ES&H Manual

Fire Protection Supplement


Chapter 14: Building Safety Assessment Procedure


1.0             Purpose

Jefferson Lab performs biennial safety assessments of all buildings and structures. These assessments focus on fire hazard issues such as electrical and housekeeping. Other safety issues found while conducting the assessment are noted and resolved in accordance with this procedure.

2.0             Scope

This program applies to all Jefferson Lab buildings and structures. Assessments are scheduled minimally every two years (starting in FY2019) based on hazard level, occupancy and use.  The assessment team utilizes the attached checklist, augmented as necessary based on building functionality and specific hazards.

3.0             Responsibilities

3.1              Fire Marshal and Emergency Manager

·         Co-lead the assessment team.

·         Schedule the date and time for each building assessment.

·         Designate two members from Facilities Management and Logistics (FM&L) and two members from Environment, Safety, Health, and Quality (ES&H) to participate on the Assessment Team.

·         Invite the specific building safety warden(s) and Division Safety Officer (DSO) to accompany the assessment team through the appropriate area. 

·         Assign risk code to each inspection finding.


3.2              Fire Marshal 

·         Distribute the annual schedule to DSO and assessment team members.

·         Confirm schedule with Accelerator Operations and Experimental Hall Coordinators prior to entering accelerator site operation buildings.

·         Distribute report and summaries for review and determination.

3.3              Emergency Manager 

·         Create CATS Issue entry for building inspection finding.

3.4              Safety Warden 

·         Accompany inspection team as schedule permits.

3.5              Division Safety Officer  

·         Follow up on any finding.

4.0             Procedure

4.1              Schedule

At the beginning of each fiscal year, the co-leads develop the tentative building assessment schedule. Each year includes approximately 50% of the building and structures. Coordinate with the Accelerator Operations and Experimental Hall DSOs, as applicable, give consideration to the accelerator maintenance periods. 

No less than two weeks prior to a scheduled assessment, the Fire Marshal distributes the building’s applicable safety warden reports from the previous year and previous building assessments to:

·         Division Safety Officers (DSO) 

·         Assessment team members

·         Applicable safety warden(s)  

4.2              Building Assessment

NOTE:  If more than one team member is unable to participate, reschedule the assessment.

·         Assessment team assembles, with the safety warden(s) if available, at the scheduled time and location. 

·         Fire Marshal distributes the appropriate Building Assessment Checklist (see attached).

·         Assessment team walks through each building space, using the assessment checklist to note any discrepancy. Include findings from previous safety warden or assessment reports that have not been rectified and take photographs of each unsafe condition (notify the Safety Warden immediately notified of any unsafe conditions and/or practices).

·         Fire Marshal shall immediately notify the applicable DSO of any hazard presenting imminent danger to severe injury.

·         All team participants submit their completed building assessment checklists to the Emergency Manager at the end of the walk-through.

4.3              Report

·         Within seven days of the building walkthrough, the Emergency Manager submits a draft assessment report (listing findings, description, category and images) for team member review. The Emergency Manager compiles review comments and submits the final building assessment report to the Fire Marshal.

·         Within seven days of the report receipt, the Fire Marshal compiles the final report (including fire protection information) and submits it to the Facilities Director and the AD, ES&H for a quality review.

·         Within two days following the quality review, the Fire Marshal submits the final assessment report to the applicable division/department DSO and the Associate Director/Department Manager.

4.4              Follow-up

The Emergency Manager will follow up on the findings after 45 days of the original submittal to the DSOs. If the outstanding findings have not been corrected within the 45 day period, the remaining findings will be entered into CATS (as a single issue) assigning action to the applicable DSO. Multiple CATS issues may be created if more than one division is involved. All corrected findings will be documented on the findings report and resubmitted to the Emergency Manager by the assigned DSO.


4.5              Executive Summary

At the beginning of each fiscal period, the Fire Marshal shall submit an executive summary to the Facilities Director and the AD, ES&H. The summary will categorize deviation from safe practices for electrical, appliances, excess combustibles, compressed gas, emergency egress, ladders, lighting, slip/trip hazards, chemical storage, and other safety issues. The summary will include the total number of identified findings during the quarter, including those entered into CATS. 


5.0             References

Corrective Action Tracking System


6.0             Revision Summary


Revision 0.0 – 05/31/19 – Initial content per CATS# NE-2018-04-02 action to document a process defining expectations for configuration management










Fire Protection Department

Tim Minga





This document is controlled as an on line file.  It may be printed but the print copy is not a controlled document.  It is the user’s responsibility to ensure that the document is the same revision as the current on line file.  This copy was printed on 8/28/2019.