APS 16.1 – Fire Safety – UW Policy Directory

(Approved by the Provost and Executive Vice President by authority of Executive Order No. 4 and the Vice President for Finance and Facilities by authority of Administrative Order No. 9)

1. Policy

In accordance with Chapter 19.27 RCW, State Building Code, the University of Washington is required to comply with the state of Washington’s International Fire Code (IFC) and Chapters 296-24, 296-62, 296-67, 296-155, and 296-800 WAC. Local jurisdictions (counties and cities) are authorized to administer and enforce the IFC. Local jurisdictions may also amend the IFC provided their codes are no less stringent than state code. Seattle, Tacoma, and other local jurisdictions have adopted local amendments to the IFC through municipal and other codes. The specific ordinance reference changes every code cycle.

The IFC sets forth regulations consistent with nationally recognized practices for safeguarding life and property from the hazards of fire and explosion. The provisions of the code apply similarly to the building code, i.e., new construction and renovation. However, the code is retroactive for many administrative, operational and maintenance provisions and conditions, which, in the opinion of the fire code official (the Fire Marshal in many jurisdictions), constitutes a distinct hazard to life and property.

In compliance with Chapter 49.17 RCW, Washington Industrial Safety and Health Act (WISHA), and Chapter 296-24 WAC, Part G-1, the University is required to maintain egress and develop employee emergency and fire prevention plans.

State-licensed facilities, such as hospitals, health clinics, and daycare centers, are also regulated for fire safety by state agencies, such as the Department of Health, the Department of Social and Health Services, the State Fire Marshal’s Office within the Washington State Patrol, and other licensing bodies.

2. Scope

This policy applies at all University locations including the Seattle, Bothell, and Tacoma campuses, jointly-owned facilities, research stations, all other University-owned property, University-leased space, and temporary field operations and field trips that are under the control of University operations and staff.

UW Bothell has special considerations related to its co-location with Cascadia College and relationships with local jurisdictions and agencies that affect how this policy is implemented. Consult UW Bothell operating procedures and programs for implementation details.

UW Tacoma has special considerations related to local jurisdictions and agencies. Consult UW Tacoma operating procedures and programs for implementation.

3. UW Compliance Responsibility

It is University policy that each vice president, vice chancellor, dean, director, department chair, and supervisor is responsible for the health and safety performance in his or her respective units. This responsibility can be neither transferred nor delegated.

