Frequently Asked Questions

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Regarding the definition of Existing building, if a building was built in 2007, legally constructed and all building permits obtained, then the Life Safety Code was adopted in a manner that it applies to this building with an effective date of 2008, and then later the building was officially authorized on 2009, can we still say it is an Existing Building?

What is not clear is the last part of your statement, specifically “the building officially authorized in 2009.”

If you are referring to the fact that construction was authorized in 2007 but the building was not authorized to be occupied until 2009, in most instances the building would then be evaluated as an existing building based upon the Code that was adopted in 2008. The definition of “existing building” in NFPA 101 includes the phrase “legally authorized.” The Annex note indicates that the deciding factor in determining if a building is existing or not should be the date the plans were approved for construction. (See 3.3.28.5 and A.3.3.28.5, NFPA 101, 2006 Edition)

What occupant load do you use for waiting rooms in a health care occupancy?

The Life Safety Code does not provide a specific occupant load factor for waiting rooms/areas in health care occupancies. Instead, one is to use the assembly use factors. In this case the choice is typically between 15 sq ft/person for less concentrated use and 7 sq ft/person for concentrated use. The 15 sq ft/person factor is generally considered appropriate for seating at tables. The 7 sq ft/person factor is generally considered appropriate for rows of seats. The typical waiting room/area in a health care occupancy is probably somewhere between those two numbers. Therefore, since the Code also requires one to consider the actual number of people that are likely to be in the space, for most waiting rooms/areas an acceptable approach would generally be to start with 15sq ft/person and then also consider the actual number of people likely to be present in the space.

In some instances, fixed seating is provided and the Code would tell one to use the number of fixed seats. However, experience has shown that the actual occupant load could be higher than the number of seats based upon the presence of wheelchairs, strollers, etc. Therefore, when fixed seating is provided the number of seats should be considered along with the actual number of people that are likely to be in the space.

In all cases, the occupant load number to be used would be the higher of the numbers generated using fixed seating, an occupant load factor, or the actual number of people that are likely to be present.

We have between 300 to 1000 sprinklers in our building, and they are not all the same. Do we only need to stock a total of 12 sprinklers?

Yes, the minimum number of spare sprinklers required at a protected premise having 300-1000 sprinklers would be 12 (see 6.2.9.5, NFPA 13-2010 Edition). An Annex Note (A.6.2.9.1, NFPA 13-2010 Edition) recommends that a minimum of two sprinklers of each type and temperature rating used in the facility should be provided in the spare sprinkler cabinet. New to the 2010 Edition of NFPA 13, in addition to the spare sprinklers, one sprinkler wrench as specified by the sprinkler manufacturer shall be provided in the cabinet for each type of sprinkler installed to be used for the removal and installation of sprinklers in the system(6.2.9.6, NFPA 13-2010 Edition). This is to ensure that the proper tools are readily available on site to change and replace sprinkler heads as necessary. However, in many cases, one sprinkler wrench is suitable for many different sprinkler heads, and thus only one wrench would need to be included (A.6.2.9.6, NFPA 13-2010 Edition). Also, a list of the types of each of the sprinklers installed in the facility is required in the spare sprinkler cabinet (6.2.9.7, NFPA 13-2010 Edition). It would be reasonable to assume that the number of sprinklers of each type in the cabinet might be somewhat proportional to the number of sprinklers of each type installed in the facility. However, there may be some other considerations that might impact the distribution. For example, maybe a certain type of sprinkler is located in large open areas while another type of sprinkler is only installed in small rooms. As such, the number of sprinklers that may activate of each type could be substantially different. There may be certain environments in which sprinklers are installed that may result in more frequent replacement or a higher probability for the need for replacement. Neither NFPA 13 nor NFPA 25 (which has similar requirements) goes into this much detail but these factors may be considered when determining how many sprinklers of each type should be in the cabinet.

Does the 2000 Edition of the Life Safety Code® (LSC) permit the use of a monumental stair as a second stairwell in a Business Occupancy? The building in question is two stories and fully sprinkler protected. The first floor is 15,000 sq ft and the second floor is 12,000 sq ft. The monumental stair is completely open to the entire first floor. Paragraph 7.1.3.2 of the 2000 LSC requires an exit to be separated from other parts of the building and section 7.4 requires at least two means of egress from any story. Is the monumental stair open to the first floor not allowed as the second means of egress because it is not separated from the building by 1-hour construction?

