FIRE INSPECTION GUIDE FOR ASSEMBLY OCCUPANCIES

MECHSOFT ENGINEERING DESIGN & CONSULTANCY
INSPECTION MANUAL
FOR
FIRE PROTECTION AND
DETECTION SYSTEMS
General Guide for Fire and Life Safety Inspections
Fire & Life Safety Inspection for Health Care Facilities
In accordance with
NFPA, IBC, IFC, NBC, NDM Guidelines
Prepared by: Mehboob Shaikh
B.E(ME) || CFPS || CFI-1 || AMIE
info@mitionline.com Design|Inspections|Training +919146861270

FIRE AND LIFE SAFETY
INSPECTION/AUDIT GUIDE
FOR
OCCUPANCIES
(With Report writing)
In Accordance with
NFPA 101 (LSC - 2018)
Other Applicable NFPA Codes/Std.
&
IFC 2018
IBC 2018
Prepared by: Mehboob Shaikh

B.E(ME) || CFPS || CFI-1 || AMIE
MITI Consultancy Training|Engineering|Inspections info@mitionline.com

CONTENT
Inspection Practices & Procedure for Assembly Occupancies

o Code Summary
o Determination of Subclassification of Assembly occupancy
o Sample Project Code Summary
o Common Hazard Associated with Assembly Occupancies
o Inspection Report with applicable Codes/Standards
o Elaborated Explanation for selected Topics
Inspection Practices & Procedure for Buisness Occupancies

o Code Summary
o Determination of Subclassification of Buisness occupancy
o Common Hazard Associated with Buisness Occupancies
Inspection Practices & Procedure for Educational Occupancies

o Code Summary
o Determination of Subclassification of Educational occupancy
o Common Hazard Associated with Educational Occupancies
Inspection Practices & Procedure for Hotel Occupancies

o Code Summary
o Determination of Subclassification of Hotel occupancy
o Common Hazard Associated with Hotel Occupancies

Inspection Practices & Procedure for Mercantile Occupancies
o Code Summary
o Determination of Subclassification of Mercantile occupancy
o Common Hazard Associated with Mercantile Occupancies
Inspection Practices & Procedure for Industrial Occupancies

o Code Summary
o Determination of Subclassification of Industrial occupancy
o Common Hazard Associated with Industrial Occupancies
Inspection Practices & Procedure for Storage Occupancies

o Code Summary
o Determination of Subclassification of Storage occupancy
o Common Hazard Associated with Storage Occupancies
Inspection Practices & Procedure for Health Care Occupancies

o Code Summary
o Determination of Subclassification of Health Care occupancy
o Common Hazard Associated with Health Care Occupancies
o

Inspection Practices & Procedure for Residential Occupancies
o Code Summary
o Determination of Subclassification of Residential occupancy
o Common Hazard Associated with Residential Occupancies
Inspection Practices & Procedure for Day Care Occupancies

o Code Summary
o Determination of Subclassification of Day occupancy
o Common Hazard Associated with Day Occupancies
Inspection Check lists for various Occupancies.

Occuapncy Code Summary ( Applicable to all
Occupancies)

General Description
 Project/Job Name
 Correct Address/Building Number/Suite Number
 Key Plan/location of suite and adjacent suites in the building
 Applicable Codes
 Occupancy Classification per LSC/IBC
 Minimum Construction Type
 Sprinklers/Fire Alarm
Height & Area Limitations

 Permitted Height and Area per IBC /NFPA 5000
 Height and Area for Special Occupancies (Assembly, Day-Care) per LSC
Structural Fire Resistance Requirements

 Structural Frame
 Walls Interior and Exterior, Load Bearing and Non-Load Bearing
 Floor
 Roof
Fire-Resistance Rated & Smoke Resistant Separations

 Fire Wall Separations
 Occupancy Separations
 Occupancy Specific
 Vertical Openings per LSC/IFC
 Exit Stairs per LSC/IFC
 Exit Passageways per LSC/IFC
Exit Requirements as per LSC/IFC

 Occupant Load Calculations Including Occupant Load Factors
 Egress Capacity
 Minimum Number of Means of Egress
 Maximum Travel Distance
 Maximum Common Path of Travel
 Maximum Dead-End
 Location of Exits (Remote Exits, 1/2 or 1/3 the Diagonal)
Exit Hardware, Locks, Special Locks, Panic/Fire Exit Hardware
Interior Finish per LSC/IFC

ASSEMBLY OCCUPANCY

Determination/Classifications of Assembly
Occupancies
Assembly Group A. Assembly Group A occupancy includes, among others, the use of a building
or structure, or a portion thereof, for the gathering of persons for purposes such as civic, social
or religious functions; recreation, food or drink consumption or awaiting transportation.
Exceptions:
1. A building or tenant space used for assembly purposes with an occupant load of less than 50
persons shall be classified as a Group B occupancy
2. A room or space used for assembly purposes with an occupant load of less than 50 persons
and accessory to another occupancy shall be classified as a Group B
occupancy or as part of that occupancy.
3. A room or space used for assembly purposes that is less than 750 square feet (70m2) in area
and accessory to another occupancy shall be classified as a Group B occupancy or as part of that
occupancy.
4. Assembly areas that are accessory to Group E occupancies are not considered separate
occupancies except when applying the assembly occupancy requirements of Chapter 11.
5. Accessory religious educational rooms and religious auditoriums with occupant loads of less
than 100 are not considered separate occupancies
A-1 Assembly uses, usually with fixed seating, intended for the production and viewing of the
performing arts or motion pictures including, but not limited to:
 Motion picture theaters
 Symphony and concert halls
 Television and radio studios admitting an audience
 Theaters
A-2 Assembly uses intended for food and/or drink consumption including, but not limited to:
 Banquet halls
 Night clubs
 Restaurants
 Taverns and bars
A-3 Assembly uses intended for worship, recreation or amusement and other assembly uses
not classified elsewhere in Group A including, but not limited to:

 Amusement arcades
 Art galleries
 Bowling alleys
 Community halls
 Courtrooms
 Dance halls (not including food or drink consumption)
 Exhibition halls
 Funeral parlors
 Gymnasiums (without spectator seating)
 Indoor swimming pools (without spectator seating)
 Indoor tennis courts (without spectator seating)
 Lecture halls
 Libraries
 Museums
 Places of religious worship
 Pool and billiard parlors
 Waiting areas in transportation terminals
A-4 Assembly uses intended for viewing of indoor sporting events and activities with spectator
seating including, but not limited to:
 Arenas
 Skating rinks
 Swimming pools
 Tennis courts
A-5 Assembly uses intended for participation in or viewing outdoor activities including, but not
limited to:
 Amusement park structures
 Bleachers
 Grandstands
 Stadiums

Assembly Occupancy Code Summary
General Description
Sample Project : MITI’s Restaurant
Mumbai- 400083

Applicable Codes
Code/Standard Description Edition
NFPA 101-LSC Life Safety Code 2018
NFPA 5000 Building Construction and Safety Code 2016
IFC International Fire codeI 2018
IBC International Building Code 2018
NFPA 10 Standard for Portable Fire Extinguishers
NFPA 13 Standard for the Installation of Sprinkler Systems 2013
NFPA 14 Standard for the Installation of Standpipe and 2013
Hose System
NFPA 20 Standard for the Installation of Stationary Pumps
for Fire Protection
NFPA 22 Standard for Water Tanks for Private Fire 2013
Protection
NFPA 72 National Fire Alarm Code 2013
NFPA 80 Standard for Fire Doors and Other Opening 2013
Protectives
NFPA 90A Standard for the Installation of Air-Conditioning 2013
and Ventilating Systems
NFPA 105 Standard for Smoke Door Assemblies and Other 2013
Opening Protectives
NFPA 110 Standard for Emergency and Standby Power 2013
Systems
NFPA 220 Standard on Types of Building Construction 2013
NFPA 255 Standard Method of Test of Surface Burning 2011
Characteristics of Building Materials
NFPA 2001 Standard on Clean Agent Fire Extinguishing 2011
Systems

Height and area limitations :
Actual building area 4,750 Sq ft.

Actual Building height 25 ft
Number of Stories 1
Permitted building Area(IBC table 503) 6,000 Sq ft.
Permitted building height 40 ft.
Permitted no. of stories 1
Structural Fire Resistance :

Construction Type TypeVB
Structural Frame 0 Hours
Bearing wall( Exterior/Interior) 0 Hours
Non-Bearing wall( Exterior/Interior) 0 Hours
Floor Construction 0 Hours
Roof Construction 0 Hours
Means of Egress :
Occupant load calculations as per LSC table 7.3.1.2
Occupant Load Factors: Restaurant Seating Area: 15 sq ft per person

Waiting Area: 3 sq ft per person
Fixed Seating (Booths): 18 inches per linear feet
Kitchen: 100 sq ft per person
Office/Bathroom/Common Area: 100 sq ft per person
Area/Use Area (Sq. ft.) OLF OL
Restraunt Seating 2000 15 Sq ft/Person 133

Waiting 200 3 Sq ft/Person 67
Fixed Seating 360 Inches 18 inch/linear ft 20
Kitchen 1400 100 Sq. ft./ Person 14
Office/Common 400 100 Sq. ft./ Person 4
area
Total 4,750 238
Egress Capacity ( LSC Table 7.3.3.1)

Required egress Capacity : 0.2 inch per person
= 0.2 x 238
= 47.6 Inch.
Actual egress Capacity : 96 Inch
Number of Exit required (LSC 12.2.4) : 2 Exits

Number of Exit Provided : 2 Exits
Max. TD : 250 ft.

Actual TD : 70 ft
Max. Common Path(CP) : 20 ft. with OL of more than 20

Actual Common Path (CP) : 0
Max. Dead End (LSC 12.2.5.1.3) : 20 ft.

Actual Dead End : 0 ft.
Separation of exits required (LSC 7.5.4.2) : Diagonal x 1/3 the maximum

diagonal with a supervised sprinkler system = 96 x 1/3 = 32 ft.
Separation of Exit required : 40 ft.

Panic Hardware required( LSC 12.2.2.2.3) : Provided on all exit doors
except the main entrance.
Interior Finishes :
Interior finishes to comply with LSC chapter 8.

Class A in lobby
Class B in main dining area
Fire Alarm System and Detection System

required :
NEW: Assembly occupancies with occupant load of 300 or more (IFC
907.2.1). Voice/alarm ≥ 1,000 occupants (IFC 907.2.1.3)
EXISTING: Assembly occupancies with occupant load of 300 or more
(IFC 1103.7.1)
Sprinkler System Required :

New: See IFC 903.2.1 & 903.2.11 for specific requirements. Basements
exceeding 2,500 sq. feet for drinking and dining and bowling. (IFC
1103.5.3)

Common Hazards of Assembly Occupancy
One way to attack the problem is to look at occupancy and list the most
common hazards found. This method will help you generate a list of
areas or items to inspect. The following are hazards peculiar to Assembly
occupancies, and ones you frequently will find violated.
Assembly occupancies
Description of Non Compliance Pictorial representation

Blocked exits (constant problem)
No exit signs; exit lights out

Doors locked during hours of
occupancy
Extinguishers not serviced or

nonexistent
Overcrowding, no occupant load

sign
Aisles not adequate

Candles on tables in unsafe
holders
Extension cords and other

electrical problems
Decorations (combustible or
flammable type).
Non-flame-retardant drapes.

Smoking problems.
Heating hazards.

INSPECTION REPORT FORMAT
1.General Building information :
No. of Stories below/ above grade Mention Number of story below and above ground
level
Is building High Rise Check the height of highest occupiable floor from
the level of FD access
Is it underground ? Check
Occupancy Classification Classify occupancy and suboccupancy as applicable
Min. Construction Type Refer NFPA 5000 & IBC
Approved Fire & Life Safety drawing Available Check for approved FLS drawing
Approved Shop drawing Available Check for approved Shop drawing
Is building construction acceptable for height Refer NFPA 5000 & IBC
and occupancy ?
Were alterations/renovation made since last Check the records
inspection ?
Building Surroundings Mention about surrounding of builidng from all of its
directions.
2. Observations/Findings/Recommandations :
SN Observations Recommandation Code/Std. Refer. Compliance

(Y/N/NA)
Category- A Buidling Exterior Analysis
1 Fire Lanes are marked and Where required by the fire code IFC 503.3 & 503.4
unobstructed official, approved signs or other NFPA 1- 18.2.3.5
approved notices or markings
that include the words NO
PARKING—FIRE LANE shall be
provided for fire apparatus
access roads to identify such
roads or prohibit the
obstruction thereof.
2 Address Visible New and existing buildings shall IFC 505.1
be provided with approved
address identification. The
address identification shall be

legible and placed in a position
that is visible from the street or
road fronting the property
3 Fire Hydrant/Water Supply An approved water supply IFC 507
accessible capable of supplying the
required fire flow for fire
protection shall be provided to
premises on which facilities,
buildings or portions of
buildings are hereafter
constructed or moved into or
within the jurisdiction
4 FD key box present/maintained Where access to or within a IFC 506
structure or an area is restricted NFPA 1- 18.2.2.1
because of secured openings or
where immediate access is
necessary for life-saving or fire-
fighting purposes, the fire code
official is authorized to require
a key box to be installed in an
approved location.
5 FD Connection Fire department connections IFC 912
Visible/maintained shall be located on the street
side of buildings or facing
approved fire apparatus access
roads, fully visible and
recognizable from the street,
fire apparatus access road or
nearest point of fire
department vehicle access or as
otherwise approved by the fire
code official.
6 Dumpsters are outside and 5 ft. Dumpsters and containers with IFC 304.3.3, NFPA-1
or more from combustible walls, an individual capacity of 1.5 19.2.1.4
openings or combustible roof cubic yards [40.5 cubic feet
eave (1.15 m3)] or more shall not be
lines. stored in buildings or placed
within 5 feet (1524 mm) of
combustible walls, openings or
combustible roof eave lines.

(Y/N/NA)
Category- B Exit Features/Means of Egress

1 Adequate number of exits – Each story and occupied roof IFC1004.1.1,1015,10
shall have the minimum 21,1104.24, NFPA
minimum of two
number of separate and distinct 101 – 7.4
exits, or access to exits.
2 Exits, aisles, & corridors free of Emergency escape and rescue IFC 1030.3, NFPA 101
obstructions. openings shall have the bottom 12.2.5.4
of the clear opening not greater
than 44 inches (1118 mm)
measured from the floor
3 Exit doors open from inside – Only approved fire exit IFC 1008.1.9,
hardware shall be used on fire 1008.1.10
panic hardware over 50
protection–rated door NFPA 101 ch. 07
occupants
assemblies. New panic
hardware and new fire exit
hardware shall comply with
ANSI/UL 305, Standard for
Safety Panic Hardware, and
ANSI/BHMA A156.3, Exit
Devices.
4 Exit signs present Directional exit signs shall be IFC 1011,1104.3
provided within horizontal NFPA 101-ch.07
components of the egress path
within exit enclosures as
required by 7.10.1.2.2
5 Emergency lighting present & Exit signs connected to, or IFC 1006,1104.5
operational provided with, a battery- NFPA 101 Ch.07
operated emergency
illumination source, where
required in 7.10.4, shall be
tested and maintained in
accordance
with 7.9.3.
6 Interior finish acceptable Interior wall and ceiling finishes IFC 803,804, NFPA
shall be classified in accordance 101 Ch.10,10.2
with ASTM E84 or UL 723. Such
interior finish materials shall
be grouped in the following
classes in accordance with their
flame spread and smoke-
developed indices.
Table : 803.3
7 Exit corridors rated Interior corridors and lobbies IFC 1018.1, 1104.17
shall be constructed in NFPA 101 -12.3.6
accordance with 7.1.3.1 and
Section 8.3
8 Occupant load posted Every room or space that is an IFC 1004.9
assembly occupancy shall have

the occupant load of the room
or space posted in a
conspicuous place, near the
main exit or exit access
doorway from the room or
space, for the intended
configurations. Posted signs
shall be of an approved legible
permanent design and shall be
maintained by the owner or the
owner’s authorized agent.
9 Main exit for 50% of capacity – A building, room or space used IFC 1028.2
for assembly purposes that has
over 300
an occupant load of greater
than 300 and is provided with a
main exit, that main exit shall
be of sufficient capacity to
accommodate not less than
one-half of the occupant load,
but such capacity shall be not
less than the total required
capacity of all means of egress
leading to the exit.
10 Adequate aisle width The required capacity of aisles IFC 1029.6
shall be not less than that
determined in accordance with
Section 1029.6.1 where smoke-
protected assembly seating is
not provided, with Section
1029.6.2 where smoke-
protected assembly seating is
provided, and with Section
1029.6.3 where open-air
assembly seating is Provided
11 Installation of handrailes as per Stairs and ramps shall have NFPA 101 Ch. 07
the code requirement handrails on both sides. 7.2.2.4.5
12 Exit door release devices meets All exits must be kept unlocked NFPA 101 -7.2.2.5.5.7
code requirements and must swing towards the
direction of the egress where
serving an area with occupant
load of 50 or more. A latch or
other fastening device on a
door shall be provided with a
releasing device (push panic
hardware) that has an obvious
method of operation, and that

is readily operated under all
lighting conditions
13 Floor sign shall is provided New enclosed stairs serving NFPA 01 -7.2.2.5.4
three or more stories
and existing enclosed stairs,
other than those addressed in
7.2.2.5.4.1(P), serving five or
more stories shall comply with
7.2.2.5.4.1(A) through
7.2.2.5.4.1(O).
14 Assembly point is identified Assembly points shall be NFPA 101 Ch. 07
properly installed in area or areas shall
be adequate enough to
accommodate evacuees and at
a safe distance away from the
building to protect people from
fire, falling debris, building
collapse, etc. “Assembly points”
for the evacuees shall be
designated by a sign board in
Green color.

(Y/N/NA)
Category- C Occupancy Construction Features
1 Fire rated construction Materials and firestop systems IFC 703.1
present/maintained used to protect membrane and
through penetrations in fire-
resistance-rated construction
and construction installed to
resist the passage of smoke
shall be maintained. The
materials and firestop systems
shall be securely attached to or
bonded to the construction
being penetrated with no
openings visible through or into
the cavity of the construction.
Where the system design
number is known, the system
shall be inspected to the listing
criteria and manufacturer’s
installation instructions.

2 Incidental use areas Shall be separated from other IFC 1106.3
separated/sprinklered. area with required fire
resistance rating
3 Rated fire doors operational Swinging fire doors shall close IFC 705.2.4 NFPA 101
from the full-open position and 8.8,12.3
latch automatically
4 Vertical openings protected Shall be protected in IFC 1103.4
accordance with the NFPA 101 – 8.6,12.3
requirement of Ch. 08 NFPA
101
5 Decorations (foams, curtains, Artificial decorative vegetation IFC 807.1,
drapes, hangings) to be flame shallmeet the flame 807.4.2,NFPA 101 –
resistant in assembly propagation performance 12.3
occupancies criteria of Test Method 1 or Test
Method 2, as appropriate, of
NFPA 701. Meeting such criteria
shall be documented and
certified by the manufacturer in
an approved manner.
Alternatively, the artificial
decorative vegetation shall be
tested in accordance with NFPA
289, using the 20 kW ignition
source, and shall have a
maximum heat release rate of
100 kW.

