Smoke Detectors

By Brad Keyes…

Q: Are smoke detectors required in individual hospital patient rooms, and what are the exemptions to not have a detector in individual rooms?

A: There is no Life Safety Code or NFPA 72-2010 requirement to have smoke detectors in hospital patient sleeping rooms or treatment areas. There may be other standards or regulations that could require them, so check with your state and local authorities.

Typically, the only areas that are required to have smoke detectors in a hospital are:

  • Elevator lobbies and elevator mechanical rooms
  • Near doors that are held-open by magnets
  • In the same room with fire alarm control panels that are not constantly supervised
  • In areas open to the corridor that are not constantly supervised
  • Inside locked areas that use the Specialized Protective Measure locking arrangement identified by 19.2.2.2.5.2
  • Patient sleeping suites that do not provide direct supervision
  • Smoke compartments containing patient sleeping suites over 5,000 square feet but not exceeding 7,500 square feet and are not equipped with Quick Response (QR) sprinklers
  • Patient sleeping suites over 7,500 square feet but not exceeding 10,000 square feet

Additionally, smoke detectors may be required in patient sleeping rooms if an Equivalency was submitted and approved.

Perforated Ceiling Tiles

By Brad Keyes…

Q: My facility is installing perforated ceiling tiles because it looks “modern” and does not look like the old healthcare setting. With the perforation in the ceiling tiles, does this mean I have to install sprinklers and fire alarm smoke detectors above and below the ceiling since the dropped ceiling is no longer a smoke-resistant barrier? I believe I have to also take the smoke compartment barrier walls to the deck… is that correct?

A: First of all, do you need smoke detectors in the area where the new ceiling tiles are being installed? If yes, then we need to address this issue, but the NFPA codes and standards do not require that many smoke detectors in a hospital. Unless you are employing Specialized Protective Measure locks (see section 19.2.2.2.5.2 of the 2012 Life Safety Code), or have specific requirements from a state or local authority that exceed what NFPA requires, smoke detectors are only mandatory in the following locations of a hospital:

  • In areas open to the corridor that are not directly supervised by a person (see section 19.3.6.1 of the 2012 LSC)
  • Near doors that are held open by devices that release on a fire alarm activation (see section 17.7.5.6.5.1 of NFPA 72-2010)
  • In elevator lobbies and elevator equipment rooms (see section 9.4.3.2 of the 2012 LSC)
  • In rooms where fire alarm panels (including NAC panels and off-premises monitoring transmission equipment) are located without direct supervision by a person (see section 9.6.1.8.1 of the 2012 LSC)

You may want to revisit why the smoke detectors are there in the first place. Check with your state and local authorities to see if they have requirements for smoke detectors to be there.

But assuming you do want to maintain the smoke detection level in this area where the new ceiling tiles are located, NFPA 72-2010 does address this issue. Let’s look at section 17.5.3.1.3 which discusses the requirements for an open grid ceiling. It says smoke detectors are not required below an open grid ceiling if the openings in the ceiling are ¼-inch or larger in the least dimension, and the openings constitute at least 70% of the surface area of the ceiling. So, what this means, smoke detectors are not required above the ceiling if the openings are less than ¼-inch and the accumulative area of the openings is 30% of the total surface area of the ceiling. But this section only applies if smoke detectors are required in the general area where these new ceiling tiles are being installed. But keep in mind, if you install smoke detectors where they are not required, they still must be installed in compliance with NFPA 72-2010.

Here are the requirements found in NFPA 13-2010, at section 8.15.13 for an approved open-grid ceiling. Open-grid ceiling must be installed below the sprinklers where all of the following apply:

  1. The openings of the open-grid ceiling must be at least ¼ inch or larger in the least dimension.
  2. The thickness or the depth of the material does not exceed the least dimension of the opening.
  3. The openings must constitute 70 percent of the area of the ceiling material.

If your ceiling tile openings are less than ¼-inch and the openings in the ceiling tile equal less than 70% of the ceiling area, then I conclude sprinklers would not be required above the ceiling.

There is one issue you need to be aware of… Most surveyors will cite you for having gaps in ceiling tiles greater than 1/8-inch as that would allow heat and smoke to filter up through the ceiling and would cause the sprinklers or smoke detectors to delay activation. Make sure these ceiling tiles do not have openings greater than 1/8-inch.

