NFPA 1: How the Fire Code Mandates Annual Inspection of Fire Doors, #FireCodeFriday

The first part of this week’s post is written by Jen Sisco, Engineer in the NFPA Building and Life Safety Systems group and Staff Liaison to NFPA’s Fire Doors and Windows Technical Committee responsible for the development of NFPA 80 and NFPA 105. Thanks to Jen for sharing her knowledge of this important issue in the Fire Code!

Passive fire protection in buildings is a critical element for the protection of people and property within NFPA 1. The use of fire barriers, fire walls, and other fire rated assemblies play a vital role in the subdivision of buildings, protection of hazardous areas, and protection of means of egress. However, for these systems to function in a building there has to be allowances for openings for people, equipment, and other building systems.                   

An unprotected or improperly protected opening within a fire barrier or fire wall poses the risk of comprising the protection of the assembly. NFPA 1 requires that the installation and maintenance of all devices used to protect openings in walls, floors, and ceiling against the spread of fire and smoke comply with Section 12.4 and NFPA 80. Not only is it important to ensure that all openings are provided with appropriate opening protectives, but also to ensure that these assemblies are properly inspected and maintained.

The majority of the requirements in NFPA 1, 12.4 are extracted directly from NFPA 80. This section provides an overview of the inspection, testing, and maintenance (ITM) requirements for fire doors. NFPA 80 provides more comprehensive information relating to the ITM, as well as design and installation of 16 unique type of opening protectives, including fire doors, fire windows, glass block assemblies, fabric fire safety curtains, and fire dampers.

Selection of and proper installation of an appropriate fire door assembly or opening protective is important, but equally as important is the ongoing ITM of these assemblies. Since the 2007 edition of NFPA 80 (referenced by the 2009 edition of NFPA 1), all fire door assemblies require annual inspections. Fire dampers require inspection one year after installation and then every four years or every six years in buildings containing a hospital. As fire inspectors, it is important to understand your responsibility in the fire door (and fire damper inspection process). With many other building fire protection and life safety systems demanding inspection, testing and maintenance resources, it can be hard to juggle the ongoing inspection verification and compliance. But these common building systems that are used every day, cannot be ignored.

Building owners are responsible for ensuring that the fire door (and fire damper) assemblies in their building are properly maintained and part of an annual inspection program. This can be done by in-house personnel with an adequate level of knowledge and understanding of the systems or can be done by a third party vendor (a certified fire door inspector, for example). The fire door inspector conducts the inspections per the minimum criteria in NFPA 1 (and NFPA 80) and the fire inspector/AHJ verifies with buildings that their fire door assemblies are being inspected, testing and maintained as required.

Knowing now that doors are required to be inspected annually, how do you as the AHJ know if a door has been inspected? Records of all periodic testing is required to be maintained for at least three years and be available for review by the AHJ. New to the 2019 edition of NFPA 80, which will be referenced in the 2021 edition of NFPA 1, is the permitted use of inspection markings on the tags or stickers that are applied directly to the assembly documenting an inspection.

You can follow me on Twitter for more updates and fire safety news @KristinB_NFPA.

Stop gambling with tenants’ lives.

As a building owner or manager, it is your responsibility to ensure that your property is safe and up to code. Not only can failing to do so lead to massive liability fines, but it can also put the safety of your tenants at risk. That’s where FIRES DOOR INSPECTIONS comes in.

Our team of experts is dedicated to inspecting, testing and fixing your fire doors to ensure that they meet all necessary safety standards. With our services, you can rest easy at night knowing that your building Fire Doors are in compliance with regulations and that your tenants are safe.

Don’t wait until it’s too late. Schedule your mandatory fire door inspections with National Firedoor today and take the first step toward a safer, more secure property.

 

Call Today

WHY ARE FIRE DOORS SO IMPORTANT IN HIGH-RISE BUILDINGS?

“MAINLY BECAUSE HISTORY HAS PROVEN THAT THEY SAVE LIVES & PROPERTY!”
“FIRE DOORS HAVE MANY UNIQUE BUILD IN PURPOSES AND BENEFITS.”

-Their most visible purpose is to allow passage through an opening in a wall; this also accounts for the wear & tear caused by use by occupants. No other “Fire Protection System” gets as much misuse.

– In the event of a fire in a High-rise (the most significant percentage of fires in Residential buildings start in an apartment), the apartment entrance is supposed to be a fire-rated door whose main job is to CONTAIN the fire in the unit where it began.

– All Apartments and Enclosed Rooms in Modern High-rise buildings are constructed with fire-resistant walls, ceilings, floors, and exit doors. The apartment is built like a “Fire Safe,” with the wall-opening Door(s) being the potential
“weakest link” for prevening fire, smoke, toxic fumes, and heat from escaping into other parts of the facility.