Environmental Health and Safety
- The Environmental Health and Safety Department (EH&S) serves organizational units by conducting fire prevention surveys, promoting fire safety programs, and providing training and general consultation.
- EH&S also processes regulatory agency violations, performs fire investigations, provides fire-related content for the University’s Annual Security and Fire Safety Report in accordance with the Jeanne Clery Act, and performs design review for new construction and renovation.
- EH&S is designated as the University’s primary liaison with the Seattle Fire Department (SFD) and other agencies regulating fire safety and provides technical support to first responders during UW Seattle campus building emergencies.
- EH&S is also responsible for:
  - Assisting departments in developing a written plan for building emergencies and evacuation, and maintaining a program to train evacuation wardens.
  - Scheduling building evacuation drills and activating the alarm systems for drills for the UW Seattle campus. Medical centers and other state-licensed facilities may schedule their own drills.
  - Maintaining a chemical inventory system and establishing geographical control areas so that organizational units may maintain and manage chemical inventories in buildings.
  - Maintaining a capital plan for building fire alarm and fire protection systems to ensure those systems are provided, maintained, and replaced as needed.
Facilities Services
- Facilities Services departments at all sites are responsible for comprehensive routine maintenance and emergency repair of physical assets. Under this broad charge, Facilities Services departments are responsible for operation, maintenance, and routine testing of fire safety and alarm systems, the fire alarm monitoring system, the UW Indoor Alert System, smoke control systems, fire extinguishers, fire doors, elevators, pathway lighting, generators and emergency power systems, and other fire safety-related building systems and equipment. Self-sustaining units may operate, maintain, and test their own fire and life safety systems and equipment.
Capital Planning and Development
- The Capital Planning and Development Department (CPD) is responsible for obtaining construction permits and ensuring departments obtain required operational permits for capital construction and renovation. CPD must also oversee the commissioning of all fire and life safety systems, ensure that new facilities are ready for occupancy, and obtain the certificate of occupancy from the building department. CPD is responsible for ensuring that construction activities will not present fire risk or adversely affect egress from adjacent tenant space and buildings, and that the required fire department access is maintained. CPD is also responsible for engaging EH&S and other stakeholders in building planning and design review with respect to fire safety.
University of Washington Police Department
- The University of Washington Police Department (UWPD) monitors fire alarm systems for the UW Seattle campus and responds to provide building access and support to the fire department. Alarm signals may be forwarded to be monitored by a contracted service.
- UWPD notifies Facilities Services, EH&S, UW Emergency Management, the UW Crisis Communications Core Team, and other stakeholders as appropriate when there is a fire or fire-related emergency.
- UWPD operates the UW Indoor Alert System (a component of the fire alarm monitoring system) to notify the campus of emergency conditions.
- UWPD publishes and distributes the Annual Security and Fire Safety Report and Drug-Free Schools Act Information.
Housing and Food Services
- Student housing functions, under the respective UW Seattle, UW Bothell, or UW Tacoma Housing and Food Services departments, with support from EH&S, are responsible for maintaining appropriate policies and housing agreements with residents to satisfy fire and life safety requirements, and to be prepared for building emergencies and evacuation in residence halls and apartments.
Information Technology
- The UW Seattle campus Information Technology Department (UW-IT) is responsible for maintaining and testing the UW Outdoor Alert, outdoor emergency phones, and indoor emergency phones.
- More information is available on the Emergency Phones and Communication Systems web page.

4. Campuses, Other Organizational Units, and Departments

Each campus, organizational unit, and department is responsible for a number of specific requirements including, but not limited to:

Developing and maintaining fire safety and evacuation plans for occupied buildings and associated employee training.
Participating in building evacuation drills.
Obtaining temporary operating permits from the fire department for campus events.
Obtaining operational permits from the fire department (e.g., hazardous materials, place of assembly, welding).
Managing chemical inventories to not exceed fire code maximum allowable quantity.
Properly storing and using hazardous materials.
Reporting fire, explosion, and hazardous material spills or releases.
Developing and maintaining fire prevention plans for hazardous activities.
Conforming to policy on the use of corridors and unassigned space.
Implementing the University’s Laboratory Safety Manual to prevent fire, uncontrolled reactions, and explosions.
Preventing false and needless building fire alarms.
Working with EH&S to resolve violations from the fire department.

5. Compliance Procedures

The following summarizes fire safety compliance procedures.

Fire Department Permits and Inspections
1. Operational Permits
  
  Operational permits issued by the fire department must be obtained by organizational units responsible for their operations. Examples of permits include place of assembly for theaters, laboratories, storage and use of flammable liquids, and cutting and welding permits. More information and permit applications may be found on the Fire Department Operational Permits web page.
2. Permits for Campus Events
  
  Other permits issued by the fire department are required for fairs, concerts, festivals, public gatherings, recreational fires, pyrotechnics, cooking food outside of a commercial kitchen, and, in some cases, when a building will be used for other than its intended and approved use. Most operational permits are annual permits that must be renewed. Other permits are for a limited duration and specific location. More information is available on the Campus Events web page.
3. Agency Compliance Inspections and Violations
  
  EH&S serves as a clearinghouse for all violations issued by the fire department. Organizational units who receive a Notice of Violation, Order to Comply, or other violation or citation, must immediately provide the information to EH&S and work with EH&S to resolve the issue or develop an agreement with EH&S on management of fire department violations. More information is available on the Fire Safety Compliance Inspections/Citations web page.
Fire Prevention, Evacuation, and Training
1. Fire Safety and Evacuation Plans
  
