This article was published in the April 2020 issue of DDoor Security + Safety
.
In recent years, the increased enforcement of annual fire door assembly inspections has brought new focus to the condition of existing fire doors. Many questions have resulted – some of which have not been specifically answered by the codes and standards. In the absence of prescriptive code language, the interpretations are left up to the Authority Having Jurisdiction (AHJ), and this sometimes leads to inconsistent enforcement.
A change was made to the 2021 edition of NFPA 101 – Life Safety Code, which will help to clarify an issue that has been a source of confusion. The question: If a labeled fire door is installed in a location where a fire door is not required, must the assembly be maintained and inspected according to the requirements of NFPA 80 – Standard for Fire Doors and Other Opening Protectives?
It’s quite common for labeled fire doors to be found where they are not mandated by code. For example, the door may have been moved from its original location, or a wall that was once fire-resistance-rated may no longer require that level of protection due to the addition of an automatic sprinkler system. If a door assembly must be maintained and inspected per NFPA 80 just because the door has a label on it, this could result in expensive and unnecessary work which has no impact on life safety. What is the point of having a code-compliant fire door assembly in a wall that will provide little resistance to the spread of fire?
Intent of NFPA 101
NFPA 101 mandates the minimum fire ratings for opening protectives in fire-resistance-rated walls. This is a MINIMUM requirement – there is no language in the code that would prohibit a door with a higher rating from being installed, and the code does not restrict fire doors from being installed where they are not required. If a fire door is installed where a rating is not needed, NFPA 101 does not mandate that the door, frame, and hardware meet all of the requirements of a fire door assembly.
A label is not required by NFPA 101 to be removed if the assembly is in a location where a fire door is not required, although removing an unneeded label is not prohibited by the code. It may be advantageous to remove extraneous labels to avoid confusion during an inspection. For example, if an AHJ sees a labeled fire door without a door closer, he or she may initially believe that the door is a fire door assembly that is not self-closing; this would be perceived as a deficiency. The facility manager would then have to prove that the rating is not required. It’s important to note that once a label is removed, it can’t be reattached by facility personnel. The assembly would have to go through the field labeling process as described in NFPA 80.
AHJ Interpretation
Questions about extraneous labels have been caused by a section of NFPA 101 which states that “Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.” The motivation behind this requirement is the idea that if a building occupant sees a life safety feature and assumes that it is functional, they might make decisions based on that assumption. For example, if the occupant of an apartment sees sprinkler heads in the ceiling, they may shelter in place during a fire, based on the protection provided by the sprinkler system. But maybe the building owner shut down the sprinkler system because of a leak and never repaired it. Even if the building pre-dates the sprinkler requirements and the sprinkler system is not mandated by code or local ordinance, NFPA 101 requires the system to be maintained or removed, so that life-or-death decisions are not based on bad assumptions.
The big debate has been whether a label on a fire door or frame is something that would be “obvious to the public”, and whether it might cause someone to assume that they would be protected by the fire door during a fire. If the door was labeled but was not fully compliant with NFPA 80, the building occupant would not have the expected protection provided by a complete and code-compliant fire door assembly in a wall that meets the requirements for a fire barrier. The door might have a label, but perhaps it is not self-closing or self-latching, or does not have the proper glazing, or the wall does not offer the correct level of fire protection based on the door label.
The general consensus was that most building occupants would not notice the fire door label, or wouldn’t understand the implications, but some AHJs continued to require fire door labels to be removed if not required. In some cases, AHJs were also requiring the fire door assembly label to match what was required for that location – no more, no less. If a 45-minute door was required, the interpretation was that a 90-minute door could not be installed. The common interpretation in years past was that the fire rating of the overall assembly was equal to the rating of the lowest-rated component. As long as that rating was equal to or greater than what was required, the assembly was acceptable – a 90-minute door in a 3-hour frame could be installed in a location that required an opening protective rated for up to 90 minutes.
In the 2015 edition of NFPA 101, a line was added to the annex information for the section of the code addressing obvious life safety features, stating: “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 4.6.12.3 to require such door to be self- or automatic-closing due merely to the presence of the label.” The intent of this change was to clarify that door assemblies with a labeled component were not required to be treated as fire door assemblies if installed in a location where an opening protective was not required. Despite this clarification, some AHJs continued to require fire doors with extraneous labels to be inspected and maintained in accordance with NFPA 80, even though there was no life-safety benefit.