– if a fully functioning Fire-door does not protect it.

– If the “fire source” apartment Fire door entrance – does its CONTAINMENT job, it protects the occupants in the rest of the building.

– Besides containing the Fire and Smoke (its main job), the apartment fire Door allows “clear “ passage for those who decide to Flee and protection from Smoke, Gases, and extreme heat for those residents who choose to Stay and “Shelter-in-Place.”

– It is tough to safely evacuate a building with a large occupancy load, some of which may be mobility impaired due to age or a handicap condition. With Fire Code Compliant Fire Doors, in most cases, total evacuation is unnecessary.

– A fire in a sealed apartment will quickly run out of fuel in the form of oxygen, slowing down its growth.
– When First Responders reach the “closed” Fire apartments, “Entrance Door” – in most cases, they will not open the Door until they are prepared to attack the “Fire directly” with extinguishing water at the ready.

– Next to sprinklers and fire alarms – fire- doors are the most critical “passive” fire protection components in a building. Unfortunately, it’s hard to believe, but in many facilities, as vital as they are, Fire Doors of the most neglected, underappreciated Fire Protection Systems in a building.

-In 2007, NFPA codes were changed – calling for every Fire, Smoke, and Final Egress Door in High-rise buildings to be Inspected and Tested at least annually and for written proof of the inspection to be made available for review by any Authority Having Jurisdiction (AHJ). The majority of State and local Fire Codes follow NFPA guidance.

HAVE YOUR BUILDING FIRE DOORS BEEN INSPECTED? ARE YOU SURE THEY’RE SAFE 

YOU SHOULD CHECK AND FIND OUT – YOU, YOUR FAMILY & FRIENDS LIVES MAY DEPEND ON YOUR BUILDING’S FIRE DOORS TO BE FIRE CODE COMPLIAN.T

Why is it required for Fire Doors to be Inspected Annually?

In 2007, a new edition of the NFPA 80 Standard for Fire doors And Other Opening Protective was issued.  A number of incidents had occurred where the loss of life was determined to have been caused by either inappropriately installed hardware, hardware that had not been maintained to operational standards, or where the hardware was tampered with to provide little or no protection to the lives of building occupants. The standard has always required that fire doors be maintained in good working condition. Since building owners are ultimately responsible for the maintenance and proper function of their structures, the NFPA, in concert with the AHJ community and other interested parties, decided it was time for individual property owners to inspect their fire door assemblies annually. The way this was accomplished was the revision of the NFPA 80 Standard, 2007, as a guideline to be used by The AHJ community to ensure that certain standards were met. On average it takes around three years for any jurisdiction to adopt and write into code from an NFPA Standard. So it was not until 2010 that jurisdictions started to make these standards part of their code.

What we have found as of 2023 was that even with this standard being adopted by most if not all jurisdictions, the law is still not being aggressively enforced. There are select communities that are starting enforcement, but still not enough. We as a community must insist that Fire marshals and other AHJ’s start enforcing these Codes and Standards. We feel that the AHJ’s jst need to start asking “Eight Simple Words” – Where – is – your – Inspection – Testing – Maintenance – Log – Book, those 8 words would simplify their job without costing them any additional money. AHJ’s already ask building management for other ITM Logs this would just be another one for them to review. This would greatly improve the buildings code compliance in their jurisdictions.

NFPA 80 Chapter 5.2.3.1 States that Functional testing of fire door assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

Fire Door FAQ’s

FLORIDA FIRE CODE
*Fire Door inspections are required at least annually, as stated in the 7th Edition of the Florida Fire Prevention Code Chapter 12.4.6.8.4.1. The Standard is taken from NFPA 80, Chapter 5.2.4.1

ANSWERS TO SOME OF BUILDING MANAGERS AND OWNERS MOST REPEATED QUESTIONS


1st Q – “Why do we need to have our fire doors inspected?”
A – Because it is part of the State & Local Fire Prevention Codes and a requirement of AHCA, CMS, and it’s the LAW!

2nd Q – “Isn’t checking Fire doors included in the Annual Fire Prevention Inspection by the Fire Department?”
A – It used to be before the Fire Prevention Code was changed, making Annual Inspections the responsibility of the building operators.


3rd Q – “That doesn’t seem fair. Aren’t fire inspections by our local Fire Dept (including doors)? Why do we pay our taxes and Assessments for Fire Protection? Why should the burden of fire door inspections and maintenance be on us?”
A – It has always been the obligation of the people responsible for the operation of the building to maintain the building’s fire, smoke & egress doors in code compliant working order.