(Y/N/NA)
Category- D Storage
1 Storage neat and orderly Storage of materials in buildings IFC 315.3
shall be orderly and stacks shall NFPA 1- 34.1
be stable. Storage of
combustiblematerials shall be
separated from heaters or
heating devices by distance or
shielding so that ignition cannot
occur.
2 Combustible storage prohibited Combustible material shall not IFC 315.3.3
in electrical equipment rooms, be stored in boiler rooms, NFPA 1 – 10.18.5
restrictions apply in mechanical rooms, electrical
boiler/mechanical rooms equipment rooms or in fire
command centers.
3 Attic storage Attic,under-floor and concealed IFC 315.3.4
spaces used for storage of NFPA 1- 10.18.6

combustible materials shall be
protected on the storage side
as required for 1-hour fire-
4 Storage maintained (2’ below Storage shall be maintained 2 IFC 315.3.1
feet (610 mm) or more below NFPA 1- 10.18.3
ceiling un-sprinklered, 18” the ceiling in nonsprinklered
sprinklered) areas of buildings or not less
than 18 inches (457 mm) below
sprinkler head deflectors in
sprinklered areas of buildings.
Except.
1. The 2-foot (610 mm)
ceiling clearance is
not equired for
storage along walls in
nonsprinklered areas
of buildings.
2. The 18-inch (457
mm) ceilingclearance
is not required for
areas of buildings
equipped with an
automatic sprinkler
system
5 Rubbish/waste subject to Materials susceptible to IFC 304.3.1

spontaneous ignition shall be spontaneous ignition, such as
disposed of daily and in listed oily rags, shall be stored in a
container listed disposal container.
Contents of such containers
shall be removed and disposed
of daily.

(Y/N/NA)
Category- E Hazardous Materials
1 Compressed gas cylinders Compressed gas containers, IFC 5303.5
secured cylinders, tanks and systems NFPA 1 – 63.3
that could be exposed to
physical damage shall be
protected. Guard posts or other
approved means shall be
provided to protect

compressed gas containers,
cylinders, tanks and systems
indoors and outdoors from
vehicular damage and shall
comply with Section 312.
2 Rooms/areas properly labeled Unless otherwise exempted by IFC 5003.5
the fire code official, visible
hazard identification signs as
specified in NFPA 704 for the
specific material contained
shall be placed on stationary
containers and aboveground
tanks and at entrances to
locations where hazardous
materials are stored,
dispensed, used or handled in
quantities requiring a permit
and at specific entrances and
locations designated by the fire
code official.
3 Acceptable quantities The maximum allowable IFC 5003.1.1
quantity per control area shall NFPA 1 – 60.4
be as specified in Tables
5003.1.1(1) throug 5003.1.1(4).
4 Separation of incompatible Incompatible materials in IFC 5003.9.8
materials storage and storage of
materials that are incompatible
with materials in use shall be
separated where the stored
materials are in containers
having a capacity of more than
5 pounds (2 kg), 0.5 gallon (2 L)
or any amount of compressed
gases. Separation shall be
accomplished by:
1. Segregating incompatible
materials in storage by a distance
of not less than 20 feet (6096 mm).
2. Isolating incompatible materials
in storage by a noncombustible
partition extending not less than 18
inches (457 mm) above and to the
sides of the stored material.
3. Storing liquid and solid materials
in hazardous material storage
cabinets.
4. Storing compressed gases in gas
cabinets or exhausted enclosures in
accordance with Sections 5003.8.5
and 5003.8.6.

(Y/N/NA)
Category- F Emergency Planning
1 Crowd managers & In theaters, motion picture IFC 403.3 , 408.2.2
Announcements theaters, auditoriums and NFPA 101- 12.7 &
similar assembly occupancies in 13.7
Group A used for
noncontinuous programs, an
audible
Where facilities or events
involve a gathering of more
than 500 people, crowd
managers shall be provided in
accordance with Sections
403.12.3.1 through 403.12.3.3
2 Comply with Chapter 4 for Public In addition to the requirements IFC 403.3, 408.2.2
Assembly & Events of Section 404.2, the fire safety NFPA 101- 12.7 &
and evacuation plans for 13.7
assembly occupancies shall
include a detailed seating plan,
occupant load and occupant
load limit. Deviations from the
approved plans shall be allowed
provided that the occupant
load limit for the occupancy is
not exceeded and the aisles and
exit accessways remain
unobstructed.
3 Emergency evacuation plan An approved fire safety and IFC 403.2
provided ? evacuation plan in accordance NFPA 101- 12.7 &
with Section 404 shall be 13.7
4 Is Emergency plan in accordance prepared and maintained for IFC 403.2
with code/std. Group A occupancies, other NFPA 101- 12.7 &
than those occupancies used 13.7
exclusively for purposes of
religious worship with an
occupant load less than 2,000,
and for buildings containing
both a Group A occupancy and
an atrium. Group A occupancies
shall comply with Sections
403.2.1 through 403.2.4.
5 Fire Drills Conduted Required emergency IFC 405.2
evacuation drills shall be held at

the intervals specified in Table NFPA 101- 12.7 &
405.2 or more. frequently 13.7
where necessary to familiarize
all occupants with the drill
procedure.

(Y/N/NA)
Category- G Fire Extinguishers
1 Readily accessible Portable fire extinguishers shall IFC 906.5
be located in conspicuous NFPA 1 – 13.6 &
locations where they will have NFPA 10
ready access and be
immediately available for use.
These locations shall be along
normal paths of travel, unless
the fire code official determines
that the hazard posed indicates
the need for placement away
from normal paths of travel.
2 Travel distance not exceeded It shall be in accordance with IFC 906.1 , 906.3
table 906.3(1) & 906.3(2) NFPA 1 – 13.6 &
NFPA 10
3 Tested/inspected at least Testing and inspection shall be IFC 901.6.1
annually done as per the requirement of NFPA 1 – 13.6 &
NFPA 10 NFPA 10

(Y/N/NA)
Category- H Flammable and Combustible Liquids
1 Safety containers if used Class I liquids or, when heated IFC 5705.2.4
to or above their flash points, NFPA 1 – 66.9
Class II and Class III liquids, shall
be transferred by one of the
following methods:
1. From safety cans complying
with UL 30.
2. Through an approved closed
piping system.
3. From containers or tanks by
an approved pump taking
suction through an opening in
the top of the container or tank.

4. For Class IB, IC, II and III
liquids, from containers or
tanks by gravity through an
approved self-closing or
automatic-closing valve where
the container or tank and
dispensing operations are
provided with spill control and
secondary containment in
accordance with Section
5703.4. Class IA liquids shall not
be dispensed by gravity from
tanks.
5. Approved engineered liquid
transfer systems.
2 Not stored/kept near exits Storage of any liquids, including IFC 5704.3.3.3
stock for sale, shall not be NFPA 1 – ch.66
stored near or be allowed to
obstruct physically the route of
egress
3 No sources of ignition Smoking and open flames are IFC 5704.2.4
prohibited in storage areas in NFPA 1 – ch.66
5003.7.
4 Quantities >10 gals in cabinet Quantities in Group A IFC 5704.3.4.4
occupancies shall not exceed NFPA 1 – ch.66
that necessary for
demonstration, treatment,
laboratory work, maintenance
purposes and operation of
equipment, and shall not
exceed quantities set forth in
Table 5003.1.1(1)
In all occupancies, quantities of
flammable and combustible
liquids in excess of 10 gallons
(38 L) used for maintenance
purposes and the operation of
equipment shall be stored in
liquid storage cabinets in
5704.3.2. Quantities not
exceeding 10 gallons (38 L) are
allowed to be stored outside of
a cabinet where in approved
containers located in private
garages or other approved
locations.

5 No basement storage unless Class I liquids shall be allowed IFC 5704.3.5.1
sprinklered to be stored in basements in NFPA 1 – ch.66
amounts not exceeding the
maximum allowable quantity
per control area for use-open
systems in Table 5003.1.1(1),
provided that automatic
suppression and other fire
protection are provided in
accordance with Chapter 9.
Class II and IIIA liquids shall be
allowed to be stored in
basements, provided that
automatic suppression and
other fire protection are
provided in accordance with
Chapter 9.
6 Adequate ventilation Liquid storage rooms shall be IFC 5704.3.7.5.1
ventilated in accordance with NFPA 1 – ch.66
Section 5004.3
Indoor storage areas and
storage buildings shall be
provided with mechanical
exhaust ventilation or natural
ventilation where natural
ventilation can be shown to be
acceptable for the materials as
stored.

(Y/N/NA)
Category- I Other building Services
1 Shut off valves present on gas The installation of nonportable IFC 603.1
appliances gas-fired appliances and
systems shall comply with the
International Fuel Gas Code.
The installation of nonportable
liquid fuelfired appliances and
systems shall comply with this
section and the International
Mechanical Code.
2 Approved piping, connections & The design, construction and IFC 603.1.2
appliances used installation of fuel-fired
appliances shall be in
accordance with the

International Fuel Gas Code and
the International Mechanical
Code.
3 Combustion air supply/venting IFC 603.1
present
4 Adequate clearance between Portable outdoor gas-fired IFC 305.1, 603.4.2.1.3
combustibles and appliances heating appliances shall not be
located beneath, or closer than
5 feet (1524 mm) to
combustible decorations and
combustible overhangs,
awnings, sunshades or similar
combustible attachments to
buildings.
5 Commercial hood ducts/filters Hoods, grease-removal devices, IFC 607.3.3
are clean fans, ducts and other
appurtenances shall be cleaned
at intervals as required by
Sections 607.3.3.1 through
607.3.3.3.

(Y/N/NA)
Category- J Sprinkler System
1 Coverage is adequate Sprinkler systems shall be IFC 903.3.1
designed and installed in NFPA 13 – 8.5
903.3.1.1, unless otherwise
permitted by Sections 903.3.1.2
and 903.3.1.3 and other
chapters of this code, as
applicable.
2 Controls are readily accessible Approved access shall be IFC 509.2
provided and maintained for all
fire protection equipment to
permit immediate safe
operation and maintenance of
such equipment. Storage, trash
and other materials or objects
shall not be placed or kept in
such a manner that would
prevent such equipment from
being readily accessible
3 Valves locked open Indicating type of valves must IFC 903.4.4
be sealed, locked and NFPA 13 8.17.1.4

electrically supervised in the
locked position
4 System and valves supervised Control valves shall not be IFC 903.4
installed between the water NFPA 13- 6.7,
supply and sprinklers unless the 8.16.1.1.2
valves are of an approved
indicating type that are
supervised or secured in the
open position
5 Heads in good condition As per the requirement of NFPA IFC 903.3.1
13 & 25
6 Wrench/spare sprinklers present As per the requirement of NFPA IFC 903.3.1

13 & 25 NFPA -13 6.2.9
7 Sprinkler Protective Caps Protective caps shall be NFPA 13-8.3.1.5

removed removed from sprinklers prior
to the time when the system is
placed in service
8 Sprinklers Provided for stairways In non combustible stair shaft NFPA 13- 8.15.3.2
having non combsitible stairs
with non combustible or limited
combustible finishes sprinkler
shall be installed at the top of
the shaft and under the first
accessible landing above the
bottom of the shaft
9 Tested/inspected at least Must be done as per NFPA 25 IFC 901.6.1
annually NFPA 13- 27.1
10 Riser/pump rooms labeled Fire protection equipment shall IFC 509.1
be identified in an approved
manner. Rooms containing
controls for air-conditioning
systems, sprinkler risers and
valves, or other fire detection,
suppression or control
elements shall be identified for
the use of the fire department.
Approved signs required to
identify fire protection
equipment and equipment
location shall be constructed of
durable materials, permanently
installed and readily visible

(Y/N/NA)
Category- K Fire Pump System
1 Fire pump base plate is grouted The base plate shall be securely NFPA 20
attached to a solid foundation
in such a way that pumps and
driver shaft alignment is
ensured.
When the alignment is correct,
the foundation bolts should be
tightened evenly but not too
firmly. The unit can then be
grouted to the foundation. The
base plate should be
completely filled with grout,
and it is desirable to grout the
leveling pieces, shims, or
wedges in place.
Foundation bolts should not be
fully tightened until the grout
has hardened, usually about 48
hours after pouring.
2 Batteries are installed propertly Storage batteries shall be rack NFPA 20
supported above the floor,
secured against displacement,
and located where they will not
be subject to excessive
temperature, vibration,
mechanical injury, or flooding
with water.
Current-carrying parts shall not
be less than 12 in. (305 mm)
above the floor level.
Storage batteries shall not be
located in front of the engine-
mounted instruments and
controls.
3 Diesel tank is properly Identified Proper labeling including NFPA 20- 11.4.2.6
for its capacity identification of Contents, Tank
Volume, Hazards and Warnings
shall be done.
4 Secondary Containment for Fuel Tanks shall be enclosed / NFPA 30- 22.11.2.2
diesel tank provided with a dike / bund
sufficient to hold the entire

capacity of the tank in order to
prevent accidental spillages.
The walls and base of a dike /
bund shall be made of non-
combustible materials.
5 Weather vent pipe is terminated As per NFPA – 20, the weather NFPA 20
as per requirement vent shall be at least 3.05m
from the top of the tank fill cap
6 Gate valve in the diesel tanks fuel No other valve than a manual NFPA 20- 11.4.4
supply/return line is suprvised locked open valve shall be put
in the fuel line from the fuel
tank to the engine
There shall be no shutoff valve
in the fuel return line to the
tank.
Handles shall be removed
keeping the valves in open
position. All the handles shall
be placed inside a cabinet and
shall be placed inside the pump
room for maintenance purpose.
7 Fire Water Tank with its Capacity Sign board shall in a visible NFPA20
(Main / Reserve) & Pipe network location.
at Fire Pump Room and Valves
were identified.
8 Pressure Chart indicating cut- Cut-Off / Cut-In pressure for fire NFPA20
off/cut-in pressure for fire pumps pumps shall be permanently
were observed in the fire pump and legibly displayed in the Fire
room. Pump Room.
9 Valves at Fire Pump Room were All the isolation and section NFPA 20
supervised. control valves installed shall be
of supervised O.S. & Y gate
valve or supervised butterfly
valves installed with a tamper
or supervisory switch
connected to the building fire
alarm system for monitoring or
secured in open position
10 Fuel Line was identified for Fuel Lines (Supply / Return) NFPA 20
Diesel Engine at Fire Pump Room. shall be properly identified at
the above mentioned location.
11 Shut off valves were installed at As per NFPA-20, all pump NFPA 20
the sensing lines of the fire installations, including jockey
pumps. pumps, each controller shall
have the individual pressure-
sensing line which shall be
brass, copper, or series 300

stainless steel pipe or tube, and
the fittings shall be of ½ in. (15
mm) nominal size & shutoff
valves are not allowed in the
pressure-sensing line.
12 Suction Lines for both Electrical & Eccentric Tapered Reducer or NFPA 20- 4.14.6.4
Diesel Pumps observed with Increaser: Where the suction
concentric reducers. pipe and pump suction flange
are not of the same size, they
shall be connected with an
eccentric tapered reducer or
increaser installed in such a way
as to avoid air pockets.
13 Ventilation arrangement was not Ventilation shall be provided NFPA 20
observed for the fire pump room. for the following functions:
(1) To control the maximum
temperature to 120°F (49°C) at
the combustion air cleaner inlet
with engine running at rated
load
(2) To supply air for engine
combustion
(3) To remove any hazardous
vapors
(4) To supply and exhaust air as
necessary for radiator cooling
of the engine when required
Provision shall be made to
supply fresh air to the Fire
Pump Room.
During the event of fire, the
system shall respond to operate
and shall stop until the fire-
protective signaling system has
been manually reset
14 Pressure Switch was installed for Electric alarm pressure NFPA 20
the Alarm Check Valve assembly. switches shall be installed in the
system and they shall be
mounted on a vertical branch
pipe at least 300 mm long.
The pressure switch may be of
the diaphragm bellows or

bourdon tube operated type,
and shall be sufficiently
sensitive to operate when only
one sprinkler is discharging.
The pressure switch shall be
provided with volt free
contracts to interconnect with
the building fire alarm system
for monitoring
15 Diesel Engine’s Exhaust Pipe was The Exhaust Pipe shall be NFPA 20
insulated. covered with high temperature
insulation or otherwise guarded
to protect personnel from
injury.
Exhaust pipes shall be installed
with clearances of
16 Drain arrangement for pump Floors shall be pitched for NFPA 20
room adequate drainage of escaping
water away from critical
equipment such as the pump,
driver, controller, and so forth.
The drains shall be provided
with an arrangement that is
terminated back to the fire
water tank or to open drain/pit

(Y/N/NA)
Category- L Fire Alarm and Detection System
1 Control panel/annunciator panel Its is recommanded that to IFC 901.6, 901.7
in normal condition check if all the devices are
[no trouble or alarm conditions] communicating with FACP
2 Detectors properly installed As per the requirement of NFPA IFC 907 , 1103.7.1
72 NFPA 72 – 17.4
3 Appropriate type of detectors As per the requirement of NFPA
are installed in locations 72
4 Detectors coverage meeting the As per the requirement of NFPA NFPA 72 – 17.5.3
requirements 72
5 Tested/inspected at least As per the requirement of NFPA IFC 907.8
annually 72
6 Fire alarm system installed An approved fire alarm system IFC 907.2.1, 1103.7.1
where required installed in accordance with the
provisions of this code and
NFPA 72 shall be provided in

new buildings and structures in
accordance with Sections
907.2.1 through 907.2.23 and
provide occupant notification in
accordance with Section 907.5,
unless other requirements are
provided by another section of
this code.
7 Manual Call points are installed Manullally actuated alarm NFPA 72 – 17.14
as per requirment intitiating devices for initiating
signals other than for fire alarm
shall be premitted if the devices
are differentiated from manual
for fire alarm boxes by a color
other than red and labeling.

