Fire doors – a key line of hospital defence

Peter Barker, Senior Consultant at BM TRADA, discusses the key role of fire doors within healthcare premises, highlighting the importance of training and competence for estates departments tasked with their maintenance

Health sector buildings present particular fire safety challenges, primarily in safeguarding patients with a wide range of dependencies in the event of fire. In addition, the size and complexity of a modern day hospital or care centre will often mean that complete evacuation of the building is neither practical nor appropriate.

It is for this reason that the most common approach adopted in healthcare buildings is progressive horizontal evacuation, moving occupants from the fire-affected area, through a fire-resisting barrier to an adjoining area, which is designed to protect the occupants from the immediate danger of fire and smoke. The occupants then remain in the fire safe area (refuge) until the fire is extinguished or, if necessary, further evacuation is required to another refuge or down the nearest stairway.

Key to this strategy – in conjunction with other fire safety measures – is the use of fire-resistant compartment lines, which form barriers between the fire and the refuge points; and fire doors, which allow the passage of persons and objects through them.

If the fire-resistant compartment lines and fire doors cannot be relied upon, the evacuation strategy for the hospital will be severely compromised and the lives of patients, staff and visitors will be placed in jeopardy.

Even though hospitals are increasingly fitting sprinklers and healthcare facilities are now being built to a fire-engineered design (resulting in atria, larger open spaces and reduced compartmentation), currently the majority of hospitals in the UK still adopt phased horizontal evacuation and therefore effective passive fire protection is paramount.

Fire doors: damage prevention and maintenance

Fire risk is something that has always been taken seriously within hospitals, as has the installation of equipment to help mitigate the effect of fire and to aid the process of evacuation. Virtually all healthcare premises have good strategies in place for fire risk management.

Understandably one of the biggest problems in a hospital is the maintenance of fire safety equipment, especially those assets that are prone to a high level of use, wear and tear and abuse. Fire doors are a large part of a hospital’s fire safety equipment but their condition can be degraded over time for a number of reasons including:

• incorrect specification of a doorset (not suited to environmental conditions)
• location of the door in a heavy traffic area
• deliberate vandalism
• ignorance and misuse.

The ideal situation is to prevent damage in the first place. Damage is predominately caused by staff transporting patients, trolleys and heavy hospital equipment, and so a key way to avoid fire door degradation is to educate staff and encourage them to use the doors carefully.

The main points to stress to staff to help avoid damage to fire doors include:

1. A fire door that has been seriously damaged will not perform its required function to resist the passage of fire and smoke. Fire doors are integral to the fire safety and escape strategy for most hospitals. By damaging fire doors, staff could potentially affect patients’ and visitors’ safety as well as their own.
2. Repairing, maintaining and installing fire resisting doorsets is costly. By looking after fire doors a significant contribution is made in maintaining the value of the estate, allowing money to be spent elsewhere within the hospital.
3. Hospital service levels and performance are disrupted while fire door replacements and repairs take place, which negatively impacts on the patients’ environment.
4. Defective passive fire protection could allow a fire to destroy a greater part of the building. This will increase disruption to the hospital and have a negative impact on the entire community in terms of available healthcare provisions, while the wing/hospital is rebuilt.

Fire safety training for hospital staff should therefore explain why fire doors are relevant in the overall fire strategy of the hospital and how the performance can be degraded by misuse. This is best visually displayed by showing what fire conditions a fire door has to cope with and examples of where fire doors and items of passive fire protection have not only aided escape, but also helped with property protection and business continuity.

The role of the estates department

The majority of UK hospitals have evolved and grown over many years. As a result, within each hospital the fire-resisting doorsets can vary in condition and age, although all are likely to have been compliant with the relevant standards and codes in force at the time.

Generally speaking, maintenance of the building systems and infrastructure provided for fire safety is the responsibility of the Director of Estates or another senior manager responsible for the relevant maintenance budget. Therefore, it will typically fall to the estates department to demonstrate or confirm that items, such as fire doors, have been maintained in efficient working order and in good repair and are likely to provide the required level of fire resistance. This can be difficult to ascertain as over time supporting documentation may have been lost or the doors may have been changed from their original specification.

Alterations to a fire resisting doorset are often made for non-fire related reasons e.g. the addition of crash plates and edge guards for doors in heavy traffic areas or glazed apertures being cut to comply with a change in regulations, such as the DDA (Disability Discrimination Act). All of these changes could have a negative impact on the door’s fire resistance if they are not compatible with the original doorset or carried out correctly.

If the condition of the doors in terms of the overall fire strategy of the hospital is uncertain or they are protecting the means of escape in a high risk location (e.g. an intensive care unit), the risk assessor or the inspecting fire officer is likely to ask for supporting evidence of the doors’ fire resistant performance in their present condition. If the inspecting officer considers the fire doors are particularly deficient, the request for proof of performance may also be coupled with an enforcement notice.

