RSSAll Entries in the "Life Safety Code" Category

A safety committee topic we can all toast to

How well does your safety committee manage “telling people what to do”?

In reviewing safety committee minutes in all different parts of the country, I’ve run into a certain reluctance to mandate compliance with sensible safety practices. The most common issue I’ve encountered is the management of heat-producing appliances in various departments. Yes, I am talking about toaster ovens, household-use toasters, household-use coffee makers and other appliances of that ilk.

I personally think that toaster ovens are among the most risky pieces of common-use equipment I can imagine. You can put something in it, set the temperature, and walk away from it – with the common refrain being, “What’s that smell? Oh, $@?&!!”

When I encounter these appliances during mock surveys, I ask what folks what they’ve done to manage the risks associated with these devices, and the response is frequently a shrug.

Now I don’t advocate an obstreperous approach to enforcement activities, but it is certainly a weapon to have in your arsenal (sort of along the lines of nuclear proliferation – we don’t want to have to go there, but if you insist, we will).

Sometimes corrective measures are perceived as being optional, even when there is a clear advantage to adopting those measures as a standard of practice. But – and I quote one of my former boss’ favorite sayings – you can’t mandate intelligence and in those instances, you sometimes have to mandate a practical application.

I know we didn’t get into this field to boss people around. But sometimes there’s very little standing between disaster and any number of folks working for us. Sometimes you have to risk being a wee bit prickly in order to keep your safety roses in bloom. And that’s enough mixing of metaphors for this session.

So, until next time, this Safety Mac Daddy is signing off…

Since I am already on the subject of BMPs…

As a final note on the building maintenance program-and I will admit to having a little obsessive-compulsive disorder about this topic- it is important to periodically review your program’s data.

While the 95% compliance rate might seem like a pretty comfortable margin with which to work, it is important in this less-than-perfect world to validate your assumptions. It is more than likely that 90% of your rated doors function appropriately every time. But it’s those other 10% of “trouble” doors that can get you into hot water.

For the “good” 90%, you might be able to get away with an annual inspection frequency (if the data supports that frequency), but those other 10% might need checking more often.

Remember, the goal is 95% at any given moment in time. If you’ve got maintenance challenges, it is imperative that you identify them and take appropriate actions to ensure proper operation of items in question.

Stay safe,
Steve Mac.

And now for something completely related…

Let’s talk more about The Joint Commission’s building maintenance program. Be forewarned that a BMP is not necessarily a panacea during survey.

Yes, there are some surveyors that might cut you some slack if you have a BMP, but, strictly speaking, if they find three Life Safety Code deficiencies during survey that cannot be reconciled with the items on your current PFI, and cannot be identified as having an approved equivalency, then you can receive an RFI under EC.5.20.

“What?” you might say, “That’s now how I understood it to work!”

Ah, my fine colleague, but what do we actually know about this process? If you look at the Statement of Conditions, it indicates that an organization may choose to resolve each of the noted deficiency types through a building maintenance program and goes on to describe an effective BMP as maintaining the noted life safety features at a 95% compliance rate.

What it doesn’t say is that there is no way, unless you have a very small inventory of a particular item, that a surveyor could inspect a sufficiently-sized sample to render a verdict on your actual compliance percentage.

But don’t jump off the ledge just yet! Where your maintenance data comes in to play is when you have to make your case on the back end, most likely during the clarification phase (each organization has a period of time post-survey in which they can provide The Joint Commission with data to support a finding of compliance).

At that point, through your organization’s survey coordinator, you would submit your BMP data for review by the folks at The Joint Commission’s Chicago headquarters. By the way, the commission has hired additional engineers to assist with the management of all things EC, including review of the electronic Statements of Conditions and PFIs.

Stay safe,
Steve Mac.

Effective building maintenance programs involve the front line

As we move closer and closer to some sort of mandate for The Joint Commission’s building maintenance program (I don’t know that we’ll ever get all the way there, but I am absolutely convinced that eventually, you won’t be able to comply with all the Life Safety Code’s elements without a BMP), it becomes clear that you need to explain the expectations of the program to frontline staff members engaged in maintenance activities.

