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 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 of the 2012 LSC)
  • Near doors that are held open by devices that release on a fire alarm activation (see section of NFPA 72-2010)
  • In elevator lobbies and elevator equipment rooms (see section 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 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 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.

Fully Sprinkler Existing Hospitals

Q: Is there presently a date in place in which existing Healthcare Occupancies (remaining portions or in their entirety) must be fully sprinklered?

A: Yes and no.

All existing high-rise hospitals must be fully protected with sprinklers by July 5, 2028. This was decided by CMS in their Final Rule to adopt the 2012 Life Safety Code.

For existing hospitals that are not high-rise (i.e. do not have an occupied floor higher than 75 feet above the lowest level used by a fire department) there is no requirement to become fully sprinklered unless their construction type requires it or there is renovation.

Annual Fire Extinguisher Maintenance

Q: For annual fire extinguisher inspection how long before and how long after do you have to re-tag?

A: NFPA 10-2010 section says fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.

Depending on your accreditation organization, and your state agency surveying on behalf of CMS, an annual activity is required to be completed 12 months from the previous activity, during the 12th month. CMS is very adamant: If the requirement is annual, you cannot go more than 12 months between activities.


Cleaning Sprinkler Heads

Q: How would I go about cleaning the dust off the sprinkler heads?

A: Use a portable vacuum cleaner. If the dirty heads are located in the kitchen, then you will need warm soapy water and a toothbrush. But you may want to leave that to a sprinkler contractor to do.

Gaps in Ceilings

Q: I am looking for the 1/8-inch gap reference for ceiling tiles. If the ceiling has broken tiles, or misaligned tiles, or gaps greater than 1/8-inch caused by anything (such as data cables temporarily run up through the ceiling), then I see that the surveyors will cite this. Is that actually written in the NFPA codes and standards anywhere? Is the 1/8-inch gap rule “real”? Does it use the 1/8-inch measurement anywhere? If so, where? If not, where does it come from?

A: No, there is no direct statement in the LSC that says gaps greater than 1/8-inch are prohibited, but ceilings containing smoke detectors and sprinklers must form a continuous membrane and any sizable gap in this membrane would allow smoke and heat to rise above the ceiling which would delay the activation of the detector or sprinkler, thereby causing an impairment.

Since the size of the gap must be quantifiable, and NFPA does not say how big the gap has to be before it is a problem, authorities having jurisdiction have ‘borrowed’ the 1/8-inch gap concept from NFPA 80 regarding the gap between a fire door and the frame. Authorities having jurisdiction are permitted to do this as section of the 2012 Life Safety Code says the authority shall determine whether the provisions of the LSC are met. This means, when the Life Safety Code is not clear on a subject, the authorities have to make interpretations in order to determine compliance.

Annual Fire Pump Test

Q: Is it required to dropped power to your electric driven fire pump while it is running to ensure it starts back up and continues to run on emergency power?

A: If you are referring to the annual fire pump flow test, the answer is yes. Section of NFPA 25-2011 requires a simulated power failure while the pump is operating at peak capacity (150% of nameplate capacity) and confirm that the fire pump continues to operate at peak capacity under EM power. This means a second set of pitot readings are necessary while the pump is operating on EM power at peak capacity. Check with your contractor who conducts this test. Surprisingly, many contractors who perform the annual fire pump test fail to include this procedure.

Non-Sprinklered Elevator Control Room

Q: In a physician’s clinic that is claimed to be fully protected with sprinklers, the building elevator control room is not sprinklered. Must I install or can I leave it that way?

A: A Business Occupancy building that is fully protected with sprinklers provides you with the ability to meet certain options in the LSC that allows you to take advantage of certain features, such as:

  • Delayed egress locks would be permitted
  • Less restrictions on egress capacity factors
  • Exits permitted to discharge through the interior of the building
  • Less restrictions on hazardous areas
  • Less restrictions on interior finishes
  • Increased travel distances

According to NFPA 13-2010, the standard for sprinkler installation, there are very few exceptions to not installing sprinklers, and allow the building to still be considered fully sprinklered:

  • 2-hour fire-rated barriers around an electrical room
  • Clean agent suppression system installations

However, the 2012 Life Safety Code does have an exception specific to elevator machine rooms. Section says sprinklers shall not be installed in elevator machine rooms serving occupant evacuation elevators, and such prohibition shall not cause an otherwise fully sprinklered building to be classified as non-sprinklered. This is one situation where the Life Safety Code trumps NFPA 13 on the installation of sprinklers.