2021 Clarification
A new paragraph was added to the 2021 edition of NFPA 101, which further clarified the intent of the code:
“4.6.12.4 Where a door or door frame that is not required to be fire protection-rated is equipped with a fire protection listing label, the door and the door frame shall not be required to meet NFPA 80.”
The problem statement submitted as part of the code development process referenced the 2015 change to Annex A. Although that change was intended to clarify that the requirements of the section were not meant to pertain to fire doors, interpretations were still inconsistent. Facilities were being cited by AHJs for non-compliant fire door assemblies – even when those assemblies were installed in locations where a fire rating was not required. This was because some AHJs were interpreting fire doors and frames as being life safety features that were obvious to the public.
The new paragraph in the 2021 edition of NFPA 101 is very clear. If a door or frame has a label and is installed where a rated opening protective is not required, the requirements of NFPA 80 do not apply. Although a code change does not technically take effect until that edition of the code is adopted, this change is more of a clarification and the hope is that it will begin to affect AHJ interpretations immediately.
The new code language makes it clear that extraneous labels can remain, without prompting additional requirements. The intent of NFPA 101 is that only the required opening protectives indicated on a facility’s life safety drawings must be maintained in accordance with NFPA 80 and must be inspected annually. As always, the AHJ has the final say and should be consulted for their interpretation of the adopted codes.
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My feeling here is it just adds to the already confused. (AHJ) . Especially if they have not investigated the building structure or status. Not to mention the liability issues that could arise.
So one assumes that a fire rated door is (unbenonst to them installed into a non rated wall ) going to provide them adequate protection in the event of a fire however when the wall fails and the fire spreads who theñ is at fault. I see bad things arising .
Hi Lori,
In Healthcare this has become an issue dung the fire door inspection process, however in the FINAL MINUTES
Healthcare Interpretations Task Force posted on Tuesday, June 15, 2016 at the Mandalay Bay Convention Center
South Convention Center, Level 2 – Room Surf F, Las Vegas, NV agrred the labels can be removed if not required to protect the opening. Recently CMS has approved to allow covering the fire door label or obstructing the label i.e place tape over the fire label on the door if not required for protecting the opening.
Joseph A Glaski, MBA, FASHE, CFDAI
Hi Joe –
Do you have any documentation of the CMS policy allowing labels to be covered instead of removed?
– Lori
Some 30 years ago, when I worked at a university, we did a lot of our own remodeling. The carpenter shop always bought rated wood doors because they were the same price (or close to it) as non-rated wood doors. It saved inventory costs and the doors were always correct if they went into a rated opening. Unfortunately, labels were never removed when the doors went into a non-rated opening.
Hi Roger!
Yes, there are zillions of labels out in the world where they are not needed. I think it’s great that this has been clarified because trying to deal with all of those doors would be an expensive proposition and would serve no purpose other than to avoid confusion. There must be a better way – like going by the life safety drawings rather than assuming that every door with a label is a required fire door assembly.
– Lori
This has been an ongoing problem since some manufacturers provide stock doors with fire labels attached at the factory.
Lori, it is good that those that write the Life Safety Code® have clarified this item. Now we need to propose a means to mark these doors and door frames, particularly those that are existing, so that the AHJ/inspector can readily identify which ones need to comply with the inspection, testing and maintenance requirements of NFPA 80 and which ones don’t, so we are not wasting our precious inspection resources trying to figure it out.
I agree, Dwight. Any ideas about how you would like to see these extraneous labels marked in the field? Many end users are not comfortable removing them, since they can’t be reattached if there is a mistake or the door gets moved to a new location later. Maybe I need to have an Etsy store with “NOT A FIRE DOOR ASSEMBLY” labels and other random door stuff as my retirement gig. 😀
– Lori
Crazy that this was on here yesterday.
I took one of my kids to the Y last night and saw a public restroom door held open with a kickdown stop (already a problem with the clear space at the bottom for ADA purposes), but my big issue was actually the fire label on the frame. I didn’t see a label on the door, and pulled my door mirror out of my purse and the wood label on the top of the door indicated it was just standard particle core with no rating. I wondered what the stance was on a labeled frame in a non-labeled assembly. Thanks for posting this!!
I LOVE THAT YOU PULLED YOUR DOOR MIRROR OUT OF YOUR PURSE! 😀
– Lori
“Never leave home without it!”
#priorities
In my own life, I do find myself checking rated doors for labels and looking at the hardware out of habit. I would never have the time in a fire situation to try and determine my safety from either doors or walls but would head outward, hopefully directed by exit directional signs as required. Exit signage and egress lighting would be more important along with smart owners who keep their corridors clear of obstructions.
