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04/09/2009 Trinity University 1
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Emergency Action and Fire Prevention.
1. Purpose
1.1. This policy establishes guidelines to protect staff/visitors/students from the
potential hazards associated with Medical Emergencies, Chemical
Release, Natural Disaster, Fire, Security Breaches and any other
emergencies that may occur in the operation of Trinity University.
Furthermore, the intention behind this program is to reduce, control and or
eliminate hazards at Trinity University and to increase staff awareness of
hazards while providing procedural information on what to do in the case
of an emergency.
2. Scope
2.1. Trinity University’s emergency action plan will be maintained in writing
and will cover those actions Trinity University and its staff will take to
ensure staff/visitors/student safety from fire and other emergencies.
3. References
29 CFR 1910.38 (a) Emergency Plans
NFPA 101 Life Safety Codes
29 CFR 1910.39 Fire Prevention Plans
29 CFR 1910.157-.165 Fire Equipment
29 CFR 1910.1030 Bloodborne Pathogens
29 CFR 1910.151 Medical and First Aid
29 CFR 1910.252 Welding, Cutting, and Brazing
29 CFR 1910.22 General Requirements for House Keeping
29CFR 1910.176 Handling Materials General
40CFR 262.34(d)(5)(i) Contingency Plan
4. Definitions
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Class I liquids (flammable liquid)-means any liquid having a flashpoint below
100°F. (37.8°C.), except any mixture having components with flashpoints of
100°F. (37.8°C.) or higher, the total of which make up 99 percent or more of the
total volume of the mixture.
Class II liquids- includes those combustible liquids with flashpoints at or above
100°F. (37.8°C.) and below 140°F. (60°C.), except any mixture having
components with flashpoints of 200°F. (93.3°C.) or higher, the volume of which
make up 99 percent or more of the total volume of the mixture.
Class III liquids- includes those combustible liquids with flashpoints at or above
140°F. (60°C.).
Emergency Action Plan- at Trinity University this plan is title Crisis
Management Protocols
Staff/visitors/student- includes Trinity University full-time, part-time, temporary
staff and guests, visitors/students, contractors.
Building Coordinator- designated emergency manager.
Minor injuries- not requiring medical assistance from a clinic or physician.
Serious medical emergencies/conditions- requiring advanced medical
assistance.
5. Responsibilities
5.1. University Safety Coordinator:
5.1.1. The University Safety Coordinator ensures that an emergency
action plan will be maintained, kept in the Environmental Safety
Office, and available to staff for review.
5.1.2. The University Safety Coordinator ensures that a fire prevention
plan will be maintained, be kept in the University Safety
Coordinator’s office, and be made available to staff for review.
5.1.3. Crisis Management Protocols (also known as the emergency action
plan) shall be maintained by the University Crisis Management
Team.
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5.2. Building Coordinator:
5.2.1. Building Coordinator will inform staff upon initial assignment to a
job of the fire hazards, ignition sources and control methods, to
which they are exposed. The Building Coordinator shall also
inform staff of their duties during an emergency in regards to
students/visitors.
5.2.2. Building Coordinator will maintain a staff/visitor/student alarm
system which may include the building alarm system that is
maintained by the Physical Plant Department.
5.2.3. Building Coordinator at initial staff training explains the preferred
means of reporting emergencies.
5.2.4. Building Coordinator will review the emergency action plan with
each staff member.
5.2.5. Building Coordinator shall account for area staff as indicated in
Appendix D.
5.2.6. Building Coordinator shall do an area sweep for
staff/visitor/students in an evacuation of the facility.
5.2.7. The Building Coordinator assures that manually operated actuation
devices for use in conjunction with staff/visitor/student alarms are
unobstructed, conspicuous and readily accessible.
5.3. Director of Physical Plant:
5.3.1. The Director of Physical Plant shall ensure the installation,
maintenance, inspection, testing, and record keeping of the
automated fire suppressions system and portable fire extinguishers
as detailed at the end of Appendix G are carried out appropriately.
5.3.2. The Director of Physical Plant assures that all staff/visitor/student
emergency devices, components, combinations of devices or
systems constructed and installed to comply with this section and
are approved.