  Organizational units are responsible for developing a written Fire Safety and Evacuation Plan (FSEP) using the template developed by EH&S, or equivalent plan, assign evacuation wardens, and send them to evacuation warden training provided by EH&S. With support from EH&S, departments that share a building with other departments are responsible for coordinating to develop a single plan for the building. The FSEP needs to include occupant responsibilities, emergency procedures, evacuation procedures, outside assembly points, and other relevant information. More information may be found on the Building Safety Resources web page.
2. Building Evacuation Drills
  
  EH&S is responsible for scheduling fire drills for all buildings, as required by code, by providing advance notice to building coordinators, departmental administrators, and other key personnel. The drills will be planned well in advance and conducted during normal business hours, but timed to reduce disruption to operations. Housing drills will be conducted in the evening to ensure resident participation. Drills are to be announced to key personnel occupying the building but remain unannounced to most building occupants. All occupants must participate in evacuation drills. The building coordinator or evacuation director is responsible for critiquing and recording the drill with EH&S support. More information is available at the Evacuation Drills web page.
3. Fire Safety Training
  
  Organizational units need to provide information on the contents of the FSEP annually and during new employee orientation. Organizational units are responsible for training employees on fire prevention for major workplace fire hazards.
  
  Employees expected to use a fire extinguisher as part of the job assignment must be trained in the use of a fire extinguisher. Training information is available on the EH&S Training web page.
4. Fire Prevention
  
  Ignition sources such as open flames, heaters, cooking, research activities, and lights, must be controlled. A written fire prevention plan is also required for major workplace fire hazards such as cutting and welding, roofing, and similar open flame work practices. Permits may also be required. More information is available on the Fire Prevention web page.
5. Facility Design Review
  
  The CPD department, and other organizational units facilitating capital construction and renovation, are responsible for engaging EH&S fire protection engineers and other EH&S professionals to ensure compliance with code, University policy, and other health and safety requirements. More information is available on the Facilities Design Standards web page.
Operational Compliance
1. Corridors and Unassigned Space
  
  Corridors must remain free of equipment, storage, and hazards so they are available for egress. Mechanical rooms and other unassigned spaces may not be used for storage unless intended for that purpose. Specific information is available on the Use of Corridors and Unassigned Spaces web page.
2. Chemical and Hazardous Material Storage
  
  Chemicals, compressed gases, and other hazardous materials in labs, shops, art studios, Facilities Services shops, and other locations, must be inventoried in the University Chemical Management System. Quantities must be managed to comply with the fire code. EH&S maintains the system for chemical inventories. Organizational units must maintain an account, keep inventories accurate, and reduce quantities when they exceed the maximum allowed. More information is available on the Hazardous Materials web page.
3. Laboratory Fire Safety
  
  Organizational units with teaching, research, and clinical laboratories must adopt and implement controls outlined in the University’s Laboratory Safety Manual to mitigate the risk of fire, explosion, uncontrolled reaction, and hazardous materials spill. Additional fire safety requirements can be found on the Laboratory Fire Safety web page.
4. Preventing False Alarms
  
  Activities that produce smoke, fumes, mist, and airborne particulates must be controlled to prevent false and unneeded activation of the building fire alarm system. Procedures to control emissions and prevent alarm activation are available on the Prevention of False Alarms web page.
5. Fire and Life Safety System Modifications, Operations, and Shutdowns
  
  Building safety systems and equipment may not be modified, operated, shut down, or impaired by unauthorized personnel. Request system shutdown through Facilities Services.
6. Reporting Fires and Other Accidents and Incidents
  
  All fires, explosions, and hazardous material spills must be reported immediately by calling 911 and/or activating the fire alarm system. All fire/explosion incidents must also be reported to EH&S. EH&S is responsible for investigating these incidents to determine their cause, provide consultation, and to document the incident for reporting purposes. More specific information on reporting accidents, injuries, and fire is available on the Reporting Fires and Other Incidents web page.

6. Additional Information

For further information and specific guidelines and procedures regarding fire safety, contact the Environmental Health and Safety Department.

December 9, 2003; August 10, 2016.

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