The NHS has a legacy of ageing properties, many of which have ventilation systems where it is not possible to gain access for effective cleaning or mandatory annual safety inspection and testing of fire dampers. This lack of access is not a new issue, and needs to be afforded much higher priority on risk registers, argues Andrew Steel, managing director of Airmec Essential Services, an independent ventilation, air, and water hygiene specialist which provides safety services for several NHS Trusts.
Few would argue that one of the biggest ventilation management problems facing hospital Estates teams is maintenance, and maintenance access. If you cannot get to it, you cannot maintain it or certify that it is safe. Sooner or later, the equipment or plant in question is not going to do its job, and will potentially become a danger in its own right.
n the case of fire dampers, this can mean losing control of the spread of fire and smoke which – even in small volumes – can cause significant and expensive damage to critical equipment, as well as a threat to life. Sometimes the dampers cannot close properly due to accumulation (often over many years) of contamination, or they have failed and closed, which can lead to stuffy rooms and an imbalance of ventilation systems. We’ve even seen them wedged open after ‘nuisance tripping’.
So, let’s be clear: operating premises with ineffective and untested fire dampers is both unlawful and unsafe – whatever your budget challenges – and those challenges will only loom larger when you need to look at capital expenditure in order to modify your system to enable access for safety inspectors.
Issue at Birmingham hospital
Who can forget the scandal back in 2015 when Channel 4 News revealed that hundreds of dampers at a ‘flagship’ PFI hospital in Birmingham had never been tested? When attempts were made to address the situation, fewer than 50% passed the test: many were found to be damaged, and almost 200 in one section of the hospital alone could not be found or reached at all. Has the situation improved across the NHS estate as a result of this publicity? Sadly, we see that there’s still a long way to go, as we continue to come across sites where testing has been too difficult, or even impossible, due to lack of access, and has been ‘put on a back burner’. Inevitably, that means fire dampers are not being tested properly on those premises.
The issue was not unknown: a year before the Birmingham ‘exposé’, an Estates and Facilities Alert (DH/2014/0031)1 had been issued by the Department of Health. That alert says unequivocally that ‘Where a lack of safe access to a fire or smoke damper, and its associated actuating mechanism, is identified, this should be brought to the immediate attention of the Director of Estates & Facilities and the Trust Fire Safety Manager / Fire Advisor’.
The big question is what comes next – after the issue is advised to senior staff? Is it prompt action, or languishing on a risk register, where the issue competes with countless other priorities?
Out of sight but not out of mind
Our argument is that while they may be out of sight, fire dampers cannot be out of mind. If faulty, they are never a low risk issue – they are a live fire risk. The simple fact is that HTM guidance tells us that every fire damper should be inspected and physically tested annually. The ALARP principle of risk management – As Low As Reasonably Possible – surely cannot apply to such critical safety equipment. This is especially so as the risk is known, and the measures to be taken are unambiguous: annual testing and inspection – and that requires access. If you don’t have that access, you need to provide it
The solution to providing access is generally not complex – it usually involves fitting inspection hatches to ventilation ductwork adjacent to each fire damper. Sometimes additional access such as ladders/walkways is needed, which of course is not to dismiss the fact that site logistics may be complex if contractors undertaking the work are to minimise disruption to the medical team and patients. Budgeting may be even more challenging when work that falls under the capital expenditure budget comes in.
Of course, anything that hampers effective estates management, and further bolsters the backlog, has practical implications for healthcare delivery. An NHS Confederation survey2 in June 2022 – and this will come as no surprise to HEJ readers – sounded the alarm over the ability to meet the Government’s ‘ambitious targets’ to reduce the elective care backlog being ‘hampered by the £9.2 bn maintenance bill that has built up over the past decade’.
Defining the problem
The root cause of so many fire dampers dropping out of the regular inspection and testing regime is that ventilation systems throughout much of the NHS estate lack the access hatches needed to facilitate mandatory inspection, cleaning, and regular fire damper testing. Estates teams may have lost track of the infrastructure in older buildings over the years, as changes are made incrementally, or they may fall foul of fundamentally bad design and installation in newer establishments. Often there are no accurate asset registers – Estates teams may not know where their dampers are, let alone their condition or model numbers for spares.