The open monumental stair could be considered as a means of egress, but would not be considered an "exit" under the LSC. Section 39.2.4.2 requires two separate exits on each story of a Business Occupancy. If the monumental stair was open on the second story and enclosed on the first, it would be allowed as an existing "exit." In your case, there is an interesting anomaly in the Code. If this stair was enclosed in 1-hour fire-resistive construction with 1-hr rated labeled fire door assemblies, it could be an exit and it would be allowed to discharge onto the first floor (with restrictions - See 7.2.2). There are exceptions that do allow a single exit in certain business occupancies, but they are limited to a travel distance of less than 100 ft, including travel within the exit itself and do not appear applicable to this building.

Where is the main drain testing suppose to be conducted and what is the purpose of the test? I understand that by comparing the resulting pressures each year would reveal blockages, valve closures, or other issues in the supply line. We do NOT have a tank for our site, we are directly connected to the city into the building and then a backflow preventer is installed on that pipe to prevent backflow, then this pipeline travels into the fire pump room. The system risers are then pressurized by the fire pumps. We also have another dry pipe system which is connected downstream the pumps. Where exactly should the readings be taken? Are there other locations where the test can be conducted?

You raise a good question and one that has gone all the way to the NFPA Standards Council. As a point of reference, please see the Report on Comments, 2009 Annual Revision Cycle, in particular Public Comment 13-104.

The submitter of the Public Comment was in essence trying to permit what you have proposed, a single main drain test connection in buildings with multiple risers. The proposed language in 8.17.4.1.4 would allow attachments such as fire pump test headers, backflow prevention test connections, etc. to be used in lieu of the main drain test at the base of each system riser. Note that the Committee rejected the Public Comment (and the original Public Proposal). The submitter made a motion for Approval at the NFPA Annual Meeting and that motion failed. The submitter then filed an appeal to the NFPA Standards Council which was denied.

As a technical explanation, the intent of the main drain test is to ensure that water is available to the sprinkler system. The sprinkler system is defined in NFPA 13 as starting at the base of riser. The piping, pumps, etc. that lead up to the base of the riser are considered the water supply for the sprinkler system. When a single test is performed, either on the supply or discharge side of the pump, any obstruction or closed valve between the pump and the sprinkler system riser would not be detected. As such, the Committee has maintained that main drain tests shall be performed at each system riser.

Unfortunately there are a wide range of possible installations. In some locations the fire pump may be remote from the fire pump room with considerable supply pipe and a number of section control valves between the fire pump and the various sprinkler system risers. In this instance, the benefit derived from the Committee’s position and the additional tests can be well understood. In other instances, the fire pump and sprinkler risers may be in close proximity to each other, possibly even in the same room. In this latter instance, a single main drain test along with visual observation of each valve (required to be performed monthly) would possibly be adequate, although obstructions may still exist in the pipe that cannot be seen.

However, the intent of the Standard is clear based upon the action that took place in developing the 2010 Edition of NFPA 13. Main drain tests must be performed at each sprinkler system riser.

Is it possible for a room to have two Occupant Load Factors? We have an auditorium which is sometimes used with tables (less concentrated use) and sometimes strictly chairs (concentrated use). Would it be possible to post both figures?

Having two different Occupant Load Factors for a room is possible, and is very common when dealing with a multi-purpose assembly occupancy such as the auditorium example provided. Another example is large ballrooms in hotels, which often have several occupant loads based on location of demising walls and the various uses of the space. Egress requirements, such as capacity and number of means of egress, from the auditorium and other relevant safety features such as sprinkler and fire alarm provisions would be based on the higher occupant load. Refer to 2009 NFPA 101®, 12.1.7.1 and 13.1.7.1 for further detail. The lower occupant load number is strictly informational so that when the auditorium is set with tables and chairs, the corresponding occupant load number ensures that the proper aisles and aisle access ways are maintained. Posting of the occupant load for rooms constituting an assembly occupancy without fixed seats is required per Section 12.7.9.3.1. If multiple occupant loads are posted, it is advisable (and sometimes required by the Authority Having Jurisdiction) to have on record the corresponding seating layouts with the respective occupant load so that the Authority Having Jurisdiction and staff are clearly aware of the permitted uses of the room or space.

