Smoke Door Testing?

Q: The Joint Commission standard for annual door testing states “The hospital has written documentation of annual inspection and testing of door assemblies by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested”. The Joint Commission also references NFPA 105 (smoke doors). Would this include all smoke barrier doors?

A: It appears you have an older copy of the Joint Commission standards. In January, 2019, the standard in which you refer has been changed to specifically identify the need to inspect and test fire door assemblies. Their note to this standard says nonrated doors including smoke barrier doors are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105.

It is the position of CMS and all accreditation organizations that non-rated doors in smoke barriers (barriers that separate smoke compartments) do not have to be inspected on an annual basis.

Here is why: Even though section 7.2.1.15.2 of the 2012 LSC says (in part) smoke door assemblies need to be tested, that conflicts with the occupancy chapter for healthcare. Section 4.4.2.3 says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section 19.3.7.8 says doors in smoke barriers shall comply with section 8.5.4. Section 8.5.4.2 says where required by chapters 11 -43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section 8.2.2.4 (which requires testing).

Chapters 18 & 19 (healthcare occupancies) do not require smoke doors to be smoke leakaged-rated: Therefore, smoke barrier doors do not have to be tested in healthcare occupancies. Now… you may have an AHJ that believes differently. You may show them this code trail and perhaps they will allow you to not test your smoke doors, but ultimately they are an authority and if they say you have to test smoke doors, then you have to test smoke doors. But it is not required in healthcare occupancies according to the 2012 LSC.

Downgrading Fire-Rated Door Assemblies

Q: My boss has hired an outside company that has advised him to rip fire rating labels off of doors and frames that we have maintained properly for decades. We do have automatic sprinklers in all areas. It does not feel appropriate to simply downgrade hazardous rooms, corridors, and elevator lobbies. My boss refuses to contact the AHJ and will only refer to his outside company. Is this appropriate and something I can sign my name too? Thank you for any information.

A: Well… maybe yes and maybe no.

All fire rated doors must be inspected based on 2012 LSC section 4.6.12.3 and 8.3.3.1, regardless if they are located in a fire-rated barrier or not. So, if your facility has a fire-rated door installed in a barrier (i.e. a corridor wall) that is not a fire-rated barrier, then the door assembly still has to be tested and inspected even though it is not located in a fire-rated barrier.

If you have a lot of these situations, then it can be costly to test and inspect fire-rated doors where you don’t have to, so the easy solution is to remove the fire-rating label from the door and frame. If you do that, then you don’t have to test and inspect the doors as they are no longer fire-rated assemblies. But you must be very cautious before you take such action and make doubly-sure that the door assembly is no longer needed to be fire-rated.

But you said something in your question that disturbs me… You said: “It does not feel appropriate to simply downgrade hazardous rooms, corridors, and elevator lobbies.” This statement is very troubling as you are not permitted to downgrade features of life safety that were required at the time of design or construction, unless it is a change with new construction standards. So, here is a possible scenario that may apply to your facility: When your facility was originally constructed, it was required to have all hazardous rooms be 1-hour fire-rated and fully protected with sprinklers. Today, that same room is now considered ‘existing conditions’ by definition since the 2012 LSC was adopted in July 5, 2016, and your facility was constructed prior to that date. According to the 2012 LSC, existing conditions hazardous rooms are permitted to be 1-hour fire-rated or sprinklered; not both. But section 4.6.12.2 of the 2012 LSC says no existing life safety feature shall be removed or reduced where such feature is a requirement for new construction. The 2012 LSC still requires sprinklers and 1-hour fire rated hazardous rooms, so you are not permitted to down-grade the fire-rated doors to a hazardous room just because it now qualifies as existing conditions.

You have every reason to be questioning this strategy. I suggest you and your boss contact your AHJs for guidance, or at least get some decent advice from a consultant. This outside company that you refer to… are they a qualified Life Safety company to be offering advice like this?

Some AHJs will not allow any down-grading of fire-rated door assemblies even if the doors are not required to be fire-rated, so make sure you check with them before removing any labels.

