Compliance + Operations

Interpreting requirements for automatic smoke detection

ASHE's advocacy team recently helped to clarify a misinterpretation regarding total coverage automatic smoke detection required by NFPA 101
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Total coverage (complete) automatic smoke detection is where all occupiable spaces in a particular area are to be covered with smoke detection devices. This approach is required by the 2012 edition of NFPA 101®, Life Safety Code®, for new and existing hospitals in a few circumstances, such as when specialized door locking arrangements are used or when certain sleeping suites are used. 

There also are other factors for a few sections that determine when total (complete) detection is required. For example, one critieria for sleeping suites larger than 5,000 square feet is to provide either a supervised sprinkler system throughout the smoke compartment with quick response heads, or a supervised sprinkler system throughout the smoke compartment with standard response heads and total coverage (complete) automatic smoke detection throughout the smoke compartment. There are other details outlining when total (complete) smoke detection is required, and facilities managers should reference NFPA 101-2012 chapters 18 and 19 for additional considerations.

Recently, a few hospitals have been cited by accrediting organizations (AOs) for not meeting the total coverage (complete) automatic smoke detection requirement because smoke detectors were not provided above the ceiling in those spaces. This is a misinterpretation of the code. Smoke detection is not required above the ceiling simply based on the total coverage (complete) automatic smoke detection requirement.

Each time total coverage (complete) automatic smoke detection is mentioned in NFPA 101-2012 Chapters 18 and 19 it points back to NFPA 101-2012 9.6.2.9 which states, “Where a total (complete) coverage smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72®, National Fire Alarm and Signaling Code®, shall be provided in all occupiable areas in environments that are suitable for proper smoke detector operation.”  The keywords here are “in all occupiable areas” which is defined in NFPA 101-2012 3.3.21.7 as, “An area of a facility occupied by people on a regular basis.” 

Above ceiling spaces are not deemed occupiable areas. All this seems relatively straightforward, so where are the misinterpretations coming from? 

It could be that surveyors are using the definition for total (complete) coverage from the 2010 edition of NFPA 72,  National Fire Alarm and Signaling Code 17.5.3.1 which states, “… total coverage shall include all rooms, halls, storage areas, basements, attics, lofts, spaces above suspended ceilings, and other subdivisions and accessible spaces, as well as the inside of all closets, elevator shafts, enclosed stairways, dumbwaiter shafts, and chutes.”   

NFPA 72 is clear that total (complete) coverage includes “spaces above suspended ceilings,” and it is easy to get confused as to why smoke detector coverage is not required above the ceiling. As a reminder, NFPA 101-2012 provides guidance on what is required and NFPA 72 provides guidance on how to accomplish those requirements. ­

NFPA 101-2012 is clear that the intent behind total (complete) detection is for occupiable areas. If NFPA 101 wanted to use the definition for NFPA 72 it would clearly reference the definition. Since there is not a direct reference, the definition in NFPA 72 does not apply to NFPA 101-2012 Chapters 18 and 19. 

To validate this assumption/opinion, an official technical question was submitted to the NFPA 101 Technical Committee on Health Care Occupancies (SAF-HEA).  The response (NFPA Staff opinion) reiterated that Section 9.6.2.9 indicated that where a total (complete) coverage system is required by NFPA 101, detection is only required in occupiable areas and that smoke detection would not be required in areas not subject to occupancy, such as spaces above the ceiling. Further, the NFPA staff responder noted that if NFPA 101 wanted to require smoke detection in all areas required in NFPA 72, then it would provide a direct reference to the code rather than providing specific requirements to where smoke detection is required (i.e., occupiable areas).

Leveraging this information, a formal Joint Commission interpretation was requested outlining the criteria above and stating our interpretation: When total coverage (complete) automatic smoke detection is required that is only required for occupiable areas and not for other locations, such as above ceiling. The response was clear, “Your interpretation appears to be accurate. [The Joint Commission] would not require smoke detectors above ceilings unless required in the Life Safety Code (NFPA 101-2012).” 

To summarize, where total coverage (complete) automatic smoke detection is required by chapters 18 and 19 of NFPA 101-2012, smoke detection is required only in all occupiable spaces.

To ensure that this misinterpretation is not applied for future codes, a public input (PI) was submitted for the 2024 edition of NFPA 101 to remove the phrase total coverage (complete) automatic smoke detection and provided clearer language to help prevent confusion. These inputs are subject to the standard NFPA committee process and are on ASHE’s Regulatory Affairs Committee radar for monitoring.