I am still amazed to walk by a door in someone’s building with a 90 minute label on the door but the door hardware label says: “Panic Hardware”. The means of dogging the door in an unlatched state is often visible from 50 feet! I have found this deficiency in probably 30 buildings in my lifetime. In one new building I found the Panic Hardware on the fire separation doors and the Rated Hardware on the door to the outside (nothing around the discharge point to rate a door.
I’m with you Jerry – I ALWAYS look at fire doors but during a fire I would not stop and think…”Hey, this is a 90-minute door – I’ll just hide in here and I’ll be safe for the next hour and a half.”
The panic hardware vs. fire exit hardware is a constant problem…like lock functions being switched or the closer mounted on the wrong side of the door. I’m not sure what the answer is, other than to get more people noticing and having consequences for incorrect installations.
– Lori
Lori
Sorry for the delay to your question. Here is the psot from The Joint Commission and CMS directive as to obscuring the fire door label on a fire door if not needed.
Joe
Are You Using Fire Doors
Where Not Required?
IF YOU OBSCURE THE LABELING ON AN UNNECESSARY FIRE DOOR, THE JOINT
COMMISSION WON’T CITE YOU AND YOU WON’T NEED TO INSPECT THE DOOR
The Department of Engineering in The Joint Commission’s Standards Interpretation
Group (SIG) receives many questions about fire doors. These questions are
addressed under Element of Performance (EP) 9 of “Life Safety” (LS) Standard
LS.02.01.10: Building and fire protection features are designed and maintained to
minimize the effects of fire, smoke, and heat. (See the box at right.)
In response to a Centers for Medicare & Medicaid Services (CMS)
requirement,* in January 2018 The Joint Commission began requiring
hospitals, critical access hospitals, and ambulatory sites to perform annual
inspections of fire-rated door assemblies.
When The Joint Commission’s life safety surveyors conduct a building tour,
they ask to see life safety drawings that indicate the location and rating of
all firewalls. Surveyors then inspect the corresponding fire door assemblies
to make sure that they have at least the correct rating and that their labels
are legible.
It is not uncommon, however, for fire doors to be used where they are not
required. Perhaps during new construction or remodeling, the contractor
may have obtained “a great deal” on fire doors and determined it would be
less expensive to install, for example, surplus 90-minute fire-rated doors in
some of the unrated walls. What would be the harm, after all?
But the problem is that these doors create confusion among some hospital
maintenance staff members. Do all fire-rated doors—even those in unrated
walls—require an annual inspection? This is a question that the Joint
Commission engineering team is frequently asked. And the answer is no.
However, if you are using a fire-rated door where it’s not needed, we want
you to obscure the rating label on that door. You don’t need to paint over
the label or try to scrape it off because you then would deface the door.
At some point in the future—during a remodeling project perhaps—your
facility might want to relocate that door to a barrier wall where it is needed.
Fortunately, vendors actually make stickers specifically for covering
fire-rating labels, which leave the original labels intact.
So, if you cover the label on an unnecessary fire door, The Joint
Commission will not cite your facility for not inspecting that door.
If you have further questions, please contact SIG Engineering at
(630) 792-5900. EC
That’s great info to have – THANK YOU!!
– Lori
Lori,
Great article but I’d like to point out one little detail.
In the third paragraph you said “What is the point of having a code-compliant fire door assembly in a wall that will provide little resistance to the spread of fire?”.
That statement kind of contradicts the “close before you doze” campaign where it is pointed out that even a closed hollow core door provides considerable protection.
Hmmm…good point. What would you say instead?
– Lori
I would eliminate that sentence/question entirely and not say anything else.
I think trying to explain that all doors provide some level of protection would detract from the main idea of the article.
If you have a fire door in a smoke wall.You must maintain the rating of that fire rated fire door. So when they change it down the road from a smoke wall to a fire wall you will be code-compliant fire door.You will save money down the road. Do Not Remove The Labels it will cost more money to relabel it again.
Lori,
Sorry I am late to the conversation. Here are some of my thoughts on this issue:
1. I am part of the public and those labels ARE obvious to me. I wonder if I should take offense to the idea that maybe there a some at NFPA that think that I, or anyone in our industry for that matter is not a part of the public. Do I look for those labels during a time of fire emergency? No. I do however rely on their ability to keep me and my family safe. Now I am be a bit on the extreme here but I look for those labels as well as other LS elements and make mental notes of their locations the first time I walk into an unfamiliar building. I also look at egress paths for obstructions anytime I walk into an establishment. I even have my wife doing the same things. A time of fire emergency is not the time to be searching for these components or paths of egress. Good prior awareness of these things makes for a much better chance at getting out safely.