Defining the problem The root cause of so many fire dampers dropping out of the regular inspection and testing regime is that ventilation systems throughout much of the NHS estate lack the access hatches needed to facilitate mandatory inspection, cleaning, and regular fire damper testing. Estates teams may have lost track of the infrastructure in older buildings over the years, as changes are made incrementally, or they may fall foul of fundamentally bad design and installation in newer establishments. Often there are no accurate asset registers – Estates teams may not know where their dampers are, let alone their condition or model numbers for spares.
Estates & Facilities Alert warning
Of course, all that is cold comfort if your design preceded the guidance. So, let’s look at what that Department of Health Estates and Alert said in more detail: ‘There have been recent reports in the national media regarding the lack of suitable access to fire and smoke dampers, and their actuating mechanisms, to enable inspection, maintenance, and testing, to be completed in a safe and competent manner.
‘It has been highlighted that in certain circumstances, due to incorrect design and installation, maintenance personnel cannot gain safe access to facilitate the necessary statutory inspection of the fire and smoke dampers and their actuating mechanisms. In addition, there has been a failure to record the full details of where firestopping has been installed, hence causing difficulties in ensuring its integrity is maintained. This results in the organisation responsible for the building potentially being in contravention of Article 17 of the Regulatory Reform (Fire Safety) Order 2005, thereby putting patients, visitors, and staff at risk in the event of a fire.’
The Action Plan
The 2014 Estates Facilities Alert goes on to outline an Action Plan to maintain essential fire-stopping, as follows:
Fire and smoke dampers
‘All healthcare organisations should review their existing risk assessments and inspection/maintenance regimes relating to the inspection, maintenance, and testing of fire and smoke dampers, and their associated actuating mechanisms and control systems. They should ensure that they have a full inventory of all installed fire and smoke dampers within their premises. All installed fire and smoke dampers, and their associated actuating mechanisms and control systems, should be included in a formal maintenance programme to ensure that they are inspected and tested in order to confirm that they: meet regulatory guidance and are fit for the purpose they are intended for, and are in good working order, and have not been damaged, disconnected, or wedged open
‘Where a lack of safe access to a fire or smoke damper, and its associated actuating mechanism, is identified, this should be brought to the immediate attention of the Director of Estates & Facilities and the Trust Fire Safety Manager / Fire Advisor. Where problems are identified, a programme to repair or replace damaged fire and smoke dampers, and associated actuator mechanisms, should be put in place. Once any repair or replacement programme has been completed, the fire risk assessment for the premises should be updated, and key findings brought to the attention of all staff that might be affected.
Fire-stopping
‘All healthcare organisations should review their existing risk assessments and inspection regimes relating to the inspection of fire-stopping. They should ensure that they have a full inventory of fire stopping within their premises (see HTM 05-01 Appendix E – Developing fire safety protocols for advice on the information that should be collated).
‘If not already in place, systems should be implemented to ensure the integrity of fire-stopping can be confirmed within the organisation’s premises. This should incorporate permit-to-work systems that ensure fire-stopping is reinstated during, and following, works (e.g. construction, installation or maintenance) that may impinge on the integrity of the installed fire-stopping.
Is there an alternative approach?
The answer to this question is – in a nutshell – no. Inspection and testing are essential, and need to be scheduled. If fire dampers cannot be accessed, new hatches need to be fitted. Unfortunately, sometimes it is not just a case of fitting access hatches, since some dampers are not safely accessible without the installation of safe stairways, walkways, and adequate lighting.
Plenty of guidance – including from IHEEM
There is much guidance on the topic of fire damper testing and maintenance, and a good contractor will be able to navigate it all with you. A useful summary is given in IHEEM’s own Technical Guidance No 3: Maintenance, fire/smoke dampers3 issued by the Fire Safety Technical Platform. It broadly summarises the guidance on maintenance and testing provided in the HTM series, but does assume that access to the fire dampers is available, which is all too often not the case
There are three basic types of fire damper: fusible link, electrically operated, and intumescent. Intumescent fire dampers are rarely seen in NHS estates, and are not covered by the IHEEM Technical Guide (the latest BESA document, VH001, updated in May 2022, does call for their inspection, and, if necessary, cleaning or replacement).
