Operating Policy and Procedure
HSC OP: 75.16, TTUHSC Fire and Life Safety Policy
PURPOSE: The purpose of this HSC OP is to define and outline fire and life safety program requirements to assure the safety of building occupants and protect TTUHSC facilities and property.
1. Definitions
2. TTUHSC Fire and Life Safety Authority Having Jurisdiction
3. Fire Prevention
4. Fire alarm response at TTUHSC facilities
5. Monitoring and reporting requirements for fire events
6. Fire and Life Safety Training
7. Fire Drill requirements for employees and students
8. Required fire alarm system maintenance
REVIEW: This HSC OP will be reviewed by June 15 of each even numbered year (ENY) by the HSC Fire Marshal, the Senior Director of Safety Services, and the Texas Tech Police Department, with recommendations for revision forwarded to the Vice President for Facilities and Safety Services by July 30.
POLICY/ PROCEDURE:
1. Definitions:
a. Authority Having Jurisdiction: The organization, office, or individual responsible for approving equipment, materials, an installation, or a procedure relating to fire or life safety.
b. Employee Training: Basic employee training on proper response to fire alarms, fire drills and fire extinguisher usage at TTUHSC facilities.
c. Fire Alarm Monitoring: Constant attention to the status of TTUHSC fire alarm systems, and code acceptable emergency response utilizing either employee based or contracted services.
d. Fire Alarm Response: The proper and required response to fire alarm system activation is the prompt and orderly evacuation of all occupants from the areas of the building that are in alarm.
e. Fire Drill Response: Evacuation of faculty staff and students from the building during a planned drill without interrupting direct patient care, elevator travel or critical need laboratory work.
f. Non-Ambulatory Building Occupants: Building occupants who, due to the nature of their injury or illness, are incapable of taking action for self-preservation under emergency conditions without the assistance of others.
g. Required Maintenance: Code required maintenance and inspection for essential systems and components necessary for occupant and facility protection from fire and similar emergencies.
2. TTUHSC Authority Having Jurisdiction:
The TTUHSC Fire Marshal is the official contact and authority having jurisdiction for TTUHSC regarding fire and life safety issues, in addition to serving as the designated representative of the State Fire Marshal’s Office. The TTUHSC Fire Marshal is responsible for the application, interpretation and enforcement of codes adopted by the TTU Board of Regents. Communication regarding fire and life safety issues within any construction project will be conducted through the project management team communication channels. Fire and life safety related inspections or code enforcement which is not construction project related will be conducted between the TTUHSC Fire Marshal and the affected groups to achieve safe conditions and necessary corrections. Appropriate persons in the institutional chain of command will be included in this communication.
3. Fire Prevention
a. Fire prevention begins with identifying fire hazards. All faculty, staff, students, volunteers, and visitors have a personal obligation to be aware of fire hazards and to reduce or eliminate the risk of fire on our campus.
b. Identification of Common Fire Hazards
Scrap, Waste Materials, Dust, and Trash: Accumulation of these items increases the risk of fire. Under the right conditions, the buildup of dust from wood, plastic, or certain metal operations can lead to fire or explosion.
Improper Use, Storage, Dispensing or Disposal of Flammable and Combustible Liquids: Flammable and Combustible Liquids can be a prime source of fire and explosion.
Use of Extension Cords and Multiple Plug Adapters: Extension cords and multiple plug adapters may ONLY be used for temporary operations. Overloaded circuits, damaged wiring, and defective switches can all lead to electrical fires. The Fire Code prohibits “daisy chaining” power strips together.
Hot Work Hazards: Any operation involving heated materials or open flames presents a fire hazard. Hot Work procedures have been developed as part of this program. ALL Hot Work must comply with the TTTUHSC Hot Work Procedure outlined in Attachment E of this document.
Inadequate Machine and Equipment Maintenance: Electrical problems and equipment defects can lead to a fire. Routine inspection and maintenance of all machines and equipment can prevent fire hazards.
