Life Safety Essentials: Sprinkler Piping Supporting Other Items

Learning Objective: To understand the risks of sprinkler piping supporting items.

     

By Robert Trotter, CBO, CFM, MCP - Manager, Sr. Life Safety Specialist 

  

Automatic sprinkler piping and hangers are regularly found to be used supporting items such as, but not limited to, other piping systems, electrical conduit (as pictured), electrical power and lighting, communication wires, and a variety of other system components above ceilings. While contractors utilize the route of sprinkler piping through a building to support these items, failure of a single sprinkler pipe or hanger could result in a catastrophic failure of the piping system and cause extensive water damage. Unless you are prepared to quickly control water flow from any point in the building, an automatic sprinkler system will produce many gallons of water per minute flowing from an open ended pipe. A fire pump will contribute to increased water flow and pressure.

            The extinguishment requirements of the occupancy chapters in NFPA 101^®, Life Safety Code^®, 2000 Edition, refer to Section 9.7 for automatic sprinkler systems. All automatic sprinkler and standpipe systems must comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. Section 2-2.2 states “Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.”          

            When using The Joint Commission’s 2011 Hospital Accreditation Standards to address this type of deficiency apply LS.02.01.35 Element of Performance 4 “Piping for approved automatic sprinkler systems is not used to support any other item. (For full text and any exceptions refer to NFPA 25-1998: 2-2.2).

Fire Drill Schedules

Should the clinician be present during a fire drill for an off-site business occupancy in order to be credited for the drill?

Corridor Storage

Can objects and equipment be left on one side of a hospital corridor?  

Pyxis Machines

Do the Pyxis machines need to be located in an enclosed room that could be locked? Or can they be located in an alcove, where the nurse station has direct visibility of it?

Life Safety Essentials: Temporary Electrical Wiring

Learning Objective: To know that temporary wiring must be removed at the end of a project.
 
By Robert Trotter, CBO, CFM, MCP - Manager, Sr. Life Safety Specialist
 

Temporary electrical power and lighting during periods of construction, alteration, and rehabilitation commonplace in the built environment. On a regular basis life safety surveyors are discovering temporary electrical wiring for power and lighting located above suspended-grid acoustical tile ceilings. In many cases the temporary wiring is supported from sprinkler piping which is not permitted by NFPA 25, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems or The Joint Commission. Regularly the wires extend through walls and are often cut leaving exposed conductors that are potentially energized and creating a fire and life safety hazard.

Open Flames

What is TJC's stance on the use of open flame devices, such as sterno cans used to keep food hot? My director said that there can be no use of open flame devices in a hospital. Is this correct and where is the standard? Does this also apply to candles in a chapel?

MRI Suite Sink

Does TJC require hospitals to provide a hand washing sink inside the MRI suite, or can it be outside the control room area in close proximity?

Clinical Alarms

Is it an environment of care issue when a patient dies because the crisis alarm setting on his heart monitor was inadvertently turned off?   

Sprinklers

Do all closets in the hospital need sprinklers to be considered "fully sprinklered" by national standards?

Oxygen Storage

Is there a code that says there must be 5 feet between an oxygen cylinder and an ignition source? 

Height of Release Device for Doors

Learning Objective: To understand the requirements for the location of the release mechanism on doors in the means of egress.

By Robert Trotter, CBO, CFM, MCP - Manager, Sr. Life Safety Specialist

Doors in the means of egress including exit access doors from individual rooms must meet the applicable provisions of the Life Safety Code^® for the height of the releasing mechanism. Examples of devices that might be arranged to release latches include knobs, levers, and panic bars. This requirement is permitted to be satisfied by the use of conventional types of hardware, whereby the door is released by turning a lever, knob, or handle or by pushing against a panic bar, but not by unfamiliar methods of operation such as a blow to break glass. The operating devices should be capable of being operated with one hand and should not require tight grasping, tight pinching, or twisting of the wrist to operate.

ER Corridor Receptacles

From a code standpoint, can a hospital add electrical outlets (receptacles) in the corridor(s) of the emergency center, which will be used to plug in patient care equipment/attend to patients in "overflow" conditions?  Can patients be seen in the corridor?

Opening Day - Transitioning from construction to survey-ready operation

Opening Day

Transitioning from construction to survey-ready operation

This article first appeared in the May 2010 issue of HFM Magazine.

By David l. Stymiest, P.E., FASHE, CHFM

Construction project turnover time is hectic. Facility activation and move-in are usually foremost and it is often difficult to get all of the compliance work done on time. Lacking a solid process for transitioning from construction to operations and survey-ready compliance at occupancy can put a hospital at risk during an early survey.

Click here to go to article at the HFM Magazine website.

Rx for Emergency Power Reliability

by David Stymiest, P.E., CHFM, FASHE, CEM, GBE (in Maintenance Technology)

Just because EP systems are out of sight doesn’t mean they should be out of mind. Many facilities don’t know theirs are unhealthy until they really need them. As some unlucky operations have learned, that’s too late.

What is emergency power (EP) reliability? It’s having EP available to power WHAT it needs to, WHEN it needs to, FOR AS LONG AS it needs to. That’s quite a tall order, but one that can be satisfied with a comprehensive approach.

Read entire article here: Rx for Emergency Power Reliability

Patient Lift Testing

Is it required to test patient lifts annually?

