ES&H Manual Fire Protection Supplement

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 420.1B 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 Protection Engineer (FPE)

· 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

The DOE conducts assessments of both Jefferson Lab facilities and its fire protection program. This is done every three years and is 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:

· Procedures for engineering design and review;
· Procedures and reports for inspection, testing, and maintenance of installed fire protection systems;
· Number, qualifications, training of fire protection engineering staff;
· Validity of prior baseline needs assessments;
· Exemptions and equivalencies, including temporary protection and compensatory measures;
· Facility fire prevention planning documents such as evacuation plans;
· Findings and recommendations from prior fire hazards analyses;
· Accuracy of fire loss potential (MPFL) determination; 
· Fire safety training;
· Conformance with applicable Orders, codes and standards;
· Adequacy of facility assessment reports; and
· Administrative controls for hot work and impairment.
 

4.2.2 Frequency

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

4.2.3 Process Steps

4.2.3.1 Preparation

1. Determine members of the review team.

2. Gather materials necessary to accomplish the assessment (e.g.: procedures, equivalencies, exemptions, technical documents, fire hazards analyses, standards, reports, and previous assessment findings).

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

4.2.3.2 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.

4.2.3.3 Document

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 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

Facility assessments assess 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 vital programs and high-value property;
· Fire suppression equipment;
· Water runoff;
· Fire apparatus accessibility;
· Fire barrier integrity;
· Potential for toxic, biological and/or radiological incident due to fire;
· Fire loading;
· Space-use changes;
· Fire prevention activities;
· Fire protection system readiness;
· Conformance with applicable Orders, codes and standards; and
· Maintenance of temporary protection and compensatory measures.

4.3.2 Frequency

Conducted in accordance with general guidance provided by the Authority Having Jurisdiction (AHJ), outlined in the AHJ delegation letter.

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

· Facilities valued in excess of $5 million are assessed at least every three years.

· Facilities valued between $1 million and $5 million are assessed at least every six years.

· Other facilities do not require fire protection assessments but must meet applicable standards and fire protection requirements for inspection.

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

4.3.3 Process Steps

4.3.3.1 Preparation

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, and

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

4.3.3.2 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.

4.3.3.3 Document

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 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 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 (CAT)

5.1 CAT System (CATS)

Practices described in ES&H Manual Chapter 5100 Internal Inspections 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 CATS.

The inspector or cognizant manager may choose to enter into CATS deficiencies with risk code of 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.

ISSUING AUTHORITY	CHAPTER AUTHOR	APPROVAL DATE	EFFECTIVE DATE	EXPIRATION DATE	REV.	Page 1 of 7
Fire Protection Dept	Dave Kausch	09/25/09	09/25/09	09/25/12	0

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 9/30/2009.