5.3.3. The Director of Physical Plant with assistance from the fire
department assures that all staff/visitor/student alarm systems are
restored to normal operating condition as promptly as possible
after each test or alarm. Spare alarm devices and components
subject to wear or destruction shall be available in sufficient
quantities and locations for prompt restoration of the system.
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5.3.4. The Director of Physical Plant assures that the staff/visitor/student
alarm system is maintained in operating condition except when
undergoing repairs or maintenance (University Safety Coordinator
is notified when the system is down for maintenance).
5.3.5. The Director of Physical Plant maintains or replaces power
supplies as often as is necessary to assure a fully operational
condition of the staff/visitor/student alarm system. Back-up means
of alarm, such as oral communication with the building
coordinators when systems are out of service.
5.3.6. The Director of Physical Plant shall assure that the supervised
staff/visitor/student alarm system is tested at least annually for
reliability and adequacy.
6. Elements of the Emergency Action Plan
6.1. Procedures for reporting an emergency.
6.1.1. (see Appendix A)
6.2. Procedures for emergency evacuation, including type of evacuation and
primary/secondary assigned exit routes.
6.2.1. (see Appendix B)
6.3. Procedures to be followed by staff that remains to operate critical
operations before they evacuate are as follows:
6.3.1. (see Appendix C)
6.4. Procedures to account for all staff after evacuation.
6.4.1. (see Appendix D)
6.5. Procedures to be followed by staff performing rescue or medical duties
(Department of Campus Security).
6.5.1. (see Appendix E)
6.6. Job title of personnel who may be contacted by staff who need more
information about the plan or an explanation of their duties under the plan.
6.6.1. (see Appendix F)
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7. Fire Prevention
7.1. Trinity University’s fire prevention plan includes:
7.1.1. A list of all major fire hazards, proper handling and storage
procedures for hazardous materials, potential ignition sources and
their control, and the type of fire protection equipment necessary to
control each major hazard.
7.1.1.1. (see Appendix G)
7.1.2. Procedures to control accumulations of flammable and
combustible waste materials.
7.1.2.1. (see Appendix G for storage limits on flammables)
7.1.3. Procedures for regular maintenance of safeguards installed on heat-
producing equipment to prevent the accidental ignition of
combustible materials.
7.1.3.1. (see Appendix H)
7.1.4. Job title of staff responsible for maintaining equipment to prevent
or control sources of ignition or fires; and
7.1.4.1. (see Appendix H)
7.1.5. Job title of staff responsible for the control of fuel source hazards.
7.1.5.1. (see Appendix H)
8. Staff/Visitor/Student Alarm System
8.1. Trinity University has and maintains a staff/visitor/student alarm system.
The staff/visitor/student alarm system will use a distinctive signal for each
purpose and comply with the following requirements:
8.1.1. The requirements in this section that pertain to maintenance,
testing and inspection shall apply to all local fire alarm signaling
systems used for alerting staff regardless of the other functions of
the system.
8.2. General requirements.
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8.2.1. Trinity University’s staff/visitor/student alarm system provides
warning for necessary emergency action, or for reaction time for
safe escape of staff/visitor/students from the workplace.
8.2.2. Trinity University’s staff/visitor/student alarm is capable of being
perceived above ambient noise or light levels by all
staff/visitors/students in the affected portions of the workplace.
Tactile devices are used to alert those staff/visitors/students who
would not otherwise be able to recognize the audible or visual
alarm.
8.2.2.1. (see Appendix B)
8.2.3. The staff/visitor/student alarm is distinctive and recognizable as a
signal to evacuate the work area or to perform actions designated
under the emergency action plan.
8.2.3.1. (see code types in Appendix I)
8.2.4. Human Resources, at initial staff training, explains the preferred
means of reporting emergencies, such as manual pull box alarms,
two-way radios or manufacturing engineer announcements. All
emergency communication takes priority in emergency situations
on the public address system, two-way radio, and telephones.
8.2.5. The University Safety Coordinator has established procedures for
sounding emergency alarms in the workplace.
8.2.5.1. (see Appendix A)
9. Training
9.1. Trinity University has designated and trained staff to assist in a safe and
orderly evacuation of staff/visitors/students.
9.2. Training elements
9.2.1. Procedures on reporting the various emergencies.
9.2.2. Evacuation route knowledge (use of posted facility maps).
9.2.2.1. Tasks assigned to help evacuate staff/
visitors/students.
