Demystifying fire alarm maintenance

It is perhaps timely for Health Estate Journal to carry an article on the maintenance of fire alarm systems in the healthcare sector. On 1 October 2006, the Regulatory Reform (Fire Safety) Order 2005 will come into force in England and Wales and will replace most existing fire safety legislation. This article provides some practical and simple advice based on the recommendations of BS5839-1. The intended audience includes users within the healthcare sector, typically craftspeople and engineers and those with responsibility for fire safety.

Setting the scene
Both current and new legislation says in effect: “Thou shall maintain any system provided for the purposes of fire safety,” and broadly speaking that is as far as it goes. What it does not say is how one goes about it. Inevitably all published guidance on complying with fire safety legislation, in respect of maintaining a fire alarm system, will lead to ‘BS5839-1 fire detection and alarm systems for buildings – code of practice for system design, installation, commissioning and maintenance’.

There are a couple of points that require some clarification. As previously mentioned, there is a legal obligation to maintain a fire alarm system. This is often misinterpreted as “there is a legal obligation to maintain a fire alarm system in accordance with the recommendations of BS5839-1”. This, unfortunately, leads to the belief that BS5839-1 has some kind of legal status and that a prosecution could be brought for not complying with BS5839-1. This is not actually the case. While there is an obligation to maintain a fire alarm system there is no obligation to do so in accordance with BS5839-1. However, as it contains a wealth of specific detail in respect of system maintenance, it provides an excellent and obvious starting point for determining the scope of any planned fire alarm maintenance regime.

BS5839-1 is a code of practice and as such none of its contents are absolute requirements. They are merely recommendations, albeit very sound ones that have arisen out of industry custom and practice over the years. What this means is that, provided there is agreement between all interested parties and such agreement is recorded, one can depart from the recommendations of BS5839-1 and still be compliant with it. This makes provision for the fact that in the healthcare market the special nature of each hospital will inevitably require different procedures of its own. In some cases particular recommendations made by BS5839-1 may not be suitable or practical to achieve.

For instance, testing alarm sounders might cause distress to a patient in labour in a maternity ward, disturbance in a clinical area where delicate procedures take place, or might be unacceptably intrusive in a department using life support equipment. To take account of such situations, BS5839-1 therefore champions the very sensible need for wide consultation with all stakeholders of fire safety issues within each site at all stages including the planning of maintenance.

Importance of risk assessment
Although it is a requirement of the Fire Precautions (Workplace) Regulations 1997, as amended 1999, the Regulatory Reform (Fire Safety) Order 2005 brings risk assessment to the forefront in fire safety.

BS5839-1 recommends that the frequency of maintenance visits be determined by risk assessment, taking into account “the type of system, the environment in which it operates and other factors that may affect the longterm operation of the system”. However, the period between maintenance visits should not exceed six months.

It is interesting to note that the particular clause of BS5839-1 that makes the recommendation for determining the frequency of maintenance visits by risk assessment also makes the statement to the effect that if this particular recommendation is not implemented then the fire alarm system will no longer be compliant. This seems to contradict what has been previously said regarding compliance with a code of practice.

However, perhaps it is an indication of the importance with which routine maintenance should be viewed. In practice, the most frequently chosen options are two or four visits per year. Not withstanding the number of visits per year, the whole of the system should be tested in a 12-month period.

Legislation changes
One of the significant changes under the Regulatory Reform (Fire Safety) Order 2005 is the fact that the local fire brigades will no longer inspect premises to ensure that fire precautions are adequate. The onus for fire safety will be placed on a “responsible person”. Any fire certificate issued under the Fire Precautions Act 1971 will cease to have any effect. Having said this, the local brigades are still responsible for the enforcement of legislation and will still inspect premises to ensure that statutory duties are being met.

Areas of responsibility
As to who is responsible for fire safety within a hospital, it is most frequently a “responsible management person”, more often than not from the estates and facilities department, possibly supported by an experienced and competent third party fire safety consultant. Ultimately, however, full responsibility for fire safety rests with a Trust’s chief executive or the most senior person within the hospital management structure.

