Environmental Health & Safety Compliance

1. Environmental Health & Safety Compliance Michael A. Charlton, Ph.D., CHP, CIH, CSP, CHMM, CFI Director of Environmental Health & Safety The University of Texas Health Science Center at San Antonio 7703 Floyd Curl Dr. San Antonio, TX 78229 Phone: (210) 567-2955 Email: charlton@uthscsa.edu Paul D. Pousson, ARM Associate Director Office of Risk Management The University of Texas System 201 West 7th Street Austin, Texas  78701 Phone: (512) 499-4559 Email: ppousson@utsystem.edu

2. Abstract • Colleges and universities must comply with an astronomical variety of requirements, ranging from issues related to NCAA athletic compliance, student financial aid, to patient medical billing. The implications of non-compliance extend far beyond the mere imposition of penalties and sanctions. Noncompliance can result in escalated enforcement activities, damage to institutional reputation, and can serve to erode overall stakeholder trust. To reduce the risk of instances of non-compliance, systemic institutional compliance programs are being formed and put into place within universities across the country. The creation of such compliance programs represents an excellent leadership opportunity for institutional environmental health and safety programs due to their intimate familiarity with the compliance-driven environment. For example, the Federal Sentencing Guidelines define the essential components of a compliance program to include: written polices and procedures, designated responsible parties, a formalized risk assessment, monitoring plans, training, confidential reporting mechanisms, and a method for disciplinary action in instances of non-compliance. Safety organizations have maintained many of these required programmatic elements through historical regulatory interactions. Therefore, safety personnel can seize the opportunity for a leadership role within the institution by actively relaying their demonstrated experience and expertise to other units in order to bolster the overall institutional compliance effort. By actively engaging in these compliance initiatives, safety programs can better position themselves for improved institutional recognition and resource allocations.

3. Speaker Biographies • Paul D. Pousson is the Associate Director of the Office of Risk Management for The University of Texas System. He is responsible for directing the environmental health and safety, property and casualty insurance, and risk management services offered to the fifteen (15) component institutions of The University of Texas System. He has over 15 years of experience in the risk management, environmental protection and health and safety fields. Mr. Pousson is Past President of the Texas Campus Safety Association and serves on the Board of Directors of the Risk and Insurance Management Society - Central Texas Chapter and the University Risk Management and Insurance Association.  Mr. Pousson received his bachelors degree in Urban and Regional Planning (environmental management emphasis) from Southwest Texas State University. He also holds the designation of Associate in Risk Management (ARM) from the Insurance Institute of America. • Mike Charlton is the Assistant Vice President for Risk Management and Safety at the University of Texas Health Science Center at San Antonio. Mike has experience in academic research, cyclotron particle accelerators, light-water nuclear reactors, and industrial applications. He possesses a B.S. in Physics from Texas A&M University, an M.S. in Health Physics from Texas A&M University, an M.P.H. from the University of Texas at Houston Health Science Center and a doctorate in health physics from Texas A&M. Mike is board certified in health physics (CHP), industrial hygiene (CIH), as a safety professional (CSP), and hazardous waste management (CHMM).

4. Safety and Compliance • Compliance infers safety • Non-compliance • infers or connotes unsafe conditions • damages image, reputation, morale • can result in fines • can result in escalated enforcement • costs money to defend, refute • can erode stakeholder trust

5. Recent Institutional Compliance Emphasis • Genesis of the Federal Sentencing Guidelines • Non-compliance can result in penalties and punitive damages (3x?) • Reduction or insulation from punitive damages for organizations maintaining compliance programs meeting established criteria

6. Create and maintain compliance standards and procedures Identified high level executive with overall compliance responsibility Demonstrate due diligence in not delegating discretionary authority Compliance communications and worker training Monitoring, auditing, and reporting systems Consistent enforcement Interventions in cases of detected offenses Compliance Program Criteria

7. What Does This Have to do With Safety? • Colleges and universities are sites of a myriad of compliance risks • Medical billing, NCAA, financial aid, human research subjects, sexual harassment, etc. • To develop a compliance plan, a comprehensive risk assessment is necessary • Within University of Texas System, EH&S consistently identified as a high risk area

8. Implications of Being “High Risk” • Move to top of overall priority list • Will be required to address detailed compliance risk plan first • Will be subjected to increased internal examination • Will reveal weaknesses • Increased reporting requirements

9. Opportunities Inherent to Being “High Risk” • Move to top of overall priority list • Will be required to address detailed compliance risk plan first • Will be subjected to increased internal examination (show your stuff!) • Will reveal weaknesses (recurrent problems!) • Increased reporting requirements (improved access to the top!)

