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					SUMMARY OF AUDIT FINDINGS BY CAMPUS 1997 Seismic Safety and Disaster Readiness

AUDIT FINDINGS: 1997 Seismic Safety and Disaster Readiness
Environmental and Facility Controls Falling Hazards - the campus had not documented mitigation of possible falling hazards Seismic Bracing - needed for library shelving and computing equipment Fire Suppression Systems - are needed and must be maintained in main computer and telecommunications rooms Above Ground Fuel Storage - the campus had not received a city code variance nor prepared a spill control plan for above ground fuel storage Fire Alarm Panel - fire and security calls had been combined in the same receiver panel in public safety Fire Alarm System - the campus fire alarm system and procedures were not adequate to provide timely response in the event of a fire; the main computer room lacks a fully automatic fire suppression system. Emergency Generators - the backup generator for Warren Hall and library was in need of repair.

CRITERIA

HAY HUM LA

LB NOR POM SF

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SYS

18
1993 Seismic Review Board Report x x x City Fire Code x

12 22 11
x x

18

6

20 20
x x x

7

x

x

x

x x x

EO 696 which replaced EO 524 Office of Emergency Services guidelines Emergency Operations Center - needs to meet per person square footage Office specify 50 to 75 sq ft of Emergency Services guidelines; location must be adequate per person in the EOC. EO 524 Air Conditioning - the campus did not have maintenance records documenting inspection and upkeep of the system supporting telecommunications equipment Non-structural Hazards - campus had not completed mitigation of hazards in the computer center Uninterruptible Power Supply - data communications equipment was not protected by an uninterruptible power supply. Remote Alarms/Smoke Detectors - the main computer room and the telecommunication rooms did not have remote notification for high temperatures and the presence of water. Seismic Peer Review Documentation - peer reviews were not well documented BOT resolution re Peer Review RCPBG 05-9313

x

x

x

x

x x x x x x x x x x

x

x

x

x

1

SUMMARY OF AUDIT FINDINGS BY CAMPUS 1997 Seismic Safety and Disaster Readiness

AUDIT FINDINGS: 1997 Seismic Safety and Disaster Readiness

CRITERIA
In Agenda Item 7 of the May 1993 meeting of the Committee on Campus Planning, Buildings and Grounds, which established the CSU Policy on Seismic Safety, the chancellor committed to annual reports to the trustees on actions taken and actions planned. Title 19 CCR Title 23 CCR

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SYS

Seismic Program Reports - reports to the trustees do not describe outstanding risks and priorities measured against goals

x

Fire and Life Safety - issues identified by the City Fire Marshall had not been mitigated. Water Intrusion Alarms - telecomm and data communications equipment rooms lacked detectors. Telecommunications Room Halon System - is not connected to the building fire alarm system. Emergency Power Off Circuit - lacking from computer room Halon Systems Inspection - had not been recently performed Distributed Data Communications Node Sites - basic environmental controls were missing Halon System Training - computer operations staff had not received system training Disaster Planning Disaster Recovery Plan - campus (computing and telecomm) did not have one or it lacked components Information and Computing Services/IRM Risk Analysis - had not been conducted New Employee Orientation - did not include the emergency action plan for the campus Plan Approval - the campus emergency operations plan, changes and updates had not been approved by the campus administration. Emergency Locator Records - the location of utility shut-off locations, building floor plans, and staff & students were not maintained in the Emergency Operations Center Academic Involvement - was minimal in disaster planning.

x x x x x x x x x x x

EO 696 which replaced EO 524

x x

x

x x

x

x

x

x x

8CCR3220(e)(3) EO 696 which replaced EO 524

x x x

x x

x x x x

x

x x x

Violence in the Workplace - the campus did not have a policy that included education and training of departmental employees Segregation of Duties - there was not a proper segregation of emergency duties.

