Where is it stated in the codes that fire door assemblies must be inspected annually?

The detailed requirements are found in NFPA 80, which is referenced by the model codes. The adopted fire code is typically enforced throughout the life of the building, so requirements for annual inspections would be found in the fire code rather than the building code. The majority of states adopt either the International Fire Code (IFC) or NFPA 1 – Fire Code which references NFPA 101 – Life Safety Code.

Always consult the fire code that has been adopted where the building is located, as some states and local jurisdictions modify the model codes. Look for the inspection and maintenance requirements for fire doors and a reference to NFPA 80. For example, the IFC states: “Opening protectives in fire-resistance-rated assemblies shall be inspected and maintained in accordance with NFPA 80.” NFPA 1 includes detailed information that is consistent with NFPA 80, as well as additional guidance in Annex A. NFPA 101 references the inspection and testing requirements of NFPA 80 in Chapter 8: “Fire door assemblies shall be installed, inspected, tested, and maintained in accordance with NFPA 80.”

Are newly-installed fire door assemblies required to be inspected?

While the adopted fire code is typically enforced for existing buildings, the adopted building code applies to buildings during the design and construction phases. The International Building Code (IBC) is the most widely-used building code in the U.S., and references NFPA 80 for the installation of fire door assemblies: “Opening protectives required by other sections of this code shall comply with the provisions of this section and shall be installed in accordance with NFPA 80.”

Beginning with the 2013 edition, NFPA 80 requires fire doors, fire shutters, and fire window assemblies to be inspected and tested upon completion of their installation, and also upon completion of maintenance work. By reference, the 2015 edition of the IBC and subsequent editions require fire door assemblies to be inspected after they are installed, in addition to the recurring annual inspections required by the fire code.

Which types of facilities are required to conduct annual fire door assembly inspections?

The model codes and NFPA 80 do not differentiate between occupancy types when it comes to fire door assembly inspections; the inspection requirements apply to fire doors in all types of facilities. However, enforcement may vary locally. Health care facilities that receive funding from the Centers for Medicare and Medicaid Services (CMS) must conduct and document fire door assembly inspections, since the 2016 adoption of NFPA 101-2012.

Even if a state or local fire marshal is not widely enforcing the annual inspection requirements, it is likely that hospitals or nursing homes within that jurisdiction must perform fire door inspections due to enforcement by CMS.

What qualifications or certifications are required for fire door assembly inspectors?

NFPA 80 requires visual inspections and acceptance testing to be performed by a qualified person with knowledge and understanding of the types of assemblies being inspected. A qualified person is someone who has the knowledge, training, and experience to conduct inspections, and who may demonstrate their ability by possession of a degree, certification, professional standing, or skill. Although a certification is not specifically required by NFPA 80, it may help an AHJ determine whether an inspector has the required expertise.

There are many circumstances where a fire door or other component with a label may be installed in a location where an opening protective is not required. A door may have been relocated from another opening, the configuration of the building may have changed, or a facility may stock labeled doors – especially labeled hollow metal doors or 20-minute wood doors where the difference in cost is minimal but the door is more versatile.

Although the presence of a label on a door or frame may cause confusion for an AHJ or fire door inspector, the model codes do not prohibit labeled components where they are not needed and do not mandate periodic inspections of these openings. There has been some controversy about this, as NFPA 101 requires life safety features that are obvious to the public to be maintained or removed if not required by code. Some AHJs considered labeled fire door assemblies as life safety features that are obvious to the public, but it appears that this was not the intent of NFPA 101. A change has been proposed for the 2021 edition of the Life Safety Code, which states, “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.”

Based on this proposed change, extraneous labels could remain, without requiring the opening to be maintained as a fire door or inspected annually. However, some AHJs may continue to require these openings to be maintained and inspected as fire door assemblies as long as the labels are present. If it is determined that a labeled component is not required in a particular location, the labels can be removed or covered, depending on the policies of the AHJ. Note that once a label is removed, it can not be reattached.

What are the basic criteria that are verified during a fire door assembly inspection?

1. Labels are present and legible. If a label is missing from a component of a fire door assembly, the component may need to be field labeled by an authorized labeling service.

2. No holes or breaks in the door or frame. NFPA 80 addresses the acceptable means for filling fastener holes; other holes must be treated as a field modification as outlined in the standard.

3. Glazing and glass kit / glass beads are intact and securely fastened. Recent editions of the codes and standards require glazing in fire door assemblies to be labeled with information referencing applicable standards for impact resistance and fire testing.

4. Door, frame, and hardware are in proper working order. Assemblies must be visually inspected from both sides, and acceptance testing includes closing the door by all means of activation.

5. No missing or broken parts. If deficiencies are noted, they must be repaired or replaced “without delay.” Although this time frame is not defined in the codes and standards, some AHJs require deficiencies to be addressed within 60 days.

6. Door clearances are within allowable limits. The limitations of NFPA 80 apply to the installed condition of the assembly; manufacturing tolerances are not intended to be added to the maximum allowable clearance. Standard gasketing products are not likely solve clearance problems; to address excessive clearance, products must be listed for use on openings with clearances in excess of what is allowed by the standard.

7. Door closer / spring hinges are operational and the door is self-closing. Fire doors may also be automatic-closing or power-operated, in accordance with the standard.

8. Coordinator ensures that the door leaves close in proper sequence. This requirement applies only to pairs of doors where one leaf must close before the other, for example, when the inactive leaf is equipped with automatic flush bolts.

9. Door is self-latching in the closed position. This helps to ensure that the door will remain closed during a fire, to deter the spread of smoke, flames, and toxic gases.

10. Opening is not equipped with auxiliary hardware items which interfere with proper operation. An example of an unacceptable item would be a mechanical hold-open which would prevent the door from closing.

11. No field modifications have been performed that void the label. NFPA 80 details allowable job-site preparations, and field modifications may be approved by the listing laboratory.

12. Gasketing and edge seals, where required, are present, continuous, and of the proper type for a fire door. Note that gasketing is typically required for fire doors in corridors and smoke barriers but is not required for every fire door assembly. Gasketing installed on fire door assemblies must be listed for that purpose. Note: There is an exception for continuous gasketing in the case of a hospital stop, where the gasketing is terminated 6” or so above the bottom of the frame.

13. Signage on the door covers less than 5% of the door face and is not attached with mechanical fasteners. NFPA 80 requires signage to be installed with adhesive and does not allow the use of screws or nails. Signs must not be installed on fire-protection-rated glazing and must not interfere with the operation of the door.

What is required once the inspection has been completed?

NFPA 80 details specific information that must be included in the records of all inspections and testing. This includes information about the facility, the inspector, and each fire door assembly. These records must be signed by the fire door assembly inspector and kept for review by the AHJ.

Records of acceptance tests must be retained for the life of the assembly, and inspection records must be retained for 3 years unless otherwise specified. The medium used for inspection and testing records may be paper or electronic but must be able to survive the retention period.

Conclusion

For specific information about fire door assembly inspection in a particular jurisdiction, refer to the adopted codes. If you have questions, consult the AHJ for assistance. Inspecting fire door assemblies after installation, after maintenance work, and annually will help to ensure that the door, frame, hardware, and glazing are installed properly and will continue to function as intended if a fire occurs.  These requirements are in addition to maintaining an inventory of the fire protection features of the building and inspection and maintenance requirements for other life safety systems, including dampers, walls and fire stopping systems.