Fusible link, spring-operated dampers operate when a fusible link is heated to its operating temperature (usually 72 °C), allowing a spring (or in some cases gravity) to close the fire damper. They provide a barrier to fire, but will have limited control over smoke spread. Good maintenance and testing require that they are visually seen to close, and are then manually reset, with system pressure rebalanced as necessary
Electrically operated dampers
Electrically operated dampers are generally held open by an electrical actuator, and shut when triggered by the fire alarm and/or an in-duct smoke/heat detector. They usually provide a barrier to both fire and smoke. They can usually be operated remotely, and end switches (limit switches) can provide information on whether a damper is closed or open, but not if it is clogged with dirt or failing to close completely. It is not sufficient to check that a light goes on and off at the panel. Nor is it acceptable to test a ‘representative sample’ of these fire dampers.
Legislation and standards require that every fire damper must be seen to operate, and seen to be clean and clear of obstruction. The only way to achieve this is through a survey and comprehensive asset register, to determine what equipment is in place and where, and a commitment to installing adequate access hatches once and for all
Back in 2017, when Sir Robert Naylor’s review of NHS property and estates brought the colossal NHS estates maintenance backlog into the public eye, 18% of NHS properties pre-dated the formation of the NHS, and 43% were already over 30 years’ old. In addition, most builds or refurbishments were commissioned before the implementation of the revised HTM 03-01 Part A, and its strong advice on designing in ease of maintenance. This fire damper access issue isn’t just going to ‘work its way through the system’ through rolling maintenance and refurbishment programmes. It’s a nettle that needs to be grasped
In older premises, and, disappointingly, some not so old where designers might have known better, the only safe and compliant option is expenditure on capital improvement to ventilation equipment to provide the access needed to mitigate known risk. The 2017 Naylor Report also commented that ‘There is no traditional business case to justify investment in backlog maintenance’. We beg to differ. Good maintenance is not only a prerequisite for meeting the core NHS principle of providing a safe environment for care, but can also extend equipment life and boost energy efficiency, which is now another guiding principle for healthcare ventilation.
It is logical that precisely located and easily accessed fire dampers will be far less labour-intensive to check and clean than ones lurking in miles of inaccessible ducting. Similarly, after the first inspection, which may result in remedial work, regular annual inspections should become routine. At the same time, the new access doors double as points of access for general duct cleaning and inspection.
Additionally, providing access will also make HTM 03 compliance more costeffective across the board – by providing easy and quick access for contractors. An investment in getting the infrastructure right should be able to pay for itself over the medium to long term.
All these arguments aside, the simple bottom line, as the 2014 Estates and Facilities Alert said, is that failing to facilitate compliance by providing access hatches results in the organisation responsible for the building potentially being in contravention of Article 17 of the Regulatory Reform (Fire Safety) Order 2005, thereby putting patients, visitors, and staff, at risk in the event of a fire. The catch is that installing access hatches carries a capital cost. The challenge for Trusts is to break down the budget barriers between capital and operational expenditure so they can meet their operational responsibilities for fire damper inspection and testing of essential safety equipment.
Taking a risk-based approach
Given budgetary constraints, it is not surprising that Trusts may take a riskbased approach to allocating precious financial resources. However, once the risk assessment has identified an issue, then we, as external ventilation system compliance specialists, have a duty of care to report that back to the client and record it. The ball is then in the Trust’s court, but we cannot stress too much that just adding something to the risk register is an interim acknowledgement of a real problem, not a solution. There needs to be a prioritised plan of action, and serious consideration of how high a risk this is considered to be, and a longer-term view on the costs.
