Strange Observations – Ceiling Penetrations

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

This picture was taken in an electrical room. Where the conduits extend upwards and penetrate the suspended ceiling, the gaps around the conduits are too large.

Most surveyors will use the NFPA 80 maximum 1/8-inch gap rule fire door clearance to frames as a standard for the maximum gap around conduit penetrations, where the ceiling is required to act as a membrane for smoke detectors or sprinkler heads.

In situations like this, the easiest and best solution is to remove the suspended ceiling from the electrical room, and relocate the lights in the ceiling to the deck above.

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 3.3.5.1, 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 19.3.4.1 of the 2012 LSC requires compliance with section 9.6 in regards with the fire alarm system. Section 9.6.1.3 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 7.9.3.1.1 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 – Smoke Detectors

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

According to NFPA 72-2012, Annex A.17.7.4.1 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.

Coded Words for Fire

Q: Our EP manager was discussing removing the code words like Code pink for a missing infant to missing child and the conversation about code red for fire came up. Someone in the conversation said there is a NFPA code requirement that “Code Red” must be in code form instead of saying “Fire”. I have not heard of this and haven not search yet. I wondered what your take is on this. Our FA system is programmed for voice that states “Code Red” and then the location.

A: Well… that ‘someone’ is actually correct… sort of.

Section 19.7.1.7 of the 2012 Life Safety Code actually does say “When drills are conducted between 9:00 pm and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms.” So this section of the LSC does reference a code-word should be used to identify fire, such as ‘Code Red’.

But that requirement for a coded word for fire is only found in section 19.7.1.7 and is limited to a fire drill conducted without audible alarms between 9:00 pm and 6:00 am. Therefore, since the Life Safety Code does not prohibit it, the conclusion is you would be permitted to say ‘Fire’ instead of ‘Code Red’ when the fire alarm system is activated.

But is that in your best interest to do so? I am aware that there is a trend across the country to eliminate coded words for certain emergency announcements. Many coded words (i.e. ‘Code Pink’) are not used universally in all hospitals, and since healthcare staff is rather transient, the movement is to have announcements identify the actual emergency rather than using coded words. But the original intent in using ‘Code Red’ is to alert staff of a fire condition, yet not alarm visitors and patients un-necessarily, thereby causing a panic.

If it were my hospital, I would be an advocate to allow ‘Code Red’ to remain, but eliminating other coded words should be considered.

Smoke Detectors in Patient Restrooms

Q: Can I provide a smoke detector in an existing hospital patient restroom? The smoke detector was recommended by the hospital safety committee to avoid smoking in these rooms. Our patient restrooms have bathtubs but no showers. Some restrooms are protected by sprinkler systems and some are not. Some restrooms are provided with heat detectors, but of course, they do not activate during patient smoking. Even though the safety committee recommended changing to a smoke detector, I am afraid of false alarms from the high humidity a restroom can generate.

A: While the Life Safety Code and NFPA 72-2010 do not require smoke detectors to be installed in patient bathrooms, designers usually do not place them there for fear of nuisance alarms. But experience shows a smoke detector in a bathroom that has a toilet and a bathtub is not the same risk that a smoke detector located in a bathroom with a shower has. The shower will atomize water droplets to form high concentrations of water vapor and will more likely cause nuisance alarms. The bathtub and toilet would not raise the relative humidity much at all.

Try it and see how it works for you.

Smoke Detector Disabled

Q: If a smoke detecting device is disabled for a breathing treatment (often for several days), what sort of fire watch, notification or signage is necessary?

A: None. Fire watches are not for a single device taken out of service, or for a single device found to be impaired. According to section A.9.6.1.6 of the 2012 LSC, it is not the intent of the Life Safety Code to require notification of the AHJ or evacuation (or fire watch) for the portion of the building affected for a single nonoperative device or appliance.

Also, section 9.6.1.6 of the 2012 LSC says where a required fire alarm system (not a single device) is out of service for 4 or more hours in a 24-hour period then an approved fire watch should be conducted. If this smoke detector is located in a healthcare occupancy, there may be a good chance that it is not a required device. Many designers add smoke detectors throughout hospitals where the LSC does not actually require them. In my opinion, you would need to have a branch or circuit disabled on a fire alarm system before a fire watch is required.

Strange Observations – MHO Rod

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

We already talked about this issue on ‘Strange Observations – Part 20’ posted April 5, 2018, but it’s worth revisiting.

You cannot have home-made components installed on the fire alarm system. The threaded rod is not UL listed for this purpose.