Fire Pins

Q: I had a company put in the fire plugs on the doors to replace the lower bottom rods. Was this okay? They say that the plugs have a thermal-pin that will secure the door in case there was a fire.

A: You must be referring to fire pins… I cannot say if this is okay or not. That is up to the manufacturer of the fire doors. You are not allowed to modify a fire-rated door assembly other than what the manufacturer permits. If you haven’t already done so, contact the manufacturer of the door and ask them if fire pins are permitted to be installed in their door in lieu of the lower bottom rod after the door is installed.

The manufacturer achieves a listing from an independent testing laboratory for the fire-rating of their door assembly. If you modify that door assembly beyond what was tested and listed by the testing laboratory, then you have violated the listing of the door and the entire door assembly would need to be replaced.

Corridor Doors Have to Be Fire-Rated?

Q: We have an engineer who is telling us that the 2012 Life Safety Code requires our corridor doors to be fire-rated. He is referencing Table 8.3.4.2 which says exit-access corridor walls that are either 1-hour rated or ½-hour rated require a 20-minute fire-rate door. He says the healthcare occupancy chapter sections 19.3.6.2.4 and 19.3.6.3.2 support this as well. Is this true?

A: Well… it appears your engineer is reading the Life Safety Code wrong. When you want to learn what the Life Safety Code requires pertaining to any subject, you start with the occupancy chapter first, not the core chapters (chapters 1 – 11). Section 19.3.6.3.2 of the 2012 LSC says corridor walls in healthcare occupancies are ½-hour fire-rated and extend from the floor to the deck above. However, in smoke compartments that are protected throughout with approved sprinklers, the corridor walls are permitted to be non-fire-rated, but only resist the passage of smoke and extend from the floor to the ceiling provided the ceiling also resists the passage of smoke.

And according to section 19.3.6.3, doors in corridor walls in healthcare occupancies are only required to resist the passage of smoke, be 1¾-inches thick, solid bonded, wood core, or made of materials that resists fire for a minimum of 20 minutes. This does not mean the door has to be 20-minute rated… just constructed to resist fire for a minimum of 20-minutes.

According to section 4.4.2.3, whenever there is a conflict between the occupancy chapters and the core chapters, the information in the occupancy chapter governs. The information your engineer saw in Table 8.3.4.2 is general information and applies to all occupancies. However, the existing healthcare occupancy chapter differs with information in Table 8.3.4.2, which means the information in the occupancy chapter governs.

I don’t see what you are referring to regarding 19.3.6.3.2. It does not say doors have to be 20-minute rated. It says doors do not have to be 1¾-inches thick, solid bonded, wood core, and resists fire for 20-minutes for certain areas such as toilets rooms, bathrooms, and shower rooms. It is giving you a break for being an existing healthcare occupancy. In some very old hospitals, they installed doors that were not 1¾-inches thick, and this section is permitting them to remain.

And section 19.3.6.2.4 is stating what I’ve already mentioned: Corridor walls in smoke compartments that are fully protected with sprinklers are permitted to be non-fire-rated smoke resistant partitions that extend from the floor to the ceiling, provided the ceiling also resists the passage of smoke.

Fire-Rated Doors in Fire-Rated Barriers?

Q: If the health care facility is fully sprinklered do doors in a corridor, where the walls are fire rated, do the doors have to be fire rated? I read in NFPA 101 that they do not….

A: Where do you read that…? I would like to know what you’re reading to be able to provide you with a better answer.

Generally speaking, where you have a fire-rated barrier, you usually need to have fire-rated doors in openings in the fire-rated barriers. But there are some exceptions:

  • Fire-rated barriers that separate an atrium from the rest of the facility are not required to have fire-rated doors.
  • Corridor walls in existing healthcare occupancies located in a smoke compartment that is not fully sprinklered, are required to be 30-minute fire-rated and the corridor doors are permitted to be non-fire-rated, but must limit the passage of smoke.
  • Some building codes that require fire-rated corridor walls do not require fire-rated doors in the openings. But this is not a LSC issue.
  • Smoke barriers that separate smoke compartments are required to be rated (1-hour for new construction) but doors in smoke barriers are not required to be fire-rated.