(Y/N/NA)
Category- M Other Fire Protection System
1 Standpipes needed Standpipe systems shall be IFC 905
provided in new buildings and
structures in accordance with
Sections 905.2 through 905.11.
In buildings used for high-piled
combustible storage, fire
protection shall be in
2 Standpipes/hose in good Hose reels shall be dutch rolled IFC 905.2
condition Standpipe systems shall be
installed in accordance with this
section and NFPA 14. Fire
department connections for
standpipe systems shall be in
accordance with Section 912
3 Adequate coverage As per the requirement of NFPA IFC 905.2
72
4 Pressure guages are installed on A listed pressure gauge having a NFPA 14- 5.5
the remotest point of riser minimum face diameter of 31⁄2
in. (90 mm) shall be connected
to each discharge pipe from the
fire pump and the public
waterworks, at the pressure
tank, at each main drain
connection, at the air pump
supplying the pressure tank,

and at the top of each
standpipe.
5 FHR and LV height meeting the The landing valve shall be NFPA 14
code requirement installed at a height of not less
than 900 mm and not more
than 1200 mm from the
finished floor level while the
fire hose reel or Fire hose rack
shall be installed at a height of
not less than 1200 mm and not
more than 1500 mm from the
finished floor level. Fire
contractor shall make
appropriate arrangements in
order to comply with the
above-stated requirements.
6 Control valves are observed All the isolation and section NFPA 14
control valves installed shall be
secured in open position by a
padlock.
7 Kitchen Hood fuel shutoff Commercial kitchen exhaust IFC 904.11.2
present hoods shall comply with the
requirements of the
International Mechanical Code
8 Kitchen Hood system properly Each required commercial IFC 607.3 & 904.11.6
maintained/serviced kitchen exhaust hood and duct
system required by Section 607
to have a Type I hood shall be
protected with an approved
automatic fire-extinguishing
system installed in accordance
with this code.
LEGENDS
Compliance
Non Compliance
Not Applicable

MechSoft EDC Contact Number : +91 9146861270
FIRE AND LIFE SAFETY

INSPECTION/AUDIT GUIDE
FOR
HEALTH CARE FACILITIES
In Accordance with
National Disaster Management Guidlines

NFPA 101 (Life Safety Code - 2018)
Applicable NFPA Codes/Standards
Mehboob Shaikh
B.Eng(Mech.) || AMIE || CFPS || CFI-1
MechSoft EDC Design|Inspections|Training info@mitionline.com

CONTENT
Sr. No Description Page No.
1 Inspection Report
1.1 Hospital General Information 3
1.2 Hospital Performance Summary 3
1.3 Hospital Safety Evaluation Profile (SEP) Summary 5
1.4 Observation/Findings and Recommandations 6
A Building Exterior Analysis 6
B Exit Features / Means of Egress 7
C Occupancy Construction Features 20
D Storage Safety 21
E Hazardous Materials 22
F Fire Extinguishers 23
G Hazards of Combustible and Flammable Liquids 24
H Sprinkler System 26
I Fire Pump Systems 27
J Fire Alarm and Detection System 31
K Wet Chemical System 33
L Smoke Control System 33
M Emergency Planning 35
2 Fire and Safety Check Lists
2.1 General Safety Overview 37
2.2 Nursing General Safety 38
2.3 Slip, Trip, and Fall Prevention 38
2.4 Facility and Design Electrical Safety 40
2.5 Hazard Communication Evaluation 41
2.6 Basic Control of Hazardous Energy (Lockout/Tagout) 42
2.7 Confined Space Entry 43
2.8 Surgical Department 44
2.9 Storage Area Safety 44
2.10 Laboratories 46
2.11 Pharmacy 50
3 Explanation on Selected Topics
3.1 Operating Room (OR) Fire safety /Sugical Fires Safety 51
3.2 Safe Quantity of Open Medical Gases Storage in Health Care facilities 55
4 Inspection, Testing and Maintanence Requirement for FPS 59
5 Safety Evaluation Profile (SEP) 70
6 Partial List of NFPA Standards for Health Care Facilities 71

INSPECTION REPORT
Hospital General Information :
No. of Stories below/ above grade Mention Number of story below and above ground
level
Is building High Rise Check the height of highest occupiable floor from
the level of FD access
Is it underground ? Check
Occupancy Classification Classify occupancy and suboccupancy as applicable
Min. Construction Type Refer NFPA 5000
Approved Fire & Life Safety drawing Available Check for approved FLS drawing
Approved Shop drawing Available Check for approved Shop drawing
Buiding Surroundings Mention about surrounding of builidng
Hospital Performance Summary :

Status Level of Deficiency
Topic
Remarks L1 /L2/L3
Is the building accepted by local authorities? Are Check the records
acceptance documents available?
Is building construction acceptable for height Refer NFPA 5000
and occupancy ?
Were alterations/renovation made since last Check the records
inspection ?
Are certificates for all components of fire Check the records
separations available?
Are certificates available on the reaction of these Check the records
materials to a fire?
Is the actual fire compartmentation in line with Check the records
what is indicated on the plans?
Are evacuation plans available? Check the records
Are all evacuation routes clearly marked? Inspect
Can the evacuation routes be used at all times? Inspect
Is all fire detection and alarm system information Inspect
available?
Is the fire detection and alarm system installation Inspect
approved by an independent body?

Is the actual fire detection and alarm system in Inspect

line with what is indicated in the system
information?
Is the actual fire detection and alarm system fully Inspect
operational?
Is all information on automatic suppression / Inspect
smoke control systems available?
Is the automatic fire suppression / smoke control Inspect
system approved by an independent body?
Is the actual system fully operational? Inspect
Are plans available showing the location of all fire Inspect
extinguishers and hose reels?
Are all fire extinguishers and hose reels clearly Inspect
marked?
Can the fire extinguishers / hose reels be used at Inspect
all times?
Are maintenance reports available and are all Inspect
issues indicated on the reports resolved?
Are standpipes installed as indicated in the fire Inspect
safety master plan and/or building permit?
Are the fire department connections at the base Inspect
of the riser and in the building free from
obstructions?
Are good housekeeping rules applied and are Inspect
they well followed?
Are formalized permit procedures applied for hot Inspect
works and other activities that create a higher
fire risk?
Is every employee aware of the fire risks related Inspect
to his job and how to mitigate the consequences
of a fire incident (e.g., are nurses aware of the
importance of good housekeeping, unobstructed
routes in corridors, use of fire resistant doors,
etc.)?
Is a formal inspection procedure applied for life Inspect
and fire safety aspects?
Is a formalized emergency response plan Inspect
available?
Is every employee informed on how to react in Inspect
case of a fire alarm? Do the employees receive
regularly an update of these procedures?
Are at all times enough employees available that Inspect
are skilled in a first response to a fire alarm?


are skilled in the use of fire extinguishers?
are skilled in the evacuation of patients?
Are evacuation drills practiced at least once a Check Records
year?
Deficiencies — Fire safety deficiencies are found on a building-by-building basis and are rated
according to how the deficiency affects overall fire safety. Deficiencies are classified as level I, II,
or III
• Level I — A deficiency or series of deficiencies indicating a lack of proper maintenanc of building

components that play a role in the unit concept.
• Level II — A deficiency or series of deficiencies involving one or more unit-concept units that
pose a threat to life. The scope of the deficiencies is significant in a limited
area.
• Level III — A deficiency or deficiencies indicating pervasive violation of one or more of the unit-
concept units. The scope of the deficiencies is such that correction in less than three years is not
possible.
Hospital SEP Summary :
Fire and Life Safety Program Element Possible Score Actual Score
Management Leadership 36
Workplace Analysis 28
Hazard Prevention and Control 24
Safety and Health Training 12
Total 100

Observations/Findings/Recommandations :

(Y/N/NA)
Category- A Buidling Exterior Analysis
1 Fire Lanes are marked and Where required by the fire code NFPA 1- 18.2.3.5
unobstructed official, approved signs or other
approved notices or markings
that include the words NO
PARKING—FIRE LANE shall be
provided for fire apparatus
access roads to identify such
roads or prohibit the
obstruction thereof.
4 FD key box present/maintained Where access to or within a NFPA 1- 18.2.2.1
structure or an area is restricted
because of secured openings or
where immediate access is
necessary for life-saving or fire-
fighting purposes, the fire code
official is authorized to require
a key box to be installed in an
approved location.
6 Dumpsters are outside and 5 ft. Dumpsters and containers with NFPA-1-19.2.1.4
or more from combustible walls, an individual capacity of 1.5
openings or combustible roof cubic yards [40.5 cubic feet
eave (1.15 m3)] or more shall not be
lines. stored in buildings or placed
within 5 feet (1524 mm) of
combustible walls, openings or
combustible roof eave lines.
7 Sufficient access for fire  The width of NDM Hospital Safety
department is available entrances shall be
not be less than 4.5
mtrs with clear head
room not less than 5
mtrs.
 The width of the
access road shall be a
minimum of 6 mtrs
 A turning radius of 9
mtrs shall be
provided for fire
tender movement.

 The open space

around the building
shall not be used for
parking and/or any
other Purpose
 The width of the main
street on which the
hospital building
abuts shall not be less
than 12 mtrs & when
one end of that street
shall join another
street, the street
shall not be less than
12 mtr wide.
 The roads shall not be
terminated in dead
ends.

(Y/N/NA)
Category- B Exit Features/Means of Egress
Internal Staircases
Internal staircases shall be NDM Hospital Safety

constructed with non-
combustible materials
Internal stairs shall be NDM Hospital Safety
constructed as self contained
Provision of internal staircase is
units along an external wall
1 of the building constituting
as per the requirement
at least one of its sides and
shall be completely closed
A staircase shall not be NDM Hospital Safety
arranged around a Lift shaft.
Hollow combustible NDM Hospital Safety
construction shall not be
permitted.
The construction material NDM Hospital Safety
shall have 02 hrs fire
resistance.

Minimum width of stairs NDM Hospital Safety

shall be 2 mtrs.
Width of the tread shall not NDM Hospital Safety
be less than 300 mm
The height of the riser shall NDM Hospital Safety
not be less than 150 mm and
the number of stairs per
flight shall not exceed 15
Handrails shall be provided NDM Hospital Safety
at a height of 1000 mm,
which is to be measured
from the base of the middle
of the treads to the top of the
handrails
Banisters or railings shall be NDM Hospital Safety
provided such that the width
of staircase is not reduced
Minimum head room in a NDM Hospital Safety
passage under the landing of
a staircase and under the
staircase shall be 2.2 mtrs
The staircase shall be NDM Hospital Safety
continuous from ground
floor to the terrace and the
exit door at the ground level
shall open directly to the
open spaces or a large lobby
Fire/Smoke check doors shall NDM Hospital Safety
be provided for a minimum
of 2 hrs fire resistance rating.
No electrical shaft and panel, NDM Hospital Safety
AC ducts or gas pipelines,
etc. shall pass through or
open onto the staircases.
No combustible material NDM Hospital Safety
shall be used for
decoration/wall panelling in
the staircases.
2 All Exit meeting the code Exit must meet the NFPA 101, Cl. 7.1.3.2
requirement requirement of Cl. 7.1.3.2
3 StairCase Complying with the The Stair shall be in NFPA 101, Cl. 7.2.2
code requirement accordance with Cl. 7.2.2

The separation shall have a

minimum 1-hour fire
resistance rating where the
exit connects three or fewer
stories.
Protected Staircases
1 Provision for Protected Provisions given for internal NDM Hospital Safety
Staircases staircases shall apply to NFPA 101, Ch.
protected staircases 18,19,07
The staircases shall be NDM Hospital Safety
enclosed by walls having 02 NFPA 101, Ch.
hrs fire resistance 18,19,07
The external exit doors at NDM Hospital Safety
ground floor shall open NFPA 101, Ch.
directly onto open spaces or 18,19,07
a lobby and Fire & Smoke
check doors shall be
provided
Protected staircases shall be NDM Hospital Safety
pressurized. Under no NFPA 101, Ch.
circumstances shall they be 18,19,07
connected to a corridor,
lobby and staircase which is
unpressurized.
Pressurization systems shall NDM Hospital Safety
be incorporated in protected NFPA 101, Ch.
staircases where the floor 18,19,07
area is more than 500 sq.
mtr. The difference in
pressurization levels
between staircase and
lobby/corridor shall not be
greater than 5 Pa. Where 2
stage pressurization system
is is use the pressure
difference shall be as under:
(a) In normal conditions -
Minimum 8Pa to 15 Pa.
(b) In emergency conditions -
50 Pa.
2 Provision of Interfacing with The pressurization system NDM Hospital Safety
staicase pressurization system shall be interconnected with

the automatic/manual fire NFPA 101, Ch.

alarm system for actuation. 18,19,07
3 StairCase Complying with the The Stair shall be in NDM Hospital Safety
code requirement accordance with Cl. 7.2.2 NFPA 101, Ch.
18,19,07
External Staircases
1 Provision for External Staircases External staircases serving as NDM Hospital Safety
a required means of egress NFPA 101, Ch.
shall be of permanent fixed 18,19,07
construction.
External staircases shall be NDM Hospital Safety
protected by a railing or NFPA 101, Ch.
guard. The height of such a 18,19,07
guard/ railing shall not be
less than 1200 mm.
separated from the interior NFPA 101, Ch.
of the building by walls that 18,19,07
are fire resistant and have
fixed or self closing opening
protectives’, as required for
enclosed stairs. External
staircases shall extend
vertically from the ground to
a point 3 meters above the
topmost landing of the
stairway or the roof line
whichever is lower, and
atleast 3 meters horizontally
All openings below and NDM Hospital Safety
outside the external NFPA 101, Ch.
staircases shall be protected 18,19,07
with requisite fire resistance
rating.
so arranged to avoid any NFPA 101, Ch.
discomfort/obstruction for 18,19,07
persons with a fear of
heights, from using them.
so arranged to ensure a clear NFPA 101, Ch.
direction of egress to the 18,19,07

street.

continuous from the ground NFPA 101, Ch.
floor to the terrace level 18,19,07
The entrance to the external NDM Hospital Safety
staircases shall be separate NFPA 101, Ch.
and remote from internal 18,19,07
staircases.
External staircases shall have NDM Hospital Safety
a straight flight with a width NFPA 101, Ch.
not less than 2 mtrs, a tread 18,19,07
not less than 300 mm, a riser
not more than 150 mm and
the number of risers shall be
limited to 15 per flight.
The handrail shall have a NDM Hospital Safety
height not less than 1000 NFPA 101, Ch.
mm and not exceeding 1200 18,19,07
mm. Banisters shall be
provided with a maximum
gap of 150 mm.
Stair treads shall be NDM Hospital Safety
uniformly slip resistant and NFPA 101, Ch.
shall be free of projections or 18,19,07
lips that could trip stair users
External staircases used as NDM Hospital Safety
fire escapes shall not be NFPA 101, Ch.
inclined at an angle greater 18,19,07
than 45o from the horizontal
Unprotected steel frame NDM Hospital Safety
staircases shall not be NFPA 101, Ch.
acceptable means of egress; 18,19,07
however steel staircases in
an enclosed compartment
with a fire resistance of 2 hrs
will be accepted as means of
escape.
2 Provision of Elevator for Patient Elevators constitute a NDM Hospital Safety
movement desirable supplementary NFPA 101, Ch.
facility though they are not 18,19,07
counted as required exits.
Patient’s lifts shall have

sufficient space for Stretcher

trolley.
Horizontal Exit
1 Provision of Horizontal Exit Width of the horizontal exits NDM Hospital Safety
shall be same as the exit NFPA 101, Ch.
doorways. 18,19,07
A horizontal exit shall be NDM Hospital Safety
equipped with at least one NFPA 101, Ch.
fire/smoke door of minimum 18,19,07
2 hrs fire resistance of self
closing type. Further they
shall have direct access to
the fire escape staircase for
evacuation.
A refuge area of 15 Sq. Mtr. NDM Hospital Safety
or an area equivalent to 0.3 NFPA 101, Ch.
Sq Mtr. per person for the 18,19,07
number of occupants in two
consecutive floors,
whichever is more, shall be
provided on the periphery of
the floor or preferably on an
open air cantilever
projection with at least one
side protected with suitable
railings/guards with a height
not less than 1 mtr.
Within the aggregated area NDM Hospital Safety
of corridors, patient rooms, NFPA 101, Ch.
treatment rooms, lounges, 18,19,07
dining area and other low
hazards areas on each side of
the horizontal exit, a single
door may be used in a
horizontal exit given that the
exit serves one direction
only. Such doors shall be
swinging doors or a
horizontal sliding door.

Where there is a difference NDM Hospital Safety

in the level between areas NFPA 101, Ch.
connected by a horizontal 18,19,07
exit, ramps not more than 1
in 10 mtr slope shall be
provided. The steps shall not
be usedWhere there is a
difference in the level
between areas connected by
a horizontal exit, ramps not
more than 1 in 10 mtr slope
shall be provided. The steps
shall not be used
Doors shall be accessible at NDM Hospital Safety
all times from both sides. NFPA 101, Ch.
18,19,07
A horizontal exit involving a NDM Hospital Safety
corridor 8 ft or more in width NFPA 101, Ch.
serving as a means of egress 18,19,07
from both sides of the
doorway shall have the
opening protected by a pair
of swinging doors arranged
to swing in the opposite
direction from each other.
An approved vision panel is NDM Hospital Safety
required in each horizontal NFPA 101, Ch.
exit. Center mullions are 18,19,07
prohibited.
The total exit capacity of NDM Hospital Safety
other exits (stairs, ramps, NFPA 101, Ch.
doors leading outside the 18,19,07
building) shall not be
reduced to below one third
of the amount that is
required for entire area
of the building.
Door
1 Provisions of doors Every door and every NDM Hospital Safety

principal entrance that also NFPA 101, Ch.
serves as an exit shall be so 18,19,07
designed and constructed

that the way of Exit travel is

obvious and direct.
Width of the doors shall be NDM Hospital Safety
minimum 2 mtr and other NFPA 101, Ch.
requirements of the door 18,19,07
shall comply with the NBC.
Doors shall not be equipped NDM Hospital Safety
with a latch or lock that NFPA 101, Ch.
requires the use of tool 18,19,07
and/or key from the egress
side. Mental hospitals are
permitted for door locking
arrangements.
Where door locking NDM Hospital Safety
arrangements are provided, NFPA 101, Ch.
provision shall be made for 18,19,07
the rapid removal of patients
by such reliable means as
remote control of locks or
the keys of all locks made
readily available to staff who
are in constant attendance..
Doors in fire resistant walls NDM Hospital Safety
shall be so installed that they NFPA 101, Ch.
may be normally kept in an 18,19,07
open position, but shall close
automatically. Corridor
doors opening into the
smoke barrier shall be not
less than 2000 mm in width.
Provision shall also be made
for double swing
single/double leaf type
doors..
The fire resistance rating of NDM Hospital Safety
doors shall meet fire NFPA 101, Ch.
resistance rating of 18,19,07
construction material.
Corridors and Passageways
1 Provision for Corridors and The minimum width and NDM Hospital Safety
Passageways height of corridors and NFPA 101, Ch.
passage ways shall be 2.4 18,19,07
mtr. The exit corridor and

passage ways shall have a

width not less than the
aggregate required width
of Exit doorways leading
from them in the direction of
travel to the exterior.
Corridors shall be adequately
ventilated.
Corridor walls shall form a NDM Hospital Safety
barrier to limit the transfer of NFPA 101, Ch.
smoke,toxic gases and heat. 18,19,07
Transfer grills, regardless of NDM Hospital Safety
whether protected by fusible NFPA 101, Ch.
link operated dampers, shall 18,19,07
not be used in corridor walls
or doors.
Openings if required in NDM Hospital Safety
corridor walls for specific NFPA 101, Ch.
use, shall be suitably 18,19,07
protected..
Fixed wired glass opening NDM Hospital Safety
vision panel shall be NFPA 101, Ch.
permitted in corridor walls, 18,19,07
provided they don’t exceed
0.84 Sq Mtr in area and are
mounted in steel or other
approved metal frames.
Compartmentation
1 Provisions for In buildings or sections NDM Hospital Safety

Compartmentations occupied by bed ridden NFPA 101, Ch.
patients where the floor area 18,19,07
is over 280 Sq Mtr., facilities
shall move patients in
Hospital beds to the other
side of a smoke barrier from
any part of such a building or
section not directly served by
approved horizontal exits
from the floor of a building to
outside.
Any section of the building NDM Hospital Safety
more than 500 Sq.Mtr. shall NFPA 101, Ch.
be suitably compartmented 18,19,07

with fire resistance of not

less than 2 hrs.
Every storey used by NDM Hospital Safety
inpatients for sleeping or NFPA 101, Ch.
treatment shall be divided 18,19,07
into not less than two smoke
compartments
Every storey having an NDM Hospital Safety
occupant load 50 or more NFPA 101, Ch.
persons, regardless of use, 18,19,07
shall be divided into two
smoke compartments.
The size of each smoke NDM Hospital Safety
compartment shall not NFPA 101, Ch.
exceed 500 Sq Mtrs. 18,19,07
Ramps
1 All ramps shall comply with NDM Hospital Safety

the applicable requirements NFPA 101, Ch.
for stairways regarding 18,19,07
enclosure, capacity and
limiting dimensions except in
certain cases where steeper
slopes may be permitted
with inclination less than 1 in
8 ( under no condition shall
the slopes greater than 1 in 8
be used).
2 Ramps shall be surfaced with NDM Hospital Safety
approved non skid & non NFPA 101, Ch.
slippery material. 18,19,07
Service Shafts and Ducts
1 Provision of Fire protection for Service shafts/ducts shall be NDM Hospital Safety
Service shafts and ducts enclosed by walls with 2 hr NFPA 101, Ch.
and doors with 1 hr fire 18,19,07
resistance rating. All such
ducts/shafts shall be
properly shielded and
facilities shall be available to
control fires along these
shafts/ducts at all levels.