10. Creation of Risk Plan • Create universe of compliance risks • Base on regulations and recommendations (standards of care) • Show current status and processes in place • monitoring controls • oversight controls • Assign relative priority ranking • Link resource allocation requests to compliance risk ranking

11. Potential Exposure Responsible Party Operating Controls Monitoring Controls Training Reporting Life, property, revenue Vice President for Operations Systems and postings Routine safety audits Hazard awareness training Routine status reports Case Study: Life Safety Code Compliance

12. Overview of Fire & Life Safety • Code Background • Fire Alarm Systems • Fire Detection • Fire Suppression • Conducting a Basic Assessment

13. Impact of Fires on Universities • The Overall Fire Picture - 2004 • There were 3,900 civilians that lost their lives as the result of fire. • There were 17,785 civilian injuries that occurred as the result of fire. • There were 117 firefighters killed while on duty. • Fire killed more Americans than all natural disasters combined. • 83 percent of all civilian fire deaths occurred in residences. • In 2001, 2,530 fires occurred in dormitories causing 6 fatalities, 82 injuries, and $48M in property damage

14. Impact of Fires on Universities

15. Objectives • Introduce the Codes that Drive Fire and Life Safety Compliance • Overview of Fire Detection and Suppression • Provide Group With the Tools to Conduct a Basic Fire and Life Safety Assessment at Their Business

16. Nomenclature NIOSH NFPA IBC • Safety and Health Regulations • OSHA (29 CFR 1910 & 1926) • NIOSH • EPA • Fire and Life Safety Codes • International Building Code (IBC) • International Code Council (ICC) • Building Officials and Code Administrators International (BOCA) • Internationals Conference of Building Officials (ICBO) • Southern Building Code Congress International (SBCCI) • National Fire Protection Association (NFPA) • ICC Electric Code (ICC) • International Fire Code (IFC) • Municipal Requirements OSHA

17. Origin of the IBC BOCA SBCCI ICBO ICC IBC

18. Goals Of Codes • 80% of a Building Code’s Provisions Relate to Fire and Life Safety • IBC – promulgate a comprehensive and compatible regulatory system for the built environment, through consistent performance-based regulations that are effective, efficient and meet government, industry and public needs. • NFPA –reduce the worldwide burden of fire and other hazards on the quality of life by developing and advocating scientifically based consensus codes and standards, research, training, and education.

19. How are These Codes Enforced • Codes are adopted by reference through ordinance. • Plans for remodeling or a new construction must be approved by the authority having jurisdiction (AHJ) prior to starting work. • State Fire Marshal’s Office • Local Fire Department or City Code Officials • Designated Local AHJ • Take Home Message – Know what code(s) apply to your operation

20. Possible Additional Code Requirements • All codes are minimum requirements • Insurance company requirements • Company policies • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) • State and/or City requirements

21. Alarms Sprinklers Rated Corridors Exit Access Number of Required Exits Egress Widths Occupant Loads Elevator Recall Fire Rated Doors & Frames Smoke Control Rated Stairwells Fireproofing Requirements Electrical Safety Construction Combustibility Fire and Smoke Dampers Emergency Power Roof Assemblies Features of Building Fire and Life Safety

22. Fire Alarm Systems • Play an Essential Role in Protecting Property and Lives From Fire. • Protection Goals Governs System Selection • Building Occupant Safety • Satisfy Building Codes or AHJ Requirements • Property Protection • First Responder Safety • Environmental Protection • Combination

23. Fire Alarm Systems • IBC references NFPA 72 for Installation and Maintenance • NFPA 72 – National Fire Alarm Code • Basic Components • System Control Unit • Primary Power Supply • Secondary Power Supply • Initiating Device Circuits • Notification Appliance Circuits • Off-Premises Connection for Supervision

24. Basic Components Notification Appliance Circuits Notification Power Circuits Initiating Device Circuits Backup Power Supply Primary Power Supply

25. Off-Premises Connection for Supervision

26. Fire Alarm Systems • Fire Alarm System Will Provide Three Types of Signals • Alarm • Trouble – Indicates a fault in a monitoring circuit or component of the fire alarm system • Bad Smoke Detector • Ground Fault • Supervisory – Indicates that a problem exists with other fire protection systems that are being monitored by the fire alarm system. • Water Valve to Sprinkler System Closed • Clean Agent System Problem Alarm Trouble Supervisory

27. Fire Detection • Spark/Ember Detectors • Flame Detectors • Combination • Radiant Energy • UV • IR • Smoke Detector • Ionization • Photoelectric • Heat Detectors • Fixed Temperature • Rate-of-Rise

28. Manual Pull Stations • Manual Pull stations devices are located on the wall (usually near an exit). • They are activated by pulling on a handle. • This sends a signal to the building’s fire alarm system which in turn places the building into alarm.

