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Safety and Health Manual: Chapter III

Life Safety Management Program

Police and Public Safety Policy  PS 09 00d

A. Purpose. To outline the policy and procedures relating to the implementation of The University of North Carolina at Pembroke's Life Safety Management Program.
B. Scope. This applies to The University of North Carolina at Pembroke, all University employees and activities.
C. Policy. It is the policy of this University to protect employees, visitors, and property from fire, the products of combustion, or other hazards and to provide for the safe use of University properties.
D. Delegation of Authority and Responsibilities.

1. Each department has overall responsibility for monitoring and ensuring compliance with the requirements of the Life Safety Management Program, per Department. Deficiencies of the program shall be reported to the Vice Chancellor for Business Affairs to be submitted to the Chancellor through the Safety and Health Committee. Plans for correction shall be initiated.
2. All Vice Chancellors, Directors, and Supervisors shall comply with requirements of the Life Safety Management Program as described herein and will ensure that employees in their respective departments/sections are adequately trained in the areas of fire safety and fire drills.
3. All employees shall maintain their areas in a neat and fire safe condition, participate in fire drills, and report unsafe conditions immediately to Supervisors.

E. Procedures.

1. The Office of Safety and Health, in consultation with the North Carolina Department of Insurance, shall evaluate the buildings to determine that they are in compliance with the latest edition of the Life Safety Code (NFPA 101).

2. Life Safety code deficiencies identified by local staff, Industrial Risk Insurers, North Carolina Department of Insurance, NCOSHA, or others shall be addressed for correction by the Facilities Operations Department. The plan of correction will include all proposed corrective actions, total cost with sources of funding, commitment and availability of funds, timetables, and Interim Life Safety Measures taken.
3. The Facilities Operations Department and the Department of Planning and Construction, shall conduct periodic inspections of areas affected by construction to ensure that safety characteristics are not diminished. During the inspections, they will ensure that: exits remain unobstructed, access to construction areas are restricted; conditions are clean and fire safe; provisions are made for required alternate access routes; and that roads and walkways are passable in all weather conditions. In addition to inspections, these issues will be addressed to the Contractor in pre-construction meetings.
Special attention will be given to ensure that adequate advance notice is given for coordination of utility outages, fire system disruptions, and hot work. On-site contractors will ensure that the construction areas are secured and fire-safe at the completion of daily work. The Facilities Operations and the Department of Planning and Construction will monitor these areas.
All contractors and personnel directly involved with building programs/projects under the direction of the Safety Manager, Facilities Operations Department, and the Department of Planning and Construction, will ensure that Interim Safety Measures are taken during and until the completion of the project.
Interim Safety Measures are a series of operational actions taken to temporarily reduce the hazards posed by existing Life Safety deficiencies or construction such as the following:

a. Exits provide free and unobstructed egress. Affected employees shall be made aware if alternate exits must be designated.

b. Free and unobstructed access to emergency department/services and for emergency forces.

c. Fire alarm, detection, and suppression systems are not impaired.
d. Where applicable, temporary construction partitions must be smoke tight and be of non-combustible material.
e. Additional fire fighting equipment is provided and personnel are instructed in its use.
f. Storage, housekeeping, and debris removal policies and procedures that reduce the flammable and combustible fire load to the lowest level necessary for daily operations are developed and enforced.
g. Hazard surveillance of buildings, grounds, and equipment is increased with special attention to excavations, construction areas, construction storage, and field offices.
h. Personnel are instructed when structural or compartment features of fire safety are compromised.

4. The Facilities Operations Department and the Department of Planning and Construction, shall ensure that the required Interim Life Safety measures and procedures are implemented for areas under construction and areas awaiting Life Safety corrections.The Department of Planning and Construction will establish procedures, to be followed by the on-site contractor to ensure that adequate interim measures are affected, which provide a high level of fire safety during construction activities and prior to completion of Life Safety Corrections.
5. The Office of Safety and Health, in conjunction with the North Carolina Department of Insurance, shall conduct at least annual inspections of all smoke and firewalls in all buildings, as well as floors in utility closets for evidence of penetrations. When found, work orders will be issued to ensure repairs. A report will be kept indicating the area inspected, date of inspection, remarks and name and initials of inspector (can be delegated).
6. All employees will report any condition that poses a threat to life or property to their supervisors including, but not limited to, penetrations in smoke and firewalls, construction safety issues, improper storage practices, and any deficiencies pertaining to fire systems.
7. All supervisors shall ensure that employees under their supervision are sufficiently trained and are aware of, and comply with, the requirements of this manual and their respective department plans.
8. The Facilities Operations Department and the Department of Planning and Construction shall ensure that architectural firms, as well as in house design staff, consult the North Carolina Construction Manual, applicable North Carolina Building Codes, and ADA compliance Standards for Barrier Free Design (Accommodations for the Physically Handicapped) when preparing construction documents or other plans for construction. Design consideration shall be given to handicap accessibility to parking facilities, building entrances and exits, rest rooms, elevators and other public use areas.
9. University Police shall ensure that adequate patrol of grounds and parking lot areas are conducted and will report any maintenance deficiencies to the Facilities Operations. University Police will also ensure that there is a policy on file for emergency services that clearly identifies appropriate signs, traffic control of emergency service areas, and easy accessibility to emergency services.
10. The Facilities Operations Department shall maintain an active Grounds Maintenance Section that will continually work to keep parking lots, grounds, and recreation areas neat and safe for the employees, students, and visitors.
11. Recorded drawings addressing the location of all features of fire protection shall be maintained in the Facilities Operations Department.
12. Note: FIRE ALARMS/EXTINGUISHING SYSTEMS/PORTABLE FIRE EXTINGUISHERS. Maintenance, testing, and criteria for performance shall be addressed in a separate policy. Documentation of all testing and inspections shall be maintained in the Safety Office.
13. All employees are required to participate in fire drills. Response to these drills shall be in accordance with the requirements of the University Fire Regulations located in the Safety Manuals. The Office of Safety and Health shall ensure that the frequency of drills meet the requirement of the State of North Carolina, and shall ensure that adequate monitoring and documentation of drills is accomplished.
14. The Offices of Safety and Health, Public Safety, and the Facilities Operations Department shall continually monitor all elements of the Life Safety Management program. Identified deficiencies and other concerns shall be reported to the Safety and Health Management Committee. An annual review of this program shall also be conducted and the results reported to the Safety and Health Management Committee.

F. References. State Employee's Workplace Requirements Program for Safety & Health; NFPA-10; MFPA-17; and Life Safety Code 101; N.C. Construction Manual, and N.C. State Building Codes.
G. Rescissions. None.