9.2.2.1.1. Tasks assigned to staff helping special
needs individuals.
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9.2.3. Knowledge of emergency numbers.
9.2.4. Knowledge on who current key personnel are that can be contacted
with further questions about the Emergency Action Plan.
9.2.5. Familiarity with the emergency alarm system.
9.2.6. Knowledge of the key components of the fire prevention plan and
staff roles in that plan.
9.3. Fire extinguisher use
9.3.1. Where Trinity University has provided portable fire extinguishers
for staff use in the workplace, Trinity University provides an
educational program to familiarize staff with the general principles
of fire extinguisher use and the hazards involved with incipient
stage fire fighting.
9.3.2. Trinity University provides the education required in 9.3.1., of this
section, upon initial employment and at least annually thereafter.
9.3.3. Trinity University provides staff who have been designated to use
fire-fighting equipment as part of an emergency action plan with
training in the use of the appropriate equipment.
9.3.4. Trinity University provides the training required in paragraph
9.3.3., of this section, upon initial assignment to the designated
group of staff and at least annually thereafter.
10. Trinity University will Review the Emergency Action Plan with
each Staff Covered by the Plan:
10.1. When the plan is developed or the staff is assigned initially to a job.
10.2. When the staff's responsibilities under the plan change; and
10.3. When the plan is changed.
11. Recordkeeping
11.1. Trinity University conducts proper acceptance tests on sprinkler systems
and records the dates of such tests.
11.2. Central records for site locations may be used in lieu of signs at sprinkler
valves provided the records are available for inspection and copying by
the Assistant Secretary of OSHA.
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11.3. Trinity University Safety Coordinator assures that portable fire
extinguishers are subjected to an annual maintenance check. Trinity
University records the annual maintenance date and retains this record for
one year after the last entry or the life of the shell, whichever is less.
11.4. Trinity University maintains evidence (in the form of work orders) that the
required hydrostatic testing of fire extinguishers has been performed at the
time intervals shown in Table L-1. Such evidence is in the form of a
certification record that includes the date of the test, the signature of the
person who performed the test and the serial number, or other identifier, of
the fire extinguisher that was tested. Such records are kept until the
extinguisher is hydrostatically retested at the time interval specified in
Appendix G Table L-1 or until the extinguisher is taken out of service,
whichever comes first.
12. Small quantity generator of Hazardous Waste
12.1 A small quantity generator of Hazardous waste must comply with the
following requirements:
12.1.1 At all times there must be at least one employee either on the
premises or on call ( i.e., available to respond to an emergency by
reaching the facility within a short period of time) with the
responsibility for coordinating all emergency response measures.
This employee is the emergency coordinator (University Safety
Coordinator).
12.1.2. The generator must post the following information next to
the telephone:
12.1.2.1. The name and telephone number of the emergency
coordinator;
12.1.2.2. Location of fire extinguishers and spill control
material, and, if present, fire alarm; and
12.1.2.3. The telephone number of the fire department, unless
the facility has a direct alarm.
12.1.3. The generator must ensure that all employees are thoroughly
familiar with proper waste handling and emergency procedures,
relevant to their responsibilities during normal facility operations
and emergencies;
12.1.4. The emergency coordinator or his designee must respond to any
emergencies that arise. The applicable responses are as follows:
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12.1.4.1. In the event of a fire, call the fire department or
attempt to extinguish it using a fire extinguisher;
12.1.4.2. In the event of a spill, contain the flow of hazardous
waste to the extent possible, and as soon as is
practicable, clean up the hazardous waste and any
contaminated materials or soil;
12.1.4.3. In the event of a fire, explosion, or other release
which could threaten human health outside the
facility or when the generator has knowledge that a
spill has reached surface water, the generator
(Trinity University Incident Commander) must
immediately notify the National Response Center
(using their 24-hour toll free number 800/424–
8802). The report must include the following
information:
12.1.4.3.1. The name, address, and U.S. EPA
Identification Number of the generator;
12.1.4.3.2. Date, time, and type of incident (e.g., spill or
fire);
12.1.4.3.3. Quantity and type of hazardous waste
involved in the incident;
12.1.4.3.4. Extent of injuries, if any; and
12.1.4.3.5. Estimated quantity and disposition of
recovered materials, if any.