Maintenance providers
Maintenance of the fire alarm system is normally carried out by an outside fire alarm maintenance contractor. BS5839-1 makes two important points regarding this: firstly that the competence of the contractor can be assured by accreditation under a third party certification scheme such as LPS1014 or the BAFE modular scheme SP203; and secondly that in-house personnel carrying out any of the recommended work should have equivalent competence to that of the personnel of the outside maintenance provider.

This raises an important issue. It is expected that most maintenance work is carried out by an outside party. But given that hospitals are complex sites running 24 hours a day, seven days a week, it is not always convenient, for instance, for outside maintenance contractors to gain access to particular areas during a routine maintenance visit. It may not be possible to close down operating theatres to suit a maintenance schedule, or to gain access to intensive therapy units where patient care issues may be compromised.

In such cases this question can be asked: “Could certain tasks be carried out by the hospital’s own maintenance staff at appropriate times, possibly during the weekly testing that BS5839-1 recommends be carried out by the user? The answer is probably yes, depending on the task and provided that suitable and sufficient training has been given to staff, preferably by the outside maintenance provider.

What this example points to is a partnership between the maintenance provider and the end user of the fire alarm system, with the ultimate aim that the fire alarm system is suitably maintained.

Third party accreditation
Many responsible fire alarm companies are third party accredited. One such scheme is LPS1014 (to which Static Systems Group plc is accredited), run by the Loss Prevention Certification Board for fire alarm providers who are involved in the design, installation, supply, commissioning and maintenance of fire alarm systems.

This affords valuable “peace of mind” in employing third parties who are recognised and regularly audited for their competence.

It is worth mentioning that a close and constructive relationship should always be developed with the local fire authority, which is very much an “interested party” with respect to fire safety and, as previously mentioned, has responsibility for the enforcement of fire safety legislation.

False alarms
A major issue with any fire alarm system is that of false alarms. It is interesting to note that a large number of false alarms, which result in the brigade being called out, originate from healthcare premises. This observation can partly be attributed to the fact that healthcare premises are heavily populated with automatic detectors, and so, statistically, they will generate more false alarms.

It is recognised that even with a well designed, installed and commissioned system that is being well maintained, complete elimination of false alarms is impossible. Both BS5839-1 and the NHS publication ‘Fire Practice Note 11 – Reducing unwanted fire signals in healthcare premises’, set out acceptable rates of false alarms (Note: FPN 11 refers to false alarms as “unwanted fire signals”).

Both BS5839-1 and FPN11 classify false alarms under four categories:

Unwanted alarm.

Equipment false alarm.

False alarm with good intent.

Malicious false alarm.

It is a recommendation of BS5839-1 that the maintenance provider investigates and reports on all false alarms. Therefore, it is a duty of the responsible person to ensure that all false alarms are recorded in a logbook.

On every maintenance visit any false alarm that has been recorded since the previous visit should be investigated by the maintenance team. It should be noted that this is not intended to be an in-depth analysis, merely a basic check to ensure that there is no obvious cause, such as a toaster being used in a room that is being protected by an ionisation detector. It is interesting to reflect that nearly half the false alarms resulting in the fire brigade being called out to hospitals are due to fumes from cooking.

If no obvious cause can be identified then the “responsible person” should commission a further investigation, possibly by the equipment manufacturer or suitably qualified consultants.

Maintenance – every visit
To follow is a 26-point checklist of the essential tasks that should be incorporated in each maintenance visit, based on BS 5839-1, 2002, section 6.

1 Examine the logbook and check activities since the previous maintenance visit.

2 Check that all recorded faults have been attended to.

3 Ensure that manual call points remain unobstructed and conspicuous.

4 Ensure that any new exits have the provision of a manual call point nearby.

5 Ensure that any new/repositioned partitions do not encroach within 500 mm of automatic fire detectors.

6 Check whether any storage encroaches within 300 mm of ceilings.

7 Verify that there is a clear space of at least 500 mm below automatic fire detectors.

8 If changes to usage/occupancy have been made, ensure the existing fire detectors are suitable for the new situation.

9 Check whether building alterations or extensions require additional fire alarm equipment.

10 Examine the record of unwanted alarms (previously called false alarms) and record the rate at which they have occurred.

