Storage in Generator Rooms

Q: I cannot find a code reference that prohibits storage in the generator enclosure. Is there a specific reference for this in the 2000 edition of the Life Safety Code?

A: Sections 19.5.1 and 9.1.3 of the Life Safety Code (2000 edition) references NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition, section 5-2.1, which requires the generator to be installed in a separate room for Level 1 installations, which applies to hospitals. NFPA 110 does require a minimum 2-hour fire rating or the generator must be located in an adequate enclosure located outside of the building capable of resisting the entrance of snow and rain at a maximum wind velocity required by local building codes. No other equipment, including architectural appurtenances, except those that serve this space, is permitted in this room. In addition, section 5-2.2 of NFPA 110 does not allow generators to be installed in the same room where normal electrical equipment service is installed. These two sections are being interpreted by many national authorities whereby absolutely nothing is allowed in the same room as the generator. The good news (if there is any), the most recent edition of NFPA 110 (2010 edition) does allow small repair parts, tools and manuals in this generator room, but that edition will not be part of our accreditation process until CMS adopts the 2012 edition of the Life Safety Code. So for now, we must comply with the 1999 edition of NFPA 110.

Generator Rooms

imagesCA0CNZZFNFPA 110 (1999 edition) requires generators to be located in a dedicated room, separated from all other areas and spaces by 2-hour fire rated barriers. NFPA 110 is very clear that nothing else may be located, stored or mounted inside the generator room, which includes normal power distribution equipment.

NFPA 110 (1999 edition) does say it is not a retro-active code, meaning existing conditions may remain except where the authority having jurisdiction determines that nonconformity presents a distinct hazard to life. This is the catch for most national authorities for healthcare applications. The concern is if a generator shares a room with other mechanical equipment, and the other mechanical equipment causes a fire that disables the contents of the room, then the generator is out of service, or at least compromised. Since emergency power is critically important to sustain life in hospitals, most national AHJs are evoking that clause and requiring existing generator rooms to meet the full requirements of NFPA 110 (1999 edition).

Keep in mind, the whole purpose of that 2-hour fire rated barrier separating the generator from the rest of the hospital, is to protect the generator from the rest of the hospital; not to protect the hospital from the generator. The conventional wisdom is, if a fire starts on the outside of the generator room, the generators will operate for 2-hours before the fire breaks through. That should be enough time for the firemen to extinguish the fire and to evacuate the building, if need be.

So, nothing may be stored in the generator room, but NFPA 110 does permit the following emergency power supply system equipment in the generator room:

  • Energy converter (generator)
  • Day tank of fuel
  • Support equipment for the room (HVAC equipment, lighting equipment, etc.)
  • Conductors
  • Disconnecting means
  • Overcurrent protective devices
  • Transfer switches
  • Control devices
  • Supervisory devices
  • Support devices needed for the system to operate as a safe and reliable source of electric power

 The last term (support devices) can be interpreted to include necessary manuals and tools to safely operate the generator, but does not include tools to perform repairs, repair parts, discarded materials, replacement filters and oil.

Battery powered emergency lights are required in the room, connected to the load side of the transfer switch, whereby the lights will illuminate during a normal power outage. The room must be maintained to a temperature of not less than 70°F, unless the generator is equipped with a water jacket heater that maintains the engine temperature at 90°F. Where the generator is equipped with a water jacket heater, the room must be maintained at a temperature of not less than 40°F.

imagesF3QUS2EBThe amount of fuel required to be stored onsite for the generator is based on the amount of run-time. For generators located in seismic risk areas designated as Zone 3 or Zone 4 of the Uniform Building Code (see map, or Google ‘UBC Seismic Risk Map”), a minimum of 96 hours of fuel supply is required to be stored onsite. For generators not located in seismic risk areas Zone 3 or Zone 4, 26 hours of fuel supply is required.

Fire Protection of Equipment Rooms

Q: What is the fire rating supposed to be in the walls of the hospital equipment rooms, such as the generator room, boiler room, chiller rooms, and electrical rooms? We have a disagreement as to what is required and your answer decides who is correct.

