Fire Watch

Q: With regards to a fire watch, the code is specific about requiring one in an occupied building when a fire alarm system or suppression system is out of service for a prescribed period of time. This makes sense for head end shutdowns and other scenarios where entire buildings or significant portions of buildings are impacted. My question is what if you are only taking part of a “system” down? Meaning a small renovation that impairs 3 heads in a room because the ceiling grid and tile are removed for greater than 10 hours. This is not a “system”, only a part of one. Where does an AHJ draw the line? Is it possible that our ILSM and Fire Impairment Policy could allow for a certain number of heads, certain square footage or percentage of a smoke compartment to be impaired without the fire watch requirement (given that other ILSMs are in place)?

A: While the interpretation is not written down as to how many impaired sprinkler heads constitute a system, it is generally understood more than 2. While that number may fluctuate between surveyors, it would be fair to say all of the sprinkler heads inside one room that are impaired would require a fire watch. The logic is, if a fire started in the room, there is no fire suppression device to extinguish the fire if all the heads were impaired. Does not matter if the room only has 3 sprinkler heads.

To be sure, you should obtain a decision directly from your accreditation organization. But even then, the CMS state agency may not agree with what your AO says. It is best to be conservative and conduct the Fire Watch as long as the sprinkler heads are impaired. Besides, how long does it take to install upright heads within 12 inches of the deck in this room?

ILSM for Fire Alarm System in Test Mode

Q: If we put the fire alarm system in test by-pass but we are still monitoring the alarms so we can troubleshoot or test the system so we avoid nuisance FA activation do we need an ILSM (Fire watch)?

A: Well… How long do you have it in test mode? More than 4 hours? If so, then I can see where an ILSM assessment is required, but the assessment would identify that the fire alarm system is impaired since it is in test mode, but you have a Fire Watch in effect because you would have someone at the panel constantly until the panel is off test mode.

So… an ILSM assessment would be required after you reach the 4-hour mark, but the assessment should identify that you are doing a Fire Watch my posting a responsible individual at the panel.

Sounds like a paper documentation issue, as you are already doing the Fire Watch.

Smoke Detectors During Construction

Q: We are seeking to eliminate accidental activation of existing smoke heads in healthcare spaces that are taken over for renovation/construction work while maintaining fire protection coverage in the space that does not involve the use of a fire watch. We are looking at multiple sensor detectors, but the initial comment we received from our vendor is that they are sometimes triggered by dust. In your opinion, would changing the smoke detectors to heat detectors be an acceptable solution in a construction space? If the space has an active sprinkler system, in your opinion, would it be acceptable to simply remove these smoke heads? Any thoughts you can provide would be greatly appreciated.

A: Changing the smokes to heats is not an acceptable solution to prevent a fire watch, because heats do not sense the presence of smoke. But perhaps you are making this more difficult than it has to be. The code only requires a fire watch for required fire alarm devices that are impaired. Are the smoke detectors in the construction area required? If so, then you need to do the fire watch if you remove the detectors, or suffer through many false alarms.

But if they are not required devices, then you can remove the smoke detectors and not have to do a fire watch. Section of the 2012 LSC specifically says a fire watch is for required fire alarm systems out of service.

One may be surprised to learn that in the typical hospital, there are very few locations that a smoke detector is required to be installed:

  • In areas open to the corridor as described in section of the 2012 LSC
  • In areas containing fire alarm control panels (including NAC panels) that are not continuously occupied as described in of the 2012 LSC
  • Near doors that are held open that must close on a fire alarm activation as described in NFPA 72-2010, section
  • Elevator recall for fire-fighter’s service as described in NFPA 72-2010, section 21.3

There are other situations where smoke detectors may be required, but those requirements are stipulated on optional design factors, such as on-call sleeping rooms, specialized protective measure locks, and equivalencies.

Therefore, if you have smoke detectors in an area that is under construction, and these smoke detectors are not required, then you may remove the detectors without having to perform a fire watch.

Fire Watch

Q: Your recent answer regarding fire watches left me confused and requesting the clarification that follows. Your answer seems to imply that a fire watch is required anytime the sprinkler system is impaired within the construction space. The last sentence notes that the fire watch does not affect the rated barrier (because just having a fire watch does not eliminate the need for the 1-hour barrier where sprinklers are impaired). However, it seems to me that the original question posed is whether the 1-hour barrier eliminates the need for the fire watch. My understanding previously is that if the construction space is separated by a 1-hour barrier then a fire watch is not required. Is my understanding incorrect? Does the use of a 2-hour rated barrier change any of these requirements?

