Fire, Life Safety

Case Study: Health care facility design and being code-compliant

It’s vital for consulting engineers to not only identify the applicable codes and standards but also know the building and owner’s needs.
By William E. Koffel, PE, FSFPE, Koffel Associates, Columbia, Md. February 14, 2019
Photo courtesy: Amara Rozgus

The consulting engineer should identify the applicable codes and standards, know the building, and identify the owner’s needs. The following will illustrate a recent project in which the fire alarm system was designed to meet the applicable codes but did not meet the owner’s needs, in part because the consulting engineer did not know the building or the owner’s needs.

The reference facility is a new, 21-story hospital that was designed to meet NFPA 101: Life Safety Code. With respect to the requirements of NFPA 101, NFPA 13: Standard for the Installation of Sprinkler Systems, and NFPA 72: National Fire Alarm and Signaling Code, the issues addressed in this case study met the minimum requirements of the applicable codes and standards. However, the owner has spent a considerable amount of time and money to modify the fire alarm system and sprinkler system to better meet the operational needs of the facility.

A major protection feature required by NFPA 101 is to subdivide stories in a health care occupancy into two or more smoke compartments. By doing so, the number of patients initially exposed to the fire and products of combustion is reduced. From an operational standpoint, the typical fire emergency plan for a hospital indicates that when patients are to be relocated, they should be relocated across smoke barriers into a different smoke compartment. In many hospital fire incidents, it is not necessary to further relocate or evacuate the patients.

In a large hospital, such as this one, in order for the fire emergency plan to be effectively implemented, the fire alarm system needs to be designed to indicate the smoke compartment of fire origin. Since the staff response is different depending on whether they are in the smoke compartment of fire origin, in an adjacent smoke compartment, or further removed from the compartment of origin, the occupant notification needs to be zoned by smoke compartment. In addition, since sprinkler waterflow alarms initiate the building fire alarm system, the sprinkler system must be zoned by smoke compartment.

In this instance, the location of smoke barriers defining separate smoke compartments was not considered during the design of the fire alarm system or sprinkler system. As the facility became occupied and fire emergency plans were evaluated through staff fire drills, it quickly became apparent that the fire alarm system was not designed to be consistent with the fire emergency plan for the facility. Since the initiating devices were addressable devices, the problems associated with automatic-detection devices was easily solved by reprogramming the system. However, since the alarm-notification appliances were not addressable devices, the rezoning of the notification appliances required considerable rewiring. Lastly, although the sprinkler system’s waterflow devices were addressable, the sprinkler system’s piping had to be revised in some locations to be consistent with the smoke compartments within the building. This was costly, time-consuming, and disruptive to do in an occupied health care facility.

One could argue that this should have been caught earlier, and yes, it should have been caught in plan review or during commissioning. However, the regulatory bodies that perform plan reviews are only required to verify compliance with the applicable codes and are not tasked to verify that the owner’s needs are met. While it was alleged that the systems were subjected to proper commissioning, the documentation was never produced and most likely commissioning did not occur. It should be noted that most of these issues have or are being addressed by more recent editions of NFPA 101.

In addition to the more obvious problems with the fire protection systems, during the design of the corrective measures some other owner’s requirements were identified. These may not have been identified during the initial design of the fire protection systems, because the staff members for these areas were not yet hired and the department-specific fire emergency plans were not yet developed. However, these additional considerations included:

  • The emergency department personnel requested that they be notified of any fire emergency in the facility. The rationale was that they needed to prepare to receive patients, staff, or first responders that might be injured during the fire incident.
  • The dietary department also requested to be notified of the location of any fire emergency in the facility. The rationale was that they dispatch people throughout the facility to deliver food, and such services should stop for at least the smoke compartment of fire origin.
  • The facility posted emergency plans and wanted the plans to reflect the fire alarm zoning so that when a voice message was made about a reported fire in a certain smoke compartment, staff could easily identify if the compartment was an adjacent compartment. It should be noted that part of the challenge in staff recognizing adjacent fire alarm zones is the facility has an atrium, and all areas within the atrium were included in a single fire alarm annunciation zone.
  • Due to a local code requirement, smoke detectors and sprinklers were provided in the above-ceiling space. To assist in resolving nuisance alarms associated with smoke detectors in this space, it was determined that these devices only needed to activate a supervisory signal. This was accomplished by asking the authority having jurisdiction (AHJ) if the expected response to a signal from these devices would be to relocate patients or investigate the situation. When the AHJ agreed that the response should be to investigate the situation, it was determined that the signal should be a supervisory signal.

It’s important to not only identify the applicable codes and standards, but to also take the time to know the building and to identify the owner’s needs to avoid costly issues and disruptions to an occupied facility.


William E. Koffel, PE, FSFPE, Koffel Associates, Columbia, Md.
Author Bio: William E. Koffel is president of Koffel Associates. He is chair of the NFPA Correlating Committee on Life Safety and a member of several NFPA technical committees. He is a member of the Consulting-Specifying Engineer editorial advisory board.