Annual Alarm Transmission Test

Q: Is the alarm transmission verification test generally performed by a fire alarm testing company on every device during an annual test/inspection? I also thought that this was a quarterly requirement. I would verify receipt and timing of transmission with the central station once a quarter during fire drills. Do I have this confused with another standard?

A: No… NFPA changed the standard on you. Under the 1999 edition of NFPA 72, which the 2000 LSC referenced, the requirement was quarterly to test your off-premises monitoring transmission equipment. But with the 2012 LSC, it now references the 2010 edition of NFPA 72 which changed it to be an annual requirement.

But do not make the mistake of just testing the alarm transmission to the central station monitoring agency. This needs to be tested to the fire responder’s location, be it the 9-1-1 center or the local fire department. Many hospitals make the mistake of testing the alarm transmission to just the central station monitoring your fire alarm panel, but the interpretation by CMS and many of the accreditation organizations is you need to confirm that the local fire department received the alarm signal. This can be accomplished during a routine fire drill whereby you do not notify the central station monitoring company but you do notify the local fire department that a drill will be conducted, and tell them to not respond. After you complete the fire drill, contact the fire department to confirm they received the call from the central station monitoring company, and to return to normal response mode.

This test is conducted annually on a general alarm… not on every device that you test.

Magnetic Locks

Q: Is there a code requirement for testing magnetic-locking devices, for a facility maintenance director?

A: There is a requirement in NFPA 72-2010, section 14.4.5 that all interface devices (i.e. relays, control modules) be tested once per year. Since the magnetic locks in access-control and delayed egress locks are connected to the fire alarm system via an interface relay, then the magnetic lock needs to be tested once per year to ensure it disconnects during a fire alarm signal. This test is required to be conducted by someone who is certified in accordance with NFPA 72.

If you are CMS certified or accredited by any of the major accreditation organizations then you would be expected to comply with the manufacturer’s recommendations on preventive maintenance. Most manufacturers of magnetic locks requires periodic maintenance to ensure they are functioning correctly.

Staff Sleep Rooms

Q: In regards to audio/visual strobes in staff sleeping rooms, is it required for them to hear the fire alarm system?

A: According to section 26.3.4.5.1 of the 2012 Life Safety Code, single-station smoke alarms are required to be installed in sleeping rooms for lodging or rooming house occupancies. A staff sleeping room in a hospital would have to qualify for the requirements of a lodging or rooming house occupancy, so a single station smoke alarm is required.

A single station smoke alarm has a built-in occupant notification device. But section 9.6.2.10.1.4 of the 2012 Life Safety Code says fire alarm system smoke detectors that comply with NFPA 72 and are arranged to function in the same manner as a single-station smoke alarm shall be permitted in lieu of smoke alarms. Even if you install a fire alarm system smoke detector in the staff sleeping room, section 9.6.2.10.1.4 would imply that some sort of occupant notification device is still required to awaken the staff member sleeping in that room.

But section 18.4.4 of the NFPA 72-2010, allows for the Private Mode installation for fire alarm system occupant notification devices, and hospitals typically are designed to this requirement. Section 18.4.4.1 requires the occupant notification device to have an audible sound level 10 dB above the average ambient sound level to be compliant, and in many cases, an occupant notification device located in the corridor outside of the staff sleeping room can achieve this requirement.

If you measure the dB level inside the staff sleeping room of the corridor-mounted fire alarm system occupant notification device, and it is 10 dB above the average ambient sound level in the staff sleeping room, then you should be good. But have those sound readings available to show the surveyor, as they will want to see some proof of compliance.

Duct Detectors

Q: With regard to testing duct detectors in a hospital, I understand that on an annual basis the automatic shutdown of the AHU’s must be verified when duct detectors are activated. I am unclear if there is also an annual requirement to verify damper (pneumatic and/or electric type but excluding fused links) operation at the same time. Also, is there a requirement to test smoke dampers annually?

A: No… there is not. Even though NFPA 72-2010 does require confirmation of all interface relays tested on an annual basis, and does imply that actuation of the dampers are required, NFPA 72-2010 cannot regulate the testing of fire or smoke dampers. Only NFPA 80-2010 and NFPA 105-2010 can regulate testing requirements for fire and smoke dampers respectfully.

You still have to test the interface relays (modules) on an annual basis, but you are not required to confirm that the smoke dampers did close on an annual basis.

But be aware, that some surveyors may require that you do confirm the smoke dampers closed on an annual interface relay test… That would be an incorrect interpretation on their part, and you may want to point out that NFPA 4 was created (in part) to eliminate these conflicting cross-testing requirements.

Fire Alarm Notification Devices in the OR

Q: Can you explain the fire alarm notification appliance location requirements as it pertains to the operating room? I seem to recall that there’s no requirement to have them in an operating room and, in fact, that it is generally more desirable to NOT have them since they may act as a distraction to the surgical team members. We are a two-hospital system with one of the hospitals having strobe only devices in each operating room and the other hospital having no A/V devices in their operating rooms.

A: Since hospitals are a patient relocation or partial evacuation facility, the private mode of alarm notification is allowed to help avoid a panic situation.  In private mode, the intent of notification (speakers, chimes, strobes, etc.) is to alert personnel responsible for taking action when the fire alarm system activates.  In other words, only key, responding personnel need to hear or see the audio/visual device or receive notification that an alarm has activated (corridors, nurse stations, engineering & back of the house areas, etc.).

These personnel aren’t normally found in operating rooms so there is no requirement to have notification devices in those areas. Even though we all know that surgeon distraction is a very good reason to not have them in operating rooms, NFPA 101 Life Safety Code developers try to stay away from potentially subjective exceptions when they can. Private mode notification is allowed so they don’t need to make a specific exception in this case.

However, there is an exception provided for critical care areas like NICU to use just visual devices. The reason for the difference between your two hospitals is probably that designers often forget or are unaware of private mode notification as an option for these types of facilities.  99% of the time they apply public mode notification that you see in most buildings.  Additionally, they have to consider ADA requirements and for some, it’s just too much time & effort to apply exceptions, so they just paint with a broad brush.

No one minds at the time so it goes forward.  If you’d like to eliminate strobes in the operating rooms, run it by the local fire department’s fire prevention officer, citing your concerns and using private mode notification as justification.  If he’s OK with it, you’ll need to update your system drawings and ensure the wiring is reconfigured correctly, so there’s some expense to doing it. [NOTE: Gene Rowe from Affiliated Fire Systems contributed to this reply.]

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.