MRI Fire Extinguisher

Q: Do the accreditation organizations require a fire extinguisher inside the MRI room, or can it be located in the MRI control room?

A: The accreditation organizations would follow what NFPA 10 requires. NFPA 10-2010 has limitations on travel distance for portable extinguishers. An extinguisher inside the room with the magnet is not required provided the travel distance to get to the extinguisher meets the requirements set forth in NFPA 10. As an example: The maximum travel distance to get to a Class A extinguisher is 75 feet. But the travel distance to get to a Class B extinguisher is either 30 feet or 50 feet, depending on the capacity of the extinguisher and the level of hazard for the potential fire. But to answer your question, I don’t think the accreditors would require an extinguisher inside the MRI room, provided you do not exceed the travel distance to retrieve it. Also, be aware you need a non-ferrous extinguisher, but I’m sure you already knew that.

Water-Mist Fire Extinguishers in the ORs

Q: Our facility recently installed water-mist fire extinguishers in all of our operating rooms, which is the sole fire suppressant. Is this acceptable?

A: It could be okay to have water-mist portable fire extinguishers in the operating rooms, provided there is a Class B:C fire extinguisher within 50 feet travel distance from inside the ORs.

The typical water-mist fire extinguisher is rated for Class A and Class C fires; both of which are possible in an operating room. But what about Class B fires? Most operating rooms are known to have flammable liquids, and a Class B fire extinguisher would be required. NFPA 10 says the travel distance to a Class B fire extinguisher is either 30 feet for low capacity extinguishers and low hazard areas, or 50 feet to moderate capacity extinguishers and low to moderate hazards. The OR could be rated as a low hazard area, but typically a Class 10-B CO2 extinguisher qualifies for a 50-foot travel distance and a Class 5-B CO2 extinguisher qualifies for the 30-foot travel distance.

But I would suggest that your Infection Control people weigh-in on this debate because the typical water-mist fire extinguisher consists of tap water, pressurized with compressed air. That is a recipe for a breeding-ground for germs. I’ve seen some hospitals use distilled water in their water-mist fire extinguishers and pressurize it with nitrogen, to discourage germ growth. But the IC folks should have a say in this because a water-mist fire extinguisher would be expected to be used on a patient who is on fire, in surgery with an open cavity.

Here is what I would suggest:

  • Remove the water-mist fire extinguishers from the operating rooms.
  • Install 10-lb Class 10-B:C CO2 portable fire extinguishers inside each OR. This will handle all Class B and Class C fires that may occur in the OR. Discharging a CO2 extinguisher in an operating room would not be detrimental to the patient.
  • Rely on the staff having sterile water in the operating field to extinguish any Class A fires that may occur. Sterile water dosed on a patient would not be detrimental to the patient.
  • Definitely remove all Class ABC dry chemical fire extinguishers from the surgery department, so they will not be accidentally used on a patient. Nearly the last thing you want is dry powder sprayed into an open cavity of a patient during surgery.

You say the water-mist fire extinguishers are the sole fire suppressant. Does the OR have water-based fire protection sprinklers? If not, why not? There have been some mistaken ideas that water drips from sprinklers and some surgeons ‘prohibit’ sprinklers in their ORs. While it is true that a defective sprinkler could drip water, it is extremely rare and unlikely. Nevertheless, a pre-action sprinkler system would be an acceptable answer as the sprinkler pipe over each OR would be dry.

ABC Dry Powder Fire Extinguishers

Q: We are doing a fire extinguisher annual maintenance on a Hospital and find that there is a high volume of ABC dry powder units through the site and very few CO2 units. The question we are asking is this a problem? Are there regulations for a healthcare site to use other CO2 in certain areas?

A: The only regulation concerning fire extinguishers in healthcare is NFPA 10 (2010 edition). NFPA 10 requires that the classification of the fire extinguisher be matched with the classification of the potential fire. However, there are infection control issues to be concerned about and an ABC dry powder FE would not be a good selection for use in an operating room or a procedure room. There is no regulation that says you can’t use an ABC dry powder in an operating room or procedure room, but from a practical point of view… it doesn’t make sense. Some hospitals use CO2 FEs in operating rooms for flammable liquid fires on a patient, however CO2 may cause frostbite. Other hospitals rely on sterile water supply in the sterile field to extinguish flammable liquid fires on a patient, but do not rely on water-mist FEs for this purpose as the water in the water-mist FEs may contain bacteria.

