Author(s): Jesse Roman. Published on January 2, 2019.

Mind the Gap

Recent code mandates for health care facilities mean that door gaps are suddenly a big deal—and potentially a big, expensive headache for some hospitals and other health care occupancies


How significant is a sixteenth of an inch? When it comes to fire doors in health care facilities, it could mean spending many thousands of dollars to fix or replace doors that do not meet the tolerances specified by code.

Over the last two years, the space between a fire door and its frame, known as the door gap, has become a key focus of health care facility managers, code consultants, and engineers, many of whom are finding out for the first time that the gaps on many fire doors at their facilities are larger than what is allowed by NFPA 80, Fire Doors and Other Opening Protectives.

When an inspector determines that a gap between a door and frame is too large, sometimes by as little as a sixteenth of an inch, a hospital generally has 60 days to fix the problem. But depending on the problem—whether it be a lopsided door frame, an uneven concrete floor, or a faulty installation—there isn’t always an easy solution. “A lot of hospital facility managers are scratching their heads,” said Jim Peterkin, a fire protection engineer and vice president of NFPA’s Health Care Membership section. “I hear people saying, ‘There are hundreds of doors here—what are we going to do?’”

Depending on the door and its fire rating, a single door could cost a couple thousand dollars or more to replace, meaning some hospitals could be facing potentially massive bills to remedy the problem. Industry concern was evidenced by the robust attendance at a recent NFPA webinar on the topic, which drew a record 1,700 registrants. “A lot of hospitals are asking why,” Peterkin said. “They’re saying, ‘This door has been here 20 years, and now all of a sudden we have to do something about it?’”


Fire doors are critical to health care facility fire safety and are designed to be a key part of the fire protection strategy that prevents fire from spreading throughout a hospital, allowing patients and staff in other parts of the hospital to shelter in place rather than attempting a potentially life-threatening evacuation. For years, NFPA 80 has set the maximum gap that can exist between the doors and the frame on the sides, top, and bottom, with those gaps ranging from an eighth to three-quarters of an inch, depending on the side. The concern is that gaps larger than those permitted by the code could allow heat, and subsequently fire, to penetrate around the door, or could cause the latches to fail if the door, or pair of swinging doors, twists and warps from the heat of the fire.

Ideally, a problem like a bigger-than-allowed door gap would have been identified and resolved during the initial installation, but for a variety of reasons that may not have happened, said Keith Pardoe, the chair of the NFPA 80 Technical Committee on Fire Doors and Windows. One reason is there has traditionally been insufficient emphasis placed on requiring training for workers who install and maintain swinging fire doors, he said. Additionally, for years NFPA 80 lacked guidance about the criteria inspectors should check on the doors, resulting in many code compliance officers being unaware that they should be looking for larger-than-allowed door gaps. Perhaps most critically, until the 2007 edition of NFPA 80, the standard never specifically mandated annual door inspections at all.

Nurses rush a patient through an egress with the doors wide open

The current concern over door gaps in health care facilities was prompted by the recent move by the Centers for Medicare & Medicaid Services (CMS) mandating that all health care facilities comply with the 2012 edition of NFPA 101, Life Safety Code. Photograph: Getty Images

“The result is that we have this whole body of doors that have been installed for decades that have never been inspected or verified” to show that they are in compliance, Pardoe said. “Now, when an inspector goes into a building, probably one of the top two deficiencies they find is that the gaps around the perimeter of fire doors are too large. This could be dozens of doors in a single building.”

For health care facilities, the issue has come to a head in the last couple of years because of the Centers for Medicare & Medicaid Services (CMS) move to mandate that all health care facilities comply with the 2012 edition of NFPA 101®, Life Safety Code®—previously, these facilities followed the 2000 edition, with the change to follow the 2012 edition taking effect in November 2016. “Obviously, with a newer code comes with it all the references to other standards, which have also been updated,” Peterkin said. One of the standards referenced by the newer Life Safety Code is the 2010 edition of NFPA 80, which includes a requirement for annual inspections of certain fire door assemblies.

