Chapter 3: Fire Protection Program Assessments & Facility Assessments Procedure

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Fire Protection Manual

Chapter 3

Fire Protection Program and Facility Assessments Procedure

1.0 Purpose

Program documents require updates; facility use or management oversight may change over time. Periodic assessments of both the fire protection program and TJNAF facilities ensure effectiveness of the Fire Protection Program (Program) and compliance with changing standards and codes.

Assessments are conducted in accordance with Department of Energy (DOE) Order 420.1C and standards described in ES&H Manual Chapter 2410, Hazard Issues and Contractual Commitments.

2.0 Scope

This document describes assessments conducted at Jefferson Lab, including DOE, Program, and Facility assessments. Additional details associated with program and facility assessments include responsibilities, components, frequency requirements, and procedure steps.

3.0 Responsibilities

Note: Management authority may be delegated to a task-qualified TJNAF employee at the discretion of the responsible manager.

3.1 Fire Marshal

- conducts program and facility assessments using additional resources as required

- initiates work control documents, as required, to correct deficiencies

3.2 Safety Wardens

- conduct monthly safety warden assessments

- initiate work control documents, as required, to correct deficiencies

3.3 Facilities Management

- acts on recommendations made in Newport News Fire Prevention Assessments

4.0 Assessments

4.1 Department of Energy

The DOE conducts assessments of Jefferson Lab facilities and its Fire Protection Program. This is conducted triennially and is generally staggered in time with program assessments conducted by TJNAF.

4.2 Program assessments examine the accuracy and relevance of procedures and other documents.

4.2.1 Components (listed below), of the Fire Protection Program are evaluated.

·       compliance with fire protection-related statutory requirements, DOE orders, and mandatory national consensus codes and standards

·       procedures for engineering design and review

·       procedures for inspection, testing, and maintenance of installed fire protection systems and features

·       number, qualifications, and training of fire protection engineering staff

·       emergency response organizations continued ability to provide service to TJNAF, including the Baseline Needs Assessment (BNA)

·       management support

·       exemptions and equivalencies, including temporary protection and compensatory measures

·       fire protection system impairment process

·       hot work process

·       documentation and record keeping

4.2.2 Frequency of assessments, generally staggered between planned DOE assessments, are conducted every three years.

4.2.3 Process Steps

a. Prepare

i. determine members of the review team

ii. gather materials necessary to accomplish the assessment (e.g., procedures,

equivalencies, exemptions, technical documents, fire hazards analyses, standards,

reports, and previous assessment findings)

iii. determine what alterations, if any, have been made to fire protection elements

since the last program assessment

b. Conduct assessment of the selected components for accuracy and relevance.

i. review the gathered materials

ii. make meticulous observations of the components listed above

iii. compare your observations with the related standard(s) or expectations

c. Document any findings in a summary report that includes the following descriptions and items:

·       tasks accomplished during the effort (areas toured, documents reviewed, and people interviewed);

·       changes of significance in the program that occurred since the last assessment which affect fire safety;

·       note deficiencies; and

·       recommendations for remediation, interim compensatory measures, and, if necessary, pending resolution.

4.3 Facility Assessments

Evaluations of Jefferson Lab complexes are conducted to review elements of the Fire Protection Program within a specific facility.

4.3.1 Components (listed below), of the Fire Protection Program are evaluated.

·       life-safety considerations, including safe egress, emergency lighting and special hazards (cutting, welding, compressed gases, etc.);

·       fire protection of critical process equipment and programs;

·       fire protection of high value property;

·       fire suppression equipment;

·       fire detection and alarm system and equipment;

·       water runoff;

·       facility fire prevention planning documents (e.g., evacuation plan and safety warden extinguisher training)

·       emergency response capability, including fire apparatus accessibility to the facility;

·       fire barrier requirements and integrity;

·       completeness of fire loss potential determination;

·       fire safety training;

·       potential for toxic, biological and/or radiological incident due to fire;

·       status of previous findings and tracking until resolution

·       a review of the input, assumptions, and compensatory measures of equivalencies and exemptions to determine their validity;

·       fire and explosion hazards, and;

·       applicable codes and standards.