I would like your thoughts on the meaning of “fail-safe” in the context of 7.8.1.2.2. Does “fail-safe” simply mean that the units will power up with the lights on? In addition, how should the proposed 2011 wording “evaluated for this purpose” be interpreted for someone who wants to design systems to control emergency lights? Also in the proposed 2011 7.8.1.2.3, do you have an idea which organization will be listing devices as “a fail-safe device for use in the means of egress”?

Based in the information provided, the intent of “fail-safe” in 2009 NFPA 101® Section 7.8.1.2.2 is that in the event of a malfunction of the motion sensor, the illumination of means of egress is automatically restored. The illumination would have to be restored to the minimum levels and required duration as indicated in Sections 7.8.1.3 and 7.8.1.4. Thus, all of the lights would not necessarily have to illuminate. This device would have to comply at a minimum with UL 924, Standard for Safety of Emergency Lighting and Power Equipment, but a specific category for this type of device is not yet provided. There are devices currently being marketed for this purpose and some manufacturers are specifically listing compliance with NFPA 101® Section 7.8.1.2.2. The term “evaluated” in the 2011 ROP (attached) is a generic term used by NFPA to require that documentation or an engineering evaluation be provided showing the device can fail safe. Keep in mind that the Authority Having Jurisdiction (AHJ) may also request a field test.

We have many fire door frames that have UL rated labels with no hourly rating. We have been informed by an outside contractor that this is unacceptable, that all labels must have the hourly rating, and will therefore need to be replaced. Is this true?

I have a question about the means of egress in ambulatory and healthcare occupancies. Hope you can shed some light on In The Joint Commission Hospital Accreditation Standards Life Safety Chapter, it appears that LS.02.01.20 EP 13, "Exits, exit accesses, and exit discharges are clear of obstructions or impediments to the public way - For full text and any exceptions, refer to NFPA 101-2000: 7.1.10.1." NFPA 101-2000: 7.1.10.1 reads "Means of egress shall be continuously maintained...". When further reviewing the NFPA 101, chapters 18-21 for healthcare facilities refers to chapter 7 for egress standards. Chapter 7 does list minimum widths (i.e. 4 feet for healthcare facilities), but doesn't give any requirement about narrowing wide corridors. For quite some time I've heard that The Joint Commission only allows items to be "stored"in the hall for 30 minutes, but I guess my question is, if you're maintaining the minimum egress and technically not impeding egress, than why can't facilities store items in the hallway? If a facility has 8 foot corridors, and items are stored on one side decreasing the corridor to 6 feet, but still maintaining a clear line for egress with the minimum width standard, would that be out of compliance? Is there a standard that states corridors cannot have items stored for longer than 30 minutes even when those items are not obstructing egress?

I will address two key concepts with respect to your question.

Required corridor width.; You are correct that Chapter 19 requires a 4 ft corridor in Existing Health Care Occupancies. However, Chapter 18 requires an 8 ft corridor in many areas of a New Health Care Occupancy. While the building in question is an existing building, the requirements of 4.6.7 (NFPA 101-2000) must be considered.; More specifically, the paragraph states that life safety features may only be reduced to that which is required for new construction. In other words, if you already have an 8 foot corridor, an 8 foot corridor must be maintained in those areas where the Code requires an 8 foot corridor width for new construction, even in existing buildings.

Use of the corridor for storage. Paragraph 19.3.6.1 (NFPA 101-2000) requires that corridors be separated from all use areas by partitions unless the areas is one of the exceptions that permits the space to be open to a corridor.; As such, corridors must be separated from storage areas unless Exception No. 1 or Exception No. 6 are met. Note that those two exceptions indicate that hazardous areas are not permitted to be open to the corridor and Paragraph 19.3.2.1 indicates that spaces larger than 50 ft2 used for storage of combustibles in quantities deemed hazardous are hazardous areas. As such, storage areas 50 sq ft or less in area are permitted to be open to the corridor if they are protected as required by either of the referenced exceptions.

With respect to your reference to storage for 30 minutes, note that A.19.2.3.3 (NFPA 101-2000) indicates that items "in use" may be in a corridor and reduce the available width provided the facility fire plan addresses the relocation of the items. The last sentence of the Annex note reinforces the discussion above. Some AHJ's have determined that a cart that remains stationary for more than 30 minutes in not "in use" but rather, is storage. If the carts are used for soiled linen or trash collection purposes and they exceed 32 gallons in capacity they are not permitted to be "stored" in a corridor; but rather must be located in a room protected as a hazardous area when not attended (19.7.5.5, NFPA 101-2000).