2. Not all buildings have CURRENT or even a set of LS Plans available or in existence for the AHJ or Inspectors to review to determine if that opening should be rated or not. As an Inspector, I have even received Emergency Evacuation Plans (the kind you see hanging on a wall near a room exit or in a hallway) that have been highlighted with black marker to indicate where a facility employee thought the barriers might be, because that is the best they could provide. I have also received numerous LS Plans that don’t even resemble the current floor layout. I am not sure if it is a standard or requirement for construction projects to have an updated LS Drawing done or not. And what about those facilities that do their own renovation projects without consulting an Engineering or Architectural Firm prior to the project. The only advice I can give to these types of facilities are to make sure they get their current LS Plans corrected and updated or to hire an Engineering Firm that specializes in locating Fire Barriers and the requirements of current codes at the time of their last renovation to ensure that the required Fire Barriers are not only identified but that the existing construction of such Barriers is correct.
3. With regards to the removal or obscuring of the not-required labels, I feel that there needs to be some kind of checks and balances system in place prior to the removal or obscuring of these labels that will ensure that they are not inadvertently being removed, obscured or even worse, being removed, obscured to cut costs of inspections. I recall a press release from a State Fire Marshal’s office back in Oct of 2018 that had a company in their state that was selling on the companies website, a label that was intended to cover/decommission the existing Fire Label. The press release stated that it was a violation of their state fire code. In all fairness, I have tried to pull that link to the article back up and the site says it can’t be found. Even your post on Oct 9th, 2018 on this site entitled “Fire Door Decommissioning Labels” says that it can’t be found anymore. Maybe this issue was resolved somehow. I do believe that part of the issue was that the process of going through the Plan and Review stages where being bypassed which was leaving an opening to having rated assemblies erroneously being “decommissioned”. I have to say I don’t presume to even begin to know what a checks and balances system would look like. I just think that there are much smarter people in our industry that need to take a serious look at this and soon.
Just my thoughts on this.
Paul
Lori,
As an installation contractor and an FDAI, What if it was suggested that at the time of the inspection of a project or campus that the fire life safety plan be reviewed and updated for each inspection made with the records required to be recorded and made available for the next annual inspection as part of the annual inspection requirement. It may seem like a lot more work to start off with but once it was the standard those “what are they openings” would have a record to follow all the changes and then KNOW what the opening really should be. I have been the subcontractor called in to correct just this kind of issue, one on a casino project with their own fire marshall and independent inspecting AHJ that came across an opening that had a labeled door in an unlabeled frame. this was fine as this wall was not a fire wall but as it was stated by another commenter the AHJ saw a label on a door with no closer and no frame label. THat area was not allowed to be used until that door frame was field labeled, even though it was not needed or required per the building plans nor the Fire Life Safety plans. This was a situation where do I as the subcontractor correcting someone else work push the point to the AHJ and Fire Marshall that they are incorrect in there request or as I did just bring in a relabeling lab to provide a new label for the frame and install a closer ffor the opening.
Hi James –
I’m a big fan of investing some time upfront to make things easier and more accurate the next time. It may be tough to get someone to pay for it though.
– Lori
Where can I find information on what is and is not considered a fire door? I work in a Retirement Community with different occupancies – residential and, healthcare. As a newbie to the field, I was surprised at how many doors are NOT labeled within my complex!
Thanks
Hi Alena –
There are specific locations that are required by code to have fire door assemblies, for example, stairwells, residential apartment entries, some hazardous locations. The doors and frames in openings that are required to be fire door assemblies will typically have labels on the edge of the door and in the frame rabbet.
– Lori
We have a Fire Door/frame that is missing the fire rating labels.
Is there anyway to get replacements? Not positive who the manufacturer is.
Thank You
Lynn
Hi Lynn –
To get new labels, the openings will have to be inspected and re-labeled by someone who is certified to perform that service.
– Lori
I have someone who inspects the doors they said they cannot issue labels.
Do you know who/where to find someone to do that? I am in Illinois 1 hour south of Rockford.
Thank You
Hi Lynn –
UL and Intertek can perform this service. Or you can check this list for your local Allegion Code Expert (ACE): https://idighardware.com/ace-network/, and they may know of a lab nearby that can relabel fire doors and frames in the field.
– Lori