Life Safety Essentials: Legibility of EXIT Signs

Learning Objective: To be able to recognize the improper installation of EXIT signs.

By Robert Trotter, CBO, CFM, MCP - Manager, Sr. Life Safety Specialist

For a more aesthetically pleasing built environment, architects and building managers are marking the means of egress in new buildings and existing buildings with edge lit LED exit signs in favor of the standard thermoplastic or cast aluminum exit signs. Occasionally these exit signs have been in existence for many years or even recently installed where no one has noticed the sign does not meet the applicable provisions of NFPA 101®, Life Safety Code® nor any locally adopted building code. The edge lit exit sign (shown right) is listed as a ceiling mounted sign to be located near the wall. Double face signs utilize a Mylar insert to avoid viewing of the EXIT in reverse. 

Corridor Doors Blocked

Are wedges/door stops and kick-downs non-compliant when used on corridor doors that have closers on them?

Eye Wash Stations

If there is an eye wash station in a locked room because that is where the "hazard" is located, does there need to be signage regarding it's location outside the door or just in the room?

Main Drain Test

A hospital has 3 system riser drains that cannot be tested at full flow because there is insufficient drain capacity.  Should this be on the SOC?

Command Center

When you activate the Command Center do you have to notify all the Satellites listed on a hospital's license?  

Generator Annual Maintenance (PM)

I recently received the question - "Is there a requirement for generator annual PM?


The short answer is yes, but knowing what to do requires knowing what each generator's manufacturer recommends.


NFPA Disclaimer: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents.  NFPA members can obtain NFPA staff interpretations at www.nfpa.org.

NFPA 99 references NFPA 110, and it’s all based upon manufacturer’s recommendations as far as NFPA 110 is concerned.  Every emergency generator manufacturer that I am aware of recommends annual maintenance in the O&M manual.

From NFPA 99-1999:

3-4.4 Administration (Type 1 EES).

3-4.4.1 Maintenance and Testing of Essential Electrical System.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and

Transfer Switches.

(a) Maintenance of Alternate Power Source. The generator set

or other alternate power source and associated equipment,

including all appurtenant parts, shall be so maintained as

to be capable of supplying service within the shortest time

practicable and within the 10-second interval specified in

3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in ac-

cordance with NFPA 110, Standard for Emergency and Standby

Power Systems, Chapter 6.

From NFPA 110-1999:

Chapter 6 Routine Maintenance and

Operational Testing

6-1 General.

6-1.1* The routine maintenance and operational testing program

shall be based on the manufacturer’s recommendations,

instruction manuals, and the minimum requirements of this

chapter and the authority having jurisdiction.

6-1.2 Consideration shall be given to temporarily providing a

portable or alternate source whenever the emergency generator

is out of service.

AND …

6-3 Maintenance and Operational Testing.

6-3.1* The EPSS shall be maintained to ensure to a reasonable

degree that the system is capable of supplying service

within the time specified for the type and for the time duration

specified for the class.

6-3.2 A routine maintenance and operational testing program

shall be initiated immediately after the EPSS has passed

acceptance tests or after completion of repairs that impact the

operational reliability of the system.

6-3.3 A written schedule for routine maintenance and operational

testing of the EPSS shall be established.

6-3.4 A written record of the EPSS inspections, tests, exercising,

operation, and repairs shall be maintained on the premises.

The written record shall include the following:

(a) The date of the maintenance report

(b) Identification of the servicing personnel

(c) Notation of any unsatisfactory condition and the corrective

action taken, including parts replaced

(d) Testing of any repair for the appropriate time as recommended

by the manufacturer

6-3.5* Transfer switches shall be subjected to a maintenance

program including connections, inspection or testing for evidence

of overheating and excessive contact erosion, removal

of dust and dirt, and replacement of contacts when required.

6-3.6* Storage batteries, including electrolyte levels, used in

connection with Level 1 and Level 2 systems shall be inspected

at intervals of not more than 7 days and shall be maintained in

full compliance with manufacturer’s specifications. Defective

batteries shall be repaired or replaced immediately upon discovery

of defects.

If you do not have your generator set manufacturer's O&M manual, and cannot obtain it from the manufacturer's local office, service representative, factory, or website, you could use the generic recommendations in the NFPA 110 Annex.  In that case I suggest you go with the NFPA 110-2010 Annex, since those recommendations are more updated than the 1999 edition.  But the first source should always be the generator manufacturer.

There is similar (and some updated) wording in a more recent edition of NFPA 110, but the chapter numbering changed.

From NFPA 110-2010:

Chapter 8 Routine Maintenance and

Operational Testing

8.1* General.

8.1.1 The routine maintenance and operational testing program

shall be based on all of the following:

(1) Manufacturer’s recommendations

(2) Instruction manuals

(3) Minimum requirements of this chapter

(4) The authority having jurisdiction

8.1.2 Consideration shall be given to temporarily providing a

portable or alternate source whenever the emergency generator is out of service.

 etc.

Finally, don't forget TJC’s latest EC.02.05.01, EP3 and EP4.

Hand Sanitizers near Electrical Outlets and Switches

How far should a Hand Sanitizer dispenser be from electrical outlets and switches?

Exit Verbiage

A hospital has a sign posted that says “Not An Exit”, but the standard actually reads that “No Exit” should be posted.   Will this be an issue?

Equivalency Request

From whom should we request an equivalency for a Life Safety Code deficiency?