We have no axe to grind on original design and specification; only how we deal with the consequences. Our interest is in helping estates professionals, especially those with older buildings, to comply with HTM 03 Part B, Specialised ventilation for healthcare premises: The management, operation, maintenance and routine testing of existing healthcare ventilation systems. It applies to all ventilation systems installed in healthcare premises irrespective of the age of the installation, and should be considered as the standard to be achieved. Understandably, a Trust is likely to have an initial focus on ventilation systems for perceived high-risk areas, but HTM 03- 01’s ‘Must’, ‘Should’, and ‘May’ provisions apply throughout the premises. In our view, the risk of fire dampers that cannot be inspected and tested, coupled with ventilation ducts that are not accessible to be thoroughly cleaned, should always be categorised as high, and the only answer is to invest in fixing the problem.
Project management
Our intention is not to create tension between Estates and Finance Managers, or extra work for the Estates team. We simply want to stress that poor access increases both the risk of fire and smoke spread, and just makes it harder, if not impossible, for you to meet your statutory obligations. It cannot be ‘parked’ on the risk register
Bed occupancy (pre-COVID) was running at over 90%, according to the King’s Fund: that may be a very crude measure of NHS pressure, but it gives an indication of the impracticality of shutting whole areas down for annual inspection and maintenance for any longer than necessary, just because no one can get to the equipment in question
Even a relatively small – in NHS terms – remediation project we undertook just recently involved 38 days of work to provide access to around 500 fire dampers.
We all understand the need for pragmatism. Some of the revised HTM 03 guidance on ventilation, like fitting sinks and drainage in plant rooms so drip trays can be cleaned easily, could mean major works and shutdown – not least because these rooms often have a solid concrete ground floor or basement floors. However, fixing the fire damper access problem is a generally a relatively easy job, and addresses a very real issue once and for all. The work involved is usually not complex, and with the right competencies can be delivered and managed in much the same way as the routine, ongoing maintenance.
Key steps
Like most projects, step 1 is a survey to locate, inspect, and assess the dampers, and provide a full inventory of all installed fire and smoke dampers, with their locations (ideally including a plan), which includes the type and size of damper. That enables Trusts to keep critical spares to avoid delays in future repairs that would call for a review of the fire risk assessment. It’s also the starting point for maintaining a comprehensive record of maintenance work, which should be photographic, and highlighting any damper locations that cannot be reached until inspection hatches are installed.
It’s important to ensure that testing and maintenance are completed by a competent person. Competency is defined, perhaps rather loosely, as someone with sufficient training, knowledge, and experience, to complete the task. How long is a piece of string? It comes down to your choice of contractor, and the experience and knowledge they can demonstrate.
Disruption is expensive, and minimising it is site-specific, and a factor of the expertise of contractors and their ability to work collaboratively and flexibly with healthcare estates teams.
It is very unlikely that many Trusts are not aware of the issues surrounding fire damper inspection; what is in doubt is whether the risk is rated highly enough. To remind you: every fire damper must be inspected, cleaned, and performance tested at least annually. If your in-house or contractor team cannot access the fire dampers to do that, you will be in breach of established guidance, and potentially in contravention of Article 17 of the Regulatory Reform (Fire Safety) Order 2005, thereby putting patients, visitors, and staff, at risk in the event of a fire.
Andrew Steel
Andrew Steel has been working in clean air technology for 30 years – for the past decade as managing director at independent ventilation, air, and water hygiene specialist, Airmec Essential Services. He has established Airmec as a trusted provider of air and water safety and compliance services, including fire damper inspection and remediation, in the healthcare sector, and for government high security sites. Airmec also seeks to apply the disciplines and benefits of the holistic approach adopted in the healthcare sector to its work with private clients.
References 1 Estates and Facilities Alert DH/2014/003: Reminder for the testing of fire & smoke dampers and ensuring the integrity of fire stopping. Department of Health, Issued 21 October 2014. 2 Lack of capital funding risking patient safety and impeding waiting list recovery: new poll of NHS leaders. NHS Confederation press release, 14 June 2022. 3 IHEEM fire Safety Technical Platform – Library of Technical Guidance: No 3. Maintenance, Fire/Smoke Dampers. https://tinyurl.com/pc85u2cc