The 2012 Life Safety Code Handbook continues to provide insight on this prohibition:

The presence of sprinklers in the elevator machine room would necessitate the installation of a shunt trip for automatically disconnecting the main line power for compliance with ASME A17.1 Safety Code for Elevators and Escalators, as it is unsafe to operate elevators while sprinkler water is being discharged in the elevator machine room. The presence of a shunt trip conflicts with the needs of an occupant evacuation elevator, as it disconnects the power without ensuring that the elevator is first returned to a safe floor so as to prevent trapping occupants.

So, no… you should not install sprinklers in the elevator machine rooms.

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 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”.

Portable Fire Extinguishers

Q: In regards to fire extinguisher inspections… when the annual fire extinguisher maintenance is done, say in June, does the monthly fire extinguisher inspection still need to be completed?

A: Yes. According to NFPA 10-2010, there are distinctly different requirements for the annual maintenance and the monthly inspection. Typically, the annual maintenance does NOT include the actions required for monthly inspections, although there is no reason why the same person could not perform both duties during the annual maintenance process.

Annual Maintenance requires the following to be confirmed:

  • A thorough examination of the following:
    • Mechanical parts of all extinguishers
    • Physical appearance
    • Components of electrically monitored systems
    • Hoses on wheeled-type extinguishers completely uncoiled and examined for damage
  • Tamper seals on rechargeable extinguishers must be removed and replaced with new seals
  • For extinguishers that require a 12-year hydro-static test, once every 6-years the extinguisher must be emptied and subjected to an internal examination
  • A verification collar must be installed on the outside of the extinguisher, underneath the valve after an internal examination
  • CO2 hose assemblies must have a conductivity test

Monthly Inspection requires the following to be confirmed:

  • Location in designated place
  • No obstruction to access or visibility
  • Pressure gauge reading or indicator in the operable range or position
  • Fullness determined by weighing or hefting for self-expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
  • Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
  • Indicator for non-rechargeable extinguishers using push-to-test pressure indicators

So, you can see an annual maintenance activity does not meet the requirement for a monthly inspection, but there should be no reason why the same person could not perform both duties.

Warning Placards Above Class K Extinguishers

Q: We recently were cited for not having the placard placed on the wall above the K Fire Extinguisher, however, the “warning” on the front of the extinguisher is in red and it states: “WARNING” “IN CASE OF APPLIANCE FIRE, FIRST, ACTIVATE FIRE SUPPRESSION SYSTEM OR TURN OFF APPLIANCE TO REMOVE HEAT SOURCE”. The instructions on how to use the extinguisher is above that warning on the actual extinguisher. Does this meet the intent of the standard?

A: I don’t think so… While some surveyors and inspectors may accept this as meeting the intent of the standard, I’m not sure that it does. According to NFPA 10-2010, section, it says a placard shall be conspicuously placed near the Class K extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher. A warning label on the extinguisher itself is not necessarily placed “near” the extinguisher. If the Technical Committee at NFPA wanted the sign on the extinguisher, they would have said that. Also, a warning label that is part of the fire extinguisher label is not necessarily considered to be “conspicuously” placed. People will not see the warning label on the extinguisher as easily as they will see a separate placard affixed to the wall above the extinguisher.

Also, the Meriam Webster definition of ‘Placard’ is: “A poster or sign for public display, either fixed to a wall or carried during a demonstration.” I don’t think a warning label on the extinguisher meets this definition. Also, section A. in the Annex says the placard should be 11 inches by 7 5/8 inches in size. That size sign is not typically possible on a Class K extinguisher. While the Annex section is not part of the enforceable section of the standard, it is considered to be explanatory material to assist the reader to understand the intentions of the Technical Committee who wrote the standards. I would conclude the Technical Committee wants a separate sign posted on the wall near the extinguisher.

I’m sure some surveyors may accept this warning label, but I would not. [Perhaps that is good that I’m not a surveyor anymore….?]