Along with last week’s Fixed-it Friday photos, I asked some serious questions:

  • Is it a code requirement that fire doors must only be used where the fire rating is required?
  • Must the fire door label be removed if the fire rating is not required in that location?
  • Does the door have to meet the requirements for a fire door assembly (closer, latch, etc.) just because has a label – even if a fire door is not required for that location?

NFPA 101 does not prohibit fire doors from being used where a fire door is not required, and if a fire door is installed where it is not required, NFPA 101 does not mandate that the assembly must meet all of the requirements of a fire door assembly.  Labels are not required by NFPA 101 to be removed if the fire door is in a location where a fire door is not required.  I requested and received a staff opinion from NFPA to confirm the intent of NFPA 101.  The table in NFPA 101 which designates the ratings for opening protectives is called: “Table Minimum Fire Ratings for Opening Protectives in Fire Resistance–Rated Assemblies and Fire-Rated Glazing Markings,” and the ratings established in that table are the MINIMUM requirements.

Several of the comments on Friday’s post mentioned the following section of NFPA 101, as a reason that labeled doors must be maintained as fire door assemblies (even if not required) or that the labels must be removed:* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

A. Examples of such features include automatic sprinklers, fire alarm systems, standpipes, and portable fire extinguishers. The presence of a life safety feature, such as sprinklers or fire alarm devices, creates a reasonable expectation by the public that these safety features are functional.  When systems are inoperable or taken out of service but the devices remain, they present a false sense of safety. Also, before taking any life safety features out of service, extreme care needs to be exercised to ensure that the feature is not required, was not originally provided as an alternative or equivalent equivalent, or is no longer required due to other new requirements in the current Code. It is not intended that the entire system or protection feature be removed. Instead, components such as sprinklers, initiating devices, notification appliances, standpipe hose, and exit systems should be removed to reduce the likelihood of relying on inoperable systems or features. Conversely, equipment, such as fire or smoke dampers, that is not obvious to the public should be able to be taken out of service if no longer required by this Code. Where a door that is not required to be fire protection-rated is equipped with a fire protection listing label, it is not the intent of to require such door to be self- or automatic-closing due merely to the presence of the label.

I understand the intent behind this section…if a building occupant sees a fire extinguisher, they would expect it to work – even if it’s not required in that location.  But is the label on a fire door “obvious to the public”?  If a building occupant sees a 90-minute label on a fire door, but the wall does not offer the same level of protection, does this put the building occupant at risk?  Again – I requested a staff opinion from NFPA, and the staff member stated that a non-required fire door is not a feature that is obvious to the public in the context of paragraph  The last line from Annex A section A. (underlined above) was added in the 2015 edition of NFPA 101, and illustrates that the label is not required to be removed if the fire door is installed where it is not required, and that the door is not required to meet the requirements of a fire door assembly.

It’s possible that when an AHJ sees a labeled door, he or she may require the door to be compliant (as in my Fixed-it Friday post) unless the building owner can provide documentation showing that the door is not required to be fire rated.  To avoid this, it may be easier to remove the label if it is not required.

As always, the AHJ has the final say, and for many health care facilities, the Joint Commission is the AHJ responsible for accrediting the facility.  The Joint Commission’s current position is that a fire door assembly needs to match the level of protection provided by the wall, and that NFPA 101 section does apply to fire door assemblies.  Given the renovations to health care facilities that may have resulted in a reduction in required fire resistance, along with fire doors that were originally installed where not required, ensuring that fire door labels match the rating required by NFPA 101 is a major undertaking.  I’m hoping to receive further clarification to resolve the difference between the NFPA 101 staff opinion and the Joint Commission position, and I will report back as soon as I do.

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