How to deal with "inaccessible" smoke and fire dampers in healthcare facilities

It’s important to inspect each fire and smoke damper in your facility to keep your occupants safe and prepare for AHJ surveys.
NFPA 80 & 105 require that dampers are inspected one year after installation then at least once every 4 years in commercial buildings and 6 years in hospitals. But, have you ever experienced the frustration of trying to get to dampers that seem impossible to reach or received a third-party report showing many inaccessible dampers?

Many times access to dampers is hidden under insulation or installed in areas that are challenging to get to. The easiest solution may seem like marking them as “inaccessible” in your documentation, but during your Authorities Having Jurisdiction (AHJ) survey they will check the location, and sometimes require you to go back and perform an inspection. Here’s some tips to deal with seemingly “inaccessible” dampers, and dampers that truly are inaccessible due to renovation and construction work.

1. Thoroughly Check Surrounding Area
Often times dampers get labeled “inaccessible” when access can’t be located at first glance. In reality most of these fire and smoke dampers can be reached if you look a little harder. This can get facilities in trouble during AHJ surveys. In order to find access to some dampers it’s important to thoroughly check the area for access doors. Sometimes insulation needs to be pulled back and all sides of the duct needs to be searched. Certain access doors can also be located on the opposite side of the wall where the damper is located.

2. Install New Access Doors
There are instances where the initial construction of a building didn’t take into consideration that your dampers will have to be inspected, leaving access doors nowhere to be found. There are ways to get to these dampers, it just takes a little work. You can either install an approved duct access door that allows you to enter into the ductwork and properly inspect your damper, or install an access door in your dry wall that allows you to go through a firewall to gain access. If you’re using a third party inspector make sure they have the ability to do this for you.

3. Coordinate Access To Patient Rooms
If you outsource your inspections to third party contractors, often times they will say access is not possible in rooms that are occupied with patients, when in fact, access can be coordinated. Make sure you choose a contractor that is able to organize with medical staff and your facility management team to schedule appropriate times to work in those rooms while the initial inspection is still going on. This way they don’t have to come back out for another inspection, and you can save time and money.

The Joint Commission (TJC) Recommendations for “Inaccessible Dampers”
Unfortunately, if your facility has undergone major renovations since first constructed, newly installed ductwork, piping and other construction projects can often block access to originally installed fire and smoke dampers. Accessing these blocked dampers becomes an extremely difficult task and coordinating remodeling of these systems now must involve multiple sources. In this case the TJC has some recommendations.

The Joint Commission asks that facilities keep an accurate list of these particular dampers and add these items to plans for improvement (PFI). As upcoming renovations arise, facilities with the opportunity to reconfigure these out-of-the-way dampers must do so. Historically, The Joint Commission (TJC) allowed organizations to identify these dampers on their PFIs with an “open” projected completed date, now this field is required and a projected completed date must be included.

Another option is to decommission dampers that are no longer necessary, but there are many requirements that must be met in order to go this route. We’ll talk about this more in a future post.

In Summary
When it comes to fire dampers, a lot of dampers are hard to reach, but not impossible. Make sure you search thoroughly, work to install access doors and coordinate inspection times in occupied rooms. When outsourcing your work it’s also important to hire professionals that don’t just write “inaccessible” on your reports before getting their hands dirty. If your dampers really are “inaccessible” make sure you mark them on your PFI and come up with a plan so they can be inspected in the future. Fire dampers are an integral part of your buildings fire protection system, and inspections can ensure your building is kept safe.
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