July 1995 Report of the Ad Hoc Committee on Emergency Preparedness July 1995 Report of the Ad Hoc Committee on Emergency Preparedness

x

x

x

x

x

2

SUMMARY OF AUDIT FINDINGS BY CAMPUS 1997 Seismic Safety and Disaster Readiness

AUDIT FINDINGS: 1997 Seismic Safety and Disaster Readiness
Training - the Emergency Plan did not provide any specificity on training. DRP Testing & Training - none had been scheduled Alternate Processing Site - no provision in the event that the main computer facilities are unusable Alternate Responders - backup resources were unidentified Stand-by Disaster Contracts - the campus did not have pre-approved stand-by contracts for equipment and supplies Plan Updating - plan required revision

CRITERIA

HAY HUM LA x x x

LB NOR POM SF x x x x x x x

SJ

SYS

x

July 1995 Report of the Ad Hoc Committee on Emergency Preparedness EO 696 which replaced EO 524

x

x

x x x

Local Area Networks - campus wide emergency preparedness standards and procedures had not been established Utility Cut-off Locations - had not been updated for the emergency preparedness EO 696 which replaced EO 524 coordinator Volunteer Organizations - the Emergency Plan did not address how volunteer organizations will be included as part of the campus emergency response. Plan Validation and Maintenance Exercising - there had not been a combined campus-wide test event of the emergency plan that included the breadth of all elements. Registering Volunteers - the campus did not have authority to register disaster service volunteers. Hazardous Waste Inspections - inspection records were not on file Vertical Emergency Plans - was not sufficient to support the overall objectives of the campus Multi-Hazard Emergency Plan Building Evacuation Drill Procedures - were not current Emergency Response Tests/Evaluation/Reporting - reporting of drills and simulations is unclear Electric Power Generation - is not sufficient to meet campus needs Critical Campus Emergency Information - EOC lacked critical campus information EO 524 and Section 8 of the California Emergency Plan State Emergency Services Act, Governor's Executive Order W-9-9 CCR Section 6624.174 x x x x

x

x x x x

x

x

x

EO 696 which replaced EO 524

x x x

x

x x x

3

SUMMARY OF AUDIT FINDINGS BY CAMPUS 1997 Seismic Safety and Disaster Readiness

AUDIT FINDINGS: 1997 Seismic Safety and Disaster Readiness
Expenditures - did not capture and evaluate the investment in disaster readiness Generator Maintenance - was not well documented Data Safe - computer center lacked a safe to protect backup tapes Incomplete Equipment and Supplies - necessary items were unfunded Multi-Hazard Emergency Operations Plan Emergency Exercises - campus-wide emergency exercises did not occur in the last two years Vital Records - campus was not following vital record provisions Emergency Operations Center - is neither stand-alone nor immediately operational Off-site Backups Mainframe - critical records were not being backed up in a secure location. Off-site Backups Telecommunications - were lacking ISC Operations Documentation - data recovery procedures, network configuration, and information to resume operations were not fully documented and stored off-site Outdated Executive Order 524 regarding emergency preparedness plans needs update Report of the Ad Hoc Committee on Emergency Preparedness recommendations had not been implemented Mutual Aid - incomplete and informal arrangements

CRITERIA
SAM 20003

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LB NOR POM SF x x x x

SJ x

SYS x

July 1995 Report of the Ad Hoc Committee on Emergency Preparedness EO 696 which replaced EO 524 x x x x x x x x x x

x

x

x

x

x x x

EO 696 which replaced EO 524 July 1995 Report of the Ad Hoc Committee on Emergency Preparedness

x

x x

Abbreviations: BOT - Board of Trustee's (CSU) CCR - California Code of Regulations CSU - California State University DRP - Disaster Recovery Plan EC - Education Code EO - Executive Order EOC - Emergency Operations Center IRM - Information Resource Management ISC - Information Systems Center IT - Information Technology SAM - State Administrative Manual SCO - State Controller's Office SUAM - State University Administrative Manual

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SUMMARY OF AUDIT FINDINGS BY CAMPUS 1997 Seismic Safety and Disaster Readiness

