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October is Fire Safety Month
Healthcare Facility Fire Prevention Plans and
Select Fire Code Requirements
October 2009
As October
is Fire Safety Month, it is an ideal time to point out a
specific OSHA standard that is often overlooked and some
specific fire code items that may be of interest.
Fire
Prevention Plan
– OSHA 29 CFR 1910.39 requires a written fire prevention
plan be made available to employees in workplaces that
have more than 10 employees. Oral plans may be
communicated by employers with 10 employees or less.
Minimum elements of the plan must include the following:
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A list
of all major fire hazards, proper handling and storage
procedures for hazardous materials, potential ignition
sources and their control, and the type of fire
protection equipment necessary to control each major
hazard
-
Procedures to control accumulations of flammable and
combustible waste materials
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Procedures for regular maintenance of safeguards
installed on heat-producing equipment to prevent the
accidental ignition of combustible materials
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The name
or job title of employees responsible for maintaining
equipment to prevent or control sources of ignition or
fires
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The name
or job title of employees responsible for the control of
fuel source hazards
An
employer must inform employees when they are hired or when
they change positions of the fire hazards to which they
are exposed. An employer must also review with each
employee those parts of the fire prevention plan necessary
for self-protection.
Following
are some select fire code requirements:
Powered
Egress Doors
NFPA 101 “Life Safety Code®” Chapter 7.2.1.9 provides
guidance on powered egress doors. These are doors in the
path of egress that open upon the approach of a person or
open with power assisted manual operation. Powered egress
doors must fail in a manually operable mode upon loss of
power. In the case of a powered egress door that is
required to be self-closing, it must be connected to the
fire alarm system to drop out power upon detection of
smoke on either side of that door. Additionally, in the
case of a powered egress door that must be self-latching,
it is either self latching, or it becomes self- latching
upon activation of a smoke detector on either side of that
door.
Corridor
Doors
NFPA 101 does not specify a maximum allowable gap for
corridor doors and only specifies that the door must be
“relatively smoke tight”. In December of 2006, the
“Healthcare Interpretations Task Force” (HITF) in an
effort to further define the term “relatively” suggested
maximum gaps for corridor doors:
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The gap
between the door edge and the frame shall not be greater
than the depth of the door stop.
-
In a
facility that is not fully sprinklered, a maximum
gap of 1/4” between the face of the door and the door
stop is suggested.
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In a
fully sprinklered facility, the suggested maximum
gap increases to 1/2” between the face of the door and
the door stop.
-
In the
case of a two leaf door, there is no gap requirement or
suggestion but rather the meeting edges must have an
astragal, a rabbet, or a bevel.
Keep in
mind, this does not apply to corridor doors of vertical
opening, exits, and hazardous area which must meet the
more stringent requirements of fire doors.
Sprinkler
Flow and Obstruction Testing
NFPA 25 “Standard for the inspection, testing, and
maintenance of water based fire protection systems”
specifies in Chapter 13.2.1 the following:
“An
investigation of piping and branch lines conditions shall
be conducted every 5 years by opening a flushing
connection at the end of one main and by removing a
sprinkler toward the end of one branch line for the
purpose of investigating for the presence of foreign
organic and inorganic material”.
13.2.1.1
goes on to state:
“Alternative non-destructive methods shall be permitted”.
NFPA 25
Annex D describes in detail methods for testing,
identification of materials that might be encountered
during the investigation, and describes further actions to
be taken if the inspection reveals the presence of foreign
materials.
Fire Alarm
Device Visual Inspection
NFPA 72 “National Fire Alarm Code®” Table 10.3.1 lists
frequencies of visual inspections for fire alarm
equipment. Many devices require semi-annual inspections
including for example many initiating devices such as
smoke and duct detectors, heat detectors, pull boxes,
waterflow and supervisory devices. Keep in mind that most
of these devices also require an annual functional test
that will include a visual inspection during the annual
testing while radiant energy heat detectors, waterflow
devices, and valve tamper switches require semi-annual
functional testing so the visual inspection would be
conducted at that time. The frequency of functional
testing is listed in table 10.4.3.
Code
Edition
The
Joint Commission and the Center for Medicare and Medicaid
(CMS) currently use the 2000 edition of the Life Safety
Code®. You should verify with your state and local
Authority Having Jurisdiction (AHJ) which edition they
have adopted.
For
further information, please contact Geoff Gilbert at
Capaccio
Environmental Engineering, Inc. at
508.970.0033 x142 or by email at
ggilbert@capaccio.com.
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