Frequently, there is reluctance among frontline workers to report negative or deficient findings during their inspections. These folks need to be comfortable (and I suppose you do as well) that there will be no punitive aspect to this reporting, within reason.

Your organization needs that failure data to assess the performance of your BMP. You need to know:

  • What doors “fail” on a regular basis
  • Locations where those mysterious cable guys are not quite good about filling penetrations
  • If there are outdoor egress routes that suffer from an elevated level of snow and ice

Frontline staff members can help you do this if they feel confident of their roles. More about the BMP next time.

Steve Mac.

When you implement a new EC program, don’t forget to look back

A client facility of mine has a really neat process for managing penetrations in rated partitions. They have a little clipboard at the location of each partition (above the ceiling) and the maintenance folks are charged with inspecting these locations on an ongoing basis.

This works really well, up to a point. Any time there’s a penetration, it gets fixed right away, which is very cool.

However, where things broke down is that until the implementation of this process, a lot of penetrations had been filled in without using rated firestopping materials–and sure enough, those unprotected penetrations were the ones found during survey and given an RFI.

This facility’s penetration management process had reported really good compliance, but the building maintenance program couldn’t be invoked to resolve the RFI because of the number of penetrations (and these were probably filled years ago) that were not “properly” sealed.

Stay safe,

Steve Mac.

Is the clock ticking when it comes to NFPA fire watches?

Hi again everyone. A reader asked me recently about the rules for fire watches–specifically whether there any other codes that indicate watches should be done every 15 or 30 minutes, as opposed to hourly.

The place to look is the NFPA’s Life Safety Code. Upon review, I have to admit that the code is a little less draconian in its demands than I had thought (a good thing, if you ask me).

Paragraph in the code states:
Where a required fire alarm system is out of service for more than four hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

An annex note to says that fire watches should include “special action beyond normal staffing, such as assigning an additional security guard to walk the areas affected. These individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.”

So as you see, the code doesn’t really set time frames for fire watch frequencies.

I’d advise folks to look over their fire watches process and see if anything “falls out” compliance-wise when compared to the guidelines from the code.

Trash containers in soiled utility rooms

There was a posting on Safety Talk recently about whether any regulations exist governing the size of trash containers in soiled utility rooms. In this particular case, the room had no trash chute, was one-hour-rated, and had sprinklers.

There are requirements in the Life Safety Code for this type of arrangement, based on, which sets size limits for soiled linen and trash containers.

However, also notes that facilities are exempt from these limits if containers are in hazardous areas protected by a one-hour fire barriers or sprinklers (see

So, in the Safety Talk poster’s situation, it appears that particular facility met the protection criteria for such a space.

On an unrelated note, please enjoy a most freewheeling 4th!

One more thing about ratings of patient bedroom doors

Regarding my post yesterday about rated doors, perhaps a little clarification is in order. My note was aimed at exiting healthcare occupancies under Chapter 19 of the Life Safety Code.

In looking through the code for other occupancies for which this door requirement might be applicable in sleeping areas (e.g., dormitory/hotel, residential board and care), I could find no other mention.

Thanks to those who asked me about this.

Rating of patient bedroom doors

A colleague recently asked me whether patient bedroom doors should be 20-minute-rated-and the answer is yes, they should. But there are some qualifications on that answer, depending on sprinkler protection.

Under paragraph, the 2000 Life Safety Code requires doors protecting corridor openings to resist the passage of smoke and be constructed of the following:

  • 1 3/4-in. thick, solid-bonded core wood
  • Material that resists fire for at least 20 minutes

There are two exceptions to, though:

  • Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that don’t contain flammable or combustible materials don’t need to meet’s provisions
  • In smoke compartments protected by sprinklers, the door construction requirements of aren’t mandatory, but the doors must resist the passage of smoke