This article was first published in the International Federation of Healthcare Engineering’s Digest 2026. The principles discussed apply to any commercial building, not just healthcare premnises.
Fire dampers are critical safety devices, hidden away inside ventilation ducting and key to preventing the spread of fire. Hopefully, they are never required to close in anger, but regular inspection and testing of their readiness to do so is obviously vital – and required by law. However, there are a worrying number of buildings where these checks are still not happening.
This is for many reasons, but none would standup in a court of law following a disaster. The use and configuration of a building may have changed many times over the years, leading to an incomplete understanding of where the dampers even are. Stretched budgets may have pushed even mandatory actions down the list of priorities.
Chequered maintenance histories are, in my experience, all too common. Add to that any issues with incorrect installation techniques, and the bottom line is that potentially thousands of fire dampers in UK hospital premises are non-compliant with current safety legislation, posing a direct risk to building users.
The solution
NHS figures [2023/24] put the cost of eradicating all backlog maintenance in NHS estates at £13.8bn, and we all know there is not enough money to plug the gap. Trusts continue to face enormous daily challenges, and it is increasingly being accepted that choices have to be made, with a growing emphasis on risk-based maintenance.
What does this mean in practice for safety-critical infrastructure, specifically fire dampers which, following recent information campaigns and guidance updates, can no longer be kept out of mind? There is, however, a roadmap based on intelligent and diligent application of a risk-based approach to compliance management.
The first step towards resolution is to know your building, have a comprehensive asset register that gives you a complete picture, and to work to understand risk so you can manage it pragmatically with a focus on building users, not just compliance box ticking.
You will almost certainly need to work with a specialist service provider but will still hold the ultimate responsibility as a duty holder or responsible person. Choosing the right partner is essential.
Why is fire damper maintenance so urgent?
Poor compliance of fire damper maintenance has been a concern of mine for many years. I have long witnessed that it has been easy to overlook, or to defer because of logistical and budget implications. We were so often coming across buildings where there was no definitive register of where fire dampers were, let alone evidence of a robust inspection and testing regime.
Now the risk has become impossible to leave on the back burner because, back in 2022 alarm bells were rung about faulty fire damper installation practices, where contractors had used the wrong fixings. The issue was raised publicly by the Building Engineering Services Association (BESA) and prompted government action with the Office for Product Safety & Standards (OPSS) saying it would act to address the continued controversy surrounding the installation of smoke control dampers in buildings.
In a nutshell the issue was that use of self-drilling (“Tek”) screws for joining duct sections made installation quicker, cheaper, and easier. Remember, fire dampers themselves are not that expensive, the main cost is in installing them, so this was a false economy that may have benefitted installers but certainly has not helped building users. Let’s not forget that using the quick self-drilling screw option has been contrary to guidance going back to 2010. These fixings have long been a known risk and where they have been used, they must be replaced, or the risk in some way be mitigated.
This is because ductwork connected to fire dampers should be provided with “break-away” joints, which are created by using fixings and connectors with low melting points. The break-away joint reduces the risk of a fire damper being pulled away from the fire compartment in the event of a collapse of the ductwork or damaging the penetration seal around the damper through the expansion of ductwork. Self-drilling screws simply do not melt at low enough temperatures to achieve this.
BESA ran an awareness campaign about this back in 2022, at which point it was clear that all establishments had a duty to investigate their own installations urgently. Easier said than done because, for many, it meant starting from scratch and finding out where their dampers even were and then undertaking expensive work to install inspection hatches. This only highlighted how non-compliant many estates were because asset registers should already have been in place and existing guidance already stated that inspection access hatches should have been fitted.
Meanwhile BESA set about revising its existing guidance on fire damper installation. ‘DW145 – Fire Dampers (E/EI) and Leakage Guide to Good Practice for Installation, Design and Selection, Inspection and Maintenance’, was published at the end of 2024.
All credit to BESA for putting its head above the parapet and addressing a shocking situation, but the 2024 guidance has been of limited use for duty holders and competent persons managing existing infrastructure. A welcome new Technical Bulletin from BESA, published in July 2025, does now provide advice for legacy systems.
The access issue
Even before the Tek screw issue was highlighted, driving the current urgency into fire damper inspection and compliance, there was already a huge elephant in the room. While safety regulations require that fire dampers should be inspected and tested at least annually, the sheer difficulty/impossibility of getting to them meant that was not happening in many cases.
Where dampers are present, there are often not enough access hatches, perhaps only on one side of the damper and not both. This is surprising because ventilation ductwork access hatches are after all fairly basic, and they are relatively inexpensive and easy to fit when ducting is first installed. In contrast, retrofitting access hatches in a working building starts to add significant cost and disruption.
So, the inspection and testing backlog has been building for years and the current imperative to address it urgently adds unwelcome pressure to severely pressed budgets.
Even when budget is found, costs can still escalate due to lack of co-ordination between trades. In new installations and old alike, we find access hatches that are impossible to use because other pipes or ducts obstruct them, or the electrical trade has come in and installed cables and cable tray beneath them.
This lack of co-ordination is astonishing. Is it perhaps an issue that arises when too many sub-contractors are involved in the chain and the team that arrives on site armed with a specific job sheet has no overview or interest beyond it? So much for the digital record/golden thread of information which should include all new installation or modifications, as detailed in the Building Safety Act and Building Regulation 38.
The only remedy is to install new hatches and access arrangements, which can potentially be prohibitively expensive and near impossible to achieve or apply risk-based mitigation.
