Managing the Physical Environment The Life Safety Code Myths, Misconceptions & Opportunities...

© SMS, Inc., 2013

Managing the Physical Environment

The Life Safety CodeMyths, Misconceptions & Opportunities

Healthcare Facility Managers Society of New JerseyThursday, June 20, 2013

A program presented by:Robert H. Bartels, CHFM CHSP CHEP FASHE

President & FounderSAFETY MANAGEMENT SERVICES, INC.

(877) 577-6550 ** [email protected]

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mailto:[email protected]


SuitesConcept: Use of suites can alleviate some complex & costly code deficiencies. Falls under 19.2.5 & 18.2.5 “Arrangement of Means of Egress”

Premise: Every habitable room shall have an exit access door leading directly to an exit access corridor.

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SuitesIssue:

* Size* # Exits* # Intervening Rooms* Travel Distance

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SuitesIssue:

* Size & Exits- Patient Sleeping

- 1,000 SF- 5,000 SF

- Non-Sleeping- 2,500 SF- 10,000 SF

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SuitesIssue:

* Size & Exits- Patient Sleeping

- 1,000 SF requires single exit

- 5,000 SF requires 2 exits (must be remote in new)

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SuitesIssue:

* Size & Exits- Non-Sleeping

- 2,500 SF requires single exit- 10,000 SF requires 2 exits (must be remote in new)

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SuitesIssue: * Intervening Rooms & Travel Distance

- Patient Sleeping – permitted only by exceptions

- Non-Sleeping – one with travel distance of 100’ or less; two with travel distance of 50’ or less

- Intervening room may not be through hazardous area

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Code Problems In New Construction

Concept: Newly constructed buildings should be fully compliant

Premise: Buildings are designed by qualified Architects & Engineers, then site reviewed by regulators

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133 – NFPA 101 2000

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Issue: How is it possible to end up with code violations after this process & what are the violations commonly identified after taking possession of a new building?

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- Why do they occur?- Complexity of codes

- Lack of LSC knowledge- Time is money- Value engineering- User influence

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Code Problems In New ConstructionIssue: Common Violations - Not full sprinkler protection

- Utilities in exit stairs- Improper exit discharge- Oversize suites or exit issues- Inadequate building separation

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Code Problems In New ConstructionIssue: Common Violations

- Room door swing into exit corridors- Wall projections- Stair width- Shaft enclosure- Improper fire stopping

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Room Door SwingConcept: Doors from rooms should not interfere with exit corridors. Falls under 7.2.1.4.4 “Swing and Force to Open”

Premise: “During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. into the required width of an aisle, corridor, passageway, or landing, when fully open.”

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Room Door SwingIssue: We find frequent instances where doors swing into egress corridors in new and existing buildings. In many cases these doors do not swing fully open due to door closers not opening 180 degrees, & due to objects interfering with their full opening such as handrails, soap/gel dispensers, lights, fire extinguishers, etc.

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Fire Door Latching

Concept: Pairs of rated fire doors require positive latching to maintain their rating. The Code identifies specific # of latches for specific size and type doors

Premise: The number of latches required for a specific size Tin Clad Fire Doors can be found in section 3.4 of NFPA 80, Fire Doors & Windows under table 3-4.3.3(a)

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36 – SMOKE PARTITION CLOSED

© SMS, Inc., 2013


Fire Door Latching

Issue: Tin Clad Fire Doors up to 6’6” in height require 2 latches & doors over 6’6” require 3 latches. Doors over 8’6” to 10’6” require 4 latches. Often the receptacle for the bottom latch has been removed from the floor. Also, many 6’6” fire doors are installed with only the top latch.

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Fire Dampers

Concept: When an air duct penetrates multiple floors it is typically required to be enclosed with 1 or 2 hour fire resistive construction & provided with fire dampers where the duct penetrates the shaft wall

Premise: “Fire dampers shall be installed at each direct or ducted opening into or out of enclosures required by 3-3.4.1.” Falls under NFPA 90A 1999 edition “Shafts”.

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Fire Dampers

Issue: Frequent improper installation of fire dampers in new & existing construction including:• Improper floor line installation• Improper wall installation• Improperly sealed penetrations

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822 - DAMPER

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Locking Doors In Means Of Egress

Concept: Occasionally, for clinical safety reasons, a door in a means of egress may need to be locked. Falls under “Means of Egress Requirements”

Premise: The code states “Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side. There are 3 exceptions.

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Locking Doors In Means of Egress

Issue: Hospitals have a long history of locking certain high risk areas (particularly L&D & Newborn Nurseries) with non-conforming locking arrangements.

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Fire Alarm Pull Box Locations

Concept: Fire alarm pull boxes should be located in the normal path of egress & near exits. Falls under NFPA 72 1999 edition.

Premise: Fire alarm boxes should be located within 5’ of exits, the top of the device should not be more than 54” from the floor & travel distance to a box should not be more than 200’.

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Fire Alarm Pull Box Locations

Issue: Frequent findings of- Pull boxes mounted too high- Pull boxes over 5’ from exit- Horizontal exits w/o pull boxes- Mechanical room distances >200

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“Tying-off” to Sprinkler Systems

Concept: “Sprinkler piping or hangers shall not be used to support non-system components.” Falls under NFPA 13, 1999 edition.

Premise: Designs for hanging sprinkler piping are based only on the weight of the water filled pipe & a safety factor, not extra weight.

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Tying-off to Sprinkler Systems

Issue: Items supported by or on sprinkler piping is all to common a finding. It is even more problematic in older systems that have endured the effects of time & vibration for many years. TJC & CMS have become more aggressive in recent years in looking for this issue.

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Corridor Walls

Concept: Corridors in hospitals mustbe separated from rooms by compliant partitions

Premise: “Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.3” Falls under NFPA 101, 2000 edition.

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Corridor Walls

• Smoke Barriers per Chapter Requirements• Smoke Doors• Smoke Dampers• Penetrations

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Corridor Walls

Issue:- New Construction vs. Existing- Sprinklered vs. Non-Sprinklered- Code exceptions- Appendix clarifications

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Corridor Doors

Concept: Corridors in hospitals must be separated from rooms by compliant doors.

Premise: Doors protecting corridor openings in other than enclosures of vertical openings, exits, or other hazardous areas shall be substantial doors…

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Corridor Doors

Issue: - Latching- Kick Plates- Frames- Louvers, transoms, transfer grills- Undercuts

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Managing the Physical Environment The Life Safety Code Myths, Misconceptions & Opportunities...

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