A: Sorry. No, your understanding is not correct. The need to conduct a fire watch is based on whether or not the required fire alarm system is impaired (see section of the 2012 LSC) or the required sprinkler system is impaired (see section 15.5.2 (4) of NFPA 25-2011). It has nothing to do with the level of fire-rating on the temporary construction barriers. Increasing the temporary construction barrier to a 2-hour rating does not change the need to conduct a fire watch.

Is a Fire Watch Necessary?

Q: We have a complete gut renovation project that consist of two buildings (Admin. Bldg. & Lab Bldg.). The buildings are connected in all three levels and will be unoccupied. Both buildings are connected on the first level only to the adjacent occupied building. A one-hour barrier will be built to separate the occupied building from the construction areas. Is a fire watch required once the sprinklers system and fire alarm system is demolished?

A: According to section, whenever a required fire alarm system is out of service for 4 or more hours in a 24-hour period, you are required to do the following:

  • The AHJ must be notified. Don’t forget to notify your state AHJ, your insurance company AHJ, as well as your local AHJ. There is no need to notify your accreditation AHJ.
  • The building must be evacuated, or an approved fire watch must be conducted. An approved fire watch consists of a designated, trained individual who has no other responsibilities, continuously patrols the entire area affected by the outage looking for signs of fire and potential situations where fire could start, and has the ability to communicate to call the local fire responders in case of fire. This individual cannot leave the impaired area until the fire watch is discontinued or is relieved by another designated, trained individual.

So, you are saying these buildings will be unoccupied, so it appears you do not have to conduct a fire watch for the impaired fire alarm system, provided you have a 2-hour fire-rated barrier separating the unoccupied building and the occupied building. But let’s look at NFPA 25-2011, section 15.5.2 which says this about sprinkler impairments: Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:

  1. The extent and expected duration of the impairment have been determined;
  2. The areas or buildings involved have been inspected and the increased risks determined;
  3. Recommendations have been submitted to management or the property owner or designated representative;
  4. Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for: A) Evacuation of the building or portion of the building affected by the system out of service; B) An approved fire watch, which must be the same as the approved fire watch described above; C) Establishment of a temporary water supply; D) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire;
  5. The fire department has been notified;
  6. The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified;
  7. The supervisors in the areas to be affected have been notified;
  8. A tag impairment system has been implemented;
  9. All necessary tools and materials have been assembled on the impairment site.

So, again since you have an unoccupied building, it appears to me that you do not have to conduct a fire watch for an impaired sprinkler system, provided you have a 2-hour fire-rated barrier separating the unoccupied building and the occupied building. Item #4 above clearly states a fire watch is not required if you have evacuated the building.

Fire Watch Guidance

Q: We are looking for guidance now that the language of “If a fire watch is required, fire/smoke detection or alarm system outage” has become a point of conversation with our local and state Fire Marshals. We can’t seem to get a straightforward answer from them as to when exactly we need to implement a fire watch. For large projects, we will definitely be bringing in a contractor to install upright heads. Our question is related to the small, 1-2 day projects that may only have 1-2 heads without a ceiling barrier, making them non-compliant. Would this scenario, in your eyes, require a fire watch assuming no upright head installation? We struggle with the feasibility of both situations: implementing a continuous fire watch and also bringing in a contractor for just a couple of heads for one or two days.

A: Let’s take our guidance from section of the 2012 Life Safety Code, which says where a required fire alarm system is out of service for more than 4 hours in a 24 hour period, then an approved fire watch must be conducted. Now, if we go to the Annex section A. it says the term ‘out of service’ is intended to imply a significant portion of the fire alarm system is not in operation, such as an entire initiating device circuit, signaling line circuit, or notification appliance circuit. It is not the intent to require a fire watch for a single non-operating device or appliance.

Now, I know that is for fire alarm systems and your question was specific towards sprinkler impairments, but the problem is beginning with the 2012 LSC, the LSC discontinued to have a standard on sprinkler system impairments, but in turn referenced NFPA 25-2011. So, we go to section 15.5.2 (4) through (6) for guidance. This section basically says whenever the sprinkler system is out of service for more than 10 hours in a 24 hour period, then you do a fire watch, contact the fire department, and notify the insurance carrier and the state AHJ. But in this case, the Annex section does not offer any explanatory information as what constitutes ‘out of service’ like the Annex section in the LSC does for fir alarm systems.