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Appendix A
REPORTING PROCEDURES FIRES AND OTHER EMERGENCIES
Emergency situations may include the following:
Fire (all types/sizes) Medical Emergency
Chemical Spill/Release Severe Weather
Major Utility Loss Accidents
Security Breach Explosion
Bomb Threat
STAFF reporting procedures
When a suspected or confirmed emergency comes to the attention of staff, the following
steps will be taken:
1) Use the two-way radio to contact the University Safety Coordinator or Security,
dependent on the type of emergency.
A) In case of Fire staff may also use pull down alarm.
B) If there is immediate danger to staff, he/she should seek safety. Then he/she
shall contact the University Safety Coordinator or Security, dependent on
emergency.
C) If the emergency is considered to be a serious medical emergency by the staff,
staff can call 911. Then he/she shall contact the University Safety
Coordinator.
D) If it is an emergency spill (those that require specialized clothing, equipment,
and training for clean-up) staff shall leave area and then contact the University
Safety Coordinator.
2) After relaying relevant information, the staff will wait for instruction from the
University Safety Coordinator.
*See procedure book for further detail
Emergency Coordinator Reporting Procedures
1) The University Safety Coordinator shall consult the emergency action procedure
book for the appropriate course of action.
Dial 911 for all emergency calls
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Appendix B
Emergency Evacuation Procedures
Evacuation from buildings may be in response to any of the following:
Fire (all types/sizes) Medical Emergency
Chemical Spill/Release Severe Weather
Major Utility Loss Security Breach
Explosion Bomb Threat
Accidents(all types)
Staff/Visitor/Student evacuation from a building:
1) Upon notification (sounded alarm, via two-way radio, phone call, or from area
Building Coordinator) for evacuation, staff will proceed in an orderly manner to
the nearest building exit or alternative evacuation exit if notified that primary
escape route is blocked.
2) If the staff members have any doubts of primary and secondary escape routes,
they shall consult escape route maps that are posted in their work area.
3) If visitors/students are in the building, staff will conduct their assigned
visitor/student evacuation tasks.
A) Staff assigned to aid physically challenged visitors/students/staff shall
inform these visitors/students/staff and their companions of the
appropriate escape route. If visitors/students are hearing or sight impaired,
assigned staff shall clearly explain the situation to the visitors/student/staff
through visual or vocal direction dependent upon visitor/student/staff
need.
4) All staff will assemble at designated evacuation points (see emergency map), once
finished with their evacuation duties.
5) Each areas Department Head is responsible for a quick sweep of his/her area
ensuring that all staff/visitors/students are evacuated (unless deemed unsafe to do
so).
Staff evacuation to a safe area within the building:
1) Upon notification (via sounded alarm, two-way radio, public announcement, or
from area Department Head) for evacuation to an appropriate safe area based
upon emergency, staff will proceed in an orderly manner to the nearest preset safe
area or alternative safe area if notified that primary safe area is blocked.
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2) If staff members have any doubts of primary and secondary safe areas, they shall
consult posted area facility maps with indicated safe areas based upon emergency.
3) If visitors/students are in the building, staff will conduct their assigned
visitor/student evacuation tasks.
A) Staff assigned to the physically challenged visitors/students/staff shall
inform these visitors/students/staff of the appropriate safe area. If
visitors/students/staff are hearing or sight impaired, the situation shall be
clearly explained to the visitors/students/staff through visual or vocal
direction dependent upon visitors/students/staff need.
4) Each areas Building Coordinator is responsible for a quick sweep of his/her area
ensuring that all staff/visitors/students are moved to a safe area.
Staff will be made aware of any blocked evacuation routes via public announcement or
by their Building Coordinator. Any questions regarding evacuation routes or escape
procedures should be directed to your area Department Head.
In regards to chemical spills/Hazardous Waste release: If spill reporting is required by
state or federal agencies, then these agencies must be contacted immediately. This will be
determined by outside contractor.
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Appendix C
Procedures for staff who operate critical operations before evacuation
1) Upon notification of evacuation (via department head announcement, two-
way radio, or activated alarm), all staff will evacuate or assist visitors/students
in evacuation- If Chemical experiments are being conducted by staff or
students then all effort will be made to prevent addition harm to be caused as
it relates to the experiment and the emergency.