A: According to NFPA 110 (1999), section 5-2.1, generator rooms are required to have 2-hour fire rated barriers that protects the room from fire outside the room. Any 2-hour fire rated barrier is required to have 90-minute fire rated doors and frame and if there are any HVAC duct penetrations through the 2-hour barrier, then the HVAC duct opening needs to be protected in accordance with NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating System, which would require a 90-minute fire damper. A boiler room is considered a hazardous area, and according to the 2000 edition of the LSC, sections 18/, the hazardous area is required to be protected with 1-hour fire rated barriers if it is considered new construction, or 1-hour barriers if it is considered existing and is not protected with sprinklers. Existing boiler rooms that are protected with sprinklers only require smoke resistant walls. All door openings in a 1-hour barrier are required to be ¾ hour fire rated, with fire rated frames. However, unlike the 2-hour barrier, a 1-hour fire rated barrier for a hazardous area is not required to have any fire dampers in a HVAC duct penetration, unless the HVAC penetration is not fully ducted. Electrical rooms typically are not required by the LSC to have fire rated barriers (walls), however NFPA 13 (1999 edition) Standard for the Installation of Sprinkler Systems, section 5-13.11 does permit an electrical room to be protected with 2-hour fire rated barriers in lieu of being protected with sprinklers. Therefore if the room does have fire rated barriers for any reason (including local or state building codes) then it would need fire dampers in the HVAC duct penetration if it is 2-hour fire rated or greater. Chiller rooms typically do not require fire rated barriers, unless the chillers are fuel-fired, then they would require the same protection as the boilers. As always, please check with your local and state authorities to determine if there are other regulations that may affect this situation.

Good Luck!

Fire Alarm Monitoring of the Generator

imagesFWTL2IM2Does your fire alarm system monitor the emergency power generator? It may have to. Section 1-5.8.7 of NFPA 72 (1999) requires the fire alarm system to monitor the primary and secondary power supplies for the presence of voltage at the point of connection to the fire alarm system. Failure to monitor either connected power supply should result in a ‘Trouble’ signal. Under normal power conditions, the emergency power from the generator is not connected, and therefore is not monitored. But when the emergency power is connected, it must be monitored, according to NFPA 72. However, there is an exception to 1-5.8.7 that says:

“The power supply of an engine-driven generator that is part of the secondary power supply, provided the generator is tested weekly in accordance with chapter 7”.

So, that means if the generator is tested weekly, then the generator is not required to be monitored. But Table 7-3.2 of NFPA 72 (1999) says engine driven generators must be tested monthly, not weekly. So is this a conflict in the standard? I looked at the 2010 edition of NFPA 72, and apparently the technical committee thought it was, as they corrected their table (Table 14.4.5 which is comparable to Table 7-3.2 of the 1999 edition) which now says the generator must be tested weekly, and Table (of the 2010 edition) on Test Methods, says the test must be in accordance with NFPA 110.

But NFPA 110 does not require weekly operational tests, only weekly inspections. They do require monthly tests of the generators. Again, is this another conflict? Perhaps not, as the frequency of the generator test (weekly) is determined by NFPA 72, but the methods and parameters of the test are determined by NFPA 110.

This is what is apparent to me: NFPA 72 requires the fire alarm system to monitor the voltage at the point of connection on both primary and secondary power supplies. The exception to this requirement for monitoring is if the generator is being tested weekly, but not many organizations are testing their generators weekly. If you are not testing the generators weekly, then make sure your fire alarm system is monitoring the voltage output of the generators when they are connected to the fire alarm system.

Is any national AHJ currently enforcing this issue at the moment? I am not aware that any of them are, but it is a NFPA requirement and healthcare organizations are required to be compliant with all NFPA standards referenced by the Life Safety Code. Better to be on top of this and have your fire alarm system compliant before one of the AHJs asks to see your documentation.


Enclosures for Emergency Generators

Q: Do emergency power generators have to be located in a room by themselves? We have a generator that is located in a mechanical room which is shared with an air-handler, condensate pumps and other equipment. This generator was installed in the 1970’s, but a consultant told us we had to relocate the generator to a 2-hour room where it can be located by itself.

