoke detector installation (at left) inside a mechanical room. It made me stop and exam the installation as my first thought was the smoke detector was too close to the air diffuser. As the pictures indicate, the detector was only about 4 inches from the actual air diffuser, and NFPA 72 (1999 edition) A-2-3.5.1 requires detectors to be spaced a minimum of 36 inches from air supply or return diffusers. Now, to be sure, this reference is found in the Annex section which is not part of the enforceable standard, but many (if not all) AHJs use the Annex section to help them determine compliance with the standard. The 36 inch rule is enforced by many of the AHJs which inspect hospitals.

Let’s review what the pictures indicate: This is new construction for this situation and the wall to the left of the air diffuser is a 2-hour fire rated vertical shaft which also doubles as the smoke compartment barrier in this area. In the pictures you will notice a combination fire/smoke damper in the short duct which is connected to the return air system. It is understandable that a fire damper would be required in a 2-hour vertical shaft (or for that matter, any vertical shaft where the duct penetrates the vertical barrier), but a smoke damper? Well, yes, it is required, as, exception #2 in the 2000 edition of the LSC says smoke dampers are not required in smoke barriers with fully ducted HVAC systems. The pictures indicate that the return air is not fully ducted, but a case could be made that is is “fully ducted” since there is no suspended ceiling in this mechanical room, and the return air diffuser location is no different than if it was ducted to a ceiling mounted diffuser. Besides, in this situation, the IBC building code is used and they do not have an exception for smoke dampers in smoke barriers.

But back to my first thought: Is the spot-type smoke detector too close to the return air diffuser? According to NFPA 72 (1999 edition) A-2-3.5.1 it is. But one needs to take into consideration section 2- of the same standard. This section says if smoke detectors are required in the return air system by other NFPA standards then a smoke detector listed for the air velocity present should be located where the air leaves each smoke compartment or in the duct system before the air enters the return air system. Well, smoke detectors are required to activate the smoke damper, according to NFPA 105 which says smoke detectors that activate smoke dampers need to be installed according to NFPA 72.

Section 2- of NFPA 72 (1999 edition) does state that detectors in the return air system are not required if the entire smoke compartment is protected with smoke detectors. In this situation, that is not the case, so it is not an option. Going back to the Annex section A-2- of NFPA 72 (1999 edition) we find that the smoke detector needs to be listed for the air velocity present and installed up to 12 inches in front of or behind the opening of the return air system.

So, in summary, I see two issues in this installation: 1). Is the smoke detector listed for the air velocity present? and 2). Is the smoke detector mounted up to 12 inches in front of or behind the opening for the return air system?

For #1, I cannot answer this question, but I did inform the organization that they need to confirm the smoke detector is listed for the  air velocity in which it is used. I was later informed that the detector was a Siemens ILI-1 which is rated for 0 – 300 ft./min. The airflow around this detector would have to be measured to confirm it is within the listed operating range of the detector.

For #2, the detector is mounted within 12 inches of the air diffuser, so it is well within the limitations of the specifications.

Based on the above, the spot type smoke detector in the picture appears to be within the requirements of NFPA 72.

[Thanks to Greg Waldman of Stanford Healthcare for assistance with this issue.]

Fire Alarm System in Construction Sites

The subject of a working, operable fire alarm system in construction sites recently came up and the question was: Are pull stations and occupant notification devices required in a construction site, inside an occupied hospital?

My answer was Yes, based on section 18/19.3.4 of the 2000 edition of the Life Safety Code (LSC) which requires healthcare occupancies to comply with section 9.6. Now sections 18/ requires fire alarm initiation to be from manual (pull) stations in accordance with 9.6.2, and by water-flow switches. Pull stations are required to be located so the maximum travel distance to get to a pull station is 200 feet. Also, a pull station is required no more than 5 feet from an exit.

Occupant notification devices are required according to sections 18/, which again refers to section 9.6.3, and they are required to be placed in strategic locations to alert occupants of fire or other emergencies.

According to section 18/19.3.4, fire alarm systems are required throughout healthcare occupancies. I do not see any exceptions to this requirement for construction zones or areas under renovation. Just because hospital staff (nurses, technicians, aids, etc.) are not occupying the area under construction, it is still occupied by construction workers, and adequate protection is required. So, I can say without hesitation that fire alarm pull stations and occupant notification are required in construction areas inside a hospital.

Now, having said that, section does allow construction sites to be compensated with alternative life safety measures (also known as Interim Life Safety Measures, or ILSM) for features of life safety that are impaired due to the construction. Well, if there is demolition underway, I can see the desire to remove pull stations and horn/strobe units to prevent them from being damaged. If the decision is made to remove these features of the fire alarm system, then a risk assessment must be conducted to determine what interim measures should be implemented to compensate for the deficiency.

So, as I see it, the organization has two options in regards to operable fire alarm systems in construction sites: 1). Leave the pull stations and occupant notification devices and water-flow switches in normal operating condition, or: 2). Remove all devices and implement ILSMs.

But what are the Pros and Cons to these two options?