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Appendix D
Procedures to account for all staff after evacuation
1) The Building Coordinator will do a head count with the staff from their area and
will determine if all personnel are present.
2) The Building Coordinator shall supply the head count to the University Safety
Coordinator as soon as possible.
3) The University Safety Coordinator will immediately provide the following
information to the first arriving officer of the outside emergency response
organization.
A) Nature of the emergency.
B) Status and extent of the evacuation.
C) Any information regarding missing/unaccounted staff, contractors, or
visitors/students and their last known location inside the building.
* Emergency status report may be used
Under no circumstance will any staff re-enter a building once it has been evacuated until
the building is cleared and the University Safety Coordinator has given an all clear.
Trained emergency response personnel will be the only people to enter into an evacuated
area.
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This form is designed to be used after an emergency situation and provides a format for reporting
the status of facility damage and staff/visitors/student injuries.
Trinity University EMERGENCY STATUS REPORT
The Building Coordinators fill out a status report and passes them on to the University Safety
Coordinator.
University Safety Coordinator shall consolidate reports and give them to the responding
emergency teams (Fire Department, Police Department…)
Department
Name
Problems Exact Location/ Details
Serious Yes No _______________________________________________________
Injuries?
Fire? Yes No
Explosion? Yes No
Building Yes No
Collapse?
People Yes No
Trapped?
Disabled Yes No
evacuated
from
Building?
Hazardous Yes No
Material
Spill?
Electricity Yes No
Functional?
Emergency Yes No
Lighting
functional?
Water Yes No
functional?
Gas Yes No
Functional?
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Appendix E
Procedures for Rescue and Medical Duties
Rescue
1) All rescue attempts will be made by the appropriate outside agency (police
department, fire department…)
Medical Duties
1) Only trained personnel will carry out any basic first aid and CPR duties.
A) See Procedures Book
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Appendix F
Information or clarification on the Emergency Action Plan
Contact
Police Contact Number:
Security Contact Number:
Physical Plant Director Contact Number:
University Safety Coordinator Contact Number:
Chemical Spill/Hazardous Waste Release Contact Number:
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Appendix G
Major Fire Hazards and Locations:
1) Physical Plant:
A) Flammable Liquids (Paint, Thinner, LPG…) - Physical Plant Building,
Brooks Bldg, Grounds Garage, SCIENCE BLDG. Labs
B) Flammable Gasses (Acetylene…) - Grounds Garage, Boiler House,
SCIENCE BLDG. Labs
C) Combustible Liquids (Oil…) - Grounds Garage, Physical Plant Building,
SCIENCE BLDG. Labs
D) Other Fire Hazard Gasses (Oxygen…) - Boiler House, Labs
Handling and Storage Procedures:
1) Use appropriate PPE for hazard type as defined by the PPE hazard assessment
form and PPE policy.
2) Good housekeeping practices in storage area and location where material is being
used.
A) Storage areas shall be kept free from accumulation of materials that
constitute hazards from tripping, fire, explosion, or pest harborage.
B) The floor of every workroom shall be maintained in a clean and, so far as
possible, a dry condition. Where wet processes are used, drainage shall be
maintained, and false floors, platforms, mats, or other dry standing places
should be provided where practicable.
C) To facilitate cleaning, every floor, working place, and passageway shall be
kept free from protruding nails, splinters, holes, or loose boards.
3) Flammable material storage cabinets are used for appropriate material in the
Physical Plant.
A) Not more than 60 gallons of Class I or Class II liquids, nor more than 120
gallons of Class III liquids may be stored in a storage cabinet.
B) Storage cabinets shall be designed and constructed to limit the internal
temperature to not more than 325°F. when subjected to a 10-minute fire
test using the standard time-temperature curve as set forth in Standard
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Methods of Fire Tests of Building Construction and Materials, NFPA 251-
1969.
4) Flammable and combustible vessel size shall adhere to those shown on table H
12. Chart may be posted at locations where flammable material is stored.
Table H–12—MAXIMUM ALLOWABLE SIZE OF CONTAINERS AND
PORTABLE TANKS
Flammable liquids Combustible liquids
Container type
Class IA Class IB Class IC Class II Class III
Glass or 1 pt 1 qt 1 gal 1 gal 1 gal.
approved
plastic
Metal (other 1 gal 5 gal 5 gal 5 gal 5 gal.
than DOT
drums)
Safety cans 2 gal 5 gal 5 gal 5 gal 5 gal.