29. Notification Appliances • Audible alarms (How loud is loud enough?) • Public – SPL must be 5 dB above any ambient noise that lasts 60 sec. or more, or 15 dB above the 24-hr average, whichever is greater. • Sleeping quarters – Minimum of 75 dBA. Frequency may be important • Voice Communication • Better to have a larger number of lower SPL units are used vs. a few very loud units. • Intelligibility can be a problem

30. Notification Appliances • Visual alarms • Primarily intended to augment audible alarms • Device output measured in candela (cd) • 15-635 (cd) • Common Locations of Visual Alarms • Corridors • Meeting rooms • Restrooms

31. Fire Alarm System Interfaces • Heating Ventilation and Air Conditioning (HVAC) • AHU Shut-Down • Duct Detectors • Sprinkler Waterflow Alarms • Magnetic Lock Release Mechanisms • Door Unlocking Devices • Elevator Recall • Stairwell Pressurization

32. Sprinkler Flow Alarms • Building sprinkler systems have switches inside the piping that will detect water flowing. • When a water flow is detected the building fire alarm system will activate.

33. System Reliability • Based on Four Elements • Design • Equipment • Underwriters Laboratories Inc. • Factory Mutual Global • Installation • Maintenance • Inspection, Testing, and Maintenance are crucial. • Unfortunately some problems may be identified after the previous three have been completed.

34. Fire Suppression • Water Based Suppression • Clean Agent Systems • Fire Extinguishers

35. Water Based Suppression • Sprinkler System Components • Insert picture of typical system • Sprinkler Systems Fall Into Four Categories • Wet-Pipe • Dry-Pipe • Preaction • Deluge

36. Wet-Pipe System • System contains water under pressure at all times. • Series of closed sprinkler heads • Heat activates sprinkler head • Water is discharged immediately * Not recommended if system could be exposed to temperatures below 40ºF.

37. Wet-Pipe System • Indicating Valve • Alarm Check Valve • Fire Department Check Valve • Fire Department Connection • Water Motor Alarm • Automatic Sprinkler • Inspector’s Test Valve

39. How do Sprinklers work? Sprinkler head Water is released and deflected in a spray pattern As temperature rises the bulb will shatter • only the sprinkler heads directly heated by the fire activate • A fire sprinkler sprays approximately 18 gallons of water per minute to provide early fire control

40. Sprinkler Color Codes and Ratings

41. Dry-Pipe System • System contains air under pressure • Compressor on system keeps pressure up • Sprinkler heads hold the pressure • A dry-pipe valve holds back the water supply • Valve opens when pressure falls below a predetermined level • Sprinkler head activation – pressure drop – valve opens – water sent to all heads – water discharged from activated sprinkler heads. * Recommended for areas that could experience freezing temperatures

42. Supply Check Valve Indicating Valve Dry Pipe Valve Fire Department Check Valve Dry Pipe System • Fire Department Connection • Water Motor Alarm • Automatic Sprinkler • Inspector’s Test Valve

43. How do Dry-Pipe Systems Work? • Heat Activated • Pressure Drop • Valve Opens • Water sent to all sprinkler heads • Water Discharges from activated head

44. Preaction System • System contains air under pressure • Compressor on system keeps pressure up • Water held back by preaction valve • System equipped with supplemental detection • Operation of detection system allows preaction valve to open and water fills the system. • Water not discharged until fire has generated sufficient heat to activate a sprinkler head. * Typically found in computer rooms, museums, communication rooms

45. Pre-Action System • Supply Check Valve • Indicating Valve • Water Control or Deluge Valve • Fire Department Check Valve • Fire Department Connection • Water Motor Alarm • Sprinkler (closed) • Detector • Electrical Bell • Manual Release Station • Control Panel • Inspector’s Test Valve

46. How do Pre-Action Systems Work? • Smoke Detected • Valve Opens • Water sent to all sprinkler heads • Water Discharges from activated head

47. Deluge Systems • System designed to deliver large quantities of water over a specified area in a short period of time. • All piping is at atmospheric pressure • All sprinkler heads are in the open position • Deluge valve keeps the water back • Supplemental detection activated deluge valve • Water is discharge from all heads immediately * Typically used to protect against rapidly spreading fires

48. Fire Pumps • Fire pumps are utilized when the hydraulic demand exceeds public supply capacity. • Components • Pump and motor • Controllers (Fire pump and jockey pump) • Jockey pump • Water Tank

49. Water Supply • Standpipe System • Class I – 2 ½ inch hose connection intended for fire department use. • Class II – 1 ½ inch hose connections intended for first-aid fire fighting • Class III – Provided with both 2 ½ inch and 1 ½ inch hose connections. • Fire Department Connection

50. Suppression Without Water • Halon – NFPA 12A • Being phased out as per 1987 Montreal Protocol • Carbon Dioxide – NFPA 12 • Clean Agent – NFPA 2001 • Inert gas formulation * Many times these systems are not recognized as allowable substitute for water suppression.