So, this means the AHJ gets to decide what ‘out of service’ means. I know that CMS and the accreditation organizations interpret it to mean a circuit or zone has to be out of service before a fire watch is required, and a single device impaired does not warrant a fire watch. But in your case, you’ve asked your state AHJ to explain their position and so far they have not.

I suggest you decide for yourself, since your AHJ refuses to make a decision. Write a policy that states a single device out of service does not warrant a fire watch, but rather a zone or circuit that is impaired does, and reference Annex section A. of the 2012 LSC as a guidance.

If the AHJ won’t help you by informing you what they expect, then you do the next best thing and decide for yourself based on referenced standards.

Sprinklers in Construction Areas

Q: My question is about removing ceiling tiles in a construction area, and not having adequate fire protection in a 6′ to 8′ high ceiling plenum. The suggestion had been made to turn the sprinkler heads up, but the water spray still will not reach 12 inches below the deck since the deck is very high. What would be considered an adequate solution besides erecting fire rated walls surrounding a construction area? Also, where in NFPA 13 does it mention the requirement for 12 inches below deck, and is there is a requirement to turn the existing sprinkler heads up?

A: NFPA 13-2010, section says the distance between the sprinkler deflector and the ceiling above must be based on the type of sprinkler and the type of construction. Section of the same standard says for standard pendant and upright type sprinklers, the minimum distance is 1 inch and the maximum distance is 12 inches between the sprinkler deflector and the ceiling. In your case, when the suspended grid and acoustical tile ceiling is removed for construction, the deck above now becomes the ceiling. If you have 6 feet of interstitial space above the suspended ceiling, that is more than 12 inches so the piping needs to extend upwards so the sprinkler deflector are within 12 inches of the deck. Make sure you install upright sprinklers… you cannot use pendant sprinklers in an upright position. There are exceptions and added requirements for ductwork, piping and ceiling-mounted obstructions.

The requirement to provide sprinkler fire-protection during a construction project comes from the NFPA 241-2009 standard on demolition and construction, required by of the 2012 Life Safety Code. If your construction project is not protected with sprinklers during the construction phase, then you must construct 1-hour fire-rated barriers between the construction project and the occupied areas of the facility. A fire-rated barrier that is 1-hour is typically steel studs with one layer of 5/8 gypsum board on each side with all seams taped and covered with joint compound, and any openings would have to be 45-minute fire-rated door assemblies with closer and positive latching hardware. If the construction area is protected with sprinklers, then the barrier is not required to be 1-hour fire-rated, but construction tarps and flame-retardant plastic sheeting would not be permitted. Actual non-rated walls would be required.

Also, if an area of the healthcare facility is already protected with sprinklers, and the area is undergoing construction/remodeling that requires the removal of the suspended grid and acoustical tile ceiling, then a fire watch is required to be enacted until such time the sprinklers are no longer impaired. A fire watch is now based on the CMS Final Rule published on May 4, 2016. A fire watch must be performed by a trained individual who has no other duties to continuously patrol the impaired area looking for unsafe fire conditions, and must have the ability to immediately contact the fire department if they spot a fire. Continuous means this person is in the impaired area and does not leave to use the restroom, take a break or for any other reason. This is based on NFPA 25-2011, section A.15.2(4)(b). This goes on for 24-hours a day until the sprinklers are back in service. Even if you used minimum-wage individuals that would cost the hospital $3,500 to $4,000 per week, because you would need 5 individuals. This money could be better used to either turn sprinklers up to within 12 inches of the deck, or install sprinklers at the beginning of the project.

Sprinklers in Construction Areas

Q: We have a construction project in our cafeteria. We have an ILSM and additional measures in place. However, it was determined last week that we need to remove the sprinklers in the area for eight weeks. The construction is located on the lowest level and is unoccupied with no patient care in the area (but there’s patient care in the building). With the sprinklers out of service 24 hours a day, is a fire watch required? We also are looking at using 1 hour barriers and 3/4 hour doors during that time. Do the barriers change anything with a fire watch? Thank you

A: Can’t you re-install temporary sprinklers in this construction area for the duration of the project? You will need to turn the sprinkler lines upward to within 12 inches of the deck and install upright sprinklers. It is imperative that you have sprinkler protection, otherwise you will need to conduct a fire watch, continuously for the 8 weeks there are no sprinklers.