Smoking: Smoking is prohibited in facilities owned or leased by the university. Outdoors, discarded smoking materials carelessly tossed in waste containers or into landscaping can easily start a fire.
Electric Space Heaters: All electric space heater models must be approved by TTUHSC Fire Marshal.
Aerosol Spray Cans: Read label prior to use. Butane and propane are the most common accelerant propellants and should never be exposed to heat or flames.
Non-Compliant Renovation or Maintenance: Renovation or maintenance projects that do not meet the requirements of the state of Texas and/or applicable building and fire codes can result in improper egress, improper construction methods or materials, and electrical hazards.
c. Basic Fire Prevention Strategies
Accumulation of Combustible Materials: The accumulation of combustible materials is prohibited (e.g. cardboard boxes, magazines/journals, paper products). Combustible material must never be stored any closer than 36’’ from a radiant heat producing appliance or electrical light.
Storage: Stored materials shall not obstruct the fire suppression sprinkler heads. Best practice is at least 18’’ below the suppression system (sprinklers).
Decorations: Decorations, signs and other items may not be hung on or near sprinkler heads.
Obstructing Portable Fire Extinguishers: Do not obstruct access to portable fire extinguishers. They must be clearly visible with notification signs displayed.
Spills on Floor: Correct any condition causing leaks or drips of flammable or combustible liquids and keep floor free of spills.
Blocking Fire Doors: Assure fire doors are unobstructed and operate freely. Never block fire doors in the open position with wedges or stoppers. These doors are to remain closed to prevent the spread of fire and smoke through the building.
Fire Exit Stairway: Stairway shall be kept clear at all times. Nothing shall be set, stored, or placed in any fire exit stairway.
Hoarding: Maintain premises free of unneeded or unnecessary materials. Hoarding of equipment increases the risk of fire and possible structural damage due to weight loading on floors.
Clear Passage: Keep passageways free of obstacles, including furniture and equipment.
Fire-rated Doors: Fire-rated doors are generally found at any opening to a corridor, stairwell, storage room, mechanical and/or electrical equipment room. Blocking doors with wedges or other items allows smoke to spread rapidly through a building, possibly preventing occupants from quickly evacuating during a fire emergency.
Magnetic Door Hold Open Devices: Magnetic door hold open devices are permitted only if they are tied to the local fire alarm system or to a single station smoke detector located in front of the door.
Renovation Projects: All materials used in renovation or building projects shall meet the intent of the International Building Code construction type as accepted by TTUHSC Fire Marshal, State of Texas requirements as well as fire code requirements for fire-resistance.
Firestopping: All penetrations of floors, ceilings, and/or walls are avenues for smoke and heat travel. Penetrations shall be properly firestopped where required and shall be approved by the TTUHSC Fire Marshal. This includes the replacing of ceiling tile when disturbed for any reason.
Wiring, Switches, and Plugs: Inspect all wiring, switches, and plugs. Report any damage found to Facilities Operation & Maintenance to have a qualified electrician make any needed repairs.
Electrical Outlets: All electric outlets, junction boxes, and electrical panels are required to have proper cover plates at all times. If a cover plate is missing, contact Facilities Operation & Maintenance to have the hazard addressed.
Junction Boxes and Electrical Panels: Junction boxes and the breakers/disconnects in electrical circuit panels are required to be labeled advising what it controls for emergency response and maintenance personnel.
Wet Electrical Cords: Do not use electrical cords or equipment that is damp or wet unless they are approved for such use. Do not connect or disconnect electrical equipment when your hands are wet.
Overloaded Motors or Circuits: Do not overload motors or circuits. Overloaded motors and circuits can easily be a source of ignition. Electric space heaters that exceed 750 WATTS are often the cause of overloaded circuits and tripped breakers.
Lighting Fixtures: Report any problems with lighting fixtures to Facilities Operation & Maintenance immediately.