A vent opening at the top of NDM Hospital Safety

a service shaft shall have an NFPA 101, Ch.
area between one fourth and 18,19,07
half of the area of the shaft.
Refuge chutes shall have NDM Hospital Safety
openings at least 1 mtr above NFPA 101, Ch.
the roof level for venting 18,19,07
purpose and they shall have
an enclosure wall of non
combustible material with
fire resistance rating of 2 hrs.
They shall not be located
within the staircase
enclosure or service shaft
and be as far away from the
exit as possible.
The inspection panels and NDM Hospital Safety
doors of air conditioning NFPA 101, Ch.
shafts shall be well fitted, 18,19,07
with a fire resistance rating
of 1 hr.
Openings in Separation Walls and Floors
1 Provisions for Separations of At the time of designing NDM Hospital Safety

walls and doors openings in separation walls NFPA 101, Ch.
and floors particular 18,19,07
attention shall be paid to all
factors that will help limit the
spread of fire through these
openings and the fire ratings
of these structural members
shall be maintained.
For type 1 to 3 construction, NDM Hospital Safety
a door way or opening in a NFPA 101, Ch.
separation wall on any floor 18,19,07
shall be limited to 5.6 Sq.Mtr.
in area with a maximum
height/width of 2.75 mtr.
Every wall opening shall be
protected with fire resistant
doors having the fire rating
of not less than 2 hrs. in
accordance with accepted
standards.

Every vertical opening NDM Hospital Safety

between the floors of a NFPA 101, Ch.
building shall be suitably 18,19,07
enclosed or protected as
necessary to prevent the
spread of fire, smoke and
fumes such that there is a
reasonable level of safety for
the occupants using the
means of egress. It shall be
ensured to provide a clear
height of 2100 mm in the
passage/escape path of
occupants and thereby
limitation of damage to the
building and its contents.
Fire Stop or Enclosure of Opening
1 Provisions for Enclosure of Where openings are NDM Hospital Safety

Opening permitted for external walls NFPA 101, Ch.
they shall not exceed 3/4th 18,19,07
the area of the wall and shall
be protected with fire
resisting assemblies or
enclosures with a fire
resistance equivalent to that
of the wall in which these are
situated. Such assembles and
enclosures shall also be
capable of preventing the
spread of smoke and fumes
through the openings so as
to facilitate the safe
evacuation of building in
case of a fire.
All openings in the floors NDM Hospital Safety
shall be protected by vertical NFPA 101, Ch.
enclosures extending above 18,19,07
and below such openings.
The walls of such enclosures
shall have a Fire resistance of
not less than 2 hrs. and all
openings therein shall be

protected with a fire

resisting assembly.
For type 4 constructions, NDM Hospital Safety
openings in separation walls NFPA 101, Ch.
or floors shall be fitted with 2 18,19,07
hrs fire resisting assemblies.
Openings in the walls and NDM Hospital Safety
floors which provide access NFPA 101, Ch.
to building services like 18,19,07
cables, electrical wiring,
telephone cables, plumbing
pipe etc. shall be protected
by enclosures in the form of
ducts/shafts with a fire
resistance of not less than 2
hrs.
The inspection doors for NDM Hospital Safety
electrical shafts and ducts NFPA 101, Ch.
shall have fire resistance 18,19,07
rating not be less than 2 hrs
and all other service shafts
and ducts shall have a fire
resistance rating not less
than 1 hr.
Medium and low voltage NDM Hospital Safety
wiring in shafts/ducts shall NFPA 101, Ch.
either be armoured or run 18,19,07
through a metal conduit. The
space in between the
conduit pipes and the
walls/slabs shall be filled by a
filler material that has a fire
resistance rating of not less
than 1 hr. The above
parameters shall not be
applied on patients and
goods lift well opening


(Y/N/NA)
Category- C Occupancy Construction Features
Structural Fire Resistance
1 Fire rated construction Materials and firestop systems NFPA 101, Table
present/maintained used to protect membrane and 18.1.6.1 & 19.1.6.1
through penetrations in fire-
resistance-rated construction and
construction installed to
resist the passage of smoke shall
be maintained. The materials and
firestop systems shall be securely
attached to or bonded to the
construction being penetrated
with no openings visible through
or into the cavity of the
construction. Where the system
design number is known, the
system shall be inspected to the
listing criteria and manufacturer’s
installation instructions.
2 Min. Construction Requirement Min Construction requirement NFPA 101, Table
are met shall be maintained as per the 18.1.6.1 & 19.1.6.1
code
Compartmentation
1 Adequate Compartmentation is The following good practices are NFPA 101, Ch. 18 &
observed with required fire recommended: 19
resistance rating. • Every floor forms a single fire
compartment
• Every occupancy type / function
area forms a single fire
compartment
• High-risk areas are located in
separate fire compartments
• Safe means of egress are
enclosed by fire-rated walls and
doors
• Vertical openings (stairs,
elevators, utility shafts) are
enclosed by fire-rated walls and
doors.


(Y/N/NA)
Category- D Storage Safety
1 Storage neat and orderly Storage of materials in buildings NFPA 1- 34.1
shall be orderly and stacks shall
be stable. Storage of
combustiblematerials shall be
separated from heaters or
heating devices by distance or
shielding so that ignition cannot
occur.
2 Combustible storage prohibited Combustible material shall not NFPA 1 – 10.18.5
in electrical equipment rooms, be stored in boiler rooms,
restrictions apply in mechanical rooms, electrical
boiler/mechanical rooms equipment rooms or in fire
command centers.
3 Attic storage Attic,under-floor and concealed NFPA 1- 10.18.6
spaces used for storage of
combustible materials shall be
protected on the storage side
as required for 1-hour fire-
4 Storage maintained (2’ below Storage shall be maintained 2 NFPA 1- 10.18.3
feet (610 mm) or more below
ceiling un-sprinklered, 18” the ceiling in nonsprinklered
sprinklered) areas of buildings or not less
than 18 inches (457 mm) below
sprinkler head deflectors in
sprinklered areas of buildings.
Except.
1. The 2-foot (610 mm)
ceiling clearance is
not equired for
nonsprinklered areas
of buildings.
2. The 18-inch (457
mm) ceilingclearance
is not required for
areas of buildings
equipped with an
automatic sprinkler
system

5 Rubbish/waste subject to Materials susceptible to

spontaneous ignition shall be spontaneous ignition, such as
disposed of daily and in listed oily rags, shall be stored in a
container listed disposal container.
Contents of such containers
shall be removed and disposed
of daily.

(Y/N/NA)
Category- E Hazardous Materials
1 Compressed gas cylinders Compressed gas containers, NFPA 1 – 63.3
secured cylinders, tanks and systems
that could be exposed to
physical damage shall be
protected. Guard posts or other
approved means shall be
provided to protect
compressed gas containers,
cylinders, tanks and systems
indoors and outdoors from
vehicular damage and shall
comply with Section 312.
2 Rooms/areas properly labeled Unless otherwise exempted by NFPA 99
the fire code official, visible
hazard identification signs as
specified in NFPA 704 for the
specific material contained
shall be placed on stationary
containers and aboveground
tanks and at entrances to
locations where hazardous
materials are stored,
dispensed, used or handled in
quantities requiring a permit
and at specific entrances and
locations designated by the fire
code official.
3 Acceptable quantities The maximum allowable NFPA 1 – 60.4
quantity per control area shall
be ensured
4 Separation of incompatible Incompatible materials in NFPA 99
materials storage and storage of
materials that are incompatible
with materials in use shall be

separated where the stored

materials are in containers
having a capacity of more than
5 pounds (2 kg), 0.5 gallon (2 L)
or any amount of compressed
gases. Separation shall be
accomplished by:
1. Segregating incompatible
materials in storage by a distance
of not less than 20 feet (6096 mm).
2. Isolating incompatible materials
in storage by a noncombustible
partition extending not less than 18
inches (457 mm) above and to the
sides of the stored material.
3. Storing liquid and solid materials
in hazardous material storage
cabinets.
5 Location & Quantity of alcohol in 1. Individual dispenser NFPA 101, NFPA 32B
ABHR capac ity is limited to 0.32
gal (1.2 L) for dispensers
in rooms, corridors, and
spaces open to corridors
and to dispenser. 0.53 gal
(2 L) when located in
suites of rooms. Aerosol
dispenser capacity is
limited to 18 oz (510 g) of
a Level 1 aerosol
2. ABHR disp ense rs may
only be installed over
carpeted floors within
sprinklered smoke com
partments. The solution
used sh uld not exceed 95
percent alcohol by
volume.

(Y/N/NA)
Category- F Fire Extinguishers
1 Readily accessible Portable fire extinguishers shall NFPA 1 – 13.6 &
be located in conspicuous NFPA 10
locations where they will have
ready access and be
immediately available for use.
These locations shall be along
normal paths of travel, unless
the fire code official determines
that the hazard posed indicates

the need for placement away

from normal paths of travel.
2 Travel distance not exceeded It shall be in accordance with NFPA 1 – 13.6 &
table 906.3(1) & 906.3(2) NFPA 10
3 Tested/inspected at least Testing and inspection shall be NFPA 1 – 13.6 &
annually done as per the requirement of NFPA 10
NFPA 10

(Y/N/NA)
Category- G Flammable and Combustible Liquids
1 Safety containers if used Class I liquids or, when heated NFPA 1 – 66.9
to or above their flash points,
Class II and Class III liquids, shall
be transferred by one of the
following methods:
1. From safety cans complying
with UL 30.
2. Through an approved closed
piping system.
3. From containers or tanks by
an approved pump taking
suction through an opening in
the top of the container or tank.
4. For Class IB, IC, II and III
liquids, from containers or
tanks by gravity through an
approved self-closing or
automatic-closing valve where
the container or tank and
dispensing operations are
provided with spill control and
secondary containment in
5703.4. Class IA liquids shall not
be dispensed by gravity from
tanks.
5. Approved engineered liquid
transfer systems.
2 Not stored/kept near exits Storage of any liquids, including NFPA 1 – ch.66
stock for sale, shall not be
stored near or be allowed to
obstruct physically the route of
egress

3 No sources of ignition Smoking and open flames are NFPA 1 – ch.66

prohibited in storage areas in
5003.7.
4 Quantities >10 gals in cabinet Quantities in Group A NFPA 1 – ch.66
occupancies shall not exceed
that necessary for
demonstration, treatment,
laboratory work, maintenance
purposes and operation of
equipment, and shall not
exceed quantities set forth in
Table 5003.1.1(1)
In all occupancies, quantities of
flammable and combustible
liquids in excess of 10 gallons
(38 L) used for maintenance
purposes and the operation of
equipment shall be stored in
liquid storage cabinets in
5704.3.2. Quantities not
exceeding 10 gallons (38 L) are
allowed to be stored outside of
a cabinet where in approved
containers located in private
garages or other approved
locations.
5 No basement storage unless Class I liquids shall be allowed NFPA 1 – ch.66
sprinklered to be stored in basements in
amounts not exceeding the
maximum allowable quantity
per control area for use-open
systems in Table 5003.1.1(1),
provided that automatic
suppression and other fire
protection are provided in
Class II and IIIA liquids shall be
allowed to be stored in
basements, provided that
automatic suppression and
other fire protection are
provided in accordance with
Chapter 9.
6 Adequate ventilation Liquid storage rooms shall be NFPA 1 – ch.66
ventilated in accordance with
Section 5004.3 Indoor storage

areas and storage buildings

shall be provided with
mechanical exhaust ventilation
or natural ventilation where
natural ventilation can be
shown to be acceptable for the
materials as stored.

(Y/N/NA)
Category- H Sprinkler System
1 Coverage is adequate Sprinkler systems shall be NFPA 13 – 8.5
designed and installed in
903.3.1.1, unless otherwise
permitted by Sections 903.3.1.2
and 903.3.1.3 and other
chapters of this code, as
applicable.
2 Controls are readily accessible Approved access shall be
provided and maintained for all
fire protection equipment to
permit immediate safe
operation and maintenance of
such equipment. Storage, trash
and other materials or objects
shall not be placed or kept in
such a manner that would
prevent such equipment from
being readily accessible
3 Valves locked open Indicating type of valves must NFPA 13 8.17.1.4
be sealed, locked and
electrically supervised in the
locked position
4 System and valves supervised Control valves shall not be NFPA 13- 6.7,
installed between the water 8.16.1.1.2
supply and sprinklers unless the
valves are of an approved
indicating type that are
supervised or secured in the
open position
5 Heads in good condition As per the requirement of NFPA
13 & 25

6 Wrench/spare sprinklers present As per the requirement of NFPA NFPA -13 6.2.9
13 & 25
7 Sprinkler Protective Caps Protective caps shall be NFPA 13-8.3.1.5

removed removed from sprinklers prior
to the time when the system is
placed in service
8 Sprinklers Provided for stairways In non combustible stair shaft NFPA 13- 8.15.3.2
having non combsitible stairs
with non combustible or limited
combustible finishes sprinkler
shall be installed at the top of
the shaft and under the first
accessible landing above the
bottom of the shaft
9 Tested/inspected at least Must be done as per NFPA 25 NFPA 13- 27.1
annually
10 Riser/pump rooms labeled Fire protection equipment shall NFPA 13
be identified in an approved
manner. Rooms containing
controls for air-conditioning
systems, sprinkler risers and
valves, or other fire detection,
suppression or control
elements shall be identified for
the use of the fire department.
Approved signs required to
identify fire protection
equipment and equipment
location shall be constructed of
durable materials, permanently
installed and readily visible

(Y/N/NA)
Category- I Fire Pump System
1 Fire pump base plate is grouted The base plate shall be securely NFPA 20
attached to a solid foundation
in such a way that pumps and
driver shaft alignment is
ensured.
When the alignment is correct,
the foundation bolts should be
tightened evenly but not too
firmly. The unit can then be

grouted to the foundation. The

base plate should be
completely filled with grout,
and it is desirable to grout the
leveling pieces, shims, or
wedges in place.
Foundation bolts should not be
fully tightened until the grout
has hardened, usually about 48
hours after pouring.
2 Batteries are installed propertly Storage batteries shall be rack NFPA 20
supported above the floor,
secured against displacement,
and located where they will not
be subject to excessive
temperature, vibration,
mechanical injury, or flooding
with water.
Current-carrying parts shall not
be less than 12 in. (305 mm)
above the floor level.
Storage batteries shall not be
located in front of the engine-
mounted instruments and
controls.
3 Diesel tank is properly Identified Proper labeling including NFPA 20- 11.4.2.6
for its capacity identification of Contents, Tank
Volume, Hazards and Warnings
shall be done.
4 Secondary Containment for Fuel Tanks shall be enclosed / NFPA 30- 22.11.2.2
diesel tank provided with a dike / bund
sufficient to hold the entire
capacity of the tank in order to
prevent accidental spillages.
The walls and base of a dike /
bund shall be made of non-
combustible materials.
5 Weather vent pipe is terminated As per NFPA – 20, the weather NFPA 20
as per requirement vent shall be at least 3.05m
from the top of the tank fill cap
6 Gate valve in the diesel tanks fuel No other valve than a manual NFPA 20- 11.4.4
supply/return line is suprvised locked open valve shall be put
in the fuel line from the fuel
tank to the engine
There shall be no shutoff valve
in the fuel return line to the
tank.


7 Fire Water Tank with its Capacity Sign board shall in a visible NFPA20
(Main / Reserve) & Pipe network location.
at Fire Pump Room and Valves
were identified.
8 Pressure Chart indicating cut- Cut-Off / Cut-In pressure for fire NFPA20
off/cut-in pressure for fire pumps pumps shall be permanently
were observed in the fire pump and legibly displayed in the Fire
room. Pump Room.
9 Valves at Fire Pump Room were All the isolation and section NFPA 20
supervised. control valves installed shall be
secured in open position
10 Fuel Line was identified for Fuel Lines (Supply / Return) NFPA 20
Diesel Engine at Fire Pump Room. shall be properly identified at
the above mentioned location.
11 Shut off valves were installed at As per NFPA-20, all pump NFPA 20
the sensing lines of the fire installations, including jockey
pumps. pumps, each controller shall
have the individual pressure-
sensing line which shall be
brass, copper, or series 300
stainless steel pipe or tube, and
the fittings shall be of ½ in. (15
mm) nominal size & shutoff
valves are not allowed in the
pressure-sensing line.
12 Suction Lines for both Electrical & Eccentric Tapered Reducer or NFPA 20- 4.14.6.4
Diesel Pumps observed with Increaser: Where the suction
concentric reducers. pipe and pump suction flange
are not of the same size, they

shall be connected with an

eccentric tapered reducer or
increaser installed in such a way
as to avoid air pockets.
13 Ventilation arrangement was not Ventilation shall be provided NFPA 20
observed for the fire pump room. for the following functions:
(1) To control the maximum
temperature to 120°F (49°C) at
the combustion air cleaner inlet
with engine running at rated
load
(2) To supply air for engine
combustion
(3) To remove any hazardous
vapors
(4) To supply and exhaust air as
necessary for radiator cooling
of the engine when required
Provision shall be made to
supply fresh air to the Fire
Pump Room.
During the event of fire, the
system shall respond to operate
and shall stop until the fire-
protective signaling system has
been manually reset
14 Pressure Switch was installed for Electric alarm pressure NFPA 20
the Alarm Check Valve assembly. switches shall be installed in the
system and they shall be
mounted on a vertical branch
pipe at least 300 mm long.
The pressure switch may be of
the diaphragm bellows or
bourdon tube operated type,
and shall be sufficiently
sensitive to operate when only
one sprinkler is discharging.
The pressure switch shall be
provided with volt free
contracts to interconnect with
the building fire alarm system
for monitoring
15 Diesel Engine’s Exhaust Pipe was The Exhaust Pipe shall be NFPA 20
insulated. covered with high temperature
insulation or otherwise guarded
to protect personnel from
injury.

