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.

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.

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.

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 7.14.4.2 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 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”.

Sprinkler Inventory

Q: We are a life safety service company that provides consultation services for multiple hospitals. We had a hospital go through a survey recently, and the surveyor wrote them up for not having an inventory of sprinkler heads. Would you know where we could find this requirement for this inventory?

A: The surveyor may be looking at NFPA 13-2010, section 6.2.9.7, which does require the facility to have a spare sprinkler list, which is based on the different types of sprinklers in your facility and the quantity of those sprinklers. While this is not the same as saying an inventory of the sprinkler heads is required, you do need to know the types and quantities of sprinklers in your facility.

Or the surveyor may be looking at NFPA 25-2011 section 5.2.1, which requires an annual inspection of all the sprinkler heads. Usually, the hospital will contract this out to a sprinkler contractor and often the report simply says “All sprinkler heads inspected”, or something like that. The problem is, how does the hospital know that the contractor actually inspected every sprinkler head in the hospital? Did the contractor enter every room, every closet, every office, every OR, every equipment room, etc. in the facility? Without a detailed inventory or documentation (such as drawings of sprinklered areas) showing the heads were inspected in the respective areas, what assurance does the hospital (and the surveyor) have that every head was inspected?

But to be sure, there is no direct NFPA standard that says “Thou shalt inventory every sprinkler”, but it is well within the right of the authorities to request documentation that assures how the facility documented the spare sprinkler list and that the contractor inspected every head.

Sprinkler Obstructions

Q: My question is in regard to NFPA 13 sprinkler obstruction compliance…We want to install some surveillance monitors in our security office along a wall. How much vertical clear space is required between the monitors to the ceiling, if the monitors will be 30 inches away, horizontally from the sprinkler head?

A: Those monitors may extend vertically up to the ceiling as long as they are not directly underneath a sprinkler head, and they are attached to the wall. You said they were 30 inches away horizontally from the sprinklers, so you should be okay.

The Annex section A.8.6.6 of NFPA 13-2010 says the following:

“The 18 in. (457 mm) dimension is not intended to limit the height of shelving on a wall or shelving against a wall in accordance with 8.6.6, 8.7.6, 8.8.6, and Section 8.9. Where shelving is installed on a wall and is not directly below sprinklers, the shelves, including storage thereon, can extend above the level of a plane located 18 in. (457 mm) below ceiling sprinkler deflectors. Shelving, and any storage thereon, directly below the sprinklers cannot extend above a plane located 18 in. (457 mm) below the ceiling sprinkler deflectors.”

While the monitor may not be shelves, the concept is the same.

Strange Observations – Sprinkler Pipe Supported From Ductwork

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

This is another picture of sprinkler pipe supported from HVAC ductwork, similar to last week’s Strange Observations.

I include it here to emphasize that sprinkler pipe cannot be supported from anything except the building structure itself.

I suspect I see this problem in 75% of the hospital where I consult… but then, I’m looking for it.

There is one exception to that rule… Sprinkler pipe may be suspended from a hanger that also supports ductwork, provided the hanger is designed to support the weight of the duct, the pipe, the water in the pipe, and an additional 250 lbs. (see NFPA 13-2010, 9.2.1.5). If you ever see sprinkler pipe suspended from the same hanger that supports ductwork, ask the installer to provide documentation that the hanger can support that weight.

Strange Observations – Sprinkler Pipe Suspended From Ductwork

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

Some organizations fail to install sprinklers underneath the ductwork that is 48-inches wide or wider. This facility did not forget, but the sprinkler-fitter who installed this pipe for the sprinkler head attached it to the ductwork, which is not permitted.

The sprinkler pipe can only be suspended from the building itself (i.e. structural beams, joists, etc.), and not from anything else.

There is one exception to that rule… Sprinkler pipe may be suspended from a hanger that also supports ductwork, provided the hanger is designed to support the weight of the duct, the pipe, the water in the pipe, and an additional 250 lbs. (see NFPA 13-2010, 9.2.1.5). If you ever see sprinkler pipe suspended from the same hanger that supports ductwork, ask the installer to provide documentation that the hanger can support that weight.

Sprinkler Inventory List

Q: NFPA 13, 2010 edition, sections 6.2.9.7 & 6.2.9.7.1: 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 6.2.9.7 (although, that’s a good inventory list to have).

But section 6.2.9.7 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.