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.

 

Door Lever Hardware

Q: Is there a Life Safety Code requirement for door lever hardware to have a return, so as to not “hook” passing clothing, straps, purses during emergency evacuations? I swear I remember this for healthcare occupancies from somewhere, but can no longer find it in the Life Safety Code.

A: No, the 2012 Life Safety Code does not require a return on door lever handles to prevent hooking clothing during egress. But my good friend Lori Greene (www.idighardware.com) tells me the return is only required by the California Referenced Standards Code, which says: Levers.  The lever of lever-actuated levers or locks shall be curved with a return to within 1/2″ of the face of the door to prevent catching on the clothing of persons during egress. Since this is not a requirement of the NFPA or ICC codes or standards, it would only apply in California.

Closet Doors

Q: Are closet doors located inside a corridor considered corridor doors and do they have to meet life and safety codes referring to corridor doors?

A: It depends…. What does your Life Safety drawings say?

Section 19.3.6.3 of the 2012 LSC requires doors in the corridor to be positive latching. If the closet door is in the corridor wall then it must be positive latching. However, there may be a possibility that the corridor wall could run behind the closet, provided the back of the closet wall meets the requirements of 19.3.6.2 for construction of corridor walls.

But your Life Safety drawings need to specifically identify that the corridor wall runs behind the closet. If they do not, then the surveyor has no choice but to hold your closet doors compliant to 19.3.6.3 for positive latching corridor doors.

Strange Observations -Disabled Latches

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

Boy… I bet you’ve never had this problem at your facility, eh?

[Sarcasm]

This is why you need to do frequent rounds (i.e. weekly, if needed) to spot these trends and nip it in the bud.

Healthcare staff will frequently tape over a latch on a door or on a strike on the frame to make it easier to gain access to a utility room.

Door Frames

Q: I had an independent Life Safety inspection and during the inspection the inspector cited me for my 2-hour fire door frames not having a fire rating visible. I explained that we went to a fire rated continuous hinge on these doors that covered the labels. He said that that was not enough, he needed to see a label. Should I remove each hinge and take a picture of the fire rating labels?

(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: This topic has come up before, and I asked some AHJs about it since the answer is not found in the codes and standards.  The consensus was that the label should be documented with photos before the hinges are installed – close-up photos to show what is written on the label, and wider photos to show the location of the door.

I’m sure it’s a pain to get this documentation now, but I think that’s the only way to do it for a retrofit situation unless you want to have the doors relabeled.  For new doors and frames, the labels can be applied in another location – on the frame head, and for the doors – either on top or on the lock edge.

Corridor Doors

Q: I have a healthcare occupancy under existing construction. The building was built back in the 50’s and 60’s, with a major renovation in 1992. The available plans have indicated the fire-rated walls and doors, but there are other doors not specifically designated as smoke doors or fire-rated doors. My question is, what doors would fall under the description of corridor doors? Would it be all doors that exit directly into the egress corridor? Some of these doors are to normally occupied offices, some are to patient rooms, and some are to conference rooms that are only occupied during meetings.

A: Corridor doors are those that separate the corridor from a room, suite, or area. They are not cross-corridor doors that separate a corridor from another corridor. Do not be fooled by a double set of doors, as they can be either corridor doors (an entrance to a room, or suite), or cross-corridor doors (smoke barrier doors, or privacy doors in a corridor).

Here is a summary of the Life Safety Code requirements for corridor doors:

  • Corridor doors must comply with section 19.3.6.3 of the 2012 LSC, and have certain requirements that they must meet, such as:
    • They must resist the passage of smoke (no holes in them)
    • They must be 1¾-inch thick, solid-bonded wood core
    • Constructed with materials that resist fire for a minimum of 20 minutes (NOTE: This does not mean the corridor doors must be 20-minute fire rated).
  • Corridor doors to toilet rooms, bathrooms, shower rooms, sink closets and similar auxiliary spaces that do not contain flammable or combustible materials are not required to comply with the above requirements.
  • In smoke compartments protected throughout by automatic sprinklers the corridor door construction requirements listed above are not mandatory, but the corridor doors must resist the passage of smoke (no holes).
  • Corridor doors are not required to meet the NFPA 80 standards for fire-rated door assemblies, unless the door also serves a fire-rated barrier.
  • The clearance between the bottom of the corridor door and the floor (i.e. undercuts) must not exceed 1 inch.
  • The corridor doors must have positive latching hardware.
  • Corridor doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials are not required to have positive latching hardware.

You will notice section 19.3.6.3 does not say anything about self-closing devices for corridor doors, because they are not required on corridor doors, unless the corridor serves another purpose, such as a smoke barrier, horizontal exit, or hazardous area.

Check with your state and local authorities before you make any modifications, to determine if they have other regulations or requirements regarding corridor doors.

Window Frame Rating

Q: Can you verify what a window frame rating should be in a 1-hr load bearing wall? Does the frame need to maintain the 1-hr rating of the wall or can it be 45-minutes? This window is in a load bearing wall that separates a corridor from an office.