11 Carry out a preliminary investigation of unwanted alarms under the following circumstances: – Unwanted alarms over the previous 12 months exceeding one unwanted alarm per 25 detectors. – More than 10 unwanted alarms occurring since the time of the previous service visit. – Two or more unwanted alarms arising from any single device since the time of the last service visit.

12 Simulate full alarm load by simultaneous evacuation with batteries disconnected.

13 Examine batteries and connections.

14 Simulate full alarm load by simultaneous evacuation with mains disconnected.

15 Check the function of the fire alarm panel(s) by the operation of at least one device in each zone.

16 Record in the logbook, device(s) used for the test.

17 Check fire alarm panel(s) for correct operation.

18 Check the operation of any facility for automatic transmission of alarm signals.

19 Test all ancillary functions of the fire alarm panel(s).

20 Check fault indicators by simulation of fault conditions where this is practical.

21 Check all printers including consumables to ensure that the printer can be expected to operate until the next maintenance visit.

22 Service any radio systems in accordance with the manufacturer’s recommendations.

23 Carry out further checks and tests recommended by the system manufacturer.

24 Report outstanding defects to the responsible person.

25 Record details of the maintenance visit in the system logbook.

26 Issue a maintenance certificate covering the work/part of the system applicable to the visit.

Annual maintenance visits
To follow is a 15-point checklist for maintenance carried out every 12 months or over a period of 12 months, again based on BS 5839–1, 2002, section 6.

1 Test the function of every manual call point by using a test key, ensuring correct operation and indication.

2 Examine every automatic fire detector, as far as is practicable – checking for damage and other factors that might affect their operation.

3 Test the function of every detector by a suitable fire-like phenomenon, to ensure correct operation and indication.

4 Provide a status report of devices to determine whether devices are within range (no contamination) and advise accordingly.

5 Check the operation of audible and visual fire alarm warning devices (note: this is not a check of audibility).

6 Check that any visual fire alarm devices are not obstructed and that the lenses are clean.

7 Replace any unmonitored, permanently illuminated filament lamp indicators at fire alarm panels.

8 Check any radio signal strengths for adequacy.

9 Check and confirm that all readily accessible cable fixings are secure and undamaged.

10 Test the full cause and effect of the system.

11 Establish that the power supply capacity remains suitable for continued service by full evacuation with mains disconnected.

12 Carry out all further checks and tests recommended by the system manufacturer.

13 Report any defects to the responsible person.

14 Record details of the maintenance visit in the system logbook.

15 Issue a maintenance certificate covering the work/part of the system applicable to the visit.

Of course, it may be possible to omit any of the points referred to subject to agreement by the relevant interested parties and still be compliant with BS5839-1.

Conclusion
The importance of fire safety and intelligent maintenance regimes to protect patients, public, staff and management within healthcare establishments are self-evident.

Comprehensive and reliable fire safety does not just happen. It is incumbent on many people from the most senior person within a hospital Trust to maintenance staff, fire safety advisors, system manufacturers, regulators, fire authority staff and patients.

All these people play their part and the consequences and importance of their actions, or indeed lack of actions, cannot be stressed too highly.

This article has attempted to give an insight into how planning, common sense and partnership can provide answers to all the challenges presented by fire systems maintenance.

References
1 BS5839-1. Fire Detection and Alarm Systems for Buildings – code of practice for system design, installation, commissioning and maintenance. 2002.

2 LPS 1014. Requirements for Certificated Fire Detection and Alarm System Firms Regulatory Reform (Fire Safety) Order, 2005.

3 Fire Practice Note 11. Reducing Unwanted Fire Signals in Healthcare Premises.