Exhaust pipes shall be installed

with clearances of
16 Drain arrangement for pump Floors shall be pitched for NFPA 20
room adequate drainage of escaping
water away from critical
equipment such as the pump,
driver, controller, and so forth.
The drains shall be provided
with an arrangement that is
terminated back to the fire
water tank or to open drain/pit
SN Observations Recommandation Code/Std. Compliance

Refer. (Y/N/NA)
Category- J Fire Alarm and Detection System
1 Availability of System Information • Fire detection plans, single-line General
diagrams
• Datasheets of all components
• Calculations (voltage drop
calculations, battery capacity)
• Cause and effect matrix
• Testing and commissioning
documents
• System logbook
2 Installation Approvals Fire detection system shall be General
approved by the independent
body.
3 Control panel/annunciator panel Its is recommanded that to check General
in normal condition if all the devices are
[no trouble or alarm conditions] communicating with FACP
4 Detectors properly installed In Accordance with NFPA 72 NFPA 72 – 17.4
requirement
5 Appropriate type of detectors are In Accordance with NFPA 72
installed in locations requirement
6 Detectors coverage meeting the In Accordance with NFPA 72 NFPA 72 – 17.5.3
requirements requirement
7 Tested/inspected at least annually In Accordance with NFPA 72
requirement
8 Manual Call points are installed as Manullally actuated alarm NFPA 72 – 17.14
per requirment intitiating devices for initiating
signals other than for fire alarm
shall be premitted if the devices
are differentiated from manual

for fire alarm boxes by a color

other than red and labeling.
 Manual pull boxes should
be securely mounted on
a background of
contrasting color.
 The operable part of the
fire alarm box should not
be more than 1.07 m (42
inches) to 1.22 m (48
inches) above floor level.
be located so that they
are conspicuous,
unobstructed, and
accessible.
be located so that the
horizontal travel distance
between boxes on any
floor is not more than 61
m (200 feet).
 Additionally, manual pull
boxes should be located
within 1.52 m (5 feet) of
either side of a grouped
opening (e.g., a bank of
elevators and staircases
located together) that is
over 12.2 m (40 feet) in
width.
9 Notification Appliance are installed Alarm sounders should be NFPA 72 – Ch. 18
as per the requirement strategically installed in the
building to obtain a distinctive
alarm signal throughout

Refer. (Y/N/NA)
Category- K Wet Chemical System
1 Provision of protection for Kitchen hood systems are NFPA 17A
kitchens designed to extinguish cooking
fires caused by grease or grease-
laden vapors.

The suppression agent consists of

a wet chemical or a water mist.
2 Min. requirements are met The extinguishing system is in its NFPA 17A, Ch.
proper location. 7,7.2
The manual actuators are NFPA 17A, Ch.
unobstructed. 7,7.2
The tamper indicators and seals NFPA 17A, Ch.
are intact. 7,7.2
The maintenance tag or NFPA 17A, Ch.
certificate is in place. 7,7.2
No obvious physical damage or NFPA 17A, Ch.
condition exists that 7,7.2
might prevent operation.
The pressure gauge(s), if NFPA 17A, Ch.
provided, has been inspected 7,7.2
physically or electronically to
ensure it is in the operable
range.
The nozzle blowoff caps, where NFPA 17A, Ch.
provided, are intact and 7,7.2
undamaged.
The hazard has not changed, NFPA 17A, Ch.
including replacement, 7,7.2
modification, and relocation of
protected equipment.

Refer. (Y/N/NA)
Category- L Smoke Control System
1 Provision of smoke Control System  Corridor smoke NFPA 92
removal systems are
fairly basic systems in
which a fixed number of
air changes is imposed
in corridors. A corridor
smoke removal system
creates safer egress
routes, due to the
constant supply of fresh
air which dilutes smoke
that enters the corridor.
Corridor smoke
removal systems are
often required by local

codes Pressurization
systems impede smoke
spread to certain areas
of the building by
creating an
overpressure. They are
commonly used and
highly recommended in
staircases in high-rise
buildings, since they
provide an extra grade
of protection that allows
for longer evacuation
times.
 Pressurization systems
in staircases should be
carefully designed: they
should create a pressure
difference of at least 50
Pa (all doors closed)
and an airflow of at least
0.75 m.s-1 through an
open door. On the other
hand, it should still be
possible to open the
staircase doors easily
(most codes prescribe a
maximum opening
force of 100 N).
 Pressurization systems
can also be installed to
protect elevator shafts
against vertical smoke
spread.

(Y/N/NA)
Category- M Emergency Planning
1 Availabiltiy of formalized Following Information shall be NFPA 101, Ch. 18, Cl.
emergency response plan ? inclued in the Emergency plan 18.7 & Hospital fire
• Use of alarms prevention and
• Transmission of alarms to fire evacuation Guide
department

• Emergency phone call to fire

department
• Response to alarms
• Isolation of fire
• Evacuation of immediate area
• Evacuation of safe refuge area
• Preparation of floors and
building for evacuation
• Extinguishment of fire
2 Number of Trained Staff Effective evacuation of a health NFPA 101, Ch. 18, Cl.
care facility depends on the 18.7 & Hospital fire
number of staff and trained prevention and
personnel available, at any evacuation Guide
given point in time, to perform
the necessary evacuation
duties. Understanding the
scope of the evacuation and
knowing the minimum number
of people required to
undertake these procedures in
the event of an emergency is
paramount in saving lives.
LEGENDS
Compliance
Non Compliance
Not Applicable

CHECK LISTS

Checklist 01 : General Safety Overview
Topics Yes No N/A Commment

1 Planned and systematic written safety program in place?
2 Safety or EC committee established?
3 Committee responsibilities and authorities defined?
4 Safety program approved by senior leadership?
5 Medical professionals involved in the safety program?
6 Departmental and specific safety policies and procedures
reviewed as needed or every 3 years?
7 Risk management monitors and reports on a regular basis?
8 Quality assurance monitors and reports on a regular basis?
9 Infection control monitors and reports on a regular basis?
10 Facility-wide hazard surveillance program developed?
11 Environmental tours or surveys conducted in each clinical area
semiannually and annually elsewhere?
12 Patient care equipment inspected and results documented?
13 Patient care equipment failures reported on a regular basis to
the committee and to meet Safe Medical Device Act
requirements?
14 Incidents and accidents involving patients, visitors, and guests
reported on a regular basis?
15 Safety committee meets as required?
16 Safety committee membership includes personnel from
administration, clinical, and support service areas?
17 Safety committee reports to governing board, administration,
and department managers as required?
18 New employee orientation and training conducted?
19 Annual safety training conducted and documented?
20 Hazardous materials program reviewed annually with all
employees?
21 Education/training director reports on a regular basis?
22 Emergency management drills conducted at least once each 6
months using hazard vulnerability analysis priorities?
23 Emergency management plan updated regularly?
24 Emergency drills evaluated, critiqued, and documented?
25 Fire drills conducted quarterly on all shifts?
26 Regular environmental testing being performed as required?
27 Security program reviewed and approved?
28 Fire prevention plan reviewed and approved?
29 Documentation of inspections by outside regulatory agencies
maintained?

30 Interim life safety inspections and correctiveactions reported

on a regular basis?
31 Equipment management issues reported ona regular basis?
32 Utilities management issues reported on aregular basis?
33 Corrective actions documented for utilitiesmanagement
reports?
34 Medical devices act safety plan in place?
Checklist 02 : Nursing General Safety

1 All rooms where medications are prepared properly lit to
prevent errors?
2 Floors free from breaks, loose tiles or linoleum, or any
obstructions that might cause people to stumble or fall?
3 Medicine cabinets/carts locked when unattended?
4 Employees fully instructed in the proper manner of lifting and
moving patients and residents?
5 Hazardous substances properly labeled, stored, and handled?
6 Staff familiar with MSDS file location and how to find
information?
7 Staff familiar with chemical spill response and procedures?
8 Staff properly instructed regarding any hazards related to
required work?
9 Plastic liners used in all garbage containers?
10 Red bags used for medical wastes at generation points?
11 All liquid containers clearly labeled with type of contents?
12 Exits and aisles of storerooms uncluttered?
13 Rubbish, empty cartons, and paper disposed of immediately?
14 Spillage items stored below eye level?
15 Stored materials clear of both sprinkler heads (at least 18
inches) and other firefighting equipment?
16 Safety committee membership includes personnel from
administration, clinical, and support service areas?
17 Safety committee reports to governing board, administration,
and department managers as required?
18 Flammable liquids are:
18.1 Stored in approved containers?
18.2 Stored in safe quantities?
18.3 Stored in approved cabinets?

Checklist 03 : Slip, Trip and Fall Prevention

1 Aisles, halls, passageways clear?
2 Aisles, halls, and walkways marked as appropriate?
3 Wet surfaces properly signed or roped off?
4 Holes in floors, sidewalks, or other walking surfaces repaired
properly, covered, or otherwise made safe?
5 Materials or equipment stored in such a way that hazards do
not interfere with the walkway??
6 Changes of direction or elevations readily identifiable?
7 Adequate headroom provided for the entire length of any
aisle or walkway?
8 Steps, stairs, and stairways designed or provided with a
surface that renders them slip resistant?
9 Where stairs or stairways exit directly into any area where
vehicles may be operated, adequate barriers and warnings
provided to keep employees from stepping into the path
of traffic?
10 Surfaces elevated more than 30 inches above the floor or
ground provided with guardrails?
11 Permanent means of access and egress provided to elevated
storage and work surfaces?
12 Materials on elevated surfaces piled, stacked, or racked in a
manner to prevent tipping, falling, collapsing, rolling, or
spreading?
13 Floor openings guarded by a cover, guardrail, or equivalent on
all sides (except at entrances to stairways or ladders)?
14 Wet floor signs removed when area is dry?
15 Hallways mopped one side at a time?
16 Warning signs used to identify hazards?
17 Wet-floor signs 32 to 36 inches high?
18 Facility uses proper nonskid floor waxes or polishes?
19 Exits marked with exit signs and illuminated by reliable light
sources?
20 Directions to exits, where not immediately apparent, marked
with visible signs?
21 Doors, passageways, or stairways that are not exits properly
marked “Not an Exit,” “To Basement,” “Storeroom,” etc.?
22 Do signs with the word “EXIT” have lettering at least 5 inches
high and the stroke of the lettering at least 1/2 inch wide?
23 Special precautions taken to protect employees during
construction and repair operations?

24 Doors serving as exits designed and constructed so the exit

route is obvious and direct?
25 Windows or glass that could be mistaken for exit doors made
inaccessible by means of barriers or railings or markings?
26 Do extension cords run across pathways?
27 Housekeeping and cleaning processes evaluated on a regular
basis?
28 Housekeeping keeps water cleaned up around doors on rainy
days?
29 The facility uses flush, floor-level mats and runners of
sufficient length?
30 Procedures developed for placing, removing, cleaning, and
storing mats?
Checklist 04 : Facility and Design Electrical Safety

1 When electrical equipment or lines are to be serviced,
maintained, or adjusted, necessary switches opened, locked-
out, and tagged whenever possible?
2 Portable electrical tools and equipment grounded or of the
double-insulated type?
3 Electrical appliances such as vacuum cleaners, polishers,
vending machines, etc. grounded?
4 Extension cords have grounding conductors?
5 Multiple plug adaptors prohibited?
6 Ground-fault circuit interrupters installed on each temporary
15- or 20-ampere, 120- volt, AC circuit at locations where
construction, demolition, modifications, alterations, or
excavations are being performed?
7 Electrical installations in hazardous dust or vapor areas meet
the National Electrical Code (NEC) for hazardous locations?
8 Exposed wiring and cords with frayed or deteriorated
insulation repaired or replaced promptly?
9 Flexible cords and cables free of splices or taps?
10 In wet or damp locations, electrical tools and equipment
appropriate for that type of use or location or otherwise
protected?
11 Energized parts of electrical circuits and equipment guarded
against accidental contact by approved cabinets or
enclosures?

12 Sufficient access to and working space around provided and

maintained for all electrical equipment to permit ready and
safe operation and maintenance?
13 Electrical enclosures such as switches, receptacles, junction
boxes, etc. provided with tight-fitting covers or plates?
14 Electrical cords in good condition and properly used and no
“permanent” extension cords being substituted for fixed
wiring?
15 Adequate lighting provided throughout the facility, especially
at stairs and other hazardous areas?
16 Fuses (or circuit breakers) on lighting and small appliance
circuits are of proper capacity, and the use of multiple plugs
monitored to prevent overloading of circuits?
17 Switches for electrical equipment located so they can be
reached easily in the event of an emergency, without having
to lean on or against metal equipment.
Checklist 04 : Facility and Design Electrical Safety

1 When electrical equipment or lines are to be serviced,
maintained, or adjusted, necessary switches opened, locked-
out, and tagged whenever possible?
2 Portable electrical tools and equipment grounded or of the
double-insulated type?
3 Electrical appliances such as vacuum cleaners, polishers,
vending machines, etc. grounded?
4 Extension cords have grounding conductors?
5 Multiple plug adaptors prohibited?
6 Ground-fault circuit interrupters installed on each temporary
15- or 20-ampere, 120- volt, AC circuit at locations where
construction, demolition, modifications, alterations, or
excavations are being performed?
7 Electrical installations in hazardous dust or vapor areas meet
the National Electrical Code (NEC) for hazardous locations?
8 Exposed wiring and cords with frayed or deteriorated
insulation repaired or replaced promptly?
9 Flexible cords and cables free of splices or taps?
10 In wet or damp locations, electrical tools and equipment
appropriate for that type of use or location or otherwise
protected?
11 Energized parts of electrical circuits and equipment guarded
against accidental contact by approved cabinets or

enclosures?
12 Sufficient access to and working space around provided and
maintained for all electrical equipment to permit ready and
safe operation and maintenance?
13 Electrical enclosures such as switches, receptacles, junction
boxes, etc. provided with tight-fitting covers or plates?
14 Electrical cords in good condition and properly used and no
“permanent” extension cords being substituted for fixed
wiring?
15 Adequate lighting provided throughout the facility, especially
at stairs and other hazardous areas?
16 Fuses (or circuit breakers) on lighting and small appliance
circuits are of proper capacity, and the use of multiple plugs
monitored to prevent overloading of circuits?
17 Switches for electrical equipment located so they can be
reached easily in the event of an emergency, without having
to lean on or against metal equipment?
Checklist 05 : Hazard Communication Evaluation

1 Hazard communication program — The program is in writing and:
2 a. Describes how hazards will be evaluated (employers may
rely on the chemical manufacturer or importers)?
3 b. Tests all hazardous materials in the workplace (employers
may rely on the chemical manufacturer or importers)?
4 c. Describes labeling system in use?
5 d. Lists hazardous chemicals referenced on MSDSs for all
hazardous materials used in the workplace?
6 e. Describes employee education and training program?
7 f. Describes hazards of nonroutine tasks?
8 g. Describes how hazards of unlabeled pipes will be handled?
9 h. Includes procedures for informing on-site contractors of
hazardous substances in the workplace to which their
employees may be exposed?
10 i. Makes the program available to employees, their designated
representatives, the Assistant Secretary of Labor for OSHA,
and the director of NIOSH?
11 List of hazardous materials in the workplace contains all hazardous chemicals, including, but not
limited to:
12 a. Raw materials?

13 b. Both isolated and nonisolated intermediates?

14 c. Final products?
15 d. Cleaning and maintenance chemicals?
16 e. Laboratory chemicals for which MSDS information has been
received?
17 f. Waste products not regulated under RCRA but which are
hazardous under this standard?
18 g. Impurities and byproducts?
19 h. Waste treatment and products?
20 Hazardous materials labeling:
21 a. All products containing hazardous materials are labeled?
22 b. Stationary containers are labeled?
23 c. Temporary containers used between workshifts or by
different workers are labeled?
24 d. Methods are established to ensure that labels correct and
up to date?
25 e. Chemical name coincides with name on MSDS?
26 f. Hazards are identified by words (in English), pictures, or
symbols?
27 g. Hazards of immediate and direct consequences of
mishandling are noted?
28 h. Information does not conflict with DOT regulations?
29 i. Other OSHA standards apply, if material already regulated?
30 j. Name and address of a responsible party (or parties) are
provided?
31 k. The labels on incoming containers have not been removed
or defaced unless immediately replaced with labels?
32 l. The hazards in pipelines are identified, although they do not
have to be labeled under this standard?
33 m. Labels are legible and in English?
34 Material Safety Data Sheets:
35 a. Are available for all hazardous materials in use, including
drugs not in final form for oral dispensing (includes crushing
of drugs)?
36 b. Are readily accessible to exposed employees in the various
work areas throughout their shifts?
37 Procedures have been established for:
38 a. Updating MSDSs (or receiving updated copies from
suppliers)?
39 b. Taking appropriate action if a shipment received without an
MSDS?
40 c. Getting new and updated MSDSs to employees handling the
materials?

41 d. Advising employees of any changes in the MSDSs?

42 e. Documenting efforts to obtain MSDSs from suppliers
(recommended practice but not required by this standard)?
43 Employee education and training — Procedures have been established to:
44 a. Cover all manufacturing, quality control, plant service, and
R&D employees who may be exposed to hazardous materials?
45 b. Teach employees the requirements of the Hazard
Communication standard?
46 c. Identify operations where hazardous materials present?
47 d. Make readily available the written hazard communication
program, including the hazardous chemical list and MSDSs?
Checklist 06 : Basic Control of Hazard Energy ( Lockout/ Tagout)

1 Does the facility have a written program that outlines
procedures for lockout/tagout?
2 Does the program address authorized maintenance
personnel, affected employees who work with the
equipment, and other workers who have access?
3 Does the lockout/tagout program include all energy types
(electrical, mechanical, pneumatic, chemical, thermal, and
residual) found in elevated machine parts?
4 Employees properly trained on all aspects of the program,
including recognizing hazardous energy sources?
5 Does the program provide the sequence of each
lockout/tagout procedure?
6 Are periodic inspections made to be sure that policies are
being followed?
7 Does the company provide authorized employees with the
necessary locks and tags?
8 Are lockouts performed only by authorized employees?
9 Do all locks contain the names of employees using them?
10 Are locks made of substantial material to preclude removal
without using excessive force?
11 Do employees follow a checklist when restoring energy?
(highly recommended)
12 When outside employers perform maintenance, are
procedures established for exchanging information about
lockout/ tagout procedures?

13 When a group lockout is necessary, does a single authorized

individual have primary safety responsibility for the group?
Checklist 07 : Confined Space Entry

1 Did a competent person evaluate the facility with regard to
the presence of confined spaces?
2 Written descriptions and designations of each confined space
type and location maintained and updated as necessary?
3 Each confined space evaluated carefully for hazards within
them (e.g., safe entry, descent equipment)?
4 Confined spaces thoroughly emptied and tested for corrosive
or hazardous substances?
5 All lines to a confined space containing inert, toxic, flammable,
or corrosive materials valved off and blanked or disconnected
and separated before entry?
6 Lockout required for all impellers, agitators, or other moving
equipment inside confined spaces if they present a hazard?
7 Natural or mechanical ventilation provided before anyone
enters a confined space?
8 Adequate illumination provided?
9 Atmosphere inside the confined space frequently tested or
continuously monitored during work?
10 An assigned, appropriately trained and equipped standby
employee stationed outside the confined space when
required?
11 Safety devices tested and working properly?
12 All portable electrical equipment used inside confined spaces
either grounded and insulated or equipped with ground fault
protection?
13 Required permits documented and work orders on file, along
with employee training records??
14 Holes in floors, sidewalks, or other walking surfaces repaired
properly, covered, or otherwise made safe?
15 A respiratory protection program in effect and enough
emergency respirators available?
16 Training provided and training records maintained, including
dates and summaries of training sessions?
17 Permit-required spaces identified with proper signs?