AUDIT FINDINGS: 1997 Seismic Safety and Disaster Readiness

CRITERIA

HAY HUM LA

LB NOR POM SF

SJ

SYS

Criteria
8CCR3220(e)(3) states that the employer shall review with each employee upon 8CCR3220(e)(3) initial assignment those parts of the plan which the employee must know to protect the employee in the event of an emergency State Emergency Services Act, Governor's Executive Order W-9-9 obligates the campus to maintain a multi-hazard emergency response program. According to the State Office of Emergency Services, only properly registered disaster service workers are covered by the state's Workers' Compensation program. CCR 66264.174 requires weekly inspections of areas used for container storage of transfer of hazardous waste. RCPBG 05-93-13 of the CSU BOT Committee on Campus Planning Buildings and Grounds states that independent technical peer reviews of the seismic aspects of all construction projects will be performed starting at design initiation to assure conformance with good seismic resistant practices and pertinent provision of Title 24 of the CCR.

66264.174

EO 696 which replaced Section 8 of the California Emergency Plan defines a full scale exercise as one EO 524 that simulates an actual emergency; involves complete emergency mgmt staff and is designed to evaluate the operational capability of the emergency mgmt system. SAM 20003 states that the elements of a satisfactory system of internal accounting and administrative control shall include a system of authorization and old citing recordkeeping procedures adequate to provide effective accounting control over assets, liabilities, revenues, and expenditures. 1995 CSU Report of the Ad Hoc Committee on Emergency Preparedness - for text, see Recommendation #4 of the Systemwide Audit SYS CSU EO 696: Implementation of the California State University Emergency EO 696 which replaced Preparedness Program EO 524

5

SUMMARY OF AUDIT FINDINGS BY CAMPUS 2003/4 Disaster Contingency Planning

Disaster Contingency Planning 2003/4 AUDIT FINDINGS CRITERIA

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LA

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5

8

7

14

3

12

9

9

9

Emergency Readiness Emergency Plan Updating - campus did not have an up-to-date emergency management SAM 4843.1 plan or improvements were required Position Designees - roster of designees in key emergency plan positions was incomplete Title 5 section 41302 and procedures for concurrent absences had not been established

EO 696 California Office of Emergency Services Standardized Emergency Mgmt Sys Guidelines, Part EO 696

x x

x x

x x

x

x x

Emergency Building Coordinators/Marshals and Building Emergency Evacuation campus did not have a recognized network of trained coordinators to assist in emergencies or controls to ensure evacuation from buildings needed improvement Subordinate Plan Integration - related emergency plans were not centrally reviewed and EO 814 approved to ensure coordination with the campus-wide emergency mgmt plan Constituency Orientation/Plan Communication - faculty and students did not receive the SAM 20050 same type of emergency mgmt plan orientation as staff, and the plan was not well communicated Mutual Aid/Contingency/Purchasing & Contracting Agreements - campus mutual aid FEMA agreements were not in writing or did not address activities and resources that might be needed in an emergency or needed updating

x
EO 696 EO 696

x x

x

x x

x x x

x
California Office of Emergency Services, Standardized Emergency Management Systems Guidelines, Part II, §A5 California Office of Emergency Services, Standardized Emergency Management Systems Guidelines, Part III, §II SAM 8652 CCR Title 19 section 904a

x

x

x

x

x

x

x

x

Exercises and Plan Tests - the documentation for emergency exercise and test results did California Code of Regulations, not cover response actions, application of the standardized emergency mgmt system, Title 19, §2447 modifications to plans and procedures, training needs, and recovery activities. The emergency management plan had not been extensively tested.

x

x

x

x

Facility Issues/EOC/Emergency Supplies - the current EOC was not well supplied and inventories of available supplies were infrequently performed Facility Issues/Fire Suppression - the campus had not been properly inspecting and servicing fire sprinklers and standpipes.