An ABC dry powder FE may not be a good choice for critically sensitive equipment such as computer rooms. A risk assessment may reveal that a Halon or a FM-200 type extinguisher is more appropriate. In the Laboratory where there are flammable liquids in use, a CO2 extinguisher is the proper choice. Hospitals would be expected to have a documented risk assessment conducted, that determines what type of FE should be used in certain areas.

Portable Fire Extinguishers

Q: Are fire extinguishers required to be placed in mechanical rooms in our hospital? I’ve searched NFPA 10 and the Life Safety Code and haven’t found anything concrete. The mechanical rooms in our facility are strictly boiler rooms, electrical control panel rooms, and so on. They are considered restricted areas and are always kept locked, with access granted to just the facilities staff and the security staff. Any help you can provide is greatly appreciated.

A: Yes, according to sections and of the 2012 Life Safety Code, you must be in full compliance with NFPA 10 (2010 edition) for maximum travel distance to the location of a portable fire extinguisher, in all areas of your facility. Each classification of extinguishers has their own different requirements, as follows:

Class A Extinguishers

Maximum travel distance to extinguisher:                  75 feet

Maximum floor area for each extinguisher:               11,250 sq. ft.

Maximum floor rating per unit of ‘A’:                       3,000 sq. ft. for Light (Low) Hazard

1,500 sq. ft. for Ordinary (Moderate) Hazard

1,000 sq. ft. for Extra (High) Hazard


Class B Extinguishers

Light (Low) Hazard:

5-B                  30 feet maximum travel distance

10-B                50 feet maximum travel distance

Ordinary (Moderate) Hazard:

10-B                30 feet maximum travel distance

20-B                50 feet maximum travel distance

Extra (High) Hazard:

40-B                30 feet maximum travel distance

80-B                50 feet maximum travel distance

Class C Extinguishers

Class C fires are started with electrical current, but the actual fuel that burns is either a Class A or a Class B hazard. Therefore, Class C extinguishers should be mounted and located according to either Class A or Class B requirements, depending on the potential fire.

Class K Extinguishers

Maximum travel distance is 30 feet.

Even mechanical rooms where very few people have access are required to be protected with portable fire extinguishers, so make an assessment of what the potential fuel that could catch on fire, and obtain the classification of extinguisher(s) that meets that potential fuel, and space them out accordingly.

Fire Extinguisher Inspections

Q: I work in a 420 bed Hospital and during a recent survey we got cited for our yearly inspection dates on our fire extinguishers, which I understand. But on the monthly inspection dates, does the inspector put the date they do the inspection or the date of the next month?

A: For monthly inspections of portable fire extinguishers, NFPA 10 (2010 edition) section says at a minimum of 30 day intervals, the date the inspection was performed and the initials of the person performing the inspection must be recorded. So each month, the person making the inspection must record the date that the inspection is made, on the extinguisher tag. Most authorities want to see an actual date, written in a month/day format provided the year is clearly identified on the tag. Initials of the individual conducting the inspection are usually accepted over actual signatures.

Monthly Inspections vs. Annual Maintenance on Fire Extinguishers

Q: During a recent survey, we were cited for not having monthly inspections on our extinguishers during the month of the annual inspection. We have never run into this before. Doesn’t the annual service include and go beyond a monthly check?

A: You would think so, wouldn’t you… But, technically speaking, no the annual maintenance does not include and go beyond the monthly inspection. There are differences between the monthly inspection and the annual maintenance, which are:

Monthly inspection (per NFPA 10):

Confirm the following:

  • Location in designated place;
  • No obstruction to access or visibility;
  • Operating instructions on nameplate legible and facing outward;
  • Safety seals and tamper indicators not broken or missing;
  • Fullness determined by hefting;
  • Examination for obvious physical damage, corrosion, leakage, or clogged nozzle;
  • Pressure gauge reading or indicator in the operable range;
  • Condition of tires, wheels, carriage, hose, and nozzle;
  • HMIS label is in place.

Annual Maintenance (per NFPA 10):

Perform the following:

  • Examine all mechanical parts;
  • External examination;
  • Pull pin and replace tamper seal.

So, you can see that the annual maintenance activities are entirely different than the monthly inspection activities. It is entirely possible that the person conducting the annual maintenance can also do the first monthly inspection, but that would have to be documented. Typically it would be documented on the tag on the fire extinguisher. If that was not documented then it did not happen.It appears to me that the surveyor who made that citation was very astute.

New Fire Extinguisher Inspection Frequency

Q: I could’ve sworn I read somewhere that a monthly fire extinguisher inspection shall be done within 30 days AND that there is to be a 10 day grace period… For example, If the date of a tag showed Jan.31, the next inspection date permitted would be Feb.9th?   You can write down Jan. 31 and then Feb. 1st for the next inspection. Also, If a date is written May 13th, the next date needs to be done BY June 23rd? 10 day grace period from the previous monthly inspected date. Am I wrong or confused on this, I can’t seem to find the language in NFPA 10.