Proving the fire-resistant performance of the door can be difficult without a ‘paper trail’ or a manufacturer’s certification mark linking the door to the relevant supporting test data. This leads to the question of whether the doors should continue to be maintained or be upgraded or replaced.

Maintain, upgrade or replace?

The maintenance of fire doors should be considered distinctly from upgrading. Critical to the principle of maintenance is the understanding that the door has proven fire-resistant performance. Maintenance activities are therefore focused on the correct repair and replacement of doorset components, so that the doorset can continue to provide the level of fire resistance for which it was designed.

Ideally the proof of performance required to instigate a suitable and robust maintenance programme will be indicated by a permanent label or mark fixed to the door under the auspices of a recognised third party certification scheme. If it is not possible to identify the provenance of the door by identifying marks or documentation, the judgement that the door is suitable for the required level of fire-resistant performance needs to be made by the fire risk assessor or a suitably qualified independent expert. Without the types of assurance listed above, the judgement that the door is suitable for the required level of fire resistance is only being made by the individual or team carrying out the maintenance activities on the doors, which will typically be the estates department of the hospital.

Upgrading the fire resistance of doors is a process that aims to increase the fire resistance of a door. Upgrading activities include adding components to the door such as intumescent strips or replacing non-fire rated components with proven systems e.g. glass and hardware. The upgrading of doorsets for fire resistance must therefore be considered very carefully. It is easy to spend a lot of money upgrading doors for fire resistance and yet achieve little in terms of added performance. The TRADA Wood Information Sheet 1-32 Upgrading timber doorsets for fire resistance gives further guidance on this subject.

Replacement of the doors should only need to be considered if the door cannot be economically or suitably repaired or if the door is non-rated and unsuitable for upgrading to the necessary level of fire resistance. A suitable and sufficient programme of maintenance, upgrading and replacement for fire-resisting doors must therefore consider how and where to spend the money to offer a satisfactory level of protection to the means of escape and progressive horizontal evacuation strategy as required by the fire risk assessment.

Planned Preventative Maintenance (PPM)

A large number of estates departments within healthcare organisations use Planned Preventative Maintenance (PPM) as the best approach for providing an efficient maintenance service, with regular inspections of the equipment dictated by relevant risk assessment, professional judgement and local circumstances. Fire doors therefore feature heavily in the PPM process.

Estates departments may have the skills for carrying out the required maintenance of fire-resisting doorsets, but only with the correct training. A suitably trained engineer will not only know what to look for in terms of critical damage to a fire doorset, but also how to repair the door to reinstate its integrity.

A comprehensive training programme, carried out by an independent body with the necessary level of expertise, should demonstrate the relevance of maintaining and correctly specifying fire-resisting doorsets and also highlight the importance of considering doorsets as a complete installed assembly. Ideally, the training should be tailored to suit the needs of the estates department. The Fire Doors Explained for the Health Sector course operated by BM TRADA has been given to numerous Health Estates departments including joiners, technicians, engineers, fire officers, senior managers, architects and project managers working on behalf of the relevant NHS Trust

Without suitable training the inherent risk is that critical problems with the doors are missed during the PPM process or a lot of money is spent on repairing the door and little is achieved in improving or reinstating the doorsets’ fire resistance. In more than one instance, BM TRADA has spoken to a building manager who has spent a considerable amount of money maintaining doors, only to discover they are unlikely to perform for more than 10 minutes in a fire because of an oversight in a fundamental component, such as glazing. The main danger is the subsequent reliance on systems that will not perform as expected.

Certification of products and personnel

A third party product certification scheme certifies compliance with the requirements of a recognised document and provides confidence that the product will perform as expected, as well providing an audit trail back to the manufacturer, and the supporting test evidence. Although third party certification is not currently mandated in the UK, NHS bodies are encouraged to utilise such schemes, through the advice given in HTM 05-02: Guidance in support of functional provisions for healthcare premises.  HTM 05-02 also highlights the importance of schemes for the accreditation and certification of installers and maintenance firms, since they will offer confidence in the standard of workmanship provided.

Clearly, third party certification schemes for fire-resisting products and the personnel responsible for installing and maintaining those products should be of particular interest to a director or manager of a health estates department. For example, the schemes operated by BM TRADA for fire door manufacture, fire door installation and fire door maintenance provide confidence in the doorset’s performance from when it was constructed, through installation and throughout its lifetime.

Ensuring competency

Competency of individuals is critical for any industry involved with life safety, and fire protection is no exception. Competency, as defined by the Regulatory Reform (Fire Safety) Order (RRFSO) and HTM 05-02, means someone who has sufficient training, experience or knowledge and other qualities to properly assist in undertaking the preventative and protective measures.

In healthcare premises, the estates department has a key role in maintaining protective measures and it should be ensured that personnel have the necessary knowledge through appropriate training and/or certification of individuals within the team.

Furthermore, explaining to all members of staff that by using fire doors in a careful manner they can play a significant part in reducing damage to the hospital’s fire safety provisions, which benefits all users of the hospital or healthcare facility.