Penetrations in a Smoke Compartment Barrier

Q: In an EXISTING hospital, when the corridor walls are ALSO a smoke compartment barrier, can the penetrations above the ceiling be sealed with a non-rated sealant or are they required to be treated the same way as a 1-hour rated wall?  Please advise.

A: All smoke compartment barriers need to have penetrations sealed with proper fire-rated materials designed for use on fire-rated walls. The reason for this is, while the smoke barrier is not a fire-rated barrier because the doors in the smoke barrier are non-fire-rated, the actual wall that makes up the smoke barrier is a fire-rated wall (1-hour for new construction and 30-minutes for existing construction… see 18.3.7.3 and 19.3.7.3 in the 2012 LSC). Since the actual wall of the smoke barrier is required to be fire-rated, all penetrations in that wall need to be sealed using approved fire-rated materials.

Even though section 8.5.6.2 of the 2012 LSC implies that non-rated materials are permitted to seal penetrations in smoke barriers, the occupancy chapters for Healthcare Occupancies over-rides that and requires fire-rated materials for sealing penetrations in a smoke barrier, since they require fire-rated barriers for smoke barriers.

You may be thinking about smoke resistant partitions (such as corridor walls or walls separating an existing hazardous area protected with sprinklers), that are not required to be fire-rated. Those walls may have penetrations sealed with non-fire-rated materials.

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.

Fire Rated Barriers vs. Smoke Barriers

Q: Are doors in fire rated barriers also required to be listed and installed as a smoke barrier?

A: No… Fire rated barriers are not necessarily smoke barriers. They are two distinctly different barriers with different purposes. Now, if an organization wanted to combine the two purposes into one barrier, then that is acceptable as long as you meet the most restrictive requirements of each type of barrier. A fire-rated barrier requires fire-rated opening protectives (i.e. doors, windows). Fire rated door assemblies are required to have fire-rated doors and frames, self-closing devices, and positive latching. A fire rated barrier that is rated at 2-hours or greater must have fire dampers in any HVAC ductwork that penetrates that barrier.

A new construction smoke barrier is required to have walls constructed to 1-hour rating, but the doors and frames in the smoke barrier are not required to fire-rated. The doors are only required to be 1¾ inch thick, solid bonded, wood-core doors, or be of construction that resists fire for 20 minutes. Please understand that this does not mean the door has to be 20 minute rated; only be of construction that resists fire for 20 minutes. The door has to be self-closing but is not required to be positive latching. HVAC ductwork penetrating a smoke barrier must have smoke dampers, unless both sides of the smoke compartment barrier are protected with sprinklers. However, please understand this is an NFPA exception and the IBC does not recognize that, so your state or local authorities may not allow a smoke barrier without smoke dampers in the HVAC ductwork.

So, technically, a combination fire-rated barrier and a smoke barrier could be the same wall, but the requirements for both barriers need to be included.

Smoke Barrier Doors

Q: Are smoke barrier doors and frames required to have a fire rating label?

A: No. This seems to be a difficult issue for many people (including surveyors) to grasp. According to section 19.3.7.6 of the 2012 LSC, doors in smoke barriers are required to be 1¾ inch thick, solid-bonded, wood-core doors, or be of construction that resists fire for at least 20 minutes. This does not mean the door and frame must be a fire-rated door. It only means the door must be of construction that resists fire for at least 20 minutes.

The confusion surrounding this issue may be found in section 8.3.4.2 of the 2012 LSC, which says doors in smoke barriers must have a fire rating of not less than 20 minutes. But whenever there is a conflict between the core chapters (chapters 1 – 11) and the occupancy chapters (chapters 12 – 42), the requirements of the occupancy chapter over-rides the requirements of the core chapter (see section 4.4.2.3). In other words; the occupancy chapter trumps the core chapters.

Section 19.3.7.8 of the 2012 LSC continues to say that doors in smoke barriers are not required to be positive latching That alone should be the tell-tale sign that the door is not required to be a fire-rated door since all fire rated doors must be positive latching (according to NFPA 80).

Some architects do specify 20-minute fire rated doors in smoke barriers, and while this practice is not a violation of the LSC, it does present a burden on the healthcare facility because now they have to maintain it as a fire rated door, even though it is not required to be a fire rated door. This causes more headaches because the 2012 LSC references the 2010 edition of NFPA 80 which will require an annual inspection of all side-hinged swinging fire doors.

Are Smoke Barrier Doors Required to be Inspected in Hospitals?

Q: Do doors in smoke barriers in healthcare occupancies have to be tested and inspected? Section 7.2.1.15.2 of the 2012 Life Safety Code says smoke door assemblies have to be inspected and tested in accordance with NFPA 105.

A: Well, the answer is no… Smoke barrier doors that are non-rated are not required to be inspected annually in healthcare occupancies, even though 7.2.1.15.2 says they do. Here’s why:

  • Section 19.3.7.8 says doors in smoke barriers shall comply with 8.5.4 and all of the following: 1) Doors shall be self-closing; 2) Latching hardware is not required; and 3) The doors do not have to swing in direction of travel.
  • Section 8.5.4.2 says where required by chapters 11 through 43, doors in smoke barriers that are required to be smoke leakage-rated shall comply with section 8.2.2.4. [NOTE: Chapters 18 & 19 for healthcare occupancies do not require smoke leakage-rated doors in smoke barriers…. Therefore, compliance with section 8.2.2.4 is not required.]
  • Section 8.2.2.4(4) says where door assemblies are required elsewhere in the Code to be smoke leakage-rated, door assemblies shall be inspected in accordance with 7.2.1.15.

CONCLUSION: Since the healthcare occupancy chapters do not require smoke barrier doors to be smoke leakage-rated, then there is no requirement to be compliant with 7.2.1.15.2 that says the smoke doors need to be inspected.

Section 4.4.2.3 says where specific requirements contained in chapters 11 through 43 differ from general requirements contained in chapters 1 through 4 and from chapter 6 through 10, then the requirements of chapters 11 through 43 govern. Since the healthcare chapters do not require smoke barrier doors to be smoke leakage-rated, then it conflicts with section 7.2.1.1.5.2, and when that happens, you follow the occupancy chapter requirements.

The problem is… not all authorities having jurisdictions (AHJs) knew this or understood this. Case in point: The Centers for Medicare & Medicaid Services (CMS) had instructed their state agency Life Safety surveyors that all smoke doors in healthcare occupancies need to be tested and inspected, citing section 7.2.1.15.2.

In addition, CMS also taught their LS surveyors that doors in healthcare occupancies that meet the requirements of 7.2.1.15.1 have to be tested as well, which is not entirely true. These doors identified in 7.2.1.15.1 only have to be tested in assembly occupancies, educational occupancies, or residential board & care occupancies. The exception is, some hospitals have mixed occupancies that include the requirements for assembly occupancies, so in those cases, yes, the doors in 7.2.1.15.1 would have to be tested and inspected on an annual basis.

But on July 28, 2017, CMS issued S&C memo 17-38 which corrected this error. In this memo, CMS says smoke barrier doors do not have to be tested in healthcare occupancies. So, they saw an inconsistency with the 2012 Life Safety Code, and corrected their position. They even admitted some confusion on their part regarding door testing in general and decided to extend the date that the first fire door test is due from July 5, 2017 to January 1, 2018. But be careful with that: Not all AHJs are moving the date that the first fire door test is required.

You can expect a similar announcement from Joint Commission, if it hasn’t happened already. I’ve been told they will changed their standards to reflect what CMS has said.