The final winners of the 10th anniversary contest are Barry Caesar of Bay Lock & Alarm (Yeti cooler) and Brandon Griffith of ESa (Yeti tumbler).  Congratulations to all the winners!  I will be sending each of you a form by email and we will ship out all of the prizes shortly!

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In NFPA 80 – Standard for Fire Doors and Other Opening Protectives, the requirements for the inspection of fire door assemblies are found in Chapter 5.  Fire door assemblies are typically required to be inspected after installation and after maintenance work, in addition to being inspected annually.

Annex J details an alternative to the annual inspection, where fire door assemblies may be inspected less frequently when allowed by the Authority Having Jurisdiction (AHJ).  NFPA 80 states: “The goal is to balance the inspection frequency with proven reliability of the assembly. The goal of a performance-based inspection program is also to adjust test and inspection frequencies commensurate with historical documented equipment performance and desired reliability.”

NFPA 80In a nutshell (an overly-simplified nutshell), if there is data to show that a facility’s fire doors are in great shape (reliable), the AHJ may allow the amount of time between documented fire door assembly inspections to be extended.  Annex J uses a formula that calculates the fire door failure rate (FDFR) based on the number of failures (NF), the total number of fire door assemblies inspected or tested (NC), and the time interval of review in years (t).  This requires the collection of a lot of data over an extended period of time.

One of the critical factors in the performance-based option is for the AHJ to decide what the allowable failure rate is.  As some health care facilities are considering the performance-based option, I asked the Joint Commission whether they allow this in the facilities they survey, and if yes, whether there is established criteria regarding the maximum allowable failure rate.

As of last month, the Joint Commission’s response was that they do not accept the performance-based option for fire door inspections.  Their expectation is that all fire doors are inspected annually and any deficiencies corrected within 60 days* – with interim life safety measures in place until the deficiencies are corrected.

Do you know of a facility that is using the performance-based option, with approval from the AHJ?

If yes, what is the allowable failure rated that has been approved?

Is the performance-based option a viable solution?  WWYD?

*Note that NFPA 80 requires deficiencies to be corrected “without delay” and the Joint Commission has defined that time frame as 60 days.

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