Assuming that the above responds to your question, please note that if or when the 2012 Edition of NFPA 101 applies, some of the above will change. The 2012 Edition will contain provisions that allow certain wheeled items to be in the corridor (see 19.2.3.4, NFPA 101-2012).

I have been forwarded a hot work policy for the hospital. In the references section of the Life Safety Code 101 it talks about hot work permit but I cannot find a section which talks about hot work permits. Can you point me in the right direction?

When using NFPA 430 for a storage area, what is meant by The Bulk or Pile 0.65gpm/5000 sq ft? How does it apply if we have an area less then 2000 sq ft?

Based upon your question, we presume that the storage height is greater than 3 m and, therefore, you need to use the third column in the table. NFPA 430 does not specifically say what to do if the area involved does not equal the stated area of sprinkler operation, in this instance 5000 sq ft. Absent specific guidance in NFPA 430 and based upon a general reference to NFPA 13 within NFPA 430, the design of the ceiling sprinkler system shall be at a density of 0.65 gpm over the entire area where the Class 3 oxidizers are stored, and the area calculation of the sprinkler operation will be the area where the Class 3 oxidizers are stored up to a maximum of 5000 sq ft. If the area where Class 3 oxidizers are stored exceeds 5,000 sq ft, the hydraulically most remote 5,000 sq ft must be used. If the building contains multiple hazards, please note that the area to be protected with the density of 0.65 gpm may need to include areas adjacent to the area where the Class 3 oxidizers are stored (see Section 12.3, NFPA 13, 2007 Edition).

I have a question regarding the requirement in NFPA 101 for building access. Can you advise how many percent of a building facade needs to be accessible for emergency vehicle like a fire truck?

The issue of emergency vehicle access is not addressed in NFPA 101. Since the scope of NFPA 101 is life safety from fire and similar emergencies, access by emergency response personnel is considered beyond the scope of the document. However, you will note that NFPA 101 does indicate in Chapter 1 (Paragraph 1.1.1, 2006 Edition) that there are items presumed to be covered by other codes and standards and this would be one of those items. The height and area tables in the building codes in the USA presume that approximately 25% of the perimeter of the building is accessible. While not a strict requirement, the codes allow an increase in area when access is provided to more than 25% of the perimeter of the building. Said a slightly different way, the base height and area of a building, as governed by USA building codes, assume one side of the building is accessible to emergency response vehicles. Fire codes, such as NFPA 1, provide more specific criteria with respect to fire department access. Instead of a percent of the building that is accessible, NFPA 1 requires emergency vehicle access to within a certain distance of the building. For example, Section 18.2.3 (NFPA 1, 2006 Edition) requires access to within 15 m (50 ft) of one exterior door and 46 m (150 ft) to all portions of the exterior of the first story. Note that the presence of complete building automatic sprinkler protection changes this latter distance to 137 m (400 ft).

There are several floors of plant and a large archive store on this particular project. They are not really considered in the Industrial or storage area. Using the Life Safety Code, what occupancy classification should one use for travel distances of mechanical equipment areas?

Generally, mechanical equipment areas would be considered an industrial occupancy and the travel distances for general purpose industrial occupancies would apply. However, also note that the Life Safety Code permits incidental industrial uses to be considered part of the primary occupancy (NFPA 101-2009; 6.1.14.1.2). When the industrial space is considered part of the primary occupancy, the requirements for the primary occupancy would apply. However, with respect to certain egress issues, Section 7.12 would apply with respect to travel distance, common path of travel, and number of means of egress in the mechanical equipment areas.

Where does one find the fire-resistance rating requirements for corridors in the Life Safety Code?

Technically, in the Life Safety Code, one should go to Section 7.1.3.1 (2009 Edition) for the requirements for separation of exit access corridors when a corridor is provided. However, that paragraph indicates that the requirements contained within the paragraph may be revised by the occupancy chapter (7.1.3.1 (2)). Whereas most occupancy chapters contain specific requirements for corridor walls, one should generally go directly to the .3.6 subsection of any occupancy chapter (for example 38.3.6 for New Business Occupancies).