x

x x

x

6

SUMMARY OF AUDIT FINDINGS BY CAMPUS 2003/4 Disaster Contingency Planning

Disaster Contingency Planning 2003/4
Facility Issues/Emergency Power - campus lacked or had not tested a backup generator to power its computing equipment in the event of a power failure or testing of emergency generators did not ensure their readiness. Facility Issues/Equipment Maintenance- sprinkler system needed inspection Business Continuity - the campus did not have completed business continuity plans or outdated plans needed review. SAM 4843.1 SAM 4842.2

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x
CCR Title 19 Section 904.1 Federal Emergency Management Agency, Emergency Management Guide for Business & Industry CFR Title 8 Part 214 SAM 20050

x

x

x

x x

x

x

x

x

x

x

x

x

x

Non-immigrant Students/International Students/Emergency Readiness - the administration of information for non-immigrant students was in need of improvement Segregation of Duties - responsibilities for reviewing and approving applications for admission received from non-immigrant students were not adequately segregated from reporting responsibilities. Select Agents and Toxins - polices and procedures were not in place Training for Incident Command Personnel - a program had not been developed to ensure campus incident command personnel were trained for a potential assignment during an emergency

SAM 20050

x x

x

x

x

x

x

CFR Title 42, part 1003 SEMS Part IIA3 California Office of Emergency Services, Standardized Emergency Management Systems Guidelines, Part I, §B2 CCR Title 19 §2570.1 and §2570.2 California Code of Regulations, Title 19 §904.1 California Office of Emergency Services, State of California Emergency Plan,

x

x

x

x

x

x

x

Disaster Service Worker Volunteers - procedures had not been established to compile emergency response skills for disaster service worker volunteers within the campus community. Disposition of Fire/Life Safety Issues - were unclear on resolution

x

x

x x

x

x

General Environment Authority for Activities - authority for disaster and contingency planning activities was not SAM 20050 always formalized.

x

x

x

7

SUMMARY OF AUDIT FINDINGS BY CAMPUS 2003/4 Disaster Contingency Planning

Disaster Contingency Planning 2003/4
Fiscal Administration - budgets were not prepared for disaster and contingency planning activities Federal Emergency Management Agency, Emergency Management Guide for Business & Industry, §1 SAM 20050

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x

Cabinet level management - did not actively participate in disaster and contingency planning activities

EO 696

x

CRITERIA:
California Office of Emergency Services’ Standardized Emergency Management System Guidelines, Part I.B, dated December 23, 1994, states that the deputy incident commander should have the same qualifications as the incident commander. It further states that optional deputy positions for command, section, and branch levels provide backup support and are also used extensively on an inter-agency basis to improve coordination between multiple agencies or disciplines Title 5 §41302 states that during periods of campus emergency, as determined by the president of the individual campus, the president may, after consultation with the chancellor, place into immediate effect any emergency regulations, procedures, and other measures deemed necessary or appropriate to meet the emergency, safeguard persons and property, and maintain educational activities. Federal Emergency Management Agency, Emergency Management Guide for Business & Industry, §2, under Involving the Community, recommends establishing mutual aid agreements with local response agencies. SAM §20050 indicates that the existence of lines of organizational authority and responsibility not clearly articulated or nonexistent are indicative of a poorly maintained or vulnerable control system. It further states that elements of a satisfactory system of internal controls include appropriate segregation of duties and that elements of a satisfactory system of internal accounting and administrative control include a system of authorization and record-keeping procedures. Code of Federal Regulations, Title 8, Part 214, Retention and Reporting of Information for F, J and M Non-Immigrants; Student and Exchange Visitor Information System; Final Rule, dated December 11, 2002, prescribes institutional responsibilities for reportable events involving international students including change of address and less than full-time enrollments

