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Jul 22 2014

NFPA 101 on Fire Door Inspection

Category: Egress,FDAI,Fire DoorsLori @ 12:22 am Comments (11)

NFPA-101-2012Last week I was asked whether the 2012 edition of NFPA 101 – The Life Safety Code requires annual fire door inspections for health care facilities.  As many of you know, the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) will soon be using the 2012 edition of NFPA 101 when they survey health care facilities.

I immediately answered that yes, health care facilities would be required to have annual inspections of all fire doors, because the 2012 edition of NFPA 101 references the 2010 edition of NFPA 80 – Standard for Fire Doors and Other Opening Protectives, and NFPA 80 has required annual inspections of fire doors since the 2007 edition.  Section of NFPA 101-2012 says that openings required to have a fire protection rating must be protected by fire door assemblies or fire window assemblies in accordance with NFPA 80, which includes annual inspections.

But what about section – Inspection of Door Openings?  This section describes both egress door inspections and fire door inspections, and states that door assemblies must be inspected and tested at least annually where required by Chapters 11-43 – the occupancy chapters.  The chapters that reference section are Chapters 12 and 13 (Assembly occupancies), 14 and 15 (Educational occupancies), Chapters 16 and 17 (Day-care occupancies), and Chapters 32 and 33 (Residential Board and Care occupancies).

My world shifted on its axis…had NFPA 101 excluded all other occupancy types from the requirements for annual inspections?  The NFPA 101 Handbook gave me some hope, by stating: “Fire-rated door assemblies are required by to be in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80 requires fire-rated door assemblies to be inspected and tested in accordance with the criteria contained in that document. The requirement of is redundant in that it applies even if it were not included as part of the provisions of It is helpful to the Code user to have the road map to the complete package of inspection and testing criteria for door openings presented in one place.”

For further clarification I asked NFPA for a staff opinion (did you know that becoming a member of NFPA means that you are allowed to ask questions?!).  NFPA’s Technical Questions Service does not provide formal interpretations but their responses are usually very helpful in understanding the intent of the codes and standards.  This is NFPA’s response, which the NFPA staff member has give permission for me to post here: “All fire doors must be inspected annually.  NFPA 101 does not intend to change that provision from NFPA 80.  The provisions in NFPA 101 require additional specific egress doors, that may or may not be fire rated, to also be inspected if the occupancy chapter requires it.”

I covered egress door inspections in a recent article in Doors & Hardware, which is available on the Articles page of this site.  Inspections of certain egress doors is required for the 4 occupancy types I mentioned above.  Because fire door inspections are also mentioned in that section, this could cause confusion about where to apply NFPA 80’s requirements for fire door inspection.  But the intent is that all fire door assemblies are inspected and tested annually by a qualified person, with documentation of the inspection retained for review by the Authority Having Jurisdiction (AHJ), and any deficiencies repaired without delay.

For more information, contact the AHJ for your project or consult the applicable code.  Or if you have questions you can leave a comment below and I will do my best to get you an answer.

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11 Responses to “NFPA 101 on Fire Door Inspection”

  1. Gerald Austin says:

    As far back as I go in being responsible for directing the operation and maintenance of health care organizations is 1967. NFPA 80, 1967 Edition was incorporated under the Appendix B in NFPA 101 1967 Edition and I believe maintenance issues have been by an large found in the NFPA 80 documents. In later years the NFPA changed the word “supplemental” to what is in the NFPA 2000 Edition of Life Safety Code which is the current CMS and Joint Commission quoted standard, about to change to the 2012 I am told although I finally retired earlier this year so I am out of the loop so to speak. From the time I first assumed responsibility for this type of occupancy, I acquired the mandatory references and tried to apply them to the buildings. During my very first Joint Commission inspection, doors, their installations, their construction and their hardware played a big part in my life as did the other separation components such as walls, shafts, by way of example. Indeed the very first inspector I met, the daughter of a Boston fire chief found my new workplace had a 4 story nursing home with hollow wood doors – my first Joint Commission inspection caused project.