4.3.2 Frequency of assessments is determined by the estimated value of the facility in question.

· Annually (1 year) – facilities considered high-hazard

· Triennially (3 years) – facilities valued from $10 million to $100 million

· Quinquennially (5 years) – facilities valued from $3 million to $10

All other facilities must be inspected at a frequency determined by the Fire Protection Engineer.

Refer to the Building Features table for numerous details including estimated values of each building and its administrative contents.

4.3.3 Process Steps

a. Prepare

i. determine which facility is scheduled for the next assessment in accordance with frequency requirements

ii. gather tools and materials necessary to accomplish the facility assessment, for example

· technical documents,

· checklist(s), if considered appropriate,

· drawings,

· flashlight, and

· inspection mirrors

iii. gather fire protection engineering staff (ensure authorized and safe access to all parts of the facility in question)

iv. determine what alterations, if any, have been made to fire protection elements since the last time the facility was examined

b. Conduct assessment of the selected Jefferson Lab facility for effectiveness of its Fire Protection Program elements.

i. tour the facility in question

ii. make meticulous observations of the facility assessment components listed above

iii. compare your observations with the related standard(s), expectations and previous assessments

c. Document the assessment in a report that includes the following descriptions and items:

·       facility under evaluation;

·       tasks accomplished during the effort (areas toured, documents reviewed, and people interviewed);

·       fire protection features;

·       hazards and other occupancy considerations;

·       changes of significance within the facility that occurred since the last assessment and affect fire safety;

·       noted deficiencies; and

·       recommendations for remediation and interim compensatory measures, if necessary, pending resolution.

4.4 Safety Warden Assessment

Safety wardens conduct monthly assessments of safety items in designated areas. The list of evaluated items includes, but is not limited to, fire extinguishers, emergency exit signs and lights, functionality of door hardware, and trip hazards. Work orders are submitted to resolve any noted deficiencies.

4.5 Newport News Fire Prevention Assessment

The City of Newport News Fire Prevention Bureau, at their discretion, conducts a periodic advisory inspection of certain TJNAF facilities. This inspection is comparable to that which is performed in public occupancies elsewhere in the city. Facilities Management acts on recommendations provided, forwards the report information to building managers when tenant actions are indicated, and tracks corrective action to completion.

5.0 Deficiencies and Corrective Action Tracking

5.1 CAT System

Practices described in TJNAFs Issue and Action Management Procedure state that deficiencies with a risk code (Significance Level) of 2 or higher must be entered into the CATS (corrective action tracking system). Deficiencies requiring more than 30 days and/or more than one organization or work group to complete are also entered into the system.

The inspector or cognizant manager may choose to enter deficiencies with risk codes less than 2; but it is not required.

5.2 Work Orders

Deficiencies risk code of less than two requiring less than 30 days and one organization or work group to complete are entered into Facilities Management and Logistic Work Orders system.

6.0 Revision History

rev	summary	date
0.3	triennial review; made general edits and format updates (e.g., bullets, spacing, etc.)	04.15.2022
0.2	periodic review; no changes necessary	06.02.2019
0.2	periodic review; updated TPOC from D.Kausch to T.Minga; updated link to CATS procedure under 5.1	06.02.2016
0.1	periodic review; clarified components and frequency of assessments and frequency	09.17.2013

	ISSUING AUTHORITY	AUTHOR	APPROVAL DATE	NEXT REVIEW DATE	rev
	Fire Protection Department	Tim Minga	04.15.2022	04.15.2025	0.3

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It is the user’s responsibility to ensure that the document is the same revision as the current online file. This copy was printed on 4/19/2022.