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ES&H Manual

Fire Protection Supplement

Chapter 3:

Fire Protection Program Assessments and Facility Assessments Procedure

 

1.0             Purpose

Program documents require updates and facility usage or management oversight may change over time. Periodic assessments of both the fire protection program and Jefferson Lab facilities ensure effectiveness of the fire protection 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 assessments, program assessments, and facility assessments. Additional details associated with program assessments and facility assessments include responsibilities, components, frequency requirements and procedure steps.

3.0             Responsibilities

3.1              Fire Marshal   

·         Conducts program assessments 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 

·         Act on recommendations made in Newport News Fire Prevention Assessments. 

4.0             Assessments

4.1              DOE Assessments

DOE conducts assessments of both Jefferson Lab facilities and its fire protection program every three years; generally staggered in time with program assessments conducted by Jefferson Lab.

4.2              Program Assessments

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

4.2.1        Components

Program assessments encompass the following elements of the fire protection program:

·         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, training of fire protection engineering staff.
·         Emergency response organizations continued ability to provide service to Jefferson Lab, 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

·         Program assessments are conducted every three years; generally staggered between planned DOE assessments.

4.2.3        Process Steps

Step 1:            Prepare for Program Assessment 

1.      Determine members of the review team.

2.      Gather materials necessary to accomplish the assessment, e.g.:

·         procedures

·         equivalencies

·         exemptions

·         technical documents

·         fire hazard analyses

·         DOE standards

·         reports

·         previous assessment findings

3.      Determine what alterations have been made to fire protection elements since the last program assessment, if applicable.

Step 2:            Conduct Assessment

Assess the selected components for accuracy and relevance: 

1.      Review the gathered materials

2.      Make meticulous observations of the components listed above

3.      Compare your observations with the related standard(s) or expectations

Step 3:            Document Findings

Document 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 have occurred since the last assessment and will potentially affect fire safety  

·         Deficiencies

·         Recommendations for remediation, interim compensatory measures, and pending resolution (if needed)

4.3              Facility Assessments

Facility assessments evaluate elements of the fire protection program within a specific facility.

4.3.1        Components

Facility assessments encompass the following elements of the fire protection program:

·         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/safety wardens 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
·         Applicable codes and standards

 

4.3.2        Frequency

The frequency depends on the estimated value of the facility in question:

·         High Hazard facilities – Annually

·         Facilities valued $10M up to $100M – Every 3 Years

·         Facilities valued $3M up to $10M –  Every 5 Years

·         All other facilities must be inspected at a frequency determined by the Fire Marshal

 

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

 

4.3.3        Process Steps

Step 1:            Prepare for Facility Assessment 

1.      Determine which Jefferson Lab facility is scheduled for the next assessment in accordance with frequency requirements.

2.      Gather tools and materials necessary to accomplish the facility assessment, e.g.: 

·         technical documents

·         checklist(s) if considered appropriate

·         drawings

·         flashlight

·         inspection mirrors

3.      Gather tools fire protection engineering staff (Ensure authorized and safe access to all parts of the facility in question.

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

Step 2:            Conduct Assessment

Assess the selected Jefferson Lab facility for effectiveness of its fire protection program elements:

1.      Tour the facility in question

2.      Make meticulous observations of the facility assessment components listed above

3.      Compare your observations with the related standard(s), expectations and previous assessments

Step 3:            Document Findings

Document findings in a summary 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 in the program that have occurred since the last assessment and will potentially affect fire safety  

·         Deficiencies 

·         Recommendations for remediation, interim compensatory measures, and pending resolution (if needed)

4.4              Safety Warden Assessment

Safety Wardens conduct monthly assessments of safety items in designated areas. The list of evaluated items include, 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 Jefferson Lab 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 (CATS)

Practices described in JLab’s Issue and Action Management Procedure state that deficiencies with a risk code (Significance Level) of 2 or higher must be entered into Jefferson Lab’s CATS. 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 Summary

 

Periodic Review – 01/03/19 – No changes per TPOC

Revision 0.2 – 06/02/16 – Periodic Review; updated TPOC from D.Kausch to T.Minga; updated link to CATS procedure under 5.1

Revision 0.1 – 09/17/13 – Periodic Review; clarified components and frequency of assessments and frequency

 

ISSUING AUTHORITY

CHAPTER AUTHOR

APPROVAL DATE

REVIEW DATE

REV.

 

 

Fire Protection Department

Tim Minga

01/03/19

01/03/22

0.2

 

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 1/11/2019.