Checklist 08 : Surgical Department

1 Designated person oversees safety issues?
2 Employees receive safety training at time of hire and annually,
as required?
3 Safety policies available to all employees on all shifts?
4 Floors well maintained and free of tripping hazards?
5 Floors covered with approved conductive material and tested
regularly for conductivity, if necessary?
6 Aisles and work areas maintained in an orderly manner?
7 Suction lines and cords arranged to minimize tripping?
8 Storage no more than 24 inches from ceiling and 18 inches
from a sprinkler head?
9 Computer areas ergonomically correct with adjustable
keyboards and screens, adjustable chairs, and glare-free
monitors?
10 Lighting adequate in all areas?
11 Humidity and temperature monitored and properly
maintained?
12 Air exchange at least 25 exchanges per hour?
13 Volume of used anesthetic gases properly noted and records
analyzed for leakage?
14 Stable stools and ladders with safety treads available when
employees need to reach files on high shelves?
15 Heavy boxes and supplies stored on low shelves?
16 Hazard communication program and MSDS training
completed?
17 MSDS files available to employees during all working hours?
18 Employees aware of fire alarm pull box locations, O2 shutoffs,
and fire alarm protocols?
19 Proper types and number of fire extinguishers available?
20 Employees have received fire extinguisher training, know how
to respond to a fire drill, and know what evacuation route to
use?
21 Stairwells, exit doors, and emergency egresses accessible and
free of obstructions?
22 Employees understand what the acronyms PASS and RACE
mean?
23 Visible signs indicate location of an eye wash station?
24 Preventive maintenance and routine checks of eye washes
well documented?
25 Compressed gas cylinders handled

appropriately during use, storage, and transport and gas hose

connections in satisfactory condition?
26 All trash receptacles fire rated?
27 Patients positioned to prevent pressures areas during
procedures?
28 Patient restraints correctly used during procedures if
required?
29 Good housekeeping practices observed in all areas?
Checklist 09: Storage Area Safety

1 Person appointed to inspect safety issues?
2 Floors free of tripping hazards and well maintained?
3 Aisles free of trash and other debris and work areas
maintained in an orderly manner?
4 Adequate lighting and ventilation provided in all areas?
5 Area clear of prohibited items including combustible
materials?
6 Hazard Communication program and MSDS training
completed?
7 MSDS files available to employees during all working hours?
8 All caution signs for hydrogen, bulk oxygen, storage cabinets,
etc. permanently installed?
9 Combustible waste material such as oily rags and paint rags
stored in covered metal containers and disposed of daily?
10 Piping systems, including tubing, flanges, bolting, gaskets,
valves, fittings, and all pressurized parts containing flammable
and combustible liquids, meet the requirements of NFPA 30?
Properly identified?
11 Openings to rooms and buildings have noncombustible,
liquid-tight, raised sills or ramps at least 4 inches high or
otherwise designed to prevent flow of liquids to adjoining
areas?
12 Proper types and number of fire extinguishers available?
13 Door closer operable and has a positive latch?
16 Unsafe equipment taken out of use or tagged?

17 Electrical equipment grounded via use of a three-pronged

plug or protected by GFCIs, and all receptacles properly
wired?
18 All trash receptacles fire rated?
19 Overhead items secured and heavy objects below eye level?
from sprinkler heads?
Checklist 10: Laboratories

1 Safety/chemical hygiene officer appointed to oversee
laboratory safety issues?
2 Employees receive safety training at the time of hire and
annually thereafter?
3 Safety manual available to all employees on all shifts?
4 Lab locked when lab personnel not in the building?
6 Floors cleaned and wax stripped regularly to prevent paraffin
buildup?
from a sprinkler head?
8 Trash removed daily?
9 Hazard Communication plan training completed?
10 MSDS files accessible to employees during all working shifts?
11 List of carcinogens maintained?
12 Flammable or toxic chemicals kept in closed containers when
not in use?
13 Chemicals stored away from heat, sunlight, and reactive
substances?
14 Incompatible chemicals stored properly?
15 Working supplies of chemicals limited to 1 gal/100 ft2?
16 Chemical spill kits and materials assembled, evaluated for
proper signage, and available for use?
17 With regard to other potentially toxic substances, periodic
monitoring performed of employee breathing zones to ensure
compliance with PELs and ceiling limits, and records kept?
18 All safety cabinets vented to the outside?
19 All hoods in working condition and certified annually?
20 Face velocity of a hood maintained at 100 fpm?

21 Temperatures of refrigerators monitored and units cleaned

weekly?
22 Proper types and numbers of fire extinguishers available?
23 Employees understand what the acronyms PASS and RACE
mean?
free from obstructions?
25 All waste and potentially infectious material disposed of
properly to meet federal, state, and local regulations?
26 Light switches and coverplates are in place?
wired?
28 Gas cylinders for blood gas machines chained and stored in an
upright position and personnel instructed in how to transport
gas cylinders? (Gas hose connections in satisfactory
condition?)
Checklist 11: Pharmacy

1 Person appointed to oversee safety issues?
2 Employees receive safety training at time of hire and annually
thereafter?
3 Pharmacy area locked when not occupied and only authorized
personnel granted access?
5 Aisles free of trash and other debris and work areas
maintained in an orderly manner?
from sprinkler heads?
7 Storage area clean, orderly, and well arranged?
8 Lighting and ventilation adequate in all areas of operation?
9 Hazard Communication program training completed?
10 MSDS files accessible to employees during all working hours?
11 Incompatible chemicals stored separately (refer to MSDSs)?
12 Chemical spill kits and materials assembled and available for
use?
13 Monthly medication area audits done and documented?
14 All hoods in working condition and certified annually?
15 Proper types and numbers of fire extinguisher available?

16 Employees have received fire extinguisher training and know

how to respond to a fire drill and what evacuation routes to
use?
19 Light switches and coverplates in place?
wired?
21 Electrical circuit breakers labeled and panels kept clear within
3 feet to the front?
22 Unsafe equipment taken out of use or tagged?
23 Good housekeeping practices observed in all areas?
24 Employees know and understand what to do in case of fire?
25 Employees aware of fire extinguisher location nearest them?
26 Employees know location of material safety data sheets
(MSDSs)?
27 The no-smoking policy reviewed and posted?

SELECTED TOPICS EXPLANATION
1. OPEARTING ROOM FIRE

The Elements of Operating Room Fires
Operating Room Fire Prevention

 Minimize ignition risks during the use of electrosurgical devices and surgical lasers
(safe and appropriate use of electrosurgical pencils, use of bipolar electrosurgery,
use of the laser standby mode).
 Minimize ignition risks by selective pre-use wetting of likely fuels present at the
incision (gauze, sponges, pledgets, towels).
 Use specific procedures to minimize ignition risks in oropharyngeal surgery
(oropharyngeal gas scavenging, wetted gauze, sponges, or pledgets).
 Minimize oxidizer risks (oxygen and nitrous oxide) in general surgery and
specifically during oropharyngeal surgery.
 Use open-source supplemental oxygen safely and appropriately.
 Minimize fuel risks with flammable surgical preps and in general (e.g., cautious
use of alcohol-based preps and other flammable liquids, coating of facial hairs).
 Plan the response to surgical fires.
 Extinguish small fires with the hand.

 For large fires on or in the patient, stop the flow of oxidizers, remove burning
materials from the patient, extinguish burning material, and care for the patient.
 Follow correct procedures for using recommended types of fire extinguishers, such
as carbon dioxide (for surgical fires, water-based and dry-powder extinguishers are
not recommended).
 Use aqueous solutions, fire blankets, sprinkler systems, and fire hoses to extinguish
fires (fire blankets and fire hoses are specifically not recommended, and sprinkler
systems are not likely to become activated by a surgical fire).
 Develop evacuation procedures (RACE: rescue the patient, alert staff, confine the
smoke and fire, evacuate the area).
First Response
 Small fires on a patient, such as those caused when a hot electrosurgical pencil ignites
drapes on a patient or when an electrocautery pencil ignites a blotting sponge,can be
extinguished by patting out the fire with a gloved hand or towel.
 Large fires on or in the patient require a more comprehensive response that stops the flow
of oxidizers to the patient. In many cases, doing so will cause the fire to go out or at least
lessen in intensity.
 The burning materials must then be removed from the patient and extinguished to protect
the patient from the heat of these materials.
 The patient should receive immediate care; breathing should be restored, if necessary (with
air, never O2), and injuries dealt with. Some debate exists with regard to this sequence —
specifically, the order in which these steps should be carried out. In any case, they should
both be done as close to instantaneously as possible.
Fire Extinguishers
 Although they should not be the weapon of first resort when dealing with a surgical fire,
fire extinguishers may be required to deal with fires that engulf or have migrated off the
patient.
 As noted earlier, the correct procedure for using any fire extinguisher can be recalled by
the acronym PASS (pull the pin, aim the horn or nozzle, squeeze the trigger, and spray in
a sweeping motion to put out the fire).
 The types of fire extinguishing devices commonly available in operating rooms are water
based, CO2, and dry powder. Not all of these are equally safe or effective. Some experts
recommend CO2 extinguishers and recommend that a 5-lb CO2 extinguisher be mounted
just inside the entrance of each operating room in the hospital.
Fire Blanket
 Typically, fire blankets are wool blankets treated with fire retardants that are placed over a
fire to smother it.

 They should never be located in an operating room and should never be used for patient
fires.
 Their use will likely cause more severe injuries to the patient; however, they can be placed
outside the operating room in case of a fire on a conscious person, such as a surgical team
member.
 In such a fire, the person can exit the operating room to use the blanket in a room that likely
is not oxygen enriched and can tell others about the fire.
Sprinkler Systems
 Sprinkler systems can be found in the operating rooms of newer facilities but may activate
only in response to large fires.
 Like water from extinguishers, sprinkler system water is not sterile and could, under some
circumstances, present an electricshock hazard.
 Fire hoses are sometimes found in hallways and stairwells of older facilities. Water from
hoses is also not sterile and can also create an electric shock hazard. In addition,the water
stream itself can deliver sufficient force to cause injury or mechanical damage and can
make the hose dif difficult to hold onto. The use of fire hoses to extinguish surgical fires is
not recommended.
Fire Drills
Fire drills not only allow staff to practice for a fire but also help troubleshoot any
difficulties that might occur. Some elements to consider in planning a fire drill include:
• The proper response of surgical team members and the operating suite staff
• How the patient can easily and safely be moved to another operating room
• How the spread of smoke could be prevented (for example, through the use of
smoke doors and air duct dampers)
• Location and operation of fire extinguishers, fire alarm pull stations, and exits
• The response of additional firefighting personnel (such as the fire response team
and local fire department)

2. Safe Quantity of Open Medical Gas Storage in Healthcare

Facility Smoke Compartments in accordance with NFPA 99

The Volume of Medical gases Recommendations
< 300 ft3

 Not required to be stored in an
enclosure being associated with a
smoke compartment
 Precautions for handling the

cylinders must still be observed
Between 300 ft3 and 3000 ft3

 Outdoors or in an interior enclosure
of noncombustible or limited
combustible construction
 Indoor locations must include the

following:
 Restriction of oxidizing gases such

as oxygen and nitrous oxide from
being stored with any flammable gas,
liquid, or vapor
 Separation of oxidizing gases from
combustibles or flammables (more
than 20 ft separation distance in an
un-sprinklered building or 5ft in a
sprinklered building, or gas cabinet in
a sprinklered building)
 Cylinder temperatures less than 52C
(125F)
 Appropriate restraints per NFPA 99
(2018), 11.6.2.3.
 Cylinder valve protection caps
 Smoking, open flames, electric
heating elements and other sources
of ignitions prohibited from storage
locations and within 20ft of outside
storage locations
> 3000 ft3

 Access to move cylinders on hand
trucks
 Availability of lockable doors or gates

 Availability of minimum two

entries/exits (if outdoors and
>200ft2)
 Interior finishes, racks, shelves, and
supports with noncombustible or
limited combustible material (if
indoors)
 Walls and floors made with 1-hour
fire-resistance rating & other
openings with ¾-hour fire protection
rating (if indoors)
 Racks, chains or other fastenings to
secure cylinders from falling
 Access for delivery vehicles and
management of cylinders
 Regulation of temperature
 Prohibition of motor-driven
machinery
 Additional ventilation requirements

WATER BASED FIRE PROTECTION

SYSTEM ITM TAGGING

Water-Based Fire Protection System ITM( Inspection & Maintenance Deficiencies )

Item Deficiency Tag NFPA Reference
SPRINKLER SYSTEMS - INSPECTION NFPA #25
All sprinklers Leaking - Spraying or running water Red Impairment 5.2.1.1.1
All sprinklers Leaking - dripping water Red Critical 5.2.1.1.1
All sprinklers Foreign material attached or suspended from Red Impairment 5.2.1.1.1
Spray pattern obstructed - less than 18" or 36" below deflector (stock, furnishings, and equipment),
All sprinklers Red Critical 5.2.1.2
temporary or nonpermanent (signs, banners, decorations, etc.)
All sprinklers Lightly loaded Yellow Noncritical 5.2.1.1.1
Standard-response sprinklers in nonresidential One sprinkler and less than 50% of sprinklers in compartment is heavily loaded or corroded; painted
Red Critical 5.2.1.1.1
occupancies operating element, bulb, deflector, or cover plate; improper orientation; glass bulb has lost fluid
Standard-response sprinklers in nonresidential Two or more sprinklers in compartment are heavily loaded or corroded; painted operating element,
Red Impairment 5.2.1.1.1
occupancies bulb, deflector, or cover plate; improper orientation; glass bulb has lost fluid
Fast-response element, quick-response, residential
Any sprinklers, heavily loaded or corroded; painted operating element, bulb, deflector, or cover plate;
sprinklers and standard-response in residential Red Impairment 5.2.1.1.1
improper orientation; glass bulb has lost fluid
occupancies
No sprinklers in an area Note: Outside scope of NFPA 25 N/A Observation
Walls relocated, spacing issues Note: Outside scope of NFPA 25 N/A Observation
Cover plates Concealed sprinkler cover plates caulked or glued to ceiling Red Impairment 5.2.1.1.1
Missing recessed or flush escutcheons, concealed cover plates with deflector and operating element in
Escutcheons and cover plates Yellow Noncritical 5.2.1.1.6
correct position
Missing recessed or flush escutcheons, concealed cover plates with deflector and operating element
Escutcheons and cover plates Red Impairment 5.2.1.1.6
not in correct position
Escutcheons Recessed of flush escutcheons caulked or glued to ceiling Red Critical 5.2.1.1.1
Cabinet missing, temp. over 100°F, not proper number and type, missing wrench for each type, missing 5.2.1.4(1), 5.2.1.4(2),
Spare sprinkler cabinet Yellow Noncritical
list of spare sprinklers 5.2.1.4(3)
Pipe and fittings Leaking - slowly dripping and/or moisture on surface Red Critical 5.2.2.1
Pipe and fittings Leaking - spraying or running water Red Impairment 5.2.2.1
Pipe and fittings Critical mechanical damage Red Critical 5.2.2.1
Pipe and fittings Poor condition/ external corrosion, mechanical damage, external loads Yellow Noncritical 5.2.2.1 5.2.2.2
Hangers & seismic braces Damaged or loose Yellow Noncritical 5.2.3.2
Hangers & seismic braces Unattached Red Critical 5.2.3.2
Gauges Poor condition Yellow Noncritical 5.2.4.1, 5.2.4.2
Gauges Not showing normal water/air/nitrogen pressure Red Critical 5.2.4.1, 5.2.4.2
Gauges Freezer - system pressure lower than compressor Red Impairment 5.2.4.4
Alarm devices Physical damage apparent Yellow Noncritical 5.2.5
Hydraulic design information sign Not attached properly, illegible or missing Yellow Noncritical 5.2.6
Heat tape Not in accordance w/ manufacturer's instructions Red Critical 5.2.7
Information sign Not attached, illegible or missing Yellow Noncritical 5.2.8
General information sign Not attached, illegible or missing Yellow Noncritical 5.2.9
Inspection reports No previous inspection reports on site N/A Observation
SPRINKLER SYSTEMS - TESTING NFPA #25
Sprinklers - standard No test after 50 years, every 10 years thereafter Red Critical 5.3.1.1.1,
Sprinklers - standard Prior to 1920 not replaced Red Critical 5.3.1.1.1.2
Sprinklers - fast response No test after 20 years, every 10 years thereafter Red Critical 5.3.1.1.1

Sprinklers - solder-type 325°F or greater No test after 5 years, every 5 years thereafter Red Critical 5.3.1.1.1.4
Sprinklers - standard No test after 75 years, every 5 years thereafter Red Critical 5.3.1.1.1.5
Sprinklers - dry No test after 10 years, every 10 years thereafter Red Critical 5.3.1.1.1.6
(Corrosive atmospheres, corrosive water supply, includes freezers and coolers) No test after 5 years,
Sprinklers - subject to harsh environments Red Critical 5.3.1.1.2
every 5 years thereafter
Sprinklers - solder type (Commercial-type cooking eqpt. & ventilating systems) No replacement after one year Red Critical 5.4.1.7
Not protected or plastic or paper bags used to protect against overspray residue, with deposits or
Sprinklers in spray coating areas Red Impairment 5.4.1.8.3
residue accumulation
Gauges Not replaced or calibrated in 5 years, not accurate within 3% of scale Yellow Noncritical 5.3.2
Alarm devices Water motor and gong not functioning Red Critical 5.3.3
Alarm devices Pressure switch or vane-type switch not functioning or no alarm Red Critical 5.3.3
Antifreeze systems Mixture and concentration does not meet requirements of 5.3.4.2.1 Red Critical 5.3.4
Antifreeze systems Concentration is inadequate to prevent freezing Red Impairment Table A.5.3.4.2.1 (1)
Main drain More than 10% drop in full flow pressure Red Critical 13.2.5.3
Assessment of internal condition Inspection revealed presence of MIC, zebra mussels, rust and scale Red Critical 14.2.1
Assessment of internal condition No assessment of internal condition of main and branch line piping after 5 years Yellow Noncritical 14.2.1
STANDPIPE & HOSE SYSTEM - INSPECTION
Piping Leaking - slowly dripping and /or moisture on surface Red Critical 6.2.1, Tble 6.1.2
Piping Leaking - spraying or running water Red Impairment 6.2.1, Tble 6.1.2
Piping Critical mechanical damage Red Critical 6.2.1, Tble 6.1.2
Piping Poor condition/external corrosion, mechanical damage, external loads Red Critical 6.2.1, Tble 6.1.2
Gauges Poor condition Yellow Noncritical 6.2.2.1, 13.2.7.1
Gauges Not showing normal water/air pressure Red Critical 6.2.2.1, 13.2.7.1
Hydraulic design information sign Missing Yellow Noncritical 6.2.3
Hose connection pressure reducing valves Handwheel broken or missing, hose threads damaged, leaking, reducer missing Red Critical 13.5.2.1
Hose connection pressure reducing valves Cap missing Yellow Noncritical 13.5.2.1
Hose rack assembly pressure reducing valve Handwheel broken or missing, leaking Red Critical 13.5.3.1
Leaking, visible obstructions, caps, hose threads, valve handle, cap gasket, no restricting device,
Hose valves Red Critical 13.5.6.1
damaged, or in poor condition
Hose valves Hose threads not compatible Red Impairment 13.5.6.1
Hose Cuts, couplings not of compatible threads Red Critical Tble 6.1.2, NFPA 1962
Hose Deterioration, no gasket or damaged gaskets Red Critical Tble 6.1.2, NFPA 1962
Hose Mildew present, corrosion present, hose not connected, hose test outdated Yellow Noncritical Tble 6.1.2, NFPA 1962
Hose nozzle Missing, broken parts or thread gasket damaged Red Critical Tble 6.1.2, NFPA 1962
Hose storage Hose not properly racked or rolled, nozzle clip missing, nozzle not contained, damaged, obstructed Red Critical Tble 6.1.2, NFPA 1962
Corroded or damaged parts, not easy to open, not accessible, not identified, door glazing in poor
Cabinet condition, lock not functioning in break glass type, valve, hose nozzle, fire extinguisher, etc.. not readily Red Critical Tble 6.1.2, NFPA 1962
accessible
STANDPIPE & HOSE SYSTEM - TESTING NFPA #25
Hose connection pressure-regulating devices Test results not comparable to previous results Red Critical 13.5.2.2
Hose connection pressure-regulating devices No full flow test done after 5 years Yellow Noncritical 13.5.2.2
Hose rack assembly pressure-regulating devices Test results not comparable to previous results Red Critical 13.5.3.2
Hose rack assembly pressure-regulating devices No full flow test done after 5 years Yellow Noncritical 13.5.3.2
Hose valves (Class I and Class III standpipe

