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.

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.]

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.

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 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.

 

 

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.