 

NOTE: I’ve received some skepticism on the validity of saying the door release equipment is part of the fire alarm system. I base my position on section 21.8 of NFPA 72-2010, which says the door release equipment is a function of the fire alarm system, and according to section 10.3, all equipment used in conformity with NFPA 72-2010 must be listed for the purpose for which it is used. If the manufacturer of the door release device obtained a UL listing for the threaded rod, then I stand corrected. But as far as I know, that has not happened.

 

 

Duct Detector Test

Q: During our inspection our surveyor was looking for 3/8″ holes, 3 feet upstream, before the smoke detectors in the ductwork. He requested testing procedures for the duct detectors from the tester who stated the test was performed by putting smoke onto the duct detector, which shut down the air-handler unit. The surveyor says the smoke must be inserted 3 feet prior to duct detector to test the actual tube for blockages. Can you tell me the actual regulation that states this requirement?

A: According to NFPA 72-2010, section 14.4.2.2, the method to conduct testing of fire alarm systems must comply with Table 14.4.2.2:

14(g) Smoke detectors

1) Smoke detectors/smoke alarms shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol, acceptable to the manufacturer of the aerosol or the manufacturer of the smoke detector/smoke alarm and identified in their published instructions, shall be permitted as acceptable test methods. Other methods listed in the manufacturer’s published instructions that ensure smoke entry from the protected area, through the vents, into the sensing chamber shall be permitted.

6) Duct detectors

In addition to the testing required in Table 14(g)(1), duct smoke detectors utilizing sampling tubes shall be tested by verifying the correct pressure differential (within the manufacturer’s published ranges) between the inlet and exhaust tubes using a method acceptable to the manufacturer to ensure that the device will properly sample the airstream. These tests shall be made in accordance with the manufacturer’s published instructions for the device installed.

Here is a summary on how to test duct detectors:

  1. The test must ensure smoke/aerosol enters the sensing chamber and an alarm responds.
  2. You must verify the correct air pressure differential between the inlet and exhaust tubes, in accordance with the manufacturer’s instructions.

So, while the vendor appears to be testing the detector, it does not appear he is testing the air pressure differential of the inlet and outlet tubes. I don’t see anything in NFPA 72-2010 that requires putting smoke/aerosol in the actual air tube for duct detectors. I do see where that is required for air sampling smoke detectors, but duct detectors are not the same as air sampling smoke detectors.

Qualifications of Personnel

Q: We recently acquired a hospital that has been performing segments of their own fire system testing. What are the specific requirements or qualifications for an individual conducting testing or inspections on fire alarm systems and sprinkler systems?

A: NFPA 72-2010, section 10.4.3.1 requires a certified individual to perform service, testing, inspection and maintenance on fire alarm systems and components. The certification must be one (not all) of the following:

  • Factory trained and certified for the specific type and brand of systems being serviced
  • Persons who are certified by a nationally recognized certification organization (NICET, IMSA, etc.)
  • Persons who are registered, licensed or certified by the state
  • Persons who are employed and qualified by an organization listed by a national recognized testing laboratory for servicing fire alarm systems.

I have seen some larger hospitals that do employ people who meet one of the above requirements, but most hospitals contract this work to a qualified vendor who has these credentials. When it comes to sprinkler system testing/inspecting, NFPA does not require certification of the individuals performing the test/inspection. However, please check with your state and local AHJ to determine if they have additional requirements.

Fire Alarm System Strobes

Q: I work in a healthcare facility and we are in need to find an answer to a question regarding strobe lights. When we test our fire alarm system, and we silence the alarm, the strobe lights do not continue to flash. We were told that this is not “code” and the lights need to continue to flash even if system is silenced. I cannot seem to find this located in any part of the Life Safety Codes. Also, this is an older facility, so at some point/date do some healthcare facilities get grandfathered in if this is a newer code?

A: No… older facilities do not get to be grandfathered, or in any other way, exempt from complying with the code.

Section 19.7.1.4 of the 2012 Life Safety Code requires the transmission of the fire alarm signal during a fire drill. That means you cannot silence the audible alarms and you cannot disable the visual (i.e. strobe) notification devices. If you are doing either during a fire drill, then you are non-compliant and need to discontinue this practice and make sure the audible notification devices and the visual notification devices operate properly during each fire drill.

Now, having said that, there is one exception that you may qualify for and that is found in section 19.7.1.7 of the 2012 Life Safety Code, which says when drill are conducted between 9:00 pm and 6:00 am a coded announcement is permitted to be used instead of the audible alarms. But, the visual notification devices (i.e. strobes) must operate.