Metal drums 60 gal 60 gal 60 gal 60 gal 60 gal.
(DOT
specifications)
Approved 660 gal 660 gal 660 gal 660 gal 660 gal.
portable
tanks
5) All compressed gas cylinders are to be stored in accordance to the compressed gas
storage guidelines. Propane cylinders will not be stored inside any building.
A) Propane storage outside of buildings, for containers awaiting use, shall be
located in accordance with Table H-33 with respect to:
1) The nearest important building or group of buildings;
2) Busy thoroughfares;
TABLE H–33
Quantity of LP–Gas Stored Distance
500 pounds or less 0
1
501 to 2,500 pounds 0
2,501 to 6,000 pounds 10 feet
6,001 to 10,000 pounds 20 feet
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Over 10,000 pounds 25 feet
1
Container or containers shall be at least 10 feet from any building on adjoining property,
any sidewalk
3) Containers shall be in a suitable enclosure or otherwise protected
against tampering.
B) Physical Plant shall determine if compressed gas cylinders under their
control are in a safe condition to the extent that this can be determined by
visual inspection.
C) The handling, storage, and utilization of all compressed gases in cylinders
and portable tanks follows guidelines set out in the Compressed Gas
Association Pamphlets.
1) Oxygen cylinders are separated from combustible materials, such
as oil, a minimum distance of 20 or by a noncombustible barrier at
least 5 feet high having a fire-resistance rating of at least one-half
hour.
2) Cylinders, cylinder valves, couplings, regulators, hose, and
apparatus are kept free from oily or greasy substances.
2) Acetylene is stored valve end up.
3) Unless cylinders are secured on a special truck, regulators shall be
removed and valve-protection caps shall be put in place before
cylinders are moved.
4) Valves shall be closed when work is finished.
6) Cylinders are stored far enough away from the actual welding or
cutting operation so that sparks, hot slag, or flame will not reach
them, or fire-resistant shields shall be provided.
7) Cylinders are not be placed where they might become part of an
electric circuit.
Potential Ignitions Sources:
1) Welding Operations
2) Boiler in the Boiler Room
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3) Electrical Sources (see electrical policy- for appropriate wiring and installation)
Control Procedures
1) Welding Operations- Abide by safe operating procedures
A) If the object to be welded or cut cannot readily be moved, all
movable fire hazards in the vicinity shall be taken to a safe place.
B) If the object to be welded or cut cannot be moved and if all the fire
hazards cannot be removed, then guards/shields shall be used to
confine the heat, sparks, and slag, and to protect the immovable
fire hazards.
C) When using guards/shields, suitable fire extinguishing equipment
shall be maintained in a state of readiness for instant use.
D) Fire watchers shall be required whenever welding or cutting is
performed in locations where other than a minor fire might
develop. They shall remain in place for no less than 30 minutes
after work is complete
E) Before cutting or welding is permitted, the area shall be inspected
by the individual responsible for the cutting and welding
operations. That staff shall designate precautions to be followed.
F) No welding, cutting, or other hot work shall be performed on used
drums, barrels, tanks or other containers until they have been
cleaned so thoroughly as to make absolutely certain that there are
no flammable materials present or any substances such as greases,
tars, acids, or other materials which when subjected to heat, might
produce flammable or toxic vapors.
2) Boiler- Boiler is maintained and inspected according to manufacture specs to
ensure good operating condition
3) Smoking is not allowed in any campus building
4) Electrical outlets shall not be overloaded. Electrical appliances and cords shall be
monitored by responsible staff and shall be maintained in good working condition
at all times. Defective equipment or cords shall promptly be taken out of service
until adequate repairs can be made (see electrical policy).
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Fire Protection equipment available
1. Heat Detection System throughout the campus (maintained by outside
contractor)
Simplex System – Alarm is strobe lighting and has intense ringing sound
2. Sprinkler System throughout the campus (maintained by outside contractor)
2.1. Trinity University assures that only approved equipment and devices have
been used in the design and installation of their automatic sprinkler
systems.