SEMS Part I

FEMA sect.2

SAM sect. 20050

Title 8, Part 214 8

SUMMARY OF AUDIT FINDINGS BY CAMPUS 2003/4 Disaster Contingency Planning

Disaster Contingency Planning 2003/4
California Code of Regulations, Title 19, §2447 requires the use of the standardized emergency management system at all levels of operation when exercises are performed. Title 19 §2446 requires state agencies to document training. California Office of Emergency Services, Standardized Emergency Management Systems Guidelines, Part III, §II, dated December 23, 1994, indicates that the completion of after action reports is a part of the required standardized emergency management system reporting process. The elements of an after action report include response actions, application of the standardized emergency management system, modifications to plans and procedures, training needs, and recovery activities. SAM §4843.1 requires each state agency to establish and maintain both an operational recovery plan and a plan to resume operations following a disaster. Federal Emergency Management Agency, Emergency Management Guide for Business & Industry, §2, under Records Preservation, indicates that preserving vital records is essential to the quick restoration of operations and recommends establishing procedures for protecting and accessing vital records. Code of Federal Regulations, Title 42, Part 1003, Possession, Use, and Transfer of Select Agents and Toxins; Interim Final Rule, dated December 13, 2002, provides a list of regulated agents and toxins along with a requirement for policies and procedures to ensure appropriate security. California Office of Emergency Services, Standardized Emergency Management Systems Guidelines, Part II, §A3, dated December 23, 1994, requires that agencies ensure that their emergency response personnel maintain minimum training competencies pursuant to the approved SEMS’ course of instruction. California Office of Emergency Services, State of California Emergency Plan, Part One – Basic Plan, dated May 1998, indicates, in part, that a comprehensive business emergency plan includes delegated authority for emergency roles. California Office of Emergency Services, Standardized Emergency Management Systems Guidelines, Part I, §B2, dated December 23, 1994, indicates, in part, that the command function with the incident command system is the action taken to direct, order, or control resources by virtue of some explicit legal agency or delegated authority. CCR

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SEMS Part III SAM 4843.1

FEMA sect. 2 Title 42, Part 1003

SEMS Part II , sect. A3 Emergency Plan SEMS Part I , sect. B2

FEMA sect.1 Federal Emergency Management Agency, Emergency Management Guide for Business & Industry, §1, Step One on establishing a planning team, recommends developing an initial budget for expenses that may be necessary during the development of an emergency management plan.

9

SUMMARY OF AUDIT FINDINGS BY CAMPUS 2003/4 Disaster Contingency Planning

Disaster Contingency Planning 2003/4
California Code of Regulations, Title 19 §2570.1 and §2570.2 indicate, in part, that the legislature has provided a state-funded program of workers’ compensation benefits for disaster service worker volunteers who contribute their services to protect the health and safety and preserve the lives and property of the people of the state. A disaster service worker is any person registered with a disaster council or the Governor’s Office of Emergency Services, or a state agency granted authority to register disaster service pursuant to the California Emergency Services Act without pay or other consideration. Government Code §3100 states, in part, all public employees are declared to be disaster service workers subject to such disaster service activities as may be assigned to them by their superiors or by law. SAM §4842.2 states, in part, that agency physical security measures must provide for protection, detection, and minimization of loss or disruption of operational capabilities due to electrical power fluctuations or failure. CSU EO 814, Policy on University Health Services, requires that the student health center staff review the medical disaster component of the campus emergency plan annually. CSU EO 696, Emergency Preparedness Program California Office of Emergency Services, Standardized Emergency Management Systems Guidelines, Part II, §A5, dated December 23, 1994, indicates that an exercise program coordinated with other agencies for multi-agency or multi-jurisdictional field exercises should be considered. California Code of Regulations, Title 19 §904(a), states that all automatic fire extinguishing systems, including systems installed as an alternate to other building requirements, shall be serviced and maintained in accordance with the following frequencies. SAM §8652 states that the person in charge of maintaining the inventory records will not be in charge of taking physical inventories California Code of Regulations, Title 19 §904.1 states that the building or system owner shall insure immediate correction of any deficiencies noted during the maintenance inspection.

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CCR

SAM 4842.2 EO 814

EO 696

SEMS Part II , sect. A5

CCR SAM 8652

CCR

10


				
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