Last 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 184.108.40.206 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 220.127.116.11 – 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 18.104.22.168 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 22.214.171.124 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 126.96.36.199.2 is redundant in that it applies even if it were not included as part of the provisions of 188.8.131.52. 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.