NFPA Journal - January/February 2018 - 58

Looking at the
Evidence

Door kick plates
NFPA 80 allows for non-labeled door kick plates
up to 16 inches. Fire-resistance-rated doors are
frequently identified in our experience with nonlabeled, field-applied kick plates greater than 16
inches above the floor. Fire-resistance-rated doors
are permitted to have kick plates installed on the
door if they are part of the door listing and appropriately labeled. The only exception to this is in
NFPA 101, which allows for field-applied, non-rated
protective plates to be installed on fire/smokerated doors in smoke barriers and to hazardous
areas extending not more than 48 inches above the
bottom of the door. These requirements should be
reviewed and coordinated with the door schedule
to ensure that any doors requiring kick plates
comply with these provisions.

LEARNING FROM

MISTAKES

A sample of compliance challenges
for Baystate Medical Center
Beginning in 2012, shortly after the opening of its Phase 1 West
Wing, Baystate Medical Center received repeated citations from
The Joint Commission, a hospital-accrediting organization approved by the Centers for Medicare & Medicaid Services (CMS),
for areas that were not in compliance with NFPA 101®, Life
Safety Code®. At that time, code compliance was based on the
2000 edition of NFPA 101; CMS has since updated to the 2012
edition of the code. The corrections necessary to fix these issues
consumed valuable resources and disrupted occupied patient
care areas.
While the evidence-based design process does not specifically
address code compliance, bringing together a multi-disciplinary
team early in the design process helped Baystate mitigate
these compliance issues and save money. The team was also
able to consider code compliance solutions that supported the
evidence-based design goals. The issues identified in The Joint
Commission citations were reviewed as part of a process to help
the Baystate design and construction teams avoid the issues
from reoccurring.

KEY COMPLIANCE ISSUES INCLUDED:
Door undercuts
NFPA 101 references NFPA 80, Fire Doors and Other Opening Protectives, which limits door undercuts to a maximum of
three-quarters of an inch for fire-resistance-rated doors. Larger
undercuts can occur in new construction due to variations in
the floor or the leveling of the door once it is hung. To allow for
variations in floor construction, specifications should require a
maximum door undercut of five-eighths of an inch.

58 | NFPA JOURNAL * J A N U A R Y / F E B R U A R Y 2 0 1 8

Door self-closing hardware
NFPA 101 requires many fire-rated doors in health
care occupancies to be installed with automatic- or
self-closing hardware. Door closers are frequently
installed and set prior to air balancing, which can
cause the failure of the doors to latch when closed. It is recommended that the closer settings be established after air balancing is completed, since pressure differentials can impact doors'
ability to close. Proper closing and latching should be field
verified by opening the door to 90 degrees and releasing.
Door push-to-exit buttons
Access-controlled egress doors are required to be provided with
a push-to-exit button as part of their hardware set, and NFPA 101
requires the hardware to be installed no more than five feet from
the doors. We have observed these buttons installed more than
five feet away from a door's opening device. A process should
be implemented during construction to ensure push-to-exit
hardware is installed within the five-foot maximum.
Maintenance and inspection of fire and smoke dampers
NFPA 80 requires dampers to be installed with access doors
no less than 12 inches square, or that are provided with removable duct sections. Fire and smoke dampers are frequently
installed without a compliant means of access for proper
maintenance and inspection. Unobstructed access is required
to be provided through the ceiling or wall to gain entry to the
access panel. The design specifications for dampers should be
reviewed to confirm these requirements are clearly outlined,
and that procedures exist during construction to ensure
compliant access is provided.
Wall joints
NFPA 101 requires that the joints created at the intersection of
fire-resistance-rated walls and floor/ceiling assemblies be protected with approved fire-stopping assemblies. During new construction or renovation projects, however, these joints are often
left unprotected. During construction, it is recommended that
the installation of the head of wall fire-stopping is reviewed prior
to the installation of any drop ceiling or mechanical systems that
would obstruct access.
Wall penetrations
NFPA 101 requires penetrations of fire-rated walls to be sealed
with an approved fire-stop system. Wire sleeves are often left at

ISTOCKPHOTO

A number of door-related issues were
identified in BMC's Phase 1 wing and
addressed in the buildout of Phase 4.

Table of Contents for the Digital Edition of NFPA Journal - January/February 2018