By leaving the pull stations, horn/strobes, and water-flow switches in operating condition inside the construction site, the PRO is the hospital has a safer environment, both for the construction workers, but also for the rest of the occupants of the facility. The occupant notification devices will alert the construction workers of any fire emergencies in the building, and the pull stations will allow quicker activation of the fire alarm system should a fire start in the construction site. The CON is these devices could be damaged during construction and therefore need replacement, and there is the cost of labor to keep these devices operating properly amidst a ‘hostile’ environment. False alarms can sometimes accidentally occur on the pull stations or by damage to the initiating circuit.

By removing all of the fire alarm devices, ILSMs will have to be implemented, such as fire watches, staff & contractor education, conduct extra fire drills, and daily surveillance. The PRO to this option is the fire alarm devices are removed so they cannot be damaged and the initiating devices cannot accidentally set off unwanted alarms. Also, ILSMs may already be implemented for other reasons on the construction site, such as a deficient smoke compartment barrier or non-operable fire rated door assemblies. The CON is no matter what ILSMs are implemented, they will never be as effective as an operable fire alarm system with pull stations and occupant notification devices. Also, the cost of hospital labor to perform fire watches, extra fire drills, education of staff and contractors and performing daily surveillance must be factored in as well.

When I was the Safety Officer at the hospital where I worked, I preferred to leave pull stations and horn/strobes in an operating condition in construction sites. I felt it provided a safer environment for everyone. However, it is recognized that it is not always possible in all conditions.

Fire Alarm Pull Stations in an Outpatient Clinic

Q: We have an outpatient clinic which is a business occupancy and provides ancillary services like physical therapy and radiology, and there are no fire alarm pull stations in the building. Are we required to have a fire alarm system and if so, do we need pull stations?

A: According to section 39.3.4 of the 2000 edition of the Life Safety Code (LSC), there are multiple options that may or may not require pull stations. An automatic fire alarm system is required if the building is two or more stories in height above the level of exit discharge, OR there are 100 or more occupants above or below the level of exit discharge, OR there are 1,000 or more total occupants in the building. Therefore, if the building does not qualify for any of the above conditions, then a fire alarm system is not required and manual pull stations also would not be required. However, if your clinic does meet one of the requirements for a fire alarm system, then initiating devices are required by one of the following methods:

•      Manual pull stations, OR

•      Smoke detectors and heat detectors installed throughout the building, OR

•      Automatic sprinklers installed throughout the building that will initiate a fire alarm upon water-flow.

Therefore, it is possible that manual pull stations may not be required in your clinic if the building meets the exceptions listed in section 39.3.4. However, please check with your local and state authorities to determine if they have other requirements you need to comply with.

Disabled Pull Station

 I was at a hospital recently that was installing a completly new fire alarm system in their building. I came across the disabled pull station in the picture to the left, and noticed that there was a large piece of tape across the handle of the pull station.

The facility manager that I was with said that particular device was part of the new system and it was not activated yet. He pointed out that there was an old fire alarm pull station (which I had not noticed), located within a few feet of this device and it was still activated.

This is a very big advantage that I have over the facility managers: They are in their building day in and day out and they do not typically think like a person who has never been been inside the facility before. Since I noticed the disabled pull station first, it did not make me look for the other activated pull station, which was about 5 feet away. If there had been an actual fire emergency, it is possible that a person who is unfamiliar with the fire alarm upgrade to see the disabled pull station, and not necessarily notice the old activated pull station, and move on down the corridor in search of one that actually operates which would delay the activation of the fire alarm.

I suggested to the facility manager that he install a sign over the disabled pull station, stating this device was not activated and a description (with an arrow) describing where the closest active pull station is located. Since this particular hospital had established a procedure of posting all public signs in three languages (English, Spanish and Chinese) then this temporary sign would also have to have all three languages.

A surveyor or inspector could very well cite this hospital for failure of proper interim life safety measures, or at the very least, failing to identify all safety and security risks in the environment.

Construction Involving the Fire Alarm System

Q: Our projects team currently disables our fire alarm control panel each morning during periods of construction and restores the panel each evening. They do this to prevent unwanted fire alarms that would be a nuisance to our staff and local fire department. This doesn’t seem to me to be the best method to deal with construction and the fire alarm panel. Do you have any thoughts or suggestions on this topic?

A: Your message did not address whether or not Interim Life Safety Measures (ILSM) are implemented during the time the fire panel is disabled, and that would be my number 1 concern. Section of the 2000 edition of the Life Safety Code® (LSC) discusses alternative life safety measures acceptable to the authority having jurisdiction (AHJ) need to be in place whenever construction, repair, alterations or additions are in progress. Also, section requires the AHJ shall be notified and a fire watch be implemented (or evacuate the entire facility, which is not desirable) whenever the fire alarm system is out of service for 4 or more hours in a 24 hour period. Those are mandatory actions that need to be followed. Other option, in lieu of disabling the entire fire alarm system, is to just remove from service the specific detectors or initiating circuit in the construction area, although you would still have to follow ILSM procedures. Most modern fire alarm systems have the ability to program initiating devices out-of-service to allow construction activities. Another option is to physically remove the detectors from their bases if this is possible. Some hospitals place protective coverings over smoke detectors during time of construction, although I am not a supporter of that practice. I have seen multiple situations where someone forgot to remove the protective cover from the detector and it remained in place long after the construction was completed. The bottom line is this: You need to develop a plan for alternative measures that is acceptable with your AHJ, presumably the local fire department, whenever a feature of fire safety is impaired. You are also required to develop a ILSM policy with written criteria for evaluating when and to what extent you should follow special measures to compensate for an increase risk to life safety, if your are accredited by the Joint Commission.