Sign off
Let’s take a pause here to wonder who ever signed off non-compliant systems in the first place? Also are current duty holders putting their name to incomplete annual inspection reports and if so are they fully cognisant of the potential implications of duty holding? Guidance (BS9999) clearly says that fire dampers should be inspected and tested at least annually and replaced or upgraded if they do not pass.
It does seem to me that the quality of reporting from inspection companies might also be an issue here. Major issues and critical failures should be clearly highlighted up front, not buried in pages of information. If nothing else, it shows that someone has read and analysed the findings. We were pleased to see a requirement for contractors/maintenance providers to record and report issues to the duty holder in the latest BESA guidance.
Risk based maintenance
Risk-based facilities management is not a new concept. It is a strategic approach that prioritises maintenance and resource allocation based on the potential risks associated with different assets, with a focus on ensuring a safe and efficient environment. By understanding the likelihood and consequences of potential failures, facilities managers can make informed decisions about where to focus their resources. As ever is starts with risk assessment so you can understand the issues.
Can it really apply in the health sector where the guidance is so very specific? The answer is yes.
While Health Technical Memoranda (HTM) 05-02 and 05-03 guide (new) design and operational management, HTM-05-01 Managing Healthcare Safety guidance helps with planning the appropriate fire safety management system. It allows for a risk-based approach that should permit the current statutory regulations to be applied sensibly and pragmatically.
Also, in its response to the BESA public warning about faulty installation the OPSS said it aims “to provide targeted, risk-based and proportionate enforcement of construction products regulations and will act fairly and firmly where product risks exist.”
The 2025 Technical Bulletin from BESA (TB59) also refers to a risk-based approach.
We also know risk-based maintenance planning works. A case in point is the Live Nation Cardiff Utilita Arena a building complex nearing the end of its operational life but still very much a commercial going concern and one where public safety is a key priority. The Arena’s replacement, a new indoor venue at Cardiff’s Atlantic Wharf, is now due to open in 2026/27 some three years later than originally planned. That means that the facilities team at the existing complex have the challenge of maintaining a safe and healthy environment a lot longer than planned, and against a commercial background where there will be reduced appetite for capital investment.
Working with long-term partner Airmec, the arena team have planned pragmatically for critical air, water, and fire safety services for the final years of the Arena’s life. Within that remit, replacement of fire dampers which fail inspection and testing is potentially particularly expensive, not least because so many are very difficult to access and/or would require major works to replace. Airmec’s suggested risk-based approach is achieving on-budget results without compromise on safety.
Decisions are based on risk factors such as:
• Is the damper in a system feeding a stairwell/escape route?
• If inspectors cannot get to the damper closest to the higher risk area, what is the location and status of the next damper upstream in the system and is that functioning? Do you need to install another damper?
• Are there other fire safety measures that can be taken to reduce risks– i.e. detectors/alarm systems, escape plans?
• The risk of fire and the likely direction of fire propagation.
• The type of ductwork connected to the fire damper (some fire-resistant ductwork may not require a break-away joint)
• The likely temperature the assembly will be exposed to given the effect of operational fire suppression systems.
• The risk of contaminants or pathogens within the ventilation systems.
• Is the fire damper otherwise installed in accordance with the manufacturer’s tested detail – as a piece of equipment is it adequately supported in line with the tested detail?
The Arena team already had experience with risk-based approach and working with Airmec. Back in 2012, they were able to extend the service life of air handling units with a planned maintenance and remediation regime. The building was then already some 20 years old and equipment failure in some air handling units (AHUs) was exposing the business to unacceptable commercial risks of having to cancel events if air exchange, temperature and humidity standards could not be maintained. What does BESA say about risk-based maintenance. The July 2025 technical bulletin on ductwork fire damper installation that gave more advice on legacy systems (TB59) embraces the pragmatic risk-based approach.
It says: “It is however, recognised that occasionally the physical constraints in place around fire dampers may hamper the remedial works associated with removal and replacement of self-drilling screws. In these instances, a risk assessment shall be undertaken to determine what action should be implemented and what control measures should be adopted, together with the level of any residual risk and how it should be managed. “
Next steps
You will doubtless understand by now that you need to review your asset register to ensure that all dampers are correctly installed – and accessible – and then plan survey and remedial works as necessary. This is on top of the routine inspection and testing which should, of course, already be being done annually in healthcare premises to comply with HTM-03. Remember, if there are no inspection hatches, there is no meaningful inspection!
This is work that involves multiple skill sets. Take time to plan the work with your specialist contractor to avoid over and under skilling. The person who can survey and report on the condition and installation of your fire damper infrastructure is not the same as the one who will typically undertake the routine inspection, testing and cleaning of dampers. Their experience and knowledge levels and hourly rates are vastly different. Do not panic or take a rushed decision: draw breath and take the opportunity to scope – and price – the work properly and fairly to all parties.
Be under no illusion: incorrectly installed and untested and inspected fire dampers may well not perform their function of reducing the spread of fire and/or smoke in a building during a fire. You need to act, starting, at least, with a survey of how all your dampers are installed, if you do not already have that information on record.
There are a lot of people involved in fire damper specification, installation, testing and maintenance but ultimately it remains the responsibility of the duty holder and the competent person appointed by them to fully consider the fire safety requirements, the level of risk that exists and the need for remedial works.
Doing nothing is not an option. Step one is to commission a review of your asset register and, if it does not reassure you that your fire dampers have been correctly fitted and maintained, then a full survey is called for.
Be sure to work with specialist contractors with a deep understanding of legal, safety and practical priorities and who can go the extra mile to help create and manage a pragmatic, risk-based plan of works. This does not have to be a big-ticket project.
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