UNIVERSITY POLICY
SUBJECT: |
HEALTH AND SAFETY |
TITLE: |
FIRE AND LIFE SAFETY
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CODING: |
00-01-45-60:00 |
ADOPTED: |
05/10/96 |
AMENDED: |
03/18/08 |
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The purpose of this policy is to safeguard life and property at the University from the hazards of fire arising from storage, handling, or use of materials or equipment, and from conditions hazardous to life and property. This policy identifies all fire and life safety codes applicable to the University, and delineates and assigns roles and responsibilities to achieve the highest level of fire safety, property protection, and compliance within the University community.
II. ACCOUNTABILITY
Under the direction of the President, the Executive Vice President for Academic and Clinical Affairs and the Senior Vice President for Administration shall ensure compliance with this policy. The Executive Director of the Office of Emergency Management and Occupational Health and Safety (EMOHS), along with the Director of the Department of Environmental and Occupational Health and Safety Services (EOHSS) is responsible for implementation of all related policy and programs, in conjunction with the Senior Vice Presidents, Deans, Vice Presidents, and Presidents/CEOs of the Healthcare Units or their designees.
III. APPLICABILITY
In matters related to fire protection, prevention, preparedness and response, this policy shall apply to all University faculty, staff, students, volunteers, visitors, and outside contractors working on University premises. The policy is applicable to all UMDNJ owned/leased and/or operated facilities, whether occupied or unoccupied.
IV. REFERENCES
A. Clean Air/Smoke-Free Environment 00-01-10-15:00
B. Emergency Operations Management 00-01-10-17:00
C. Environmental/Occupational Health 00-01-45-20:00
D. NJ Worker and Community Right to Know Act 00-01-45-25:00
E. Hazardous Waste Management 00-01-45-35:00
V. DEFINITIONS
A. Facility means all UMDNJ owned/leased and/or operated buildings, types of containers, storage and work trailers, parking areas, and other places under the control of the University - whether occupied or unoccupied.
B. Fire and Life Safety Compliance Guide offers guidance on some of the most common fire and life safety issues, which if not properly addressed, can become fire code violations. It addresses four major areas: fire prevention, fire protection, fire emergency preparedness and fire response. It serves as a guiding tool for the University community to effectively implement this policy. This Guide is available on the E OHSS website:
http://www2.umdnj.edu/eohssweb/publications/firecomplianceguide.pdf
C. Fire and Life Safety Standard Operating Procedures (SOP) includes detailed fire safety procedures that are primarily utilized by EOHSS and other departments assisting in the implementation and management of the University’s Fire and Life Safety Program. These SOPs will be used in conjunction with this policy and the Fire and Life Safety Compliance Guide.
D. Fire Barrier is a fire resistance rated vertical or horizontal assembly of materials designed to restrict the spread of fire in which openings are protected. The University utilizes the “penetrations of fire barriers permit process” to ensure that the integrity of all fire barriers is retained as required.
E. Fire exit drills are evacuation exercises that provide opportunities for faculty, staff, students, volunteers, visitors, outside contractors, and emergency responders to become familiar with the fire safety features of the building, to practice emergency procedures, and to ensure the efficient and safe use of available exit facilities.
F. Facility Safety Coordinator(FSC), or designee, is a faculty or staff member who serves as a contact/resource person for all facility-specific fire and life safety related matters. This person provides support in three primary areas: fire prevention and preparedness, initial fire incident response, and response support as outlined in this policy. FSCs are trained to perform assigned responsibilities as outlined in this policy without risking their personal safety or entering any fire, smoke-filled, or other unsafe area to assist or rescue others.
G. Fire Wardens and Buddies are faculty or staff members, who have voluntarily accepted the appointment by each department and/or Facility Safety Coordinator to assist with emergency evacuation and the safety of people with disabilities. They are trained to perform assigned responsibilities as outlined in this policy without risking their personal safety or entering any fire, smoke-filled, or other unsafe area to assist or rescue others.
