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NFPA 101®, Life Safety Code® 2012 Edition Changes to Fire Door Inspection and Testing Requirements
Proper operation of fire doors is essential to maintaining the continuity of fire barriers which are a key feature of the defend-in-place fire response strategy employed by health care occupancies. Evacuating patients incapable of self-preservation from a building may often pose more of a threat than relocating the patient across a passive fire protection barrier to a tenable environment inside the building. Passive fire protection features performing as intended are arguably equally important to life safety as active fire protection systems such as fire alarm and sprinkler systems.
NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2007 Edition introduced a requirement for inspection and testing of all fire door assemblies, including swinging doors, on an interval not less than annually. This requirement remains in the 2010 edition which is referenced by NFPA 101, Life Safety Code, 2012 Edition (LSC), recently adopted by the Centers for Medicare & Medicaid Services (CMS). A written record of the inspection is required to be signed and available for review by Authority Having Jurisdiction (AHJ). Performing the annual fire door survey will not only help to increase the likelihood the doors will operate properly during a fire condition, it has the potential to limit citations resulting from compliance surveys as fire barriers are often subject to a high level of scrutiny. NFPA 80 permits the inspection and testing requirement to exceed 12 months where approved by the AHJ based on a performance based option analysis.
The code language in the LSC 2012 Edition has caused confusion recently on whether the annual test and inspection of door assemblies is required due to §22.214.171.124.1 containing a requirement for inspection and testing of certain types of doors only where required by the occupancy chapter. The following paragraph §126.96.36.199.2 requiring an annual inspection of fire door assemblies appears to require an occupancy chapter to require the inspection however, the LSC 2015 Edition clarified the requirement and relocated it to §188.8.131.52. Regardless, LSC 2012 Edition §184.108.40.206 states features required for compliance with the Code must be maintained in accordance with the applicable NFPA requirements. It is understood that CMS will include the requirement in an interpretive guide document to be published in the future.
A complete documented inventory of fire door assemblies is necessary prior to performing the inspection and testing. Locating the doors on a modified set of life safety plans may assist in the process. It may also be helpful to include any doors which cannot simply be inspected and require coordination with other building systems to perform testing such as fire alarm, HVAC, security, etc. The individuals performing the inspection and testing of fire door assemblies are now required to have knowledge and understanding of the operation components of the door. If performing the inspection and testing by internal staff, be prepared to justify their knowledge and understanding during a compliance survey.
A visual inspection must be performed from both sides of the door and it includes ensuring door clearances are within allowable limits, there are no holes in assembly, the hardware operates properly, the glazing and gaskets are secure, the door closes completely and positive latches, etc. A complete list of items requiring inspection on swinging fire doors can be found in NFPA 80 §220.127.116.11. Testing of fire door assemblies likely will require more effort than assemblies which merely require inspection. Doors provided with electromagnetic lock release, power operated doors, latches that engage upon local smoke detector activation, etc. will likely require coordination with outside vendors to ensure the features of the door operate properly. Testing of features associated with the fire door assembly are not required to be performed at the same time as the inspection, however coordination between what testing was performed on each door will be a challenge if done a separate times.
Fire door assemblies were a topic of discussion at Health Care Interpretations Task Force (HITF) meeting at the 2016 NFPA Conference & Exhibition in Las Vegas. The HITF determined that an existing fire door assembly even if not installed in a required fire resistance rated barrier must be maintained per the requirements of NFPA 80. This is based in part on LSC §18.104.22.168 which requires existing life safety features obvious to the public to be maintained or removed. This means all labeled fire door assemblies in a health care facility must be inspected and tested annually regardless of whether the door is installed in a Code required fire barrier. In order to address this issue, the HITF is expected to publish guidance soon that label is permitted to be removed from the door. This is because the door serves no life safety function as it is installed in a nonrequired fire barrier. There is also a Public Input being considered by the NFPA Technical Committee on Fire Doors and Windows that addresses the issue of removing a label from a fire door. Covering the label with tape or paint will not be an acceptable alternative. Once the label is removed, the door would need to be evaluated by an approved agency to provide a new label if a fire protection rated of the door was needed in the future.
On a related topic the LSC §22.214.171.124.2 also requires an annual inspection and test of smoke door assemblies, however most doors installed in smoke barriers in health care facilities are not required to meet smoke leakage ratings across the door and are not subject to the annual inspection and testing requirement. However, new doors in horizontal exits are required to meet NFPA 105. With that said, it may be prudent to include doors installed in smoke barriers in your door inventory for annual inspection and testing given the importance of maintaining the continuity of smoke barriers for defend-in-place response to a fire event. It should also be noted that the applicable building code may require the door to be a smoke- and draft-control assembly and fire door and as such, inspections in accordance with NFPA 80 and NFPA 105 would be required.
The NFPA 80 annual inspection and testing requirement of fire door assemblies is vital to ensure passive fire protection systems provide the required life safety to health care facility occupants incapable of self-preservation. Performing annual inspections and testing will not only provide the required level of life safety to building occupants, it will also limit door deficiencies identified during compliance surveys.
Lennon Peake, P.E.
Licensed In MD, PA, CA
Fire Protection Engineers: Expertly Engineering Safety From Fire