I’m working on a presentation for an upcoming conference, and I’d like to get a feel for what’s happening in the field regarding the enforcement of fire door inspections. I’m hoping that some of you can help.
When the annual fire door inspection requirements were added to NFPA 80 in the 2007 edition, I had high hopes that we would see an improvement in the condition of existing fire door assemblies. In the past, a fire door with a broken door closer could spend years (decades!) in the open position, allowing smoke and flames to pass through the opening if a fire occurred. But although NFPA 80-2007 was referenced by the 2009 model codes, the annual inspections got a very slow start.
In the 2013 edition of NFPA 80, an important change was made. In addition to annual inspections, fire door assemblies are now required after installation and after maintenance and repair work. It’s shocking how many fire doors are non-compliant from the start – especially the clearances. I thought the reference to NFPA 80-2013 in the 2015 International Building Code (IBC) would be a great tool to make sure end users received fire door assemblies that were properly installed, but enforcement was still slow.
In 2016, the Centers for Medicare and Medicaid Services (CMS) announced that the Joint Commission and other accrediting organizations would be enforcing the 2012 edition of NFPA 101 Life Safety Code. This edition referenced the 2010 edition of NFPA 80, which detailed the requirements for annual inspections. CMS was clear that the fire door assembly inspection requirements would be enforced for the thousands of health care facilities that receive funding from CMS. This was an important step in understanding why the inspections were so important and motivating greater enforcement.
Now the inspection requirements are gaining some momentum beyond health care facilities. I have heard that inspections are picking up in Florida, so I asked the state fire marshal about their policy. His response was that the annual inspections were required by NFPA 80 and NFPA 1, Fire Code, and sent me the relevant excerpts:
NFPA 1: 12.4.2.8.4.1* (2021) Periodic inspections and testing shall be performed not less than annually.
NFPA 80: 5.2.4.1 (2019) Periodic inspections and testing shall be performed not less than annually.
The problem has been that although the inspections were required by code, they were often not being enforced. I’ve also heard that enforcement has increased in Massachusetts, Mississippi, some areas of Pennsylvania, Ohio, and Texas, and in hospitality-related facilities.
I’d love to know…what are you seeing in your area? Was there any sort of announcement that inspections would be enforced? Are all types of buildings being inspected? I’d appreciate any insight that you can share in the comments.
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I could use an education on fire door inspections. As an architect should I assume the inspections at the end of a project are required to be performed before close out? Who does the inspections and who pays for it?
Often the client is anxious to get into the building and the AHJs do not seem to be focused on this requirement.
Those are great questions, Charles – maybe I need to do a follow-up post! I have seen the initial fire door inspection included as part of the specification on some projects, and I have even done a couple of inspections myself when someone got in a bind at the end of a project. I would say yes – they should be done before close-out, although NFPA 80 is not specific – it just says “after installation.” Conducting the initial inspection is very beneficial to the owner, assuming that any deficiencies are corrected. The health care facility managers have caught on to this since they know they will have a fire door inspection annually and they’ll have to repair any deficiencies if they are not addressed before they take over the building.
– Lori
Lori,
Are we being TOTALLY HONEST here??? NO!!! I’m at a slight disadvantage here…. I don’t get in all of my buildings in my town. I have Company Inspections that are performed by my Lieutenants and company personnel for a large number of buildings. Although I hold annual training with them on fire hazards/violations, and we do talk about fire doors, do they even know what a fire door truly looks like?? NO!!! In the larger buildings (that we call Target Hazards, that I inspect) I TRY TO ENFORCE any door violation that I see. When it comes to the 2 universities in my town, (the most incidents of damaged fire doors) it can take 6 months or more before they even get around to repairing/replacing a damaged fire door!! It may also take that much time to order and receive a new fire door. Here’s another disadvantage…….Do I walk through EVERY FIRE DOOR in the building….NO!!! My inspection list allows me time to make one inspection a year in some occupancies and two in others. I have to admit, I try my best, but that may not be adequate at times!! Total Honesty!!!
