Sprinkler Inventory List

Q: NFPA 13, 2010 edition, sections & Do I read this to mean every sprinkler in every room and hallway in a hospital should be on an itemized list?

A: Well… yes and no. If you are asking if every sprinkler in the facility needs to be on an inventory list that identifies the precise location of each sprinkler installed, then no, that is not the intent of NFPA 13-2010, section (although, that’s a good inventory list to have).

But section does require a list of sprinklers used (but not where they are installed) in the facility, that includes:

  • The sprinkler model number or identification number from the manufacturer;
  • A general description, such as upright or pendant; temperature rating; concealed; extended coverage; Quick-response; etc.
  • The quantity of each type to be sprinkler to be maintained as spares in the Spare Sprinkler Cabinet;
  • Issue or revision date of the list.

This information can be obtained from the “Contractor’s Material and Test Certificate” that was required to be submitted to the owner after the installation of the sprinkler system.

NFPA 13-2010, section 6.2.9 requires spare sprinklers to be maintained so there can be a quick replacement of any sprinkler that has operated or became damaged. You are required to maintain at least two spare sprinklers for each type of sprinkler installed in your facility, but never less than a combined total of six spare heads.

  • For a facility that has fewer than 300 total sprinklers, you are required to maintain a combined total of six spare sprinklers.
  • For a facility that has 300 to 1,000 total sprinklers, you are required to maintain a combined total of 12 spare sprinklers.
  • For a facility that has more than 1,000 sprinklers, you are required to maintain a combined total of 24 spare sprinklers.

So, for some hospitals that have more than 1,000 sprinklers, but only 4 different types of sprinklers are installed in the hospital, that would require them to maintain 6 spare sprinklers of each type. But understand, if the hospital has only two specialty sprinklers installed in the hospital (such as high temperature heads in the boiler room), then there is no requirement to stock 6 spare heads of that type. You may stock just the two heads. A wrench for installing each type of sprinkler is required, which mean if four different wrenches are required to install the four different styles of sprinklers, then that is what you need to maintain. Where dry sprinklers of different lengths are installed in the facility, then spare dry sprinklers are not required.

Strange Observations – Sprinkler in the Alcove

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

The good news is you have an alcove in the corridor where you can store linen carts. The bad news is a sprinkler head was installed in the alcove preventing you from storing linen carts.

In this photo, the top of the linen cart is too close to the sprinkler deflector. You must maintain at least 18-inches clearance underneath the sprinkler head.

I’m not an expert on sprinkler design, but I suspect they would not need a sprinkler head in the alcove, if another sprinkler head was in close proximity.

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.

Fire Pump Phase Reversal

Q: On our fire pump, we monitor the “Fire Pump Run” and “Fire Pump Loss of Power” on our supervisor points, but the fire pump control panel has a point which could be monitored for “Phase Reversal”. My question is, are we required to monitor “Phase Reversal” as a supervisory point?

A: That answer depends on the version of NFPA 20 “Standard for the Installation of Stationary Pumps for Fire Protection” that was enforced when the pump was installed or renovated (upgraded).

According to NFPA 20-2010, section 10.4.7, where the fire pump room is not constantly attended, audible or visual signals powered by a source not exceeding 125 volts must be provided at a point of constant attendance, for each of the following points:

  • Pump running
  • Loss of power
  • Phase reversal
  • Connected to EM power

According to NFPA 72-2010, section, the building fire alarm system is to be used for fire pump monitoring.

There was a time when NFPA only required the points for “Pump running” and “Loss of power” to be monitored, so you may not have to connect “Phase reversal” to the building fire alarm system. According to section 1.4.1 of NFPA 72-2010, the NFPA 72 code/standard is not retroactive to existing equipment.

When was this fire pump controller installed? I checked the 1999 edition of NFPA 20, and that edition required all four points to be monitored. If the controller was installed or updated since March 11, 2003 (the date CMS adopted the 2000 Life Safety Code) then I would say “Phase reversal” is required to be monitored.

Frequency Between Fire Pump Tests

Q: How long is a grace period for the annual fire pump test to be past due?