 

Marked Fire/Smoke Doors

Q: We are reviewing fire policy, and are wondering if it is a Life Safety Code requirement to have fire and smoke barrier doors labeled as such? By this I mean a sign or sticker on the face of the door stating: “smoke barrier” or “fire barrier”?

A: No… there is no Life Safety Code requirement to post signage on smoke barrier doors or fire-rated door assemblies, identifying them as such. I do not see any CMS or Accreditation Organization requirement to do so, either. However, it’s not a bad idea as long as the signage meets the limitation of NFPA 80 for fire-rated door assemblies. I have seen hospitals identify their smoke barrier doors, that helps their staff be aware of the smoke compartment locations. I think that works well for many organizations. Please check with your state and local authorities to determine if they have any requirements.

 

Strange Observations – Signs on Fire-Rated Doors

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

Doors to medical gas storage rooms are required to be fire-rated.

Fire-rated doors cannot have signs applied that cover more than 5% of the total surface of the door.

A sign that does not exceed 5% surface of the fire-rated door is approximately 8.5″ x 11″. This door has signs that exceed the 5% surface amount.

Also, the signs cannot be attached to the door using screws or nails, but must use adhesive.

Home-Made Bumpers on Doors

Q: We have metal “bumpers” (for lack of a better term) that were fabricated onsite at our hospital, that are used to keep carts and beds for damaging the doors. These bumpers are installed on fire-rated door assemblies and protrude out past the push pad of the horizontal crash bar on the door. Are these bumpers allowed?

A: No… According to NFPA 80- 2010, section 4.6.1, all devices mounted to a fire-rated door assembly must be listed by an independent laboratory (i.e. UL, Intertek, FM Approval) for use on a fire-rated door assembly. Home-made devices are not permitted. Also, the bumpers may stick out more than the maximum 7 inches allowed by section 7.2.1.4.3.1 of the 2012 LSC, when the door is fully opened.

Fire Pins

Q: I have a concern regarding the use of fire pins in fire rated door leaves: Since the latching feature of these devices is not testable (that I’m aware of, anyway), and as these doors are prone to abuse and sometimes require adjustment for clearance issues and so forth, how do we ensure the alignment of the fire pin assembly when adjustments are made or even during normal expansion/contraction due to temperature/humidity changes?

(The reply for this question comes from Lori Greene, Manager of Codes & Resources at Allegion. Visit Lori’s website on doors and hardware at www.idighardware.com)

 A: You’re right – there’s no way to test the pin.  But the pin and the hole that it will project into (typically filled with a plastic cap) should be visible on the door edge so you can ensure that they’re aligned.  On most pins there is a fair amount of tolerance so the alignment doesn’t have to be perfect.  Since the pins operate only when there’s a fire, and only when the temperature reaches >1000 degrees in the vicinity of the door (approx. 450 degrees at the pin), only a very small percentage of the pins will ever be activated.  The pin doesn’t have much of an impact on life safety – by the time the pin projects, it’s mostly about compartmentalizing the building and protecting property.

Aluminum Astragals

Q: We used our recently updated Life Safety drawings to have our fire doors inspected. The inspector cited us for aluminum astragals on 13 doors. His report stated that they should be changed to steel. My boss asked me to confirm that this is fact. What are your thoughts?

A: The inspector may know something… All hardware installed on fire-rated door assemblies must be listed for use on fire-rated door assemblies, and this includes astragals. Do you have the specification sheets for the astragals that you installed? If not, can you obtain them?

Look on the specification sheets for anything that says the astragals are listed by an independent testing laboratory (UL, Intertek, ETL, etc.) for use on fire-rated door assemblies. If you find that they are listed for use on fire-rated door assemblies, then you are good to go. Photo-copy that information and send it to the inspector for his/her review.

If the specification sheets do not say the astragals are listed for use on fire-rated door assemblies, then the inspector is correct and you would have to remove them. The issue is not whether they are made with steel or aluminum, but whether they are listed for use on fire-rated door assemblies. Perhaps the inspector believes that aluminum astragals are not listed…?