A: NFPA 110 (1999 edition), section 5-2.1 says the generator must be installed in a separate room with a 2-hour fire rating, and no other equipment is permitted in the room. However, section 1-3 of the same standard says NFPA 110 only applies to new installations and existing systems are not required to conform to the standards, unless the authority having jurisdiction (AHJ) determines that nonconformity presents a distinct hazard to life. If the generator has been installed since the 1970’s and no AHJ has cited you for nonconformity, then I suggest it is safe to assume the AHJs that have inspected your facility do not have a problem with the arrangement. If an AHJ attempts to cite this situation for non-compliance with NFPA 110 (1999 edition) section 5-2.1, then I would make the case that it is not required to since this room was constructed long before NFPA 110 was in existence. NFPA 110 was first adopted in 1984 by NFPA, so it was not part of the Life Safety Code until probably the 1985 edition.  Therefore, it may be assumed it met the standards that were in existence in the 1970’s when the building was constructed.

Changes to Joint Commission Standards for 2014: Part 2


As mentioned in last week’s posting, The Joint Commission announced changes to their standards that takes affect January 1, 2014. We discussed already the change they are making with time defined which will have a significant impact on scheduling fire drills, and other quarterly activities. This week we will look at the other change that the accreditor announced: Monthly generator load testing.

During a recent webinar which was sponsored by ASHE, George Mills, the Director of Engineering for The Joint Commission, announced starting in 2014, monthly generator load testing will be permitted to be accomplished anytime during the month, rather than the current requirement of no less than 20 days and no more than 40 days from the previous monthly load test. Why this change? George did not explain why, but perhaps it is Joint Commission’s attempt to make it easier on the facility manager.

But if that is the case, then I’m not sure it is a favor, as this latest move by the accreditor is not consistent with the Life Safety Code (LSC) for new construction, nor is it consistent with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation.

But why did The Joint Commission have the 20 day/40 day requirement for generator monthly load test in the first place? Because it is a requirement of NFPA 99 Health Care Facilities (1999 edition), section 3-, and the LSC (2000 edition) section requires compliance with NFPA 99. Now, chapter 18 is for new healthcare occupancy construction, and chapter 19, which regulates existing healthcare conditions, does not have the same requirement. So, you might think the 20 day/40 day window for monthly testing only applies to new construction (since March 1, 2003) and not existing. Well, I wouldn’t bet on that.

Enter the CMS Conditions of Participation, paragraph 482.41(a)(1) interpretive guidelines says: “The hospital must comply with the applicable provisions of the Life Safety Code…and applicable references such as NFPA 99…for emergency lighting and emergency power.” This CoP standard applies to all healthcare occupancies, regardless whether they are new or existing and is required to be assessed by the LSC Survey Report Form CMS-2786, also known as the K-Tags. Tag K-144 says the following: “Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99, 3-4.4.1, NFPA 110,8-4.2.” This means CMS requires the generator monthly load tests to be conducted within the 20 day/40 day window of opportunity.

As a deeming authority who has been approved by CMS, Joint Commission is required to have standards that are at least equal to or greater than CMS’s CoP. This new change announced by Joint Commission appears to establish their standards less than what CMS’s CoP requires. Will CMS hold them accountable to this difference? If history is an indication of future events, I suspect they won’t.

As a side-note, during the Q&A session of the ASHE sponsored webinar, my good friend George Rivas of TSIG Consulting asked George Mills if Joint Commission surveyors will allow monthly generator load tests conducted on the 30th of one month, and then next on the 1st of the following month, essentially just 1 day apart. Mills kind of hesitated and said he wouldn’t know why a facility manager would want to do that, but he agreed it would be permissible.

So… What does all this mean? Joint Commission can do what they want, and they often do. But this change to their standards will only provide temporary relief for the healthcare facility managers. On this issue, CMS has more restrictive requirements, so it would be wise for facility managers to continue to conduct their generator monthly load tests within the 20 day/40 day window, so they are ready if the CMS approved state agency inspectors show up to do a validation survey.

Generator Load Tests

Q: Is it allowed to combine the 3-year 4-hour generator load test along with the annual 2-hour load test? Our generator test company plans on running the generator at 50% load for the first two hours and then elevate to 75% load for the last two hours. In your opinion would this satisfy both the 2 hour and the 4 hour load test?