Smoke compartment barrier walls always have to extend from the floor to the deck above regardless whether or not the ceiling tiles have openings in them.

Staff Sleeping Room

Q: During a recent survey, we were cited for not having a single-station smoke alarm in our hospital on-call staff sleeping rooms. Since this was cited, I have learned that these staff sleeping rooms are required to have single-station smoke alarms since they are considered a different occupancy (Lodging & Rooming House) and must meet section 26.3.4.5.1 of the 2012 LSC. But can I use the hospital smoke detector system in lieu of installing a battery-operated smoke alarm in these rooms?

A: Yes… According to section 9.6.2.10 of the 2012 LSC, smoke detectors connected to the building’s NFPA 72-2010 approved fire alarm system are permitted instead of installing the battery-operated smoke alarms. However, section 9.6.2.10.1.4 does say these system smoke detectors must be arranged to function in the same manner as single-station or multiple-station smoke alarms. The typical building system smoke detectors are detectors only and do not provide any occupant notification.

But the single-station smoke alarms provide both functions: Detection and occupant notification. Therefore, on a technical standpoint, the basic fire alarm system smoke detectors are not enough and some sort of occupant notification system must be provided. Now, having said that, I do know that some accreditation organizations are simply accepting a smoke detector in the on-call sleeping room without the inclusion of an occupant notification device. But, I am aware that some state agencies surveying on behalf of CMS do enforce the letter of the code and will cite you if you do not have an occupant notification device in the room.

Smoke Detectors During Construction

Q: We are seeking to eliminate accidental activation of existing smoke heads in healthcare spaces that are taken over for renovation/construction work while maintaining fire protection coverage in the space that does not involve the use of a fire watch. We are looking at multiple sensor detectors, but the initial comment we received from our vendor is that they are sometimes triggered by dust. In your opinion, would changing the smoke detectors to heat detectors be an acceptable solution in a construction space? If the space has an active sprinkler system, in your opinion, would it be acceptable to simply remove these smoke heads? Any thoughts you can provide would be greatly appreciated.

A: Changing the smokes to heats is not an acceptable solution to prevent a fire watch, because heats do not sense the presence of smoke. But perhaps you are making this more difficult than it has to be. The code only requires a fire watch for required fire alarm devices that are impaired. Are the smoke detectors in the construction area required? If so, then you need to do the fire watch if you remove the detectors, or suffer through many false alarms.

But if they are not required devices, then you can remove the smoke detectors and not have to do a fire watch. Section 9.6.1.6 of the 2012 LSC specifically says a fire watch is for required fire alarm systems out of service.

One may be surprised to learn that in the typical hospital, there are very few locations that a smoke detector is required to be installed:

  • In areas open to the corridor as described in section 19.3.6.1 of the 2012 LSC
  • In areas containing fire alarm control panels (including NAC panels) that are not continuously occupied as described in 9.6.1.8.1 of the 2012 LSC
  • Near doors that are held open that must close on a fire alarm activation as described in NFPA 72-2010, section 17.7.5.6.5.1
  • Elevator recall for fire-fighter’s service as described in NFPA 72-2010, section 21.3

There are other situations where smoke detectors may be required, but those requirements are stipulated on optional design factors, such as on-call sleeping rooms, specialized protective measure locks, and equivalencies.

Therefore, if you have smoke detectors in an area that is under construction, and these smoke detectors are not required, then you may remove the detectors without having to perform a fire watch.

Sprinkler System Exceptions

Q: Are there any exceptions in NFPA 13 for smoke detectors in lieu of sprinklers in areas such as radiology rooms or other high tech equipment rooms and still be considered “fully sprinklered”?

A: No. There is an exception in Section 8.15.10.3 of NFPA 13-2010 that allows electrical rooms not be sprinklered, and the building can still be considered fully sprinklered, provided the room is dedicated to electrical equipment only; only dry-type electrical equipment is used; equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations; and no combustible storage is permitted in the room.

And, you can install clean agent suppression systems in lieu of wet sprinklers and the building is still considered fully sprinklered, but there are no exceptions allowing smoke detectors in lieu of sprinklers in any type of room, and still consider the building “fully sprinklered”.

