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.”
In 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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“”number of failures””
Is this defined also?
If only a label is missing is that a failure?
If the label is painted is that a failure?
Or does a door have to have multiple problems, or is it up to the inspector, if it is a failure or not?
I agree with the Joint Commission. Only one failure is necessary for a catastrophic event. Additionally, Annexes contain only information and references, they are not code requirements . Not sure why, if this practice is permitted, that it would appear in the Annex.
Lori
CMS and The Joint Commission back in the day allowed 5% failure rate of total door inventory as part of the Hospitals Building Maintenance Programs.
However,now it’s a “see it and cite it” approach during a building survey.
Lori .none that I know of here . But I may not be privy to that information
I would never base inspection of fire doors in a hospital on some performance basis because I have walked past a normally functioning door with a Joint Commission inspector only to find a damaged door when we walked back by it an hour later!. To me, these doors are too vulnerable to damage from moving things like portable x-ray machines, and beds to say they will perform, no matter how well constructed base on past performance. Sometimes the fasteners used work loose. Years ago, I had an obstetrics physician blast the maintenance department for a door problem he had in the sleeping room, It seems like every 6 months or so, the door would stick in the frame and when an on-call person tried to quietly come in, it would rattle, waking the sleeping on-call folks. They dutifully reported it at least 4 times in two years. Each time a different maintenance person went up to fix it, found the hinge screws were loose, tightened them and went away. When the angry physician finally talked directly to me, I went up, found the same problem, researched it in the work order data base of about 20,000 work orders per year of all types and found the door by the number we assigned all doors individually. The problem was fixed for good, at least for a number of years by using a little wood glue on the screw threads. Over the years, the physician approached me several times to tell me how adequate the fix was. I think he was embarrassed by assuming the worst of the maintenance folks. My point is there were many instances of various door problems that show up in a large hospital and although I always desired to place the maintenance labor doing productive things, unfortunately, door maintenance and inspection were a productive use of time – particularly when the doors were labeled. and thus an important part of the compartmentation concept needed for patient safety.