2.2. Through the use of an outside contractor, Trinity University maintains
their automatic sprinkler system. Trinity University assures that a main
drain flow test is performed on each system annually. The inspector's test
valve shall be opened at least every two years to assure that the sprinkler
system operates properly.
2.3. Trinity University conducts proper acceptance tests on sprinkler systems
and records the dates of such tests. Proper acceptance tests include the
following:
2.3.1. Flushing of underground connections;
2.3.2. Hydrostatic tests of piping in system;
2.3.3. Air tests in dry-pipe systems;
2.3.4. Dry-pipe valve operation; and
2.3.5. Test of drainage facilities.
2.4. Trinity University assures that every automatic sprinkler system is
provided with at least one automatic water supply capable of providing
design water flow for at least 30 minutes. An auxiliary water supply or
equivalent protection shall be provided when the automatic water supply is
out of service, except for systems of 20 or fewer sprinklers.
2.5. Trinity University may attach hose connections for fire fighting use to wet
pipe sprinkler systems provided that the water supply satisfies the
combined design demand for sprinklers and standpipes.
2.6. Trinity University assures that automatic sprinkler system piping is
protected against freezing and exterior surface corrosion.
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2.7. Trinity University assures that all dry sprinkler pipes and fittings are
installed so that the system may be totally drained.
2.8. Sprinklers
2.8.1. Trinity University assures that only approved sprinklers are used
on systems.
2.8.2. Trinity University does not use older style sprinklers to replace
standard sprinklers without a complete engineering review of the
altered part of the system.
2.8.3. Trinity University assures that sprinklers are protected from
mechanical damage.
2.9. Trinity University assures that a local water-flow alarm is provided which
sounds an audible signal on the premises upon water flow through the
system equal to the flow from a single sprinkler (Requirement on all
sprinkler systems having more than twenty (20) sprinklers).
2.10. Trinity University assures that sprinklers are spaced to provide a
maximum protection area per sprinkler, a minimum of interference to the
discharge pattern by building or structural members or building contents
and suitable sensitivity to possible fire hazards. The minimum vertical
clearance between sprinklers and material below shall be 18 inches (45.7
cm).
2.11. Trinity University assures that hydraulically designed automatic sprinkler
systems or portions thereof are identified and that the location, number of
sprinklers in the hydraulically designed section, and the basis of the design
is indicated. Central records may be used in lieu of signs at sprinkler
valves provided the records are available for inspection and copying by
the Assistant Secretary.
3. Fire Extinguishers (maintained by outside contractor)
3.1 Portable Fire Extinguishers
3.1.1. Trinity University provides portable fire extinguishers mounted,
located, and identified so that they are readily accessible to staff
without subjecting the staff to possible injury.
3.1.2. Only approved portable fire extinguishers are used.
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3.1.3. Trinity University does not provide or make available portable fire
extinguishers using carbon tetrachloride or chlorobromomethane
extinguishing agents.
3.1.4. Portable fire extinguishers are maintained in a fully charged and
operable condition and kept in their designated places at all times
except during use.
3.1.5. Trinity University does not use or have in service any soldered or
riveted shell self-generating soda acid or self-generating foam or
gas cartridge water type portable fire extinguishers which are
operated by inverting the extinguisher to rupture the cartridge or to
initiate an uncontrollable pressure generating chemical reaction to
expel the agent.
3.2. Inspection, Maintenance and Testing
3.2.1. Trinity University is responsible for the inspection, maintenance
and testing of all portable fire extinguishers in the workplace.
3.2.2. Portable extinguishers are visually inspected monthly by the
Department of Campus Safety.
3.2.3. Trinity University assures that portable fire extinguishers are
subjected to an annual maintenance check(Done by an outside
contractor). Trinity University records the annual maintenance date
in the University Safety Coordinator’s Office and retains this
record for one year after the last entry or the life of the shell,
whichever is less.
3.2.4. Trinity University assures that stored pressure dry chemical
extinguishers that require a 12-year hydrostatic test are emptied
and subjected to applicable maintenance procedures every 6 years.
Dry chemical extinguishers having non-refillable disposable
containers are exempt from this requirement. When recharging or
hydrostatic testing is performed, the 6-year requirement begins
from that date.
3.2.5. Trinity University assures that alternate equivalent protection is
provided when portable fire extinguishers are removed from
service for maintenance and recharging.