H. Fire Watch is an activity involving observation of a hot work area for at least 30 minutes after such work to prevent personal injury or fires. It requires a suitable fire extinguisher ready for use and personnel trained in its use and other emergency procedures. This is performed by the department managing hot work. The Department of Physical Plant also initiates a Fire Watch request whenever conditions or activities may reduce the effectiveness of fire protection and/or emergency evacuation systems. Physical Plant may also initiate a Fire Watch if any unsafe condition necessitating this activity is reported by EOHSS or Public Safety. In such cases, Physical Plant will notify all impacted departments, and Public Safety will conduct periodic walk-through and visual inspections, as appropriate, when notified.
I. Hot work safety program is intended to prevent injury and loss of property from fire or explosion resulting from temporary operations such as welding, brazing, soldering, heat treating, grinding, powder-actuated tools, hot riveting, torch-applied roofing and all other similar applications producing a spark, flame, or heat. Routine laboratory and cooking activities do not fall within the scope of this program. The program requires proper delegation of authority, compliance with fire prevention precautions, using a hot work permit, and observing Fire Watch.
J. Incident Commander (IC) is t he indivi dual responsible for all incident activities, including the development of strategies and tactics and the ordering and the release of resources. The IC has overall authority and responsibility for conducting incident operations and is responsible for the management of all incident operations at the incident site.
K. Incident Command Post (ICP) is t he field location at which the primary tactical-level, on-scene incident command functions are performed. The ICP may be co-located with the incident base or other incident facilities.
L. Material Safety Data Sheet( MSDS) is a form containing data regarding the properties of a particular substance or chemical. It is intended to provide workers and emergency personnel with procedures for handling or working with that substance in a safe manner, and includes information such as physical data (melting point, boiling point, flash point, etc.), toxicity, health effects, first aid, reactivity, storage, disposal, protective equipment, and spill handling procedures.
M. People with disabilities (PWD) are considered to have permanent or temporary conditions that do not permit them to physically respond or evacuate the building in a safe manner without assistance in the event of an emergency. Any individual who is able to ambulate without assistance, but has limited mobility, is also to be regarded as a person with disability from the evacuation safety point-of-view. The general categories of disabilities are: mobility impairment (wheelchair or non-wheelchair, pregnancy included), visual impairment, hearing impairment, speech impairment, and cognitive impairment.
N. Safe Waiting Area or Area of Refuge is an area that serves as a temporary haven from the effects of a fire or other emergency. A person with severe m obility impairment must have the ability to travel, with assistance of others, from this area to the public way.
O. Visitors are all individuals other than University faculty, staff, students, volunteers and outside contractors, who may be present at the University’s facilities. Visitors include, but are not limited to, visiting researchers, clinical professors/instructors, patients, patients’ friends and relatives, visiting students and others.
VI . POLICY
A. Requirements:
1. The University will comply with the New Jersey Uniform Fire Code (N.J.A.C. 5:70 et. seq.) promulgated by the N.J. Department of Community Affairs (DCA), the New Jersey Uniform Construction Code (N.J.A.C. 5:23 et. seq.), and other applicable local, state, and federal regulations and standards, including: the federal Occupational Safety and Health Administration (OSHA: 29 CFR 1910.38), as adopted and implemented by the New Jersey Department of Labor, the Department of Health and Senior Services, Public Employees Occupational Safety and Health Act (PEOSHA); the National Fire Protection Association’s (NFPA) National Fire Code; requirements of the Americans with Disabilities Act (ADA); and the Joint Commission (formerly known as JCAHO).
2. Faculty, staff, students, volunteers, visitors, and outside contractors will comply with this policy to ensure their safety and the safety of others at the University; they are prohibited from any activity that will jeopardize the safety of individuals, groups, and University property. No one will enter any fire, smoke-filled, or other unsafe area without appropriate training and personal protection. The University’s Fire and Life Safety Compliance Guide and Standard Operating Procedures will be referenced for specific compliance standards in addition to the policies referenced in Section IV.
3. Departments failing to comply with this policy are subject to charges for any penalty or fine levied against the University. Individuals failing to comply will be subject to disciplinary action up to, and including, expulsion or termination of employment.
B. Roles and Responsibilities:
1. Department Managers and Supervisors are responsible for developing, reviewing, and revising Department/Unit-specific emergency response procedures, to be included in the Department-specific Disaster Plan and for ensuring compliance with all applicable fire and life safety related procedures. Their responsibilities include: working together with their Facility Safety Coordinator to achieve the established fire and life safety goals for their department or area, appointment of an adequate number of departmental fire wardens and buddies, providing and reviewing clear written directions to be used during emergencies with any known employee with disabilities, maintaining the latest chemical inventory and material safety data sheets (MSDS), ensuring safe response to fire or smoke-related emergencies in their area, including prompt reporting of all fire related incidents and initiating investigation for all fire and emergency evacuation related incidents.