Annual test revealed valve leaking or difficult to operate Red Critical 13.5.6.2.1 13.5.6.2.1.1
system)
Hose valves (Class II standpipe system) Test revealed valve leaking or difficult to operate Red Critical 13.5.6.2.2.1
Hose valves (Class II standpipe system) No test after 3 years Yellow Noncritical 13.5.6.2.2

6.1.2, Tble 6.1.2 , NFPA

Hose No test after initial 5 years or 3 years thereafter or did not pass service test Yellow Noncritical
#1962
6.1.2, Tble 6.1.2 , NFPA

Hose storage device Rack will not swing out of cabinet at least 90° Yellow Noncritical
#1962
Standpipe system Test results did not provide design pressure at required flow Red Critical 6.3.1.1
Standpipe system No flow test done after 5 years Yellow Noncritical 6.3.1.1
Manual standpipe system and semi-automatic dry
Hydrostatic test showed leaks Yellow Noncritical 6.3.2.1
standpipe systems including FDC piping
Manual standpipe system and semi-automatic dry
No hydrostatic test done after 5 years Yellow Noncritical 6.3.2.1
standpipe systems including FDC piping
Gauges Not replaced or calibrated in 5 years, not accurate within 3% of scale Yellow Noncritical 6.3.4 13.2.7.2 & 3
Main drain More than 10% drop in full flow pressure Red Critical 6.3.1.5, 13.2.5.3
Assessment of internal condition No assessment of internal condition of standpipe piping after 5 years Yellow Noncritical 14.2.1
PRIVATE FIRE SERVICE MAINS - INSPECTION
Exposed piping Leaking - slowly dripping, and/or moisture on surface Red Critical 7.2.2.1, Tble 7.2.2.1.2
Exposed piping Leaking - spraying or running water Red Impairment 7.2.2.1, Tble 7.2.2.1.2
Exposed piping Mechanical damage, corroded, not properly restrained Red Critical 7.2.2.1, Tble 7.2.2.1.2
Mainline strainers Plugged, fouled Red Impairment 7.2.2.3, Tble 7.2.2.3
Mainline strainers Corroded Red Critical 7.2.2.3, Tble 7.2.2.3
Backflow prevention assemblies Reduced pressure assemblies differential-sensing valve relief port continuously discharging Red Critical 13.6.1.2.2
Backflow prevention assemblies Backflow prevention assembly not internally inspected after 5 years Yellow Noncritical 13.6.1.4
PRIVATE FIRE SERVICE MAINS - INSPECTION - cont.
Fire department connection Not accessible, damaged couplings, or clapper not operating properly or missing Red Impairment 13.7.1
Couplings and swivels damaged, do not rotate smoothly, check valve leaking, automatic drain not
Fire department connection Red Critical 13.7.1
operating properly or missing
Fire department connection Missing identification sign(s) Yellow Noncritical 13.7.1
Fire department connection Missing FDC (Never installed) Observation
7.2.2.4 & 5Tble
Dry barrel , wet barrel & wall hydrant Inaccessible, barrel contains ice, cracks in barrel Red Impairment
7.2.2.4 & 5
7.2.2.4 & 5 Tble
Dry barrel , wet barrel & wall hydrant Barrel contains water, improper drainage from barrel, leaks at outlets or top of hydrant Red Critical
7.2.2.4 & 5
7.2.2.4 & 5 Tble
Dry barrel , wet barrel & wall hydrant Tightness of outlets, worn nozzle threads, worn operating nut, missing wrench Yellow Noncritical
7.2.2.4 & 5
Monitor nozzles Damaged, corroded or leaking Red Critical 7.2.2.6, Tble 7.2.2.6
Hose/hydrant houses Inaccessibl Red Impairment 7.2.2.7, Tble 7.2.2.7
Hose/hydrant houses Damaged Red Critical 7.2.2.7, Tble 7.2.2.7
Hose/hydrant houses Not fully equipped Yellow Noncritical 7.2.2.7, Tble 7.2.2.7
PRIVATE FIRE SERVICE MAINS - TESTING NFPA #25
Underground and exposed piping Test results not comparable to previous results Red Critical 7.3.1
Underground and exposed piping No flow test done after 5 years Yellow Yellow 7.3.1
Backflow prevention assemblies Did not pass forward flow test Red Impairment 13.6.2.1
Fire department connection FDC piping did not pass hydrostatic test Yellow Yellow 13.7.4
Fire department connection No hydrostatic test done after 5 years Yellow Yellow 13.7.4
Dry barrel & wall hydrant Hydrant did not flow clear or did not drain within 60 minutes Yellow Noncritical 7.3.2.1, 7.3.2.4
Monitor nozzles Did not flow acceptable amount of water, did not operate throughout their full range Red Critical 7.3.3.1, 7.3.3.2
FIRE PUMP - INSPECTION NFPA #25
Pump house/room Ventilating louvers not free to operate Red Critical 8.2.2 (1)
Pump house/room Heat not adequate, temperature less than 40° F Red Impairment 8.2.2 (1)
Pump house/room Heat not adequate, temperature less than 70° F for diesel pumps without engine heaters Red Impairment 8.2.2 (1)
Heat not adequate, temperature less than 40° F, not as recommended by the engine manufacturer, for
Pump house/room diesel pumps with engine heaters Red Impairment 8.2.2 (1)
FIRE PUMP - INSPECTION - cont. NFPA #25

Suction, discharge, or bypass valves not fully open, pipe leaking, suction line & system line pressure
Pump system Red Impairment 8.2.2 (2)
not normal, wet pit suction screens obstructed
Pump system Reservoir empty Red Impairment 8.2.2 (2)
Pump system Suction reservoir does not have required water level, wet pit suction screens missing Red Critical 8.2.2 (2)
Pump system Minor leaking or drips on floor Yellow Noncritical 8.2.2 (2)
Suction, discharge, or bypass valves not fully open, major leaking such as spraying or leaking to the
Pump system Red Impairment 8.2.2 (2)
extent that pump performance might be questioned
Pump system Water flow test valves in open position Yellow Noncritical 8.2.2 (2)
Pump system Pump bearing lubrication not changed, shaft end play not within specified tolerances Yellow Noncritical Table 8.1.2
Mechanical Transmission Coupling not lubricated, right angle gear drive not lubricated Yellow Noncritical Table 8.1.2
No electrical power - Controller pilot light not illuminated, transfer switch pilot light not illuminated,
Electrical power to pump system isolating switch not closed, reverse phase alarm pilot light on or normal phase light is off, oil level in Red Impairment 8.2.2(3)
vertical motor sight glass not normal and no power to jockey pump
Electrical power is provided - controller pilot light not illuminated, transfer switch pilot light not
Electrical power to pump system Yellow Noncritical 8.2.2(3)
illuminated, reverse phase alarm pilot light on or normal phase light is not illuminated
Electrical power to pump system Circuit breakers and fuses tripped/open Red Impairment 8.2.2(3)
Electrical connections loose, pressure switch settings not calibrated, mechanical parts not lubricated,
Electrical system motor bearings not greased, voltmeter and ammeter not accurate, corrosion on printed circuit boards, Yellow Noncritical Table 8.1.2
cracked cable/wire insulation, leaks in plumbing repairs, water on electrical parts
Diesel engine system Fuel tank empty Red Impairment 8.2.2(4)

Diesel engine system Alarm pilot lights are on Red Critical 8.2.2 (4)
Diesel engine system Battery charging current not normal Red Critical 8.2.2 (4)
Diesel engine system Battery failure pilot lights on Red Critical 8.2.2 (4)
Diesel engine system Battery pilot lights off Red Critical 8.2.2 (4)
Diesel engine system Battery terminals corroded Red Critical 8.2.2 (4)
Diesel engine system Battery voltage readings not normal Red Critical 8.2.2 (4)
Diesel engine system Controller selector switch not in auto position Red Impairment 8.2.2 (4)
Diesel engine system Cooling water level not normal Yellow Noncritical 8.2.2 (4)
Diesel engine system Cooling water level not visible Red Critical 8.2.2 (4)
Diesel engine system Crankcase oil level not normal Yellow Noncritical 8.2.2 (4)
Diesel engine system Crankcase oil level below low level Red Impairment 8.2.2 (4)
Diesel engine system Electrolyte level in batteries not normal Yellow Noncritical 8.2.2 (4)
Diesel engine system Electrolyte level in batteries below top of battery plates Red Critical 8.2.2 (4)
Diesel engine system Engine running time meter not reading Yellow Noncritical 8.2.2 (4)
Diesel engine system Fuel tank less than two-thirds full Red Critical 8.2.2 (4)
Diesel engine system Water-jacket heater not operating Red Critical 8.2.2 (4)
Diesel engine system Oil level in right angle gear drive not normal (not at level mark but visible in sight glass) Yellow Noncritical 8.2.2 (4)
Oil level in right angle gear drive below low level (not visible in sight glass or below one finger knuckle
Diesel engine system Red Critical 8.2.2 (4)
for inspection hole)
FIRE PUMP - INSPECTION - cont. NFPA #25

Diesel engine system - fuel Fuel tank not voided of water and foreign material, strainer, filter or dirt leg not cleaned Yellow Noncritical Table 8.1.2
Lube oil heater not operational, crankcase oil level not within acceptable range, crank case breather
Diesel engine system - lubrication system Yellow Noncritical Table 8.1.2
needs cleaned or replaced
Not adequate cooling water to heat exchanger, flexible hoses and connections damaged, cooling water
Diesel engine system - cooling system jacket heater not operational, water strainer needs cleaned, antifreeze needs changed, heat exchanger Yellow Noncritical Table 8.1.2
not rodded out, ductwork and louvers need cleaned
Diesel engine system - exhaust system Leaking, condensate trap needs drained Yellow Noncritical Table 8.1.2
Battery case corroded, battery case needs cleaned, charger and charge rate not equalized, terminals
Diesel engine system - battery system need cleaned or tightened, cranking voltage exceeds 9 volts on 12 volt system or 18 volts on 24 volt Yellow Noncritical Table 8.1.2
system
Wiring subject to movement chafing, boxes, panels and cabinets need cleaned, corrosion on printed
Diesel engine system - electrical system Yellow Noncritical Table 8.1.2
circuit boards, cracked cable/wire insulation, leaks in plumbing parts and water on electrical parts
Diesel engine system - electrical system Circuit breakers and fuses over 2 years old, Red Critical Table 8.1.2
Steam system Steam pressure gauge reading not normal Red Critical 8.2.2 (5)
FIRE PUMP - TESTING NFPA #25
Pump did not start automatically, electric pump did not run 10 minutes, diesel pump did not run 30
Fire pump test Red Impairment 8.3.2.2, 8.3.2.3, 8.3.2.4
minutes
Fire pump test - pump system System suction and discharge gauge reading, or pump starting pressure not acceptable Red Critical 8.3.2.8(1), 8.3.2.9(1)
Pump packing gland discharge not acceptable, unusual noise or vibration, packing boxes, bearings or
Fire pump test - pump system Red Critical 8.3.2.9(1)
pump casing overheating
Time for motor to accelerate to full speed, time controller is on first step or time pump runs after
Fire pump test - electrical motor - driven system Red Impairment 8.3.2.9(2)
starting not acceptable
Time for engine to crank and time for engine to reach running speed not acceptable (engine to reach
Fire pump test - diesel engine - driven system Red Critical 8.3.2.9(3)
rated speed within 20 seconds per 11.2.7.1 of NFPA 20, 2013 edition)
Fire pump test - diesel engine - driven system Low rpm Red Impairment 8.3.2.9(3)
Fire pump test - diesel engine - driven system Low oil pressure, high temperature, high cooling water pressure Red Critical 8.3.2.9(3)
Fire pump test - steam system Gauge reading and time for turbine to reach running speed not acceptable Red Critical 8.3.2.9(4)
Fire pump annual test Circulation relief valve and/or pressure relief valve did not work properly at churn condition Red Critical 8.3.3.2 (1)
Fire pump annual test Pressure relief valve did not work properly at each flow condition Red Critical 8.3.3.3.1
Overcurrent protective devices opened when simulating a power failure condition at peak load, power
Fire pump annual test (with transfer switch) not transferred to alternate source, pump did not continue to perform at peak load, pump did not Red Impairment 8.3.3.4
reconnect to normal power after removing power failure condition
Fire pump annual test Alarms did not properly operate Red Critical 8.3.3.5
Pump house/room Heating, lighting, ventilating systems did not pass test Red Critical 8.3.6.3
Fire pump annual test Parallel or angular alignment not correct Red Critical 8.3.6.4
Fire pump annual test Flow test results are not within 5% of acceptance test or nameplate Red Critical 8.3.7.3
Fire pump annual test Voltage readings at motor not within 5% below or 10% above rated (nameplate) Red Critical 8.3.7.6
Fire pump annual test Flow test results not within 5% of initial unadjusted acceptance test or nameplate Red Critical 8.3.7.3
Positive displacement pump annual test Flow test did meet the specified rated performance criteria Red Critical 8.3.5.2
Electronic fuel management control system Backup ECM and/or primary and redundant sensors failed test Yellow Noncritical 8.3.3.8
WATER STORAGE TANK - INSPECTION NFPA #25
Water level Water level and/or condition not correct Red Critical 9.2.1
Water level Tank is empty Red Impairment 9.2.1
Air pressure Air pressure in pressure tanks not correct Red Impairment 9.2.2
Heating system Heating system not operational, water temperature below 40°F Red Critical 9.2.3, 9.2.4
Heating system Water temperature below at or below 32°F Red Impairment 9.2.3, 9.2.4
Exterior Tank exterior, supporting structure, vents, foundation, catwalks or ladders where provided damaged Yellow Noncritical 9.2.5.1
Area around tank has fire exposure hazard in form of combustible storage, trash, debris, brush or
Exterior Yellow Noncritical 9.2.5.2
material
Exterior Accumulation of material on or near parts that could result in accelerated corrosion or rot Yellow Noncritical 9.2.5.2
Exterior Ice buildup on tank and support Red Critical 9.2.5.2
Exterior Erosion exists on exterior sides or top of embankments supporting coated fabric tanks Yellow Noncritical 9.2.5.2
Exterior Expansion joints leaking or cracking Red Critical 9.2.5.3
Exterior Hoops and grills of wooden tanks in poor condition Yellow Noncritical 9.2.5.4
Exterior Exterior painted, coated, or insulated surfaces of tanks or supporting structure degraded Yellow Noncritical 9.2.5.5
Automatic tank fill valve Exterior damaged, strainers, filters and orifices not cleaned Yellow Noncritical Table 9.5.1.1
Interior (pressure tanks or steel tanks w/o corrosion Pitting, corrosion, spalling, rot, other forms of deterioration, waste materials exist, aquatic growth, local
Yellow Noncritical 9.2.6.3
protection every 3 years, all others every 5 years) or general failure of interior coating
Interior (pressure tanks or steel tanks w/o corrosion

Voids beneath floor with sand in the middle of tanks on ring type foundations Yellow Noncritical 9.2.6.5
protection every 3 years, all others every 5 years)

Heating system components or piping in poor condition but working Yellow Noncritical 9.2.6.6

Heating system components or piping in poor condition and not working Red Impairment 9.2.6.6

Blockage of anti-vortex plate Red Impairment 9.2.6.7

Deterioration of anti-vortex plate Red Critical 9.2.6.7
WATER STORAGE TANK - TESTING NFPA #25

Interior testing Tank coating did not pass adhesion, coating thickness or wet sponge test Yellow Noncritical 9.2.7
Interior testing Tank walls and bottoms did not pass ultrasonic test Yellow Noncritical 9.2.7
Interior testing Tank bottom seams did not pass vacuum-box test Yellow Noncritical 9.2.7
Testing Level indicator lacked freedom of movement or not accurate Red Critical 9.3.1
Testing Level indicator not tested after 5 years Yellow Noncritical 9.3.1
Testing Low water temperature alarm did not pass test Red Critical 9.3.3
Testing High water temperature limit switch did not pass test Yellow Noncritical 9.3.4
Testing High and low water level alarms did not pass test Red Critical 9.3.5
Gauges Not replaced or calibrated in 5 years, not accurate within 3% of scale Yellow Noncritical 9.3.6
Automatic tank fill valve Valve did not operate properly during test Red Critical 9.5.3
WATER SPRAY FIXED SYSTEMS INSPECTION NFPA #25
Mechanical damage, missing or damaged paint or coating, rusted or corroded, not properly aligned or
Pipe and fittings Red Critical 10.2.4.1
trapped sections, low point drains not functioning, improper location of rubber-gasketed fittings
Damaged or missing, not securely attached to structural or piping, missing or damaged paint or
Hangers & seismic braces Red Critical 10.2.4.2
coating, rusted or corroded.
Water spray nozzles Discharge devices missing, not properly positioned or pointed in design direction, loaded or corroded Red Critical 10.2.5.1
Water spray nozzles Missing caps or plugs if required or not free to operate as intended. Red Critical 10.2.5.2
Mainline strainers and individual water spray nozzle
Strainer plugged or fouled Red Impairment 10.2.7
strainers
Mainline strainers and individual water spray nozzle

Strainer damaged or corroded Yellow Noncritical 10.2.7
strainers
Mainline strainers Mainline strainers have not been inspected within the last five years Yellow Noncritical 10.2.1.7
Drainage Trap sumps and drainage trenches blocked, retention embankments or dikes in disrepair Yellow Noncritical 10.2.8