I appreciate your honesty, Kevin! But here’s the thing…the intent is not for the AHJ to have to look at every detail of every fire door. There are fire door assembly inspectors who are trained and experienced in doing these inspections, and it is the responsibility of the building owner to have the inspections done – just like a fire extinguisher inspection, sprinklers, elevators, hoods, etc. The AHJ typically just asks to see the documentation – they are not testing every fire extinguisher (or fire door). The requirement for fire door inspections is a great tool to keep in your tool bag – especially for facilities where you see obvious violations.
Regarding the time to make repairs, NFPA 80 says “without delay,” but I have seen 60 days as the required time frame from some AHJs.
– Lori
Well when I was working four years ago, I saw:
1. In my ahj we only had one nursing home. So it had an annual inspection from us, plus all the other folks that inspect it.
2. We did annual inspections of all buildings and businesses. We did more of a visual and functional test. We did not require a third party or require the business to document.
I think problem starts with an educated ahj inspector. Know what to look for.
Then enforce it.
The problem there, some ahjs never go back into an existing building, unless a complaint or remodel. Than they still may not look at the entire building.
At some point get the business to inspect them and get a third party inspection.
Thanks Charles! I’ve seen more inspections requests coming out of Texas in the years since your retirement, especially in Houston. Hopefully it spreads!
– Lori
In Western Ma., stairwell doors at WSU Ely Campus Center were being inspected by the AHJ as recently as 9/19/25
Hi Dave!
So the AHJ was inspecting the fire doors rather than a 3rd party fire door inspector?
– Lori
I can relate at least one story that might be useful to you and would CERTAINLY be useful to me if you got an answer from the relevant parties. I was doing an inspection once and encountered a fire door manufactured by Lynden Door (affixed in a frame made by Timely) which had inspection labels by Warnock/Intertek
The door was equipped with a fancy new style of electronic access control that did not involve a raceway or transfer hinge but, rather, it had a large electronic assembly (complete with a battery pack) morticed into the door itself on the latch side, just above the fancy handle set.
Everything about this looked like an after-market field modification. I wanted to find out if this was the case, but no amount of calls and emails to Lynden and to Intertek yielded anyone getting back to me with any sort of follow-up. As an inspector, we were taught that we could contact the listing agencies and the manufacturers with questions or to validate details of their hardware (such as, in this case, what the nature of the door assembly was like during testing and certification) so I was rather shocked that no one would reply.
I have photos, serial numbers, etc. I thought it would be trivial for someone to pull the listing record and say “yes, the door was in that configuration when it was submitted for testing” or not. But there doesn’t seem to be a specific department that I could find or connect to who could offer such information.
What would you suggest?
Hi Deviant! I received your photos and I think this would make a great follow-up post!
– Lori
This is my experience with CMS/Life-Safety at our Facility,
Back in 2017 we saw the first push with this compliance. What it looked like in practice is the Inspector would ask for a map on the Fire Doors, and then the documentation of the inspection. This was the main ask that was different from the normal inspection.
One of the focuses was the gap in the assembly from the door to the casing. For the doors we could not fix, we were able to find Smoke and Fire rated Fire and Smoke Seal striping. We put this with the docs for the doors and we have passed inspection this way.
Like with most things, if you can demonstrate that you take this seriously they will work with you.
That is of course if there is not a safety issue, no CMS Life Safety Inspector is going to let that slide.
Is seems that CMS chooses different new safety codes to focus on every year;
First year they will tell you to get compliant.
Next year they will ask you if you are following your policy.
Then the audit of the area that is in question will happen with them wanting to see everything and have you demonstrate your compliance and competency.
We saw that recently with the new Legionella and Water Management protocols. It has been rolled into the infection control slanderers and the implantation was just and described above.
Good luck on the presentation,
Ray
Thanks for sharing your insight, Ray!
– Lori