Air Handler Reaction Time

Q:  Is there a minimum reaction time for an air handler to respond to a duct detector activation? We had a consultant say that we had to record documentation that includes both the time the duct detector was tested (start time) and the time that the air handler actually shut down. Is this true?

A: Well, the comment made by the consultant is partially correct. The Life Safety Code® (LSC) 2000 edition section requires compliance with section 9.6 which requires compliance with NFPA 72 National Fire Alarm Code (1999 edition). NFPA 72 section 1- does stipulate that the time delay between the activation of an initiating device (in this case, the duct detector) and the activation of a fire safety function (in this case the air handler shutdown) shall not exceed 20 seconds. However, if the device was installed after January 1, 2002, then the delay is reduced to 10 seconds. So, for this portion of the code, the consultant is correct, in that there is a predetermined amount of delay between the duct detector activation, and the shutting down of the air handler. This time delay must be met and should be recorded by the installing contractor when the equipment is originally installed or replaced. But once the equipment has passed its initial installation requirement that does not mean that the time delay must be recorded each time it is tested. NFPA 72 section 7-2.2 requires the fire alarm system to be tested according to Table 7-2.2 “Test Methods”. This table requires testing of fire alarm system devices to verify their correct operation, not their time required to initiate their correct operation. So, in summary, since Table 7-2.2 does not have a specific requirement to measure the time delay for the system function even though it was required at the time of installation, then the hospital is not required to measure that time delay during subsequent tests. However, they can if they wish, as the test methods found in Table 7-2.2 are considered minimum standards, but any AHJ who enforces NFPA standards does not have the authority to require the hospital to measure that time delay.

Fire Alarm Audible Notification Device Testing

Q: Are fire alarm notification appliances required to have annual sound level measurement testing? We had a consultant tell us that we are supposed to conduct the sound level testing annually, but we have not heard of this requirement. What have you seen in your travels?

A: Yes they are, but you may not have to do this annual testing. Let me explain: The 2000 edition of the LSC requires the fire alarm system to be tested according to NFPA 72, 1999 edition. Section 14 of Table 7-2.2 requires audible alarm notification appliances to have sound pressure levels measured with meters meeting ANSI standards. Furthermore, section 19 of Table 7-3.2 requires the frequency of this sound level measurement to be accomplished at the time the appliance is initially installed and annually, thereafter. However, the commentary in the NFPA Handbook for NFPA 72 says if the sound measurement levels comply with the requirements of the code at the initial installation, then the AHJ may deem further testing as unnecessary. The comments in a handbook are not part of the enforceable code, but the AHJs can use these comments as a guide in making their decisions. I contacted representatives from The Joint Commission and the Centers for Medicare and Medicaid Services and they both said they do not require annual sound level measurement testing on audible appliances.

However, I suggest you contact your local and state AHJs to see what their requirements are.

Fire Alarm System Used for Medical Emergencies

Q: We have our Code Blue medical emergency system tied into the hospital’s fire alarm system and the control panel is located next to the telephone operators. They will then be able to hear the Code Blue alarm and make the appropriate over-head page. We were told by a consultant that this combined use of the fire alarm system is not permitted. What do you say?

A: Not knowing what standards your consultant was referring to, I can say it is permitted according to the NFPA 101 Life Safety Code (LSC), provided you adhere to specific requirements. Section 18/19.3.4 requires compliance with section 9.6 which in turn requires the system to be installed according to NFPA 72-1999. In section 3-8.2 of NFPA 72, it permits the fire alarm system to share components, equipment, circuitry, and installation wiring with non-fire alarm systems. Other requirements for a combined system, are:

  • Short circuits, open circuits, or grounds in the equipment and wiring shall not interfere with the monitoring for integrity of the fire alarm system, nor shall it prevent alarm or supervisory signals from being transmitted
  • The maintenance or failure of any component or software shall not impair the integrity of the fire alarm function
  • Overhead speakers used as alarm notification appliances on the fire alarm system shall not be used for nonemergency purposes, with some exceptions
  • The fire alarm signal shall be distinctive, clearly recognizable, and take precedence over any other signal even when a non-fire alarm signal is initiated first
  •  If the Authority Having Jurisdiction (AHJ) determines that the information being displayed or annunciated on a combination system is excessive and is causing confusion and delayed response to a fire emergency, the AHJ shall be permitted to require that the display or annunciation of information for the fire alarm system be separate from and have priority over information for the non-fire alarm      systems
  • All of the equipment used and installed in the combined system must be listed for the purpose for which it is used

If your combined system can meet these requirements, then it is permitted under the LSC. However, please check with your local and state authorities for any differing opinions.