Automatic detection equipment Not inspected in accordance with NFPA 72 Yellow Noncritical 10.2.3.1
Automatic detection equipment (Not covered by Missing detectors, loose, not protected from corrosion or weather, damaged, communication wiring,
Red Critical 10.2.3.2
NFPA #72) control panels or pneumatic tubing system not functional
Ultra-High-Speed Detectors have physical damage or deposits on lenses of optical detectors Red Critical 10.4.2
Ultra-High-Speed Controllers found to have faults Red Critical 10.4.3
WATER SPRAY FIXED SYSTEMS TESTING NFPA #25
Heat detection system did not operate within 40 seconds, flammable gas detection system did not
Operational test Red Impairment 10.3.4.1
operate within 20 seconds
Operational test Test not done after 1 year Yellow Noncritical 10.3.4.1
Operational test Nozzles are plugged Red Impairment 10.3.3.3.1
Operational test Nozzles not correctly positioned Red Critical 10.3.3.3.1
Operational test Pressure readings are not comparable to original design requirements Red Critical 10.3.3.4.3
Operational Test Test not performed performed with maximum number of systems expected to operate Yellow Noncritical 10.3.4
Operational test Manual actuation devices did not work properly Red Impairment 10.3.5
Low point drains/weep holes Piping not drained, weep holes not clear or obstructed Yellow Noncritical 10.3.6.1.2
Ultra-High-Speed Operational test Response time was more than 100 milliseconds Red Impairment 10.4.5.2
Ultra-High-Speed Operational test Test not done after 1 year Yellow Noncritical 10.4.1
Assessment of internal condition No assessment of internal condition of piping within the last five years Yellow Noncritical 14.2.1
FOAM-WATER SPRINKLER SYSTEM INSPECTION (NFPA 16 systems only, not NFPA 11 or 409) NFPA #25
Alarm devices Physical damage apparent Yellow Noncritical 11.1.4.1.3
Automatic detection equipment Not inspected in accordance with NFPA 72 Yellow Noncritical 11.2.2
Mechanical damage, missing or damaged paint or coating, rusted or corroded, not properly aligned or
Pipe and fittings trapped sections, low point drains not functioning, improper location or poor condition of rubber- Red Critical 11.2.3
gasketed fittings
Damaged or missing, not securely attached to structural or piping, missing or damaged paint or
Hangers & seismic braces Red Critical 11.2.4
coating, rusted or corroded.
Foam-water discharge devices Discharge devices missing Red Impairment 11.2.5.1
Foam-water discharge devices Discharge devices not properly positioned or pointed in design direction, loaded, or corroded Red Critical 11.2.5.1
Foam-water discharge devices Caps and plugs not free to operate as intended. Red Critical 11.2.5.2
Foam-water discharge devices Missing caps or plugs if required Red Critical 11.2.5.2
Foam-water discharge devices Incorrect foam concentrate for application and devices Red Critical 11.2.5.4
Mainline and/or discharge device strainers Baskets or screens damaged, plugged or fouled Red Impairment 11.2.7.1
Mainline and/or discharge device strainers Corroded Red Critical 11.2.7.1
Foam concentrate strainers Blow-down valve open or not plugged Red Critical 11.2.7.2
Drainage Trap sumps and drainage trenches blocked, retention embankments or dikes in disrepair Yellow Noncritical 11.2.8
Proportioning system valves not in correct open/closed position in accordance with specified operating
Proportioning systems (all) Red Impairment 11.2.9.3
conditions
Proportioning systems (all) Concentrate tank does not have correct quantity required by original design Red Critical 11.2.9.4
Proportioning systems (all) Concentrate tank empty Red Impairment 11.2.9.4
Standard pressure proportioner Automatic drains (ball drip valves) not free or open, external corrosion on foam concentrate tanks Yellow Noncritical 11.2.9.5.1.2
Standard pressure proportioner Ball drip drain valves not cleaned within last 5 years Yellow Noncritical 11.4.3.1

Standard pressure proportioner Foam liquid storage tank not flushed within last 10 years Yellow Noncritical 11.4.3.2
Standard pressure proportioner Foam liquid storage tank not hydrostatically tested within the last 10 years Yellow 11.4.3.3
Bladder tank proportioner Water control valve to foam concentrate in "closed" position Red Impairment 11.2.9.5.2.2
Bladder tank proportioner Foam in water surrounding bladder Red Impairment 11.2.9.5.2.2
Bladder tank proportioner External corrosion on foam concentrate tank Yellow Noncritical 11.2.9.5.2.2
Bladder tank proportioner Sight glass not cleaned within last 10 years (where provided) Yellow Noncritical 11.4.4.1
Bladder tank proportioner Foam concentrate tank not hydrostatically tested within the last 10 years Yellow Noncritical 11.4.4.2
Line proportioner Strainer damaged, corroded, pressure vacuum vent not operating freely Red Critical 11.2.9.5.3
Line proportioner Strainer plugged or fouled Red Impairment 11.2.9.5.3
Line proportioner External corrosion on foam concentrate tank Yellow Noncritical 11.2.9.5.3
Line proportioner Foam liquid storage tank not flushed within last 10 years Yellow Noncritical 11.4.5.3
Line proportioner Foam liquid storage tank not internally inspected within last 10 years Yellow Noncritical 11.4.5.1
Line proportioner Pickup pipes inside the tank corroded, not separated or plugged Yellow Noncritical 11.4.5.2
FOAM-WATER SPRINKLER SYSTEM INSPECTION (NFPA 16 systems only, not NFPA 11 or 409) cont.. NFPA #25
Standard balanced pressure proportioner Sensing line valves not open, no power to foam liquid pump Red Impairment 11.2.9.5.4
Strainer damaged, corroded, plugged or fouled, pressure vacuum vent not operating freely, gauges
Standard balanced pressure proportioner Red Critical 11.2.9.5.4
damaged or not showing proper pressures
Standard balanced pressure proportioner Foam concentrate pump not operated and foam circulated within the last 5 years Yellow Noncritical 11.4.6.1
Standard balanced pressure proportioner Foam pumps, drive train and drivers not serviced within the last 5 years Yellow Noncritical 11.4.6.2
Standard balanced pressure proportioner Diaphragm balancing valve not flushed within the last 5 years Yellow Noncritical 11.4.6.3
Standard balanced pressure proportioner Foam concentrate tank not internally inspected for corrosion within the last 10 years Yellow Noncritical 11.4.6.4
Sensing line valves at pump unit or individual proportioner stations not open, no power to foam liquid
In-Line balanced pressure proportioner Red Impairment 11.2.9.5.5
pump
strainer damaged, corroded, pressure vacuum vent not operating freely, gauges damaged or not
In-Line balanced pressure proportioner Red Critical 11.2.9.5.5
showing proper pressures
In-Line balanced pressure proportioner Strainer plugged or fouled Red Impairment 11.2.9.5.5
In-Line balanced pressure proportioner Foam concentrate pump not operated and foam circulated within the last 5 years Yellow Noncritical 11.4.7.1
In-Line balanced pressure proportioner Foam pumps, drive train and drivers not serviced within the last 5 years Yellow Noncritical 11.4.7.2
In-Line balanced pressure proportioner Diaphragm balancing valve not flushed within the last 5 years Yellow Noncritical 11.4.7.3
In-Line balanced pressure proportioner Foam concentrate tank not internally inspected for corrosion within the last 10 years Yellow Noncritical 11.4.7.4
Orifice plate proportioner No power to foam liquid pump Red Impairment 11.2.9.5.6
strainer damaged, corroded, pressure vacuum vent not operating freely, gauges damaged or not
Orifice plate proportioner Red Critical 11.2.9.5.6
showing proper pressures
Orifice plate proportioner Strainer plugged or fouled Red Impairment 11.2.9.5.6
Foam concentrate Samples not taken and submitted for test Yellow Noncritical 11.2.10
FOAM-WATER SPRINKLER SYSTEM TESTING (NFPA 16 systems only, not NFPA 11 or 409) NFPA #25
Alarm devices Water motor and gong not functioning Red Critical 11.1.4.1.1, 11.3.1.1
Alarm devices Pressure switch or vane type switch not functioning or no alarm Red Critical 11.1.4.1.2, 11.3.1.2
Pressure vacuum vents Not flushed and serviced within the last 5 years Yellow Noncritical 11.4.8
Operational Test Fire detection system did not operate within requirements of NFPA #72 Red Critical 11.3.2.4
Operational Test Test not done after 1 year Yellow Noncritical Tble 11.1.1.2
Operational Test Nozzles are plugged Red Impairment 11.3.2.6.1
Operational Test Nozzles are not correctly positioned Red Critical 11.3.2.6.1
Operational Test Pressure readings are not comparable to original design requirements Red Critical 11.3.2.7.3

Operational Test Test not performed with maximum number of systems expected to operate Yellow Noncritical 11.3.3
Operational Test Manual actuation devices did not work properly Red Impairment 11.3.4
Operational Test Foam sample failed concentration test Red Impairment 11.3.5.3
Assessment of internal condition No assessment of internal condition of main and branch line piping within the last five years Yellow Noncritical 14.2.1
VALVE, VALVE COMPONENTS & TRIM - INSPECTION NFPA #25
Control valve Improper closed position Red Impairment 13.3.2.2
Control valve Improper open position, leaking Red Critical 13.3.2.2
Control valve Not accessible, no appropriate wrench if required, no identification Yellow Noncritical 13.3.2.2
Control valve Not sealed, locked or supervised Red Critical 13.3.2.2
External physical damage, trim valves not in appropriate open or closed position, retard chamber or
Alarm valve Red Critical 13.4.1.1
alarm drain leaking
Alarm valve Alarm valve, strainers, filters and restricted orifices not internally inspected after 5 years Yellow Noncritical 13.4.1.2
Check valve Check valve not internally inspected after 5 years Yellow Noncritical 13.4.2.1
Valve enclosure Upon visual observation, enclosure not maintaining minimum 40°F temperature Red Critical 13.4.3.1.1, 13.4.4.1.1
Valve enclosure Low temperature alarms (if installed) are physically damaged Red Critical 13.4.3.1.1, 13.4.4.1.1
Preaction valve and deluge valve External physical damage, trim valves not in appropriate open or closed position, valve seat leaking Red Critical 13.4.3.1.6
Preaction valve and deluge valve Electrical components not in service Red Impairment 13.4.3.1.6
Preaction valve and deluge valve Internal inspection of valve after trip test not acceptable Yellow Noncritical 13.4.3.1.7,
Interior of preaction valve/or deluge valve (that can be reset w/o removal of faceplate), strainers, filters, 13.4.3.1.7.1, 13.4.3.1.8
Preaction valve and deluge valve Yellow Noncritical
restricted orifices, and diaphragm chambers not internally inspected after 5 years
Dry pipe valve and preaction valve auxiliary drains Missing identification sign Yellow Noncritical 13.4.4.1.3
External physical damage, trim valves not in appropriate open of closed position, intermediate chamber
Dry pipe valve/quick opening device Red Critical 13.4.4.1.4
leaking
Dry pipe valve/quick opening device Internal inspection of valve after trip test not acceptable Yellow Noncritical 13.4.4.1.5
Dry pipe valve/Quick opening device Strainers, filters and restricted orifices not internally inspected after 5 years Yellow Noncritical 13.4.4.1.6
Air dryer Not being maintained per mfg. instructions Yellow Noncritical 5.4.2.3
Air compressor Filters not cleaned, oil not changed or other mfg. recommendations not performed Yellow Noncritical 5.4.2.4
Sprinkler pressure-reducing control valves Not in open position Red Impairment 13.5.1.1
Sprinkler pressure-reducing control valves Not maintaining downstream pressures in accordance with design criteria Red Critical 13.5.1.1
Sprinkler pressure reducing control valves Leaking, valve damaged, handwheel missing or broken Red Critical 13.5.1.1
Master pressure reducing valve Not in open position Red Impairment 13.5.4.1
Master pressure reducing valve Not maintaining downstream pressures in accordance with the design criteria Red Critical 13.5.4.1
Master pressure reducing valve Leaking, valve and/or trim damaged, supply pressure not in accordance with design criteria Red Critical 13.5.4.1
VALVE, VALVE COMPONENTS & TRIM - TESTING NFPA #25
Control valve Valve not operating through its full range Red Critical 13.3.3.1
Control valve No spring or torsion felt in rod when opening post indicator valve Red Impairment 13.3.3.2
No signal from two revolutions of hand wheel from normal position or when stem has moved one-fifth of
Supervisory switches Red Critical 13.3.3.5
distance from normal position, signal restored in position other than normal
Preaction valve Priming water level not correct Red Critical 13.4.3.2.1
Preaction valve No full flow trip test done after 3 years Yellow Noncritical 13.4.3.2.3
Preaction valve Three year leakage test failed Red Critical 13.4.3.2.6
Preaction valve No air leakage test after 3 years Yellow 13.4.3.2.6

Deluge valve Annual full flow trip test revealed plugged nozzles, manual actuation devices did not Red Impairment 13.4.3.2.2.6
operate properly
Pressure reading at hydraulically most remote nozzle and/or at valve not
Deluge valve Red Critical 13.4.3.2.7.3
comparable to original design values
Preaction valve Low air pressure switch did not send signal, no alarm Red Critical 13.4.3.2.13
Preaction and deluge valve Low temperature switch did not send signal, no alarm Red Critical 13.4.3.2.14
Preaction valve Automatic air maintenance device did not pass test Yellow Noncritical 13.4.3.2.15
Dry pipe valve/Quick opening device Priming water level not correct Red Critical 13.4.4.2.1
Dry pipe valve Annual trip test results were not comparable to previous tests Red Critical 13.4.4.2.2
Dry pipe valve No full flow trip test done after 3 years Yellow Noncritical 13.4.4.2.2.2
Dry pipe valve Quick opening device did not pass test Red Critical 13.4.4.2.4
Dry pipe valve Low air pressure switch did not send signal or no alarm Red Critical 13.4.4.2.6
Dry pipe valve Low temperature switch did not send signal or no alarm Red Critical 13.4.4.2.7
Dry pipe valve Automatic air maintenance device did not pass test Red Critical 13.4.4.2.8
Dry pipe valve Trip test tag or card missing Yellow Noncritical 13.4.4.2.5
Dry pipe valve No air leakage test a<er 3 years Yellow Noncritical 13.4.4.2.9
Dry pipe valve Three year air leakage test failed Red Critical 13.4.4.2.9
Sprinkler pressure reducing control valves Test results not comparable to previous results Red Critical 13.5.1.2
Sprinkler pressure reducing control valves No full flow test done after 5 years Yellow Noncritical 13.5.1.2
Master pressure reducing valve Test results not comparable to previous results Red Critical 13.5.4.3
Master pressure reducing valve No full flow test not performed after 1 year Yellow Noncritical 13.5.4.3

SAFETY EVALUATION PROFILE (SEP)
Management Leadership and Employee Participation :
A Score
Safety and Health (4) Workforce accepts, can explain, and fully understands the safety and health
Policy policy.
(3) Majority of personnel can explain policy.
(2) Some personnel can explain policy.
(1) There is a written (or oral, where appropriate) policy.
(0) No such policy exists.
Comments:
Hazard & Behavior Analysis :
A Score
Hazard Review (4) Every planned or new facility, process, material, or equipment is fully
reviewed by competent personnel.
(3) A hazard review of each planned or new facility, process, material, or
equipment is conducted by experts.
(2) Planned or new facilities, processes, materials, and equipment that are
considered high hazards are reviewed.
(1) Hazard reviews of new facilities, processes, materials, and equipment are
problem driven.
(0) No system or requirement exists for hazard review of planned or new
operations.
Comments:
Job Safety Analysis (4) Employees are involved in the development of current hazard analysis on
their jobs.
(3) A current hazard analysis program exists for appropriate jobs and processes
and is understood by affected employees.
(2) A hazard analysis program exists for appropriate jobs and processes and is
understood by affected employees.
(1) A hazard analysis program exists, but few employees are involved and most
are not aware of the results.
(0) No routine hazard analysis system is in place at this facility.
Comments:

Hazard Prevention :
A Score
Hazard Control (4) Hazard controls are fully in place that concentrate on engineering controls and
Program on reinforced and enforced safe work procedures and are known to the
workforce.
(3) Hazard controls are fully in place that give priority to engineering controls, safe
work procedures, administrative controls, and personal protective equipment (in
that order).
(2) Hazard controls are fully in place, but the order of priorities is variable.
(1) Hazard controls are generally in place, but priorities and completeness vary.
(0) Hazard controls are not considered complete, effective, or appropriate in this
workplace.
Comments:
B Score
Preventive (4) Operators are trained to recognize maintenance needs and to perform or
Maintenance order timely maintenance.
(3) An effective preventive maintenance schedule is in place and applicable to all
equipment.
(2) A preventive maintenance schedule is in place and is usually followed except
for higher priorities.
(1) A preventive maintenance schedule is in place but is often allowed to slide.
(0) Little or no attention is paid to preventive maintenance.
Comments:
Safety Health & Training :
A Score
Employee (4) Employees are involved in hazard assessment and help develop and deliver
Training training, and all are trained.
(3) Facility is committed to high-quality employee hazard training, requires
everyone to participate, and provides regular updates.
(2) Facility provides legally required training and makes an effort to include all
personnel.
(1) Training is provided when the need is apparent, and experienced personnel
are assumed to know the material.
(0) Facility depends on experience and informal peer training to meet needs.
Comments:

List of NFPA Standards
NFPA Std. Description

NFPA 1 Uniform Fire Code
NFPA 10 Standard for Portable Fire Extinguishers
NFPA 13 Standard for the Installation of Sprinkler Systems
NFPA 20 Installation of Stationary Pumps for Fire Protection
NFPA 25 Inspection, Testing, and Maintenance of Water-Based Fire Protection
Systems
NFPA 30 Flammable and Combustible Liquids Code
NFPA 30B Manufacture and Storage of Aerosol Products
NFPA 45 Standard for Fire Protection for Laboratories Using Chemicals
NFPA 55 Standard for the Storage, Use, and Handling of Compressed Gases
NFPA 70 National Electrical Code
NFPA 72 National Fire Alarm Code
NFPA 77 Recommended Practice on Static Electricity
NFPA 80 Standard for Fire Doors and Fire Windows
NFPA 92 Smoke Control Systems
NFPA 99 Standard for Health Care Facilities
NFPA 101 Life Safety Code
NFPA 704 Standard System for the Identification of the Hazards of Materials for
Emergency
Response
NFPA 5000 Building Construction and Safety Code
End of Document

FIRE INSPECTION GUIDE FOR ASSEMBLY OCCUPANCIES

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FIRE INSPECTION GUIDE FOR ASSEMBLY OCCUPANCIES

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MECHSOFT ENGINEERING DESIGN & CONSULTANCY

General Guide for Fire and Life Safety Inspections

Fire & Life Safety Inspection for Health Care Facilities

NFPA, IBC, IFC, NBC, NDM Guidelines

Prepared by: Mehboob Shaikh

B.E(ME) || CFPS || CFI-1 || AMIE

info@mitionline.com Design|Inspections|Training +919146861270

Prepared by: Mehboob Shaikh

MITI Consultancy Training|Engineering|Inspections info@mitionline.com

Inspection Practices & Procedure for Assembly Occupancies

Inspection Practices & Procedure for Buisness Occupancies

Inspection Practices & Procedure for Educational Occupancies

Inspection Practices & Procedure for Hotel Occupancies

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Inspection Practices & Procedure for Industrial Occupancies

Inspection Practices & Procedure for Storage Occupancies

Inspection Practices & Procedure for Health Care Occupancies

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Inspection Practices & Procedure for Day Care Occupancies

Inspection Check lists for various Occupancies.

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Height & Area Limitations

Structural Fire Resistance Requirements

Fire-Resistance Rated & Smoke Resistant Separations

Exit Requirements as per LSC/IFC

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Actual building area 4,750 Sq ft.

Structural Fire Resistance :

Occupant Load Factors: Restaurant Seating Area: 15 sq ft per person

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Egress Capacity ( LSC Table 7.3.3.1)

Actual egress Capacity : 96 Inch

Number of Exit required (LSC 12.2.4) : 2 Exits

Max. TD : 250 ft.

Max. Common Path(CP) : 20 ft. with OL of more than 20

Max. Dead End (LSC 12.2.5.1.3) : 20 ft.

Separation of exits required (LSC 7.5.4.2) : Diagonal x 1/3 the maximum

Separation of Exit required : 40 ft.

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Interior finishes to comply with LSC chapter 8.

Fire Alarm System and Detection System

Sprinkler System Required :

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Description of Non Compliance Pictorial representation

No exit signs; exit lights out

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Extinguishers not serviced or

Overcrowding, no occupant load

Aisles not adequate

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Extension cords and other

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SN Observations Recommandation Code/Std. Refer. Compliance

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SN Observations Recommandation Code/Std. Refer. Compliance

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