The first CMS inspections following the shift to the 2012 Life Safety Code occurred in many facilities late last fall, which is when many of the door issues first surfaced. “Now everybody is in ‘What we going to do now?’ mode,” Peterkin said. “I’m not sure how many doors are being replaced—obviously that is the last option. There are other options they will get to first.”

Depending on the issue, a contractor may be able to use a steel shim behind the hinge leaves to push the door into the right position and eliminate the excessive gaps between the door and frame. Replacing the hinges can also solve the problem, and there are also a number of aftermarket products available, although those, too, can be expensive and may not be accepted by the local authority having jurisdiction, Peterkin said. If all else fails, the door or frame might need to be replaced at a significant cost—a typical single door assembly in a health care facility could costs upwards of $2,000, but that price could double or triple depending on installation needs and whether electrified hardware is needed, Pardoe said.


What many hospitals are hoping for, however, is some relief via the code.

Pardoe, the NFPA 80 chair, acknowledges that there isn’t a lot of technical basis for the gap size recommendations in NFPA 80. In fact, NFPA 252, Methods of Fire Test of Door Assemblies, which is the predominant fire door test that NFPA 80 relies on, uses test criteria where the gaps are a sixteenth of an inch smaller than what NFPA 80 currently allows for metal doors. “There’s never been any documentation that technically supports the disparity between what NFPA 80 allows and what tests require,” Pardoe said. The gap sizes were initially expanded for metal doors under the theory that metal doors expand when heated, he said.

How much space is allowed?

NFPA 80, Fire Doors and Other Opening Protectives, contains information on maximum gap allowances for different types of fire doors. In general, those allowed gaps are as follows:

» Clearance for under the bottom of a door: 3/4”

» Clearance between door and frame: 1/8”*

» Clearance for meeting edges for a pair of doors: 1/8”*

For more detailed gap information, refer to NFPA 80, Section and Section

*Doors faced with high-pressure decorative laminate material, 1/3-hour wood doors installed in hollow metal frames, and hollow metal doors are permitted a +/- 1/16” tolerance of the nominal 1/8” clearances.

To bring more clarity, the Fire Protection Research Foundation has begun work on a full-scale fire test on fire doors with varying gaps between the door and frame. The tests will first try to verify that the minimum gap sizes mandated for years by NFPA 80 are actually sufficient to prevent door failure—an outcome that committee members are optimistic about. Next, researchers will increase gaps on the top, bottom, and sides of the doors in different combinations to try to determine how large these gaps can be without compromising the door’s function.

“Some think that we could have a gap of up to 6 inches under the bottom of the door with no negative effect on performance of door assembly itself—obviously that’s a gross exaggeration, we would never do 6 inches of clearance, but if NFPA 80 went to 1 inch of clearance to help mitigate the irregularities in a concrete floor, would that be a safe change to make?” Pardoe asked. “Those are the types of questions the technical committee has wrestled with. We are very resistant to making a technical change without having justification that this is a safe change to make. This research study is how we’re trying to get a handle on it.”

Peterkin was candid about what he hopes the tests reveal. “What I’m hoping the testing proves is, first, that the criteria we’ve been using as a standard for gap sizes the last several decades are good and should not be reduced,” he said. “The second thing I would like to see is that maybe we can go a little bit bigger than the current recommendation and still pass the test. That would give everyone a little more flexibility.”

The Research Foundation hopes to begin the full-scale fire tests this spring and to have recommendations for the NFPA 80 technical committee by its scheduled fall meeting. The committee will then review the results during the upcoming revision cycle, in preparation for the 2022 edition of NFPA 80. If committee members feel that the guidance is important enough to include sooner, changes could be incorporated into the 2019 edition of NFPA 80 as a Tentative Interim Amendment.

JESSE ROMAN is associate editor for NFPA Journal. Top Photograph: Getty Images