Yes… a fire watch is required because you have impaired sprinklers. It doesn’t matter where the impaired sprinklers are located… if you have impaired sprinklers, you must do a fire watch. NFPA 25-2011 section 15.5(4) says where the sprinkler system is out of service for more than 10 hours in a 24-hour period, you need to conduct a fire watch. CMS has said in their Final Rule to adopt the 2012 Life Safety Code published May 4, 2016, that a fire watch is conducted continuously, without interruption. The designated individual who performs no other function, continuously walks the impaired area looking for fire and the potential for a fire to occur, without leaving the area. This means the individual may not leave the impaired area to use the restroom, take a lunch break or any other function unless he is relieved by someone else.

This ‘continuous’ fire watch must be conducted for the duration that the sprinklers are impaired … 8 weeks. Can you afford to have that many FTEs designated to do nothing else but a fire watch for 8 weeks? I would believe it would be less expensive if you would turn up the sprinklers and install upright sprinkler heads in the construction area.

The fire watch does not affect the rated barrier, but the 1-hour fire rated barrier is required to separate the construction area from the occupied area if there are no sprinklers in the construction area.

Fire Watch Requirement

Q: When the code refers to a fire alarm system or sprinkler system being off-line for four or more hours in a 24 hour period (fire watch and fire department notification), does the entire system have to be off-line or just a portion to invoke the notification requirement?

A: The NFPA standards do not specifically address this issue, but I have seen The Joint Commission address this in one of their many publications, many years ago. I believe it was the EC News.

Essentially, the answer is no… the entire system does not have to be out of service before it qualifies for the fire watch and notification of the local fire department. Joint Commission said (and I’m paraphrasing here) that a single device out of service does not constitute the need for the fire watch and fire department notification, but an individual circuit or branch would. Many hospitals towers have two sprinkler zones per floor. If one of those zones were out of service for repairs for 4 or more hours in a 24 hour period, then a fire watch and fire department notification would be required.

Other AHJs have taken on the same interpretation as well.

Walking Surfaces

Walking surfaces in the means of egress are required to be even. This is one situation in the NFPA codes and standards where they clearly defined what ‘even walking’ surface actually is required to be. Take a look at section of the 2000 edition of the Life Safety Code, which says:

Abrupt changes in elevation of walking surfaces shall not exceed 1/4 inch. Changes in elevation exceeding 1/4 inch but not exceeding 1/2 inch shall be beveled 1 to 2. Changes in elevation exceeding 1/2 inch shall be considered a change in level and shall be subject to the requirements of 7.1.7.


Section 7.1.7 defines the walking surface for a ramp not to exceed 1 and 20 slope.

So, it is pretty clear that the LSC does not want abrupt changes in the walking surface to exceed 1/4 inch or 1/2 inch if it is beveled. This is logical as most people only lift their feet the minimum amount to walk safely through the path of egress. I remember a maintenance man in the hospital where I worked who ‘shuffled’ his feet as he walked, never really lifting his shoes. This eventually caught up to him as one time he caught the leading edge of his shoe on the transition where the  PVC floor tile met the concrete floor, and down he went. The edge of the PVC floor tile was 1/8 inch above the concrete floor, which by section definition, met the requirements of the LSC. But unfortunately, that 1/8 inch was enough to trip this poor individual, and cause him to fall.

In the picture above, the very nice throw rug was measured to be about 3/4 inch thick, which exceeds the limitations of Not knowing whose office the rug was located in, I informed the staff that it was a violation and needed to be removed. I found out later that the office belonged to the Chief Nurse Officer of the hospitals and she was very upset to learn that her rug was not permitted.

The picture to the left shows a more common problem. The exit is an emergency fire exit and is not used as an entrance into the hospital, which is quite common. While there is no NFPA standard that says the exit discharge (the path from the exit door to the public way) is required to be paved with concrete, crushed stone, bricks or asphalt, we revert back to section which requires a level walking surface in the means of egress. Make no doubt about it, the means of egress includes not only corridors, but aisles in rooms, and the discharge from the exit.

The common position by most (if not all) AHJs who inspect hospitals is the grassy walkway shown in this picture, between the exit door and the public way does not qualify with section for abrupt changes no more than 1/4 inch. Therefore, an improved level walking surface is required between the exit door and the public way, which is usually poured concrete. Another factor about grassy walking surfaces in the cold weather states is the lack of snow and ice removal during the winter time. With a concrete walkway, the path is likely to be cleared of snow and ice, but without a designated path, it is not as likley that the snow and ice would be removed.