NFPA 20, 2010 Edition, Section 5.5, 5.6 and 9.3.3 state the following: 5.5 Auxiliary Power. Where electric motors are used and the height of the structure is beyond the pumping capability of the fire department apparatus, a reliable emergency source of power in accordance with Section 9.6 shall be provided for the fire pump installation. 5.6* Fire Pump Backup. Fire pumps serving zones that are partially or wholly beyond the pumping capability of the fire department apparatus shall be provided with an auxiliary means that is capable of providing the full fire protection demand. 9.3.3 An alternate source of power is not required where a backup engine−driven or backup steam turbine–driven fire pump is installed in accordance with this standard. My questions are: 1. For high-rise buildings, it seems the above sections 5.5, 5.6 and 9.3.3 are contradicting. Section 5.5 and 5.6 requires emergency source of power as well as fire pump backup, where as section 9.3.3 does not require alternate power if backup fire pump is provided. Is this true? 2. What is the NFPA 20 requirement for high-rise buildings in regards to emergency power and backup fire pump?

For high-rise buildings, NFPA 20, 2010 Edition Sections 5.5 and 5.6 do not contradict Section 9.3.3 (and more generally Section 9.3); but rather, provide a more rigorous requirement for high-rise buildings. Section 9.3 contains general requirements for electric pumps and applies when the either the normal source of power for an electric drive pump is not reliable or when the height of the structure is beyond the pumping capacity of the fire department apparatus. Sections 5.5 and 5.6 apply to high-rise buildings, regardless of whether the normal source of power is deemed to be reliable and in the case of Section 5.6, regardless of the type of pump. It should also be noted that Section 5.1.1.2 indicates that the other chapters of NFPA 20 apply unless specifically addressed by Chapter 5. In other words, Chapter 5 requirements take precedent over requirements in other chapters, such as Section 9.3.3.

With that as background, starting with Section 5.6, a redundant fire pump is required in high-rise buildings for the zones that are partially or wholly beyond the pumping capability of the fire department apparatus (not necessarily the entire building). Note that Section 5.6 applies regardless of the type of fire pump to be used as the primary pump. The provisions in Chapter 9 allow for an redundant engine-driven or steam turbine-driven fire pump to be used for either of the conditions addressed by Section 9.3. Section 5.5 requires that where electric motors are used and the height of the structure is beyond the pumping capability of the fire department apparatus in a high-rise building, an on-site generator must be provided. Chapter 9 allows various sources of alternate power.

For example, where an electric motor is used in other than a high-rise building, Chapter 9 would give on the option of several different alternate sources of power, a back-up engine driven fire pump, or a back-up steam turbine-driven fire pump when the normal source of power is not reliable or the height of the structure is beyond the pumping capability of the fire department apparatus. If the building is a high-rise building, Chapter 5 would require: a redundant pump serving those portions beyond the pumping capability of the fire department apparatus; and if an electric motor is used, an alternate source of power consisting of an on-site generator if the height of the structure is beyond the pumping capability of the fire department apparatus.

We have a project at our facility involving the replacement of eight Automatic Transfer Switches (ATS). Currently there is no separation of power; however, do we fall under the NFPA 99 Type 1 category even if it’s a psychiatric facility? We feel that the facility should be a Type 3. What would be your opinion?

If there is no electrically operated life support equipment, then NFPA 99, Health Care Facilities Code, would only require a Type 3 Essential Electrical System (EES). Mental health facilities are typically considered "limited care facilities" but some might categorize them as "other health care facilities". In the 1999 Edition of NFPA 99 we get to this two different ways:

If we consider the building to be a limited care facility then 17-3.3.2 states:
17-3.3.2
Essential electrical distribution systems shall conform to the Type 2 systems as described in Chapter 3. Exception: Any freestanding limited care facility that:
(a) Maintains admitting and discharge policies that preclude the provision of care for any patient or resident who needs to be sustained by electrical life support equipment, and
(b) Offers no surgical treatment requiring general anesthesia, and
(c) Provides an automatic battery-powered system or equipment that will be effective for at least 11/2 hours and is otherwise in accordance with NFPA 101, Life Safety Code, and NFPA 70, National Electrical Code, and that will be capable of supplying lighting of at least 1 ft-candle to exit lights, exit corridors, stairways, nursing stations, medication preparation areas, boiler rooms, and communication areas. This system must also supply power to operate all alarm systems.