4th Q – “Why was it changed to call for mandatory Annual Fire Door Inspection?”
A – The importance of code-compliant Fire, Smoke, and Egress doors to protect the public has become apparent. There also was the fact that Building Operators were not doing timely inspections and maintaining their “life-safety” doors: Lack of motivation has become a significant problem, and noncompliance has become widespread.


5th Q- “Why has inspecting “life-safety” doors become a problem for fire departments?“
A – Fire Prevention Inspections by local Fire Departments during an annual visit must cover so many different fire protection elements in a limited time and with little personnel. The number of Fire-doors, alone, in many buildings, can run from just a few to hundreds. In some extensive facilities, thousands are common, making Fire Dept inspecting every door virtually impossible.


6th – “What does AHJ stand for?”
A – AHJ stands for the Authority Having Jurisdiction… it can be a local or State Fire marshal or Code Enforcement official, ACHA, CMS, or TJC (if you’re a health care facility), or an Insurance Company representative, etc. Anyone who has the right to enforce the fire code on your facility.


7th Q – “We have never been issued a citation or notified by the fire department or anyone else, officially that we are in violation of the Fire Code because we could not produce written proof that each of our doors had been Tested & Inspected. No AHJ, has ever, asked to see our Fire Door inspection Report. How Come?”
A – Maybe because your building has been overlooked or just lucky. Official notices have been sent out by many departments to Property Managers (and have been ignored), and other Depts. are getting ready to send out notifications. But remember, there is an old adage “that ignorance of the law is no excuse.”


8th Q – “Why are they making such a big deal over the fire doors? Ours have been here for over 30 years with no problems. Why now?”
A –Because doors are used, normal wear and tear can turn a fully compliant door into a potential problem. In the life of the building, it only takes one time, one fire door, to fail to do its job. You need ALL your Fire, Smoke, and Egress Doors to work, and if even one doesn’t perform its function… people may die or get injured, or property is unnecessarily damaged because the fire, smoke or egress doors failed to do their job and didn’t confine the fire or smoke, and toxic gases from spreading. A minor fire that a properly operating fire door could easily contain could turn into a significant inferno- it’s better to be “safe than sorry.”


9th Q – “Have Annual Inspections proven their value?”
A – The Short answer is YES. Investigations of Building Fires – especially over the years in High Rise structures, show that noncompliance with Fire Safety Doors was a major contributing factor (over 82%) in the loss of lives and property. In buildings with
fire-compliant doors, the damage was minimal. Pressure is starting to build to enforce the Fire Door Inspection code rigidly. Frankly, the public is beginning to realize that all Fire Smoke and Egress doors are critical in high-rise buildings (over five stories) with only limited fire exits on each floor and no access to elevators. Entrance Doors to rooms and apartments leading into closed-in corridors are essential for safely leaving the building in the event of an emergency or a fire where “sheltering-in-place” is the recommended option.


10th Q – “ What does it take to be an Inspector? Can we inspect our doors?”
A – Yes, remember that the AHJ and the Fire and Life Safety Codes require Inspectors to know about the construction of Fire, Smoke, and Egress doors. Inspectors must be familiar with fire-rated door hardware, Fire Code requirements, materials, installation, locking, and latching capabilities. In addition, inspectors must have experience and recognize non-compliant items attached to or adjacent to doors. They also must be capable of compiling the ITM (Inspection, Testing & Maintenance) report. Inspecting a fire door properly takes a lot of experience and knowledge- that’s why most buildings let professionals like National Firedoor handle the job.


11th Q – “When it says ALL fire doors, does that mean the Apartment entrance doors?”
A – Yes! Apartment entrance doors, at the minimum, should have at least a 20-minute Fire Rating, a Closer, and a solid “fire-rated” Latch.


12th Q – “Who is responsible for inspecting the building’s fire doors?”
A – Owners, property managers, Association board members, etc. Anyone, If they are responsible for operating or managing a hi-rise building.


13th Q – “How much does the inspection cost?”
A – Obviously, many factors go into the total cost. To determine the exact amount, we need to sit down with you and discuss your service needs, wants, and desires. We need to survey your property- unless you have a complete “current” door schedule including each Fire, Smoke, and Egress door’s exact location in your facility, and then we will give you a free proposal on how to get your inspections underway.


14th Q – “What can the AHJs do to us?”
A –First, give you a time limit to comply, levy fines, bring charges in court, and in some severe cases, order Suspension of Operations. The worst-case scenario would be a fire with or without the loss of life but with extensive property damage because uninspected fire doors failed. Insurance Companies can raise premiums, deny claims, or refuse coverage. It could be costly if the State, City, or Civil lawyers charge or sue the responsible parties for neglect because they didn’t follow the fire code requiring the doors to be inspected and returned to Code-compliant condition. And lawyers always look for someone to blame. And if there is NO ITM book, it sets the stage for the Lawyers.