A: Not every AHJ agrees on the Fire Extinguisher monthly inspection issue. Joint Commission will allow the FE to be inspected anytime during the calendar month, which means if it was inspected on January 1 the next inspection could be anytime in February including February 28. However, that also means the FE could be inspected on January 31 and then next on February 1. That is not desirable and will likely receive the attention of a surveyor.

I know CMS does not like the formula used by Joint Commission, and they will follow what the standard requires. NFPA 10-2010, section says extinguishers are required to be inspected manually or by electronic monitoring at a minimum of 30-day intervals. The Annex section for continues to say inspections are performed on extinguishers 12 times per year, once a month.

So, I can see your state agency who surveys on behalf of CMS to require a minimum of 30 days between the monthly inspections, but each extinguisher needs to be inspected monthly. So, this may be a problem for February… If the extinguisher was last inspected on January 31, then 30 days from January 31 is March 2 (or March 1 if it is a leap year). You can’t inspect it less than 30 days but you have to inspect it every month. That’s a Catch-22. Be careful you don’t get caught in that unique trap.

There is no 10-day grace period in NFPA 10.







Fire Extinguisher Cabinet Labeling

Q: Our hospital was surveyed recently and one of our deficiencies was that our fire extinguisher cabinets were not labeled. I can find nothing in the Life Safety Code stating this as a requirement. Could you please assist in this matter? Also, if labeling is required would the wall mounted “tent” type placards that are hung on the wall above the cabinets be acceptable?

A: Yes, NFPA 10 (1998 edition), section 1-6.12 says:

Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously.

Sections and of the 2000 Life Safety Code reference NFPA 10 as a requirement for fire extinguishers. So the expectation is you need to comply with NFPA 10.

NFPA 10 does not specify how the fire extinguisher cabinet is to be marked, but it must be marked conspicuously. A 3-deminsional arrow (tent-card style) certainly meets this requirement, but other types of markings do as well, such as painting all extinguisher cabinets red. Most authorities will accept whatever means you choose to use, as long as all the extinguisher cabinets are marked the same way, for continuity.

Certification for Annual FE Maintenance?

Q: I read in one of your posts that the annual maintenance service of fire extinguishers does not require to be conducted by a “certified” individual.  I was under the impression that the annual servicing or recharging of a fire extinguisher must be done by a certified individual. I know the monthly can be done by anybody but I thought the annual was different. Was this requirement recently changed?

A: According to NFPA 10 (1998 edition) section 4-1.4, it says annual maintenance, servicing and recharging shall be performed by trained persons having available the appropriate servicing manuals, the proper types of tools, recharge materials, lubricants, and manufacturer’s recommended replacement parts or parts specifically listed for use in the fire extinguisher. Nowhere does it say the person has to be certified.

However, there was a change as you questioned. NFPA 10 (2010 edition) section does say the person performing the annual maintenance and recharging must be certified. So when the 2012 Life Safety Code is finally adopted, that’s when the 2010 edition of NFPA 10 becomes effective and the annual maintenance and recharging must be accomplished by a certified individual.

The Annex section of NFPA 10 (2010 edition) says persons performing annual maintenance and recharging of extinguishes should meet one of the following criteria:

  1. Factory trained and certified for the specific type and brand of portable fire extinguisher being serviced
  2. Certification by an organization acceptable to the authority having jurisdiction
  3. Registration, licensure, or certification by a state or a local authority having jurisdiction

Certification confirms that a person has fulfilled specific requirements as a fire extinguisher service technician and has earned the certification. Supporters of this change wanted the technicians to be certified to ensure the portable fire extinguishers will function properly when needed. Those who opposed this change stated it was championed by a special interest group, to ensure more work would be directed to their constituents.

For whatever reason, the change will be law once the new 2012 LSC is adopted.

Strange Observations – Part 2

FE With Blurred InstructionsContinuing in a series of strange things that I have seen while consulting at hospitals….

This is a picture of a fire extinguisher that was located in a laboratory. The staff did a terrific job of cleaning the lab, but the chemicals they used where too harsh on the extinguisher label. Take a close look and you will see the printed instructions were all blurred from the corrosive chemicals in the cleaning agent.

While the extinguisher would still operate correctly in an emergency, it no longer met the requirements of NFPA 10-1998, section 1-6.11 that requires the instructions to be facing outward and be clearly visible.