What part (c) requires is essentially a Type 3 System but there are some differences, so please be aware of that when designing your EES.
If we consider the facility to be "other health care" then 13.3.3.2 states:
13-3.3.2
Essential Electrical Distribution System. The essential electrical distribution system shall conform to a Type 3 system as described in Chapter 3.
13-3.3.2.1
If electrical life support equipment is required, the essential electrical distribution system shall conform to a Type 1 system as described in Chapter 3. 13-3.3.2.2
If critical care areas are present, the essential electrical distribution system shall conform to a Type 1 system as described in Chapter 3.

Presuming your facility does not include electrical life support equipment or house critical care areas, then only the Type 3 system is required.

In the 2012 Edition of NFPA 99, there are no occupancy chapters to tell you which Type of EES must be provided. You determine the Type of EES needed by a risk assessment.

Our Family Care Clinic (Business Occupancy with >50 occupants) has 6' wide egress corridors. Staff members want to store equipment such as baby scales in the corridors. Is this allowed if they maintain the 44" clear corridor width (NFPA 101, para. 39.2.3.2)? We follow the NFPA 101, 2000 edition.

With respect to your question it should be noted that the proper reference should be Paragraph 38.2.3.2. While this may be an existing building, the fact that a change is proposed should result in referencing the requirements for new construction. Note that Paragraph 4.6.7.4 (NFPA 101-2012) or Paragraph 4.6.7 (NFPA 101-2000) indicates that existing life safety features may only be diminished if they exceed the requirements for new construction. In this instance, the requirement for new is the same as for existing and is a 44-inch (1120 mm) corridor. Also note that the requirements for corridors in business occupancies is different than what is required for corridors in health care occupancies.

Therefore, presuming that the space is a business occupancy, items may be located in the corridor provided at least a 44-inch clear-width is maintained and the quantity of such items and their appurtenances do not constitute what the Authority Having Jurisdiction would determine to be a hazardous area as described in Paragraph 38.3.2.1. Also, it is recommended that all such items be located on the same side of the corridor to provide a consistent direct path of egress. Placement of any such items must also take into account accessibility requirements of the Americans with Disabilities Act (ADA) and its Associated Design Guidelines (ADAAG).

We have many fire door frames that have UL rating labels with no hourly rating. We are being told by a labeling company that this is unacceptable and that all labels must have the hourly rating and need to be replaced. Is this true?

No, fire door frames do NOT have to have a rating, the frame just has to be labeled for use with a fire door. Per NFPA 80 2010 Edition, paragraph 6.3.1.1 “Only labeled door frames shall be used”. And the annex section for this paragraph states: “A.6.3.1.1 Door frames might carry a label stating the hourly rating. The rating of the installed assembly should carry the rating of the door or the door frame, whichever is less.” As noted by this requirement and Annex material, the frame must be labeled and the annex note states that it MIGHT carry an hourly rating. The hourly rating is NOT required.

We have a 1-3/4 inch solid wood door, that is equivalent to a 20-minute door, for a light hazard room in a non-sprinkler protected health care existing occupancy. Does this door frame need to be rated?

Per the 2000 Edition of The Life Safety Code, Paragraph 19.3.6.3.7, “Door frames shall be labeled, shall be of steel construction, or shall be of other materials in compliance with the provisions of 8.2.3.2.1.” The 2009 Edition of the Life Safety Code has the same requirement, but the references are a bit different. So, provided the frame meets one of the three options above: labeled, steel frame, or other material in compliance; it is acceptable.

During a Life Safety inspection of our Healthcare Facility, we found 4 locations where pneumatic smoke dampers were found to be inaccessible, due to conduit and piping. What are the options for the facility in so far as their PFI is concerned?

Based on the information provided in your question, the Joint Commission permits inaccessible dampers to be placed on the PFI with a six-year projected completion date. Once the six years are up, if the facility has not renovated the space or been able to remedy the issue, they can place it on the PFI for another six years. Usually within the twelve years, the area has been renovated and the inaccessible damper has been made accessible. Please see page 5 of the July 2007 Issue of the Environment of Care News, published by Joint Commission Resources, for more information on this issue.
Please note that this response only deals with The Joint Commission PFIs. If the facility has a CMS survey and the inaccessible dampers are cited, the facility will need to remedy the situation or request a waiver from CMS. It should also be noted that inability to access and maintain dampers may also affect the damper warranty.