3.3. Hydrostatic testing.
3.3.1. Trinity University assures that hydrostatic testing is performed by
trained personnel with suitable testing equipment and facilities.
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3.3.2. Trinity University assures that portable extinguishers are
hydrostatically tested at the intervals listed in Table L-1 of this
section, except under any of the following conditions:
3.3.2.1. When the unit has been repaired by soldering,
welding, brazing, or use of patching compounds;
3.3.2.2. When the cylinder or shell threads are damaged;
3.3.2.3. When there is corrosion that has caused pitting,
including corrosion under removable name plate
assemblies;
3.3.2.4. When the extinguisher has been burned in a fire; or
3.3.3. In addition to an external visual examination, Trinity University
assures that an internal examination of cylinders and shells to be
tested is made prior to the hydrostatic tests.
TABLE L–1
Type of extinguishers Test interval (years)
Soda acid (soldered brass shells) (until (1)
1/1/82)
Soda acid (stainless steel shell) 5
Cartridge operated water and/or antifreeze 5
Stored pressure water and /or antifreeze 5
Wetting agent 5
Foam (soldered brass shells) (until 1/1/82) (1)
Foam (stainless steel shell) 5
Aqueous Film Forming foam (AFFF) 5
Loaded stream 5
Dry chemical with stainless steel 5
Carbon dioxide 5
Dry chemical, stored pressure, with mild 12
steel, brazed brass or aluminum shells
Dry chemical, cartridge or cylinder 12
operated, with mild steel shells
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Halon 1211 12
Halon 1301 12
Dry powder, cartridge or cylinder operated 12
with mild steel shells
1
Extinguishers having shells constructed of copper or brass joined by soft solder or rivets
shall not be hydrostatically tested and shall be removed from service by January 1, 1982
(Not permitted).
3.3.4. Trinity University assures that portable fire extinguishers are
hydrostatically tested whenever they show new evidence of
corrosion or mechanical injury, except under the conditions listed
in paragraphs 3.3.2.1.-3.3.2.5. of Appendix G.
3.3.5. Trinity University assures that hydrostatic tests are performed on
extinguisher hose assemblies that are equipped with a shut-off
nozzle at the discharge end of the hose through the use of an
outside contractor. The test interval shall be the same as specified
for the extinguisher on which the hose is installed.
3.3.6. Trinity University assures that dry chemical and dry powder hose
assemblies with a shut-off nozzle are hydrostatically tested at 300
psi (2,070 kPa).
3.3.7. Extinguisher shells, cylinders, or cartridges which fail a hydrostatic
pressure test, or which are not fit for testing are removed from
service and from the workplace.
3.3.8. Trinity University maintains evidence that the required hydrostatic
testing of fire extinguishers has been performed at the time
intervals shown in Table L-1. Such evidence is in the form of a
certification record that includes the date of the test, the signature
of the person who performed the test and the serial number, or
other identifier, of the fire extinguisher that was tested. Such
records are kept until the extinguisher is hydrostatically retested at
the time interval specified in Table L-1 or until the extinguisher is
taken out of service, whichever comes first.
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4. Test Schedule for the Testing of the fire Alarm and Fire Suppression systems
Type of System Testing Frequency
Sprinkler System Water Flow Quarterly
Supervisory alarms Quarterly
Fire alarm Boxes Semi-annual
Heat Detection Units Semi-annual
Two Inch drain Test for Sprinklers Annual
Portable Fire Extinguishers Annual
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Appendix H
Procedures of Maintenance on Safeguards for Heat Generating
Equipment
1) All heat producing equipment is maintained in accordance with the
manufacturer’s instructions and timelines.
Job Title of staff responsible for maintaining equipment to prevent or
Control sources of Ignition
1) Director of the Physical Plant
Job Title of staff responsible for the control of fuel source hazards
1) Director of the Physical Plant
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Appendix I
Staff/visitor/student alarm:
Staff/visitor/student directly contacts the Building Coordinator or University Safety
Coordinator who then either activates fire alarm or communicates orally based on the
nature of the emergency to inform other staff/visitors/students about their appropriate
course of action: All alarms issued by the two-way radio will verbally indicate the nature
of the emergency and evacuation points.
Automated or pull down fire alarm: Trinity University uses a distinct pull down alarm
signal (intense horn).
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