15th Q – “What is a full-Service Inspection package?”
A – A ITM report and individual Door inspection forms.
• Prepare the inspection results for inclusion in the final ITM report.
• If desired, supervise any repairs and replacements resulting from the inspections to bring each door up to full compliance.
• If some doors have unreadable “painted over” manufacturer’s labels. If the doors have been inspected and are considered compliant, they can be field relabeled.
• Deliver the ITM report to the client in printed or data format.

Center for Clinical Standards and Quality/Survey & Certification Group

REPOSTED FROM THE DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-16
Baltimore, Maryland 21244-1850

Ref: S&C 17-38-LSC
DATE: July 28, 2017
TO: State Survey Agency Directors
FROM: Director
Survey and Certification Group
SUBJECT: Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies
Background
The Centers for Medicare & Medicaid Services (CMS) adopted the 2012 edition of the NFPA
LSC, which includes requirements for the maintenance, inspection, and testing of fire doors and
smoke doors in certain certified health care facilities.
The 2012 LSC added new provisions under Section 7.2.1.15 – Inspection of Door Openings for
the annual inspection and testing of certain fire doors and smoke doors assemblies in accordance
with the 2010 editions of NFPA 80 – Standard for Fire Doors and Other Opening Protectives,
and NFPA 105 – Standard for Smoke Door Assemblies and Other Opening Protectives.
The new LSC provisions under sections 7.2.1.15.1 and 7.2.1.15.2 require certain fire door and
smoke door assemblies to be inspected and tested annually in accordance with the NFPA 80 and
NFPA 105. However, section 7.2.1.15.1 states that these requirements only apply where
required by Chapters 11 through 43. Therefore, as the LSC health care occupancy chapters (i.e.,
Chapters 18, 19, 20, 21) do not directly reference section 7.2.1.15, these new annual inspection
and testing requirement do not apply to health care occupancies.
Memorandum Summary
• In health care occupancies, fire door assemblies are required to be annually inspected and
tested in accordance with the 2010 National Fire Protection Association (NFPA) 80.
• In health care occupancies, non-rated doors assemblies including corridor doors to patient
care rooms and smoke barrier doors are not subject to the annual inspection and testing
requirements of either NFPA 80 or NFPA 105.
• Non-rated doors should be routinely inspected as part of the facility maintenance program.
• Full compliance with the annual fire door assembly inspection and testing in accordance
with 2010 NFPA 80 is required by January 1, 2018.
• Life Safety Code (LSC) deficiencies associated with the annual inspection and testing of
fire doors should be cited under K211 – Means of Egress – General.
Page 2 – State Survey Agency Directors
It should be noted that the LSC chapters for assembly occupancies, education occupancies, day
care occupancies, and residential board and care occupancies do directly reference 7.2.1.15.
Therefore, if a health care occupancy contains a separated multiple occupancy, the 7.2.1.15
requirement for annual fire and smoke door inspection and testing would be applicable to these
other occupancies.
Annual Inspection & Testing Requirements in Health Care Occupancies
Although the requirements under LSC section 7.2.1.15 are not applicable to health care
occupancies, annual inspection and testing of fire doors assemblies in accordance with NFPA 80
are still required in health care occupancies by LSC section 8.3.3.1, which is applicable to all
occupancy chapters.
In addition, with the exception of new doors in horizontal exits, the annual inspection and testing
of smoke door assemblies in accordance with NFPA 105 is not required per LSC section 8.5.4.2
as doors in health care occupancies are not required to be smoke-leakage-rated.
Conclusion
In health care occupancies, annual inspection and testing in accordance with the 2010 NFPA 80
is required for all fire door assemblies. Non-rated doors, including corridor doors to patient care
rooms and smoke barrier doors, are not subject to the annual inspection and testing requirements
of either NFPA 80 or NFPA 105. But, non-rated doors should be routinely inspected as part of
the facility maintenance program as all required life safety features and systems must be
maintained in proper working order. LSC deficiencies associated with the annual inspection and
testing of fire doors should be cited under K211 – Means of Egress – General.
Compliance Time Extension
CMS regulatory adoption of the 2012 LSC regulation was July 5, 2016, therefore the required
annual door inspections and testing would be expected by July 6, 2017. However, considering
the level of reported misunderstanding of this requirement, CMS has extended the compliance
date for this requirement by six months. Full compliance with the annual fire door assembly
inspection and testing in accordance with 2010 NFPA 80 is required by January 1, 2018.
Contact: If you have questions concerning this memorandum, please send them to
[email protected].
Effective Date: Immediately. This policy should be communicated with all survey and
certification staff, their managers and the State/Regional Office training coordinators within 30
days of this memorandum.
/s/
David R. Wright
cc: Survey and Certification Regional Office Managemen