Regarding Section 7.2.1.9.2 of the 2009 Edition of the LSC (Doors Required to Be Self-Closing):Which doors are required to be self-closing? What is meant by: “Door leaves held open for any period of time close — and the power-assist mechanism ceases to function — upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.” (7.2.1.9.2(4)) Can you please offer examples of the above two questions?

Paragraph 7.2.1.9.2(4) merely requires that upon detection of smoke, the device holding the door open (typically an electromagnetic device,) releases and the doors become self-closing. Most likely, if this was cited as part of a Life Safety Code survey, the doors were not equipped with proper hold open devices or smoke detectors located at the proper locations to initiate door closure.

The first question is more challenging in that there are a variety of doors that may need to be self-closing. For the most part, the Code allows self-closing doors to be automatic-closing at the discretion of the facility (for an existing health care occupancy see 19.2.2.2.7 and 19.2.2.2.8) Doors that are required to be self-closing in a health care facility include:

Any fire door
Smoke barrier doors
Horizontal exit doors
Stair enclosure doors
Doors to hazardous areas

This list may not be all inclusive although the first bullet captures most of the doors that are required to be self-closing.

We use the 2012 Edition of the Life Safety Code. Are medication rooms, clean linen rooms and rooms that contain omnicell’s considered hazardous areas?

The requirements for hazardous areas are found in Section 18/19.3.2.1, NFPA 101®, Life Safety Code®, 2012 Edition. Rooms, including clean linen, greater than 50 sq ft and storing combustible materials are classified as hazardous areas in both new and existing construction. The determination for medication rooms or rooms containing omnicell medical dispensing equipment often is governed by what else is in the room. Medication alone in limited amounts does not require a room be classified as a hazardous area. The rooms should be classified as hazardous only if they are used to store combustible materials. The issue in most medication rooms is that the medication itself is encapsulated in combustibles, such as plastics and paper. Smaller rooms with one Pixys machine or only a few omnicells would most likely not constitute a hazardous area, but if the rooms is 50 sq ft or greater and is full of machines or omnicells it should be classified as a hazardous area. Also, large quantities of medicine could pose a danger of noxious fumes in the event of a fire, which is why, along with the amounts of plastics and papers, pharmacies are also often classified as hazardous areas.

Given the revision to the 2009 edition of the NFPA LSC #101 in 14/15.3.6(2) (b) allowing door closers to be omitted from classroom doors in sprinklered buildings where the corridor is arranged as a smoke partition are door stops allowed on these doors? The door stops might be mechanically attached to the bottom of the door or be rubber or wooden wedges. I think the answer is no. The code allows the omission of closers but does not appear to permit door stops. I have an existing fire sprinklered K-12 school with corridor walls arranged as smoke partitions that has door closers on its corridor doors and the teachers are lowering the mechanically attached closer or are inserting rubber or wooden wedges to hold the doors open.

Thank you for your inquiry. Based on the information you provided, door stops should not be allowed in the scenario you describe. NFPA 101®, Life Safety Code, 2009 Edition Section 14/15.3.6 (2)(b) allows the omission of self-closing or automatic-closing hardware on the doors between the corridors and normally occupied classrooms if the building is sprinkler protected per NFPA 13. The intent is that corridor doors will be manually closed by the staff and/or students during a fire event, which should be included as part of the emergency plan required by Section 14/15.7.1. The code does not specifically allow the wedging open of the doors.

From a practical perspective, it seems that the door closers could be removed from these doors serving normally occupied classrooms and these doors could be left open without the need for wedges.

A Private property with a huge accommodation, offices and process area having Private internal hydrants around the site where the system and water source is connected to private fire water tank and fire pump, the hazard category of the premises is fall on multiple- Hazard classification in which highest hazard prevail to because of fuel station and fuel storage among the area. I understand about this situation that the flow of hydrant should be added to the sprinkler/standpipe system flow to arrive to total fire pump capacity. My question is the NFPA 13, 14 or 24 telling how much flow or capacity of Private hydrants requires? And how many remote hydrants are should be considered? (For clarification we’re not talking about landing valve, hose reel nor fire department connection).