2. Each School/Unit Administrator or appropriate Facility Manager is responsible for designating a key administrative staff person as a Facility Safety Coordinator (FSC) for each facility, who will ensure the effective implementation of the facility-specific "Fire Safety and Emergency Evacuation Plan." School/Unit Administrator will also designate another individual as a back-up FSC to ensure continued support during the FSC’s absence. In cooperation with EOHSS, this individual will monitor compliance with applicable fire and life safety related procedures. In facilities without a clearly defined Facility Manager, School/Unit Administrators are responsible to work with EOHSS to agree upon a FSC who will have authority for that facility.
3. Facility Safety Coordinator (FSC), or designee, will serve as a contact/resource person for all facility-specific fire and life safety related matters. This person will participate in scheduled fire exit drills and training, and p rovide support in the following three primary areas without risking their personal safety or entering any fire, smoke-filled, or other unsafe area to assist or rescue others:
a. Fire prevention and preparedness: The FSC will assist EOHSS in the development, communication, implementation, and revision of the facility-specific evacuation plans; ensure that required drills are conducted; work with School/Unit Administrators, Facility Manager, and/or Department Heads to identify and train adequate number of fire wardens and buddies, and monitor their participation; assist in fire incident investigation and corrective action process; and ensure that holiday decorations and public events are organized safely in conjunction with department heads and with proper regulatory approvals.
b. Initial fire incident response: The FSC will report to the pre-determined location of fire response, provide support to facilitate appropriate evacuation and re-occupation in concert with internal and external emergency responders, and assist Public Safety and other University departments in the establishment and operation of the incident command post (ICP), as necessary.
c. Response support : In case of fire related emergencies, the FSC will serve as a primary internal resource person to provide the most up-to-date, necessary facility- or area-specific information, such as current layout, nature of activities and presence of any people with disabilities. The FSC will also assist EOHSS in obtaining the latest chemical inventory and material safety data sheets (MSDS) through Department Managers and Supervisors, as necessary.
4. Fire Wardens and Buddies will be responsible for participating in scheduled fire exit drills and training, assisting and guiding the building occupants to a safe EXIT during fire alarms, evaluating fire alarm response performance and reporting any fire safety hazards. These individuals will work together with their Facility Safety Coordinator to achieve their established area-specific fire and life safety goals. The University does not require or suggest that these faculty and staff risk personal safety as they perform their assigned responsibilities. Wardens and buddies will not enter any fire, smoke-filled or other unsafe area to assist or rescue others.
5. Environmental and Occupational Health and Safety Services (EOHSS) will develop and implement a University-wide fire and life safety program to include facility-specific Fire Safety and Emergency Evacuation Plans, related technical assistance, training and education, fire exit drills and fire code compliance inspections. EOHSS will also serve as a liaison for external regulatory agencies and will notify the NJ State Fire Marshal’s Office immediately of any fire incident in University occupied facilities. EOHSS will reach out to individual School/Unit Administrators to identify an FSC and a back-up FSC for any facility where there is no one clearly identified Facility Manager. EOHSS will create and maintain the UMDNJ Fire and Life Safety Compliance Guide and Fire and Life Safety Standard Operating Procedures. EOHSS staff responding to fire related emergencies will not enter any fire, smoke-filled or other unsafe area to assist or rescue others.
6. Physical Plant will manage the installation, maintenance, inspection, and testing of all fire detection, alarm communication, suppression, and other life safety systems in accordance with all applicable fire and life safety codes. Physical Plant will secure appropriate construction permits from the authority having jurisdiction; participate in all regulatory compliance inspections; notify the local fire department, the Office of the New Jersey State Division of Fire Safety and University’s Risk and Claims Management of any fire protection system impairments or disconnections promptly and upon completion of such work; respond to all fire alarms; and troubleshoot, investigate, and reset systems. Physical Plant will also assist in conducting fire exit drills and ensure compliance with regard to contractors’ activity, hot work safety program, fire hazard communication, penetrations of fire barriers permit process, and other functions outlined in the UMDNJ Fire and Life Safety Compliance Guide and Standard Operating Procedures. Physical Plant staff will not enter any fire, smoke-filled, or other unsafe area without appropriate training and personal protection equipment while responding to fire alarm emergencies.