Sprinklers in Lieu of Smoke Detectors

Q: We are seeking to reduce activation of smoke heads contained in our construction areas. In your opinion, if the construction area has existing sprinkler coverage or if new active sprinklers are installed in the construction area, would it be acceptable to remove the smoke heads in this space? In other words, are sprinklers a proper substitute for smoke heads?

A: No… sprinklers are never an acceptable substitute for smoke detectors, because sprinklers do not sense the presence of smoke. Conversely, smoke detectors are never an acceptable substitute for sprinklers because they do not extinguish a fire. However, if the smoke detectors are not required by code or regulation, then they can be removed without any alternative life safety measures applied.

According to 4.6.10.1 of the 2012 Life Safety Code, only deficiencies of required features of life safety necessitate alternative life safety measures (ALSM), also known as Interim Life Safety Measures (ILSM). However, be aware that not all surveyors will likely understand this and they may cite an organization for impaired smoke detectors even if the smoke detectors are not a required feature of life safety.

It is not uncommon for designers to over-install smoke detectors and place them in areas where they are not required. But if the smoke detectors are required, and you desire to remove them for construction purposes (not a bad idea) then you will have to assess them for ALSM and likely implement a fire watch, which can be very costly since it is now required to have a continuous fire watch. Replacing the smoke heads with heat detectors still does not change the result. If the smoke detectors are required then a heat detector is not an acceptable substitute.

Business Occupancy Smoke Detectors

Q: What are the requirements for the use of smoke detectors in a business occupancy physician office that does not have an automatic sprinkler system? The fire marshal is telling me that this is not required, but I cannot find a specific clause in NFPA and want to confirm that statement.

A: The fire marshal is sort-of correct. Smoke detectors are not mandatory in a business occupancy, if the building already has manual pull stations. According to section 39.3.4.2 of the 2012 LSC, only one of the following means to initiate of the fire alarm system is required:

  • Manual pull stations
  • Smoke detectors
  • Sprinkler system water-flow

Of course, you can have more than one type to initiate the fire alarm system, but if you have manual pull stations, then smoke detectors are not required. But, if you don’t have manual pull stations or a sprinkler system, then smoke detectors would be required if the building requires a fire alarm system. Some smaller business occupancies do not require a fire alarm system. Check with your state and local authorities to see if they have other regulations concerning initiating devices.

Fire Alarm Testing Qualifications

Q: I have a question regarding testing and repair of fire alarm system in a hospital setting. Is a maintenance person who is employed by the hospital as an electrician but who has 10-years of on-the-job training qualified to swap out a bad smoke detector or smashed fire pull station? Is he allowed to test the notification and transmission equipment also? Just trying to make sure I am interpreting the NFPA standards correctly.

A: Only if that individual has met the requirements of NFPA 72-2010, section 10.4.3.1, which describes the certification(s) needed in order to provide service, testing or maintenance on the fire alarm system:

“Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of systems addressed within the scope of this Code. Qualified personnel shall include, but not be limited to, one or more of the following:

  • Personnel who are factory trained and certified for the specific type and brand of system being serviced;
  • Personnel who are certified by a nationally recognized certification organization acceptable to the authority having jurisdiction;
  • Personnel who are registered, licensed, or certified by a state or local authority to perform service on systems addressed within the scope of this Code;
  • Personnel who are employed and qualified by an organization listed by a nationally recognized testing laboratory for the servicing of systems within the scope of this Code.”

Now, the Annex section A.10.4.3.1 of NFPA 72-2010 says it is not the intent to require personnel performing simple inspections or operational tests of initiating devices to require factory training or special certification, provided such personnel can demonstrate knowledge in these areas. While the Annex section is not part of the enforceable code, it is explanatory information from the Technical Committee on what they were thinking when the standards were written. Most AHJs follow the Annex section and enforce it as part of their own standards.

However, changing out smoke detectors and/or pull stations is not within the purview of what the Annex section is saying.  To directly answer your question: If your electrician does not have any of the certifications identified in section 10.4.3.1, then no, he is not permitted to replace detector and/or pull stations.

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.

Strange Observations – Smoke Detectors

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

According to NFPA 72-2010, 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.