Extension Cords: The improper use of extension cords is strictly prohibited. Do not use extension cords in place of permanent wiring in the building for extended periods of time.
Multiple Plug Electrical Adapters: The improper use of multiple plug electrical adapters is strictly prohibited. Remove multiple plug electrical adapters and install permanent electrical wall outlets or replace with power strips with breaker protection. Each power strip must be plugged directly into the wall.
d. Fire Prevention and Suppression Procedures for Hot Work Operations
If not properly controlled, Hot Work operations present serious fire hazards that can lead to significant property damage, injury and/or loss of life. To ensure safe Hot Work activities, the following procedures are set forth in Attachment E of the operating policy. These procedures apply to all work performed on TTUHSC property.
4. Fire Alarm Response Requirements:
a. Personnel at TTUHSC facilities shall respond to all fire alarms. TTUHSC employees in positions of authority or control such as instructors, doctors, directors, and supervisors are obligated to take the lead by evacuating with subordinates. Departments should establish procedures to notify and assist employees with impairments. Employees are responsible for directing the evacuation of patients and visitors in their charge during emergencies. Persons evacuating the building during fire alarms should not re-enter the building unless directed by police or fire officials.
b. Clinics and departments that may have non-ambulatory patients, visitors, volunteers, or staff should be familiar with evacuation routes that are adequate for relocation of non-ambulatory occupants from their area(s). Generally, non-ambulatory building occupants should move horizontally away from the fire, exit the building, or take refuge in a stairway landing. Facility constraints and operations are important factors that must be considered when determining non-ambulatory evacuation routes. Contact the TTUHSC Fire Marshal’s Office if assistance is needed in determining appropriate routes of evacuation.
5. Alarm System Monitoring & Fire Reporting Requirements:
Monitoring and proper emergency response are basic code required actions for the safety of building occupants and for property protection. Monitoring duty also includes the code required action of promptly notifying Fire Departments and other listed emergency response personnel. Building Maintenance and Operations assures the constant monitoring of fire alarm systems in the regions through 24/7 monitoring (Lubbock campus) and contracted services. The Facilities Operations Environmental Control (FOEC) is responsible for both the fire monitoring and notification for (3601 4th St.) Lubbock HSC facilities. All other campuses must report all fire events to the TTUHSC Fire Marshal according to the following flow chart. (Also see Attachment A)
Fire Event Reporting
6. Fire and Life Safety Training:
All new employees shall receive training in emergency fire response procedures during New Employees Safety Orientation Program (NESOP). Unit Safety Officers must conduct training for members of their department regarding emergency fire response using Attachment B at least once each year and/or by having employees complete emergency fire response training online. If no Unit Safety Officers are appointed, the local Safety Department is responsible for this employee training and documentation. Attachment D – Fire Extinguisher Operation and Types of Fire should be distributed annually.
7. Fire Drill Response Requirements:
Faculty staff and students are required to respond to fire drills. Exceptions regarding drill response are set forth in Attachment C to this policy. Fire drills are conducted annually by the TTUHSC Fire Marshal. Patients and visitors are not required to participate in fire drills.
8. Fire Equipment Maintenance Requirements
All facility fire alarm detection, notification and suppression equipment must be maintained in accordance with applicable NFPA Standards. TTUHSC fire alarm systems must meet NFPA Standard 72. Fire pumps and automatic fire sprinkler systems must meet NFPA 25. Fire extinguishers must meet NFPA 10 requirements. Building Operations and Maintenance in each region will normally accomplish or arrange for inspections or maintenance on these systems.
Attachment A - Fire Event Reporting
Attachment B - Fire Response Procedure
Attachment C - Fire Drills
Attachment D - Portable Fire Extinguisher Operation and Types of Fire
Attachment E - Policy on Hot Work Performed Outside a Designated Area
Attachment F - Contractor Access & Hot Work Notification Form
Attachment G - Outage Request Form