A: Since windows are openings in fire-rated barriers, I turn to NFPA 80-2010, section 17.1.3 on window frames. This section says fire window frame assemblies must be permanently labeled for such use. The Annex section of A.17.1.3 says the labeled assembly includes the frame and can include a ventilator, glazing material, retaining members, mullions, and hardware, if applicable.

The label reading ‘Fire Window Frame’ includes the design and construction of the frame, ventilator, glazing material retaining numbers, and hardware. Table 8.3.4.2 of the 2012 Life Safety Code provides the minimum fire protection ratings for opening protectives in fire-rated barriers. According to “Exit Access Corridors” on this table, fire window assemblies in 1-hour corridor walls are permitted to be ¾ hour fire rated. So the frame would also be ¾ hour rated.

Fire Rated Door Assemblies

Q: You have stated in previous Q&As that all fire-rated door assemblies must be tested and inspected. I don’t think that is true on fire-rated door assemblies that are not located in a fire-rated barrier. I was under the impression that the hospital’s current Life Safety drawings would be the determining factor on what barriers the hospital was responsible for maintaining. For example, if the building had rated doors on a wall that was not denoted as a fire rated barrier on the LS drawings, one could justify why there were not maintained. I run into the installation of unnecessary rated doors in many facilities, both old and new.

A: You make an interesting case. However, the Life Safety Code always trumps everything else, and in this case it would trump the hospital’s LS drawings. According to section 4.6.12.3 of the 2012 LSC, it clearly says all existing features of life safety that are obvious to the public, if not required by the LSC, must be maintained or removed. And section 8.3.3.1 says openings (i.e. doors) required to have fire protection must be maintained in accordance with NFPA 80 which requires annual testing and inspection.

Now, there’s a lot going on with this statement… For example: NFPA has said via informal comments that a fire-rated label on the edge of the door is not considered ‘obvious to the public’. But other AHJs disagree, and have stated that the fire-rating label on the door constitutes the need to maintain it as a fire-rated door. Most surveyors will go by the fire-rating label on the door, since a high percentage of Life Safety drawings are inaccurate to some degree.

I don’t disagree with your logic. If it were up to me, I would not require fire-rated doors that are not in fire-rated barriers to require testing and inspections. But think of it the way a surveyor does… Who is to say the fire-rated doors are not located in a fire-rated barrier? Just because the Life Safety drawings say it is not in a fire-rate barrier, what about building code requirements? Life Safety drawings do not always represent the rated wall requirements of building codes. There is too much ambiguity for a surveyor to take the word of the hospital that a certain fire-rated door is not located in a fire-rated  barrier.

My advice is to remove the fire-rated label from the door and frame if the facility is sure the door assembly is not located in a fire-rated barrier.

Med-Room Corridor Door

Q: As I understand the Life Safety Code, doors opening from a patient floor corridor into a patient room do not have to latch. I have a room next to a patient room that we call a support room. It contains meds, a sink and an ice machine and has to be secured. It is not a rated opening, has a closure and is secured with a mag lock and keypad and has two ways to egress when in the room. Is this a OK scenario?

A: No… that scenario is not correct. The room you described must have a door that separates it from the corridor, and the door must latch. Take a look at 19.3.6.1 of the 2012 Life Safety Code that says corridors must be separated from all other areas by partitions unless otherwise permitted by one of the nine (9) exceptions. The med room is not one of the nine exceptions. Therefore, according to 19.3.6.3.5, the door must latch. You say it is equipped with a magnetic lock. Keep in mind a magnetic lock is not an acceptable substitute for a latch. If installed in accordance with section 7.2.1.6.2 (access-control locks, having a motion sensor and a ‘Push to Exit’ button on the egress side), then the magnetic lock is permitted, but the door still needs to have a latch. CMS does not permit the allowance for existing doors to not have positive latching hardware provided a force of 5-lbs. is applied to the latch edge.

Whoever told you that patient room doors do not have to latch was wrong. Patient rooms are also required to be separated from the corridor according to 19.3.6.1, and have doors that must latch, according to 19.3.6.3.5.

Doors to Operating Rooms

Q: We have two open-heart OR’s. Each has a full 42″ wide door leaf that open to the corridor, and each has a 3’0″ door in the rear of the OR that opens into a central sterile core. The OR walls other than the corridor side are not labeled as a fire/smoke barrier on the life safety drawings. The main OR entrance door that opens into the corridor has a door closer, is rated, and has latching hardware. My question is: The 3′ 0″ doors opening into the sterile core have closers but do they have to be fitted with latching hardware?

A: Not necessarily, provided the sterile core area is qualifies as a room or a suite-of-rooms. What does the life safety drawings say about the sterile core area? Is it classified as a suite? If so, then you should be fine without a latching door between the OR and the sterile core area.

However, if the life safety drawings clearly identify the internal walls of the sterile core area as corridor walls, then the door between the OR and the sterile core area would have to latch. Remember: All corridor doors must latch.

My guess is, the sterile core area probably qualifies as a suite-of-rooms (see section 19.2.5.7 in the LSC) or if small enough, it may qualify as a simple room. As long as the 3’0” door from the OR does not open onto a corridor, then it does not need to latch.