7. Facilities Planning and Construction (FP&C) will ensure that all applicable fire and life safety codes, including the specific requirements of this policy, are included at the planning, design, and construction stage of any project. FP&C will communicate all projects for fire and life safety review to both EOHSS and Risk and Claims Management. FP&C will also comply with the requirements for penetrations of fire barriers, secure appropriate construction permits and building registration certificates, manage work by outside contractors and their subcontractors, and notify the Physical Plant of any fire protection device or system impairments during construction or renovation projects.
8. Risk and Claims Management will coordinate the review of all construction and renovation project specifications and plans, including any modifications of building fire protection systems and/or pressure vessels, with the University’s insurance carrier, FP&C, Physical Plant, and EOHSS. Risk and Claims Management will also report any fire safety related findings or recommendations of the insurance carrier to appropriate UMDNJ departments, as well as any impairments of a fire protection device or a system immediately to the University’s insurance carrier, when notified by the Physical Plant.
9. Outside Contractors and Sub-Contractors will comply with all applicable requirements of this policy in addition to any specific contract requirements. Contractors are prohibited from any activity that will jeopardize the safety of individuals and University property.
10. Department of Public Safety will provide internal and external emergency communication services related to fire alarms, fire response, emergency rescue or emergency medical treatment on the fire scene, site security, and external and internal traffic control, as well as assist in determining and directing the establishment of an incident command post as instructed by the Incident Commander. Public Safety will secure all areas affected by fire or smoke until released by the investigating State Fire Marshal and assist external responding agencies as appropriate. Public Safety will also conduct periodic walk-through and visual inspections of areas under fire safety watch, provide access to locked building areas, secure egress doors in accordance with the applicable Fire Codes, and comply with the penetrations of fire barriers permit procedure. When responding to fire alarm emergencies, Public Safety staff will not enter any fire, smoke-filled, or other unsafe or hazardous area without proper training and personal protection equipment.
11. Information Services & Technology (IS&T) will comply with the penetrations of fire barriers permit procedure by ensuring that (1) all fire rated walls, floors and ceilings are maintained, repaired, or replaced as originally designed or constructed; and, (2) holes in rated walls, floors, or ceilings are repaired to their original rating as soon as possible using approved materials and methods. During emergency situations, as applicable, the IS&T Telecommunications Operators will work in conjunction with the Public Safety Communications office and the Physical Plant Emergency Maintenance Office, and assist in communicating emergency information to the building occupants and to the local Fire Department.
12. Purchasing Services will ensure, by including in all vendor agreements, that furnishings and decorations including any item of upholstered furniture, mattresses, wardrobe, wastebaskets, curtains, draperies, surface coverings, acoustical and other materials used for decoration are documented to be non-combustible or flame resistant (capable to restrict the spread of flame) in accordance with the appropriate NFPA or other equivalent standard. Purchasing Services will ensure that all purchase of upholstered furniture including sofas and mattresses comply with California Technical Bulletin ( CAL TB) 117, furnishings and furniture to be used in general assembly areas comply with CAL TB 133 (except for fully sprinklered facilities where compliance with CAL TB 117 is considered adequate), and all other decorative materials comply with NFPA 701 standard.
13. The Office of Workplace Diversity will provide the University’s Emergency Procedures for People with Disabilities to employees with disabilities known to the Office, as outlined in the Fire and Life Safety Compliance Guide.
14. The UMDNJ Incident Commander (IC) w ill function as the IC until/unless it is necessary and/or appropriate to transfer command to a more highly qualified member of the responding fire department. If the decision is made to transfer command, the UMDNJ IC will provide a transfer of command briefing along with all appropriate materials to the fire department Incident Commander. A knowledgeable UMDNJ staff member will remain with the fire department Incident Commander as a liaison and act as part of the Unified Command structure. Upon departure of the fire department, this person will re-assume command.
By Direction of the President:
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Senior Vice President for Administration
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