A: Well, technically, there is no grace period. Either you are compliant or you are not. But most AHJs usually have their way of determining time when it involves frequencies for testing and inspection.

One AHJ may be “by the NFPA book” and when the NFPA code or standard says annually, that means it needs to be done within 12-months of the previous annual test. CMS typically does not allow for more than 12-months for an annual test. In other words, there is no “12-months plus 30-days” for CMS.

But accreditation organizations (AO) seem to have a slightly different interpretation of time. Where NFPA says annually, one AO could mean 12 months from the previous test, plus or minus 30 days. But, as mentioned, CMS does not like the “plus” side of the equation, meaning they don’t mind if you do your flow-test before 12 months has pass from the last test, but they don’t care for one day beyond 12 months. So, state agencies surveying on behalf of CMS would likely cite an organization if the test is one or more days beyond 12 months from the last test, but many accreditation organizations would allow up to 30-days past the 12-month date.

This is one area where NFPA has not clearly defined how they interpret the different time periods for testing or inspection. They purposefully leave this open for the AHJ to decide, but the problem is, hospitals typically have 5 or 6 different AHJs who inspect them for compliance with the Life Safety Code. Chances are, you will never get all 5 or 6 AHJs to agree on what it means. It’s a crap-shoot sometimes. You don’t know how one particular AHJ will respond until they are onsite and write a citation. So, the hospital has to follow the most restrictive interpretation.

Fire Extinguishers in an ASC

Q: We have a 1400 square foot ambulatory surgical center (ASC). In the plans there are only 5 Fire Extinguishers throughout the facility. I looked at 2012 Life Safety Code and the referenced NFPA 10-2010 but still not sure. What are the locations and how many fire extinguishers should be in this 3 operating room 1400 square foot ASC?

A: The placement of portable fire extinguishers is determined on the length of travel distance to get to a fire extinguisher…. It is not determined by the total square footage of the facility. According to NFPA 10-2010, the maximum travel distance to get to a fire extinguisher is dependent on the classification of the fire extinguisher, the capacity of the fire extinguisher, and the potential level of hazard from the fire.

Class A fire extinguishers are for normal combustibles, such as paper, wood, plastic and linens. The maximum travel distance to get to a Class A extinguisher is 75 feet for all capacities of Class A extinguishers, and all potential levels of hazard from the fire. That means you need a Class A extinguisher within 75 feet of all paper, wood, plastic and/or linen. Since paper, wood, plastic and linen are nearly everywhere in a healthcare facility, you will need a Class A fire extinguisher within 75 feet of everywhere inside the facility.

Class B fire extinguishers are for flammable liquids, such as alcohol, alcohol-based hand-rub (ABHR) solution, and xylene. The maximum travel distance to get to a Class B extinguisher is either 30 feet or 50 feet, depending on the capacity of the Class B fire extinguisher, and the level of hazard of the potential flammable liquid fire. The capacity of a Class B extinguisher is pre-determined by the manufacturer, and is identified on the extinguisher label. Usually, it is determined by the ability of the extinguisher to extinguish a fire, so the quantity of the product in the extinguisher is a factor. According to Table of NFPA 10-2010, where the level of the potential hazard is low, a 5-B extinguisher is only permitted a 30-foot travel distance, but a 10-B extinguisher is permitted a 50-foot travel distance. Similarly, if the level of potential hazard is moderate, then a 10-B extinguisher is permitted a 30-foot travel distance, and a 20-B extinguisher is permitted a 50-foot travel distance.

Class C fire extinguishers are for electrical fires. An electrical fire is started by electricity, but the actual substance that burns is either Class A (normal combustibles) or Class B (flammable liquids). Therefore, where potential electrical fires are expected, then a Class C extinguisher is needed, based on the maximum travel distance to get to the extinguisher on either Class A or Class B standards.

Class D fire extinguishers are for combustible metals such as magnesium, zirconium, and potassium, which a typical healthcare facility does not have. Therefore, Class D extinguishers are not required if you do not have any of the combustible metals.

Class K extinguishers are for fires from cooking appliances that involve combustible cooking media (vegetable or animal oils and fats). These are found in kitchens and the maximum travel distance to get to a Class K extinguisher is 30 feet.