    One change that has occurred as the result of fire sprinkler requirements is that many portions of corridor walls are no longer requiring fire rating although most of the doors would at least meet a 20 minute rating or more, this is not a requirement. These non-rated corridor doors have not required closers in many years although they must be fitted with hardware that will hold them firmly closed. The change made good sense to those of us in the hospitals because automatically closing the doors and latching them had a high risk of trapping a patient inside the room if the smoke had not made it to the doorway to alert staff to which of the many doors to open to find the fire. These unrated corridor walls are still important for smoke movement control and they result in many maintenance hours every year inspecting every inch about the ceilings. My hospitals had someone dedicated to doors and walls.

    Over my career I worked at 3 different metropolitan hospitals. I observed something similar in each hospital. Installers who are installing both fire rated hardware and panic hardware, do not know the distinction between them for the most part. It is super easy catch this error by looking for the means to dog a panic bar or push-plate (hole in the plate for a hex wrench) AND I have found this problem in nearly every building for which I have been responsible. We were often able to correct this by looking for the outside door that had unnecessary fire rated hardware of the same configuration, and interchanging it with the improperly used panic bar hardware.

    One thing about being retired, you are not compelled to be brief so sorry for the long, maybe irrelevant discussion.

  2. al says:

    what is the hardware requirement on a rated Dutch door. also at what height should the top of the shelve be to meet ada

    • Lori says:

      Hi Al –

      Each leaf has to have an active latchbolt, the top leaf has to be self-closing or automatic-closing (automatic-closing is typical), and an astragal is attached to the pull side of the top leaf overlapping the bottom so when the top leaf closes, the bottom does too. Depending on the door manufacturer, the latches may both have to project into the jamb (which creates an egress issue), although some manufacturers’ listings allow the top leaf to latch into the bottom leaf. Steelcraft can label this application and you avoid the egress problem that way.

      Dutch door shelves aren’t specifically addressed in the accessibility standards, but if you go by the requirements for sales and service counters, the maximum allowable height of the counter is 36″ above the floor. This is a problem because the range for operable hardware is 34″-48″ above the floor, and the latchset needs to be in the bottom leaf (if it was in the top leaf you could release the latch but the bottom leaf would still be closed). I am going to ask the ICC for their opinion on this and I will write a post when I hear back from them.

      The other thing to consider for dutch door shelves is that the shelf can’t project more than 4″ into the required clear opening width when the door is open 90 degrees.

      – Lori

  3. Jon Pitcock says:

    I have a question For health care corridor doors leading to patient rooms. They are not required to be fire rated but be constructed to meet at least a 20 min. rating, latch and resist the passage of smoke. Would these doors need to be inspected annually or not?

    • Lori says:

      Hi Jon –

      That’s a really good question. Although some people would call these “smoke doors” because they’re in a smoke partition and designed to resist the passage of smoke, the doors are not required to meet NFPA 80 or NFPA 105, so I don’t think they would have to be inspected annually. I will ask the Joint Commission and see if I can get an answer.

      – Lori

  4. Jim ELder says:

    “Latching and locking devices comply with” What is the specific way you test this? Open the door all the way and let it close? open the door half way? Let the latchbolt touch the strike and release?

  5. Mohammed Abdul Razak says:

    thank u for NFPA knowledge And E learning

  6. Joseph Glaski,MBA,FASHE says:

    Hi Lori,

    Here is the new Joint Commission standard effective 1-7-2017 for complying with fire door inspections. Please not that NFPA 105 is also referenced.

    EC.02.03.02 EP 25: The hospital has written documentation of annual inspection and testing of door
    assemblies by individuals who can demonstrate knowledge and understanding of the
    operating components of the door being tested. Testing begins with a pre-test visual
    inspection; testing includes both sides of the opening.
    Note: For additional guidance on testing of door assemblies, see NFPA 101-2012:;; NFPA 80-2010: 4.8.4; 5.2.1; 5.2.3; 5.2.4; 5.2.6; 5.2.7;; NFPA 105-2010: 5.2.1.

    Last week the NFPA and Door Safety Foundation provided a one day education session in Quincy MA on fire door compliance.

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