NFPA 13, 14, and 24 do not contain requirements or recommendations on flow or capacity of private fire hydrants. The flow or capacity of private fire hydrants is determined by the applicable fire code, for example NFPA 1, Fire Code. The 2012 edition of the NFPA 1 is the latest edition, provides robust guidance, and will be referenced in this response. Note that older editions of NFPA 1 may not contain as much guidance. This analysis is only for fire protection water demand and not domestic use.

Where no adequate and reliable water supply exists, NFPA 1 §13.5.2 references NFPA 1142, Water Supplies for Rural and Suburban Fire Fighting, for calculating the minimum total water supply volume needed for firefighting operations. NFPA 1142 uses parameters such as construction type, hazard classification, building size, and if there are exposing structures within 50 feet and larger than 100 sq ft in area. Typically, the fire flow is determined from the single most demanding building on a site as multiple fire events seldom occur. Note that all buildings on the site must be analyzed to find the most demanding as the most demanding may not always be obvious due to the parameters evaluated.

NFPA 1 sets fire flow requirements for both One- and Two-Family Dwellings and other types of buildings. NFPA 1 Table 18.4.5.1.2 provides specific requirements for the flow and duration of fire hydrants. This table calculates the flow and duration of fire hydrants based on construction type and building size. The building size is based on the aggregate area of all floors in buildings of combustible construction or the three largest successive floors in buildings of non-combustible construction per §18.4.4. Presuming there are no One- and Two-Family dwellings on this site, NFPA 1 requires a minimum fire hydrant water flow of 1,000 gpm for sprinkler protected buildings per §18.4.5.2.1 (1,500 gpm for non-sprinkler protected buildings) at 20 psi per the note to Table 18.4.5.1.2.

NFPA 1 §18.5.1 requires a fire hydrant at “approved locations.” Locations and distribution of fire hydrants are provided in NFPA 1 Annex E. However, note that Annex E of the fire code is only enforceable if adopted by the local Authority Having Jurisdiction (AHJ), so be sure to check local requirements.

The International Fire Code (IFC) published by the International Code Council (ICC) contains Appendix B for determining fire-flow and duration requirements for buildings, and Appendix C for determining locations and distribution of fire hydrants. However, note that Appendix material of the IFC is not considered enforceable unless formally adopted by the local AHJ.

Koffel Associates has used both NFPA 1 and the IFC criteria in the past for determining flow/capacity of fire hydrants and hydrant locations. There may be alternative ways to provide the fire flow or reduce the fire flow rather than the requirements/recommendations contained solely in NFPA 1 and the International Code, but those alternatives and reductions must be approved by the local AHJ.

This is a design compact modular outpatient treatment/ rehabilitation centers for veterans. Each treatment center will be single-story, and quite small – from 2,000 to 5,000 sf. They will be constructed mainly of 15’ x 48’ prefabricated modular units (exterior dimensions). In different student designs, these modules may be placed adjacent to each other, or separated by outdoor space. When it is necessary to travel along the length of a module with side-by-side rooms along a corridor, a wide corridor uses up quite a bit of the interior space, which is only about 13’-6” net width. I learned the VA requirement for ambulatory care clinics is 6’ corridor width. But I wonder whether being very small (under 5,000 sf), would qualify us for the reduced width normally permitted in a suite? Also, all corridors would be single-loaded, with at-grade exit doors possible almost anywhere along the corridor. Because some of the users would be in wheelchairs, we would need to provide extra width for passing, at intervals. It would really help us to know whether the corridors could be smaller than 6’ in places.

Based on the information that you have provided it sounds as though clients receiving treatment at these facilities are not receiving treatment that would render them incapable of self-preservation. In other words, the clients may be disabled to some level prior to entering a facility, but none of the treatment provided at the facility makes the clients less capable of self-preservation.

Having said that, the facilities you describe would be classified as a business occupancy by both the 2012 International Building Code (IBC) and the 2012 Life Safety Code® (LSC), not an ambulatory health care occupancy. The minimum egress width within a business occupancy serving more than 50 occupants is required to be 44 inches per §38.2.3.2 of the LSC (and IBC Table 1018.2) and where serving less than 50 occupants the minimum egress width is permitted to be 36 inches per §7.3.4.2 (2) (and IBC Table 1018.2). Information regarding dimensional criteria for passing spaces on accessible routes can be found in Section 403 of the latest ADAAG dated June 23, 2004.

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