The determination of the level of hazard for a Class B potential fire is subjective and could vary depending on the surveyor and authority having jurisdiction (AHJ). For a healthcare facility, a low level of hazard would be areas where individual (or low quantities) of ABHR dispensers or bottles are located, and low levels of alcohol or xylene are located. A potential hazard of flammable liquids is moderate where larger quantities of flammable liquids are stored. But be careful: Based on the information in NFPA 10-2010, you would need Class B extinguishers with a 10-B rating with a maximum travel distance of 50 feet to cover potential fires from ABHR dispensers. This is often overlooked by designers when they are placing portable fire extinguishers in new facilities. Instead of the usual 75 maximum travel distance to get to a Class A extinguisher, you will need to place the Class B extinguishers with a maximum 50-foot travel distance to cover potential fires from ABHR dispensers.

There are fire extinguishers that have the rating to fight Class A, Class B, and Class C fires all in one extinguisher. These are typically ABC dry powder extinguishers, but there are other media types, such as clean agent extinguishers that can achieve an ABC rating. But dry powder extinguishers are not desirable in operating rooms where the possibility of infection is high if the dry powder extinguisher is activated. Therefore, many healthcare facilities rely on water-mist Class A:C extinguishers and a carbon dioxide (CO2) Class B inside the operating room. But you would have to make sure the water-mist extinguishers are charged with distilled water and nitrogen to prevent the growth of pathogens.

Other healthcare facilities do not use water-mist extinguishers in the operating room and rely on the sterile water in a bowl in the sterile field to extinguish any Class A fires that may occur. They then find Class B:C extinguishers to cover Class B and Class C potential fires. Keep in mind, there is no requirement that portable fire extinguishers have to be located inside each operating room. The fire extinguishers just have to be located within the maximum travel distance permitted for each classification of extinguisher, capacity of the extinguisher, and the level of hazard for the potential fire. But be careful: Some operating rooms are rather large, and it might be more than 30 feet to travel from the far corner of the operating room, to the Class B extinguisher in the hallway.

Class K extinguishers are required in kitchens, and the maximum travel distance to get to a Class K extinguisher is 30 feet. A placard needs to be installed above the Class K extinguisher that informs the staff to activate the kitchen hood suppression system first, before using the Class K extinguisher.

Fire Hose Valves

Q: Are we allowed to remove the 1½-inch fire hose valves in our hospital? The local fire department would not even have a means of using them?

A: Section of the 2012 Life Safety Code does imply that you can remove the valves. This section says no existing life safety feature shall be removed or reduced where such feature is a requirement for new construction. Well, 1½-inch fire hose valves are not required in hospitals under new construction standards so the implication is you may remove them.

However, you really need permission from you AHJs in writing before you do. So, contact your local fire department, your state fire marshal, your state department with authority over hospital construction, your accreditation organization, and your liability insurance provider, and get it in writing from each before you remove the valves. If one of the five refuses to allow you to remove the valves, then you cannot regardless what the other AHJs say.

Fire Hose Removal

Q: We have an email confirmation from the State Fire Marshal that approves of our removal of the occupant-use fire hoses in our hospital. What exactly do we have to do with this email?  Do we have to let any other AHJ know?

A: Depending on your accreditation organization (AO), you may have to ask for their permission as well. I do know that Joint Commission used to have a policy that requires hospitals to ask them for permission to remove the occupant-use fire hoses, but I do not believe HFAP or DNV has the same requirement.

Contact your AO and your local AHJ to see if they have regulations that require asking them for permission to remove your occupant-use fire hoses

Strange Observations – Ceiling Gaps

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

Ceilings that contain smoke detectors and/or sprinkler heads have to resist the passage of smoke.

For ceilings that are constructed with acoustical tile and grid assembly, this can be challenging in electrical rooms, or IT rooms where there are a lot of penetrations.

Gaps between the ceiling tile and the conduit cannot exceed 1/8-inch.

Sprinklers in Patient Room Lockers

Q: Are sprinklers required in patient room lockers for existing facilities?

A: No… Section 8.1.1 (7) of NFPA 13-2010 says furniture not intended for occupancy is not required to be sprinklered.