A: You are allowed to combine the 2-hour load test and the 4-hour load test. The 2-hour load test is required to be conducted once per year when the generator cannot meet the load test of 30% of nameplate rating every month. When this occurs, you still conduct the monthly load tests but once per year you need to conduct a 2-hour load test (usually by connecting the generator to a resistive load bank) that consists of the following sequences:

  • 25% load for 30 minutes, then
  • 50% load for 30 minutes, then
  • 75% load for 60 minutes for 2 continuous hours.

The scenario that you described allowed 50% load for the first two hours and then a 75% load for the last two hours. This would be acceptable in meeting both test requirements since the percentages listed in the standards are minimum settings, and you are permitted to exceed them. But you need to be careful, because if you combine these two tests and start out at 25% load (as required for the 2-hour load test) for the first 30 minutes, then you are out of compliance with the 4-hour test, unless you run an extra 30 minutes after you reach or exceed 30%.


Circuit Breaker Testing

Q: During a recent survey, the inspector cited us for not exercising our circuit breakers downstream of our generator. Does the LSC require annual exercising of all circuit breakers between the generator and the connected load?

A: The LSC section 9.1.3 does require emergency power generators to comply with NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition. Section 6-4.6 of NFPA 110 requires the main and feed circuit breakers between the generator and the transfer switch terminals to be exercised annually with the generator in the off position. This appears to me that all emergency source circuit breakers are required to be exercised annually.  This would include the generator output breaker and all downstream distribution breakers, up to and including any breakers that feed the emergency feed side of the automatic transfer switch (ATS).  I believe that would exclude any loads connected to the load side of the ATS such as motors, lights, pumps, etc.  The process is a simple one because all affected breakers are normally in a de-energized state. I do not recall ever seeing a reason for this procedure published, although I’m sure there is a good reason.  In my experience though, breakers that are not exercised regularly can be extremely (if not impossible) to reset, even though the internal trip mechanism may work perfectly. This may lead an organization to not conduct this annual test, which may result in them being cited for noncompliance. Some organizations will purchase replacement circuit breakers and have them available on a shelf in case the breaker will not reset. While this is a very proactive approach to testing and a quick response to potential repairs, it can be rather costly as the large current breakers are a bit pricey. While this issue may not come up very often during a survey, it is a LSC requirement and the surveyor has the obligation to cite the issue if he or she sees it as being noncompliant.

Combined load tests on generators

Q: The AHJs who inspect my hospital require that I conduct a three-year, four-hour load test, which we do simultaneously with our annual load bank test. One AHJ says this is acceptable while another AHJ doesn’t like it and says the annual load test is required to be conducted at varying loads of 25%, 50%, and 75%, and the three-year test is required to be conducted at 30% load. Which one is correct, and where do I find the standards for this testing requirement?

A: Both The Joint Commission and CMS require the three-year, four-hour generator load test, which was introduced in the 2005 edition of NFPA 110, Emergency and Standby Power Systems. This test was further explained in the following 2010 edition of the same NFPA 110 standard. Section 8.4.9 of NFPA 110 requires the three-year test to be conducted at 30% of the nameplate rating of the generator for four continuous hours. The annual load test is only required when the monthly load tests cannot meet the 30% nameplate rating capacity. The annual load test is required to operate the generator at 25% capacity for 30 minutes, 50% capacity for 30 minutes and 75% capacity for 60 minutes for 2 continuous hours. If you combined these two load tests, then the one AHJ is correct; 25% capacity is not equal to 30% capacity for the first 30 minutes of the load test, and that AHJ would be correct for refusing to accept this combined test as evidence of meeting the three-year, four-hour load test. An easy solution to this would be to operate the first 30 minutes of the combined test at 30% capacity, as the load values given are minimum values and may be exceeded.

Emergency Generator Batteries

Q: Are we required to replace the batteries that start our emergency generators every two years? Our generator service contractor told us that the code requires us to replace the batteries that often.

A: I’m not sure what code your service contractor is referring to, but I’m not aware of this requirement. Section 19.5.1 of the LSC requires compliance of section 9.1 for all utilities. Section 9.1.3 requires emergency generators to comply with NFPA 110 (1999 edition) Standard for Emergency and Standby Power Systems. Section 6-3.6 of NFPA 110 requires the batteries to be maintained according to the manufacturer’s specifications and inspected at intervals of not more than 7 days. The annex section states that the specific gravity should be checked and recorded. I suggest that you contact your local and state authorities to see if they have any other requirements.