dynalife - dl.labqms.com

DynaLIFE Policy - xxx - xxxx Proprietary Insert Document Title Here of 17

Printed copies are UNCONTROLLED unless stamped in red.

Introduction Division B, Section 2.8 of the Alberta Fire Code (AFC 2019), requires all worksites to

have a fire safety plan. OHS has developed this plan to meet these legislative requirements, provide instructions on the building's safe evacuation, and identify staff and supervisory duties during a fire emergency.

Ultimately the building owner is responsible for carrying out the provisions of the

Alberta Fire Code. AIMCO is the building owner, and EDON is the building owner's representative and the building operator. DynaLIFE (DL) is a tenant in the building.

A copy of the fire safety plan shall be prominently posted at:

the first floor 103 street entrance

the first floor 102 street staff entrance

outside of the Flammable liquid room.

Further:

• This Fire Safety plans must be acceptable to the Fire Department; • The fire safety plan shall be reviewed at intervals not greater than 12 months

to ensure that it takes account of change in the use and other characteristics of the building;

• Fire wardens will supervise the evacuation of the building from 7:00 am – 1:00 am. Between the hours of 1:00 am – 7:00 am, Base lab occupancy is less than 50 people; during these hours, the staff in each department are responsible for evacuating themselves.

DynaLIFE Policy – SAF - 1520 Proprietary 15.1 Fire Emergency Procedures for DynaLIFE Base Laboratory of 17


Definitions Alberta Fire Code (AFC): The AFC establishes provisions to address three

objectives: Safety, Health and Fire Protection of Buildings and Facilities.

Authorities: All departments affected by the fire alarm system, which

includes but is not limited to the following:

• Local fire department; • Alarm monitoring company if appropriate;

• Contractors working on-site; • Property management;

• Tenants.

Building Management Control System (BMCS): A computer-based system that

controls and monitors a building's mechanical and electrical equipment such as

boilers, chillers, ventilation systems, lighting, and power systems.

Building owner: a lessess, a person in charge who has care and control and a person who holds out that the person has the powers and authority of ownership or who for the time being exercises the powers and authority of ownership.

Daily Mechanical Log: A spreadsheet used by the building operator to record critical building functions as part of operator best practice.

Emergency Power Supply: A battery or generator that provides emergency

power to a load when the input power source, typically main power, fails.

Emergency Voice Communication System: A firefighting telephone or public

address system organized for the primary purpose of supporting one way and

two-way communication of emergency messages between individuals and groups

of individuals.

Fire Watch: Tours at intervals of not more than one (1) hour for all areas

affected by the disabled fire alarm system.

Monitored System Alarm: An automated system that monitors life safety or

critical building functions for normal operation or trouble states. These

monitored systems can include fire panels, security, and building management

controls.

Service Provider: The company that provides monitoring services for a particular system.



General Building Description

The building is a combustible structure that has two stories above grade and three parking levels below grade. Construction is concrete with interior room partitions

of gypsum on steel studs. The building has a combustible roof.

The ground floor consists of medical laboratory departments which contains diagnostic instruments and analysis equipment. There are also offices, washrooms, janitorial storage, flammable storage room, gas room, wood shop, Deionized water (DI) room, and a first aid room. The second floor is the administrative area which includes main reception, support and administrative departments/offices, staff lockers, lunchrooms, washrooms with shower facilities and meeting rooms.

Hours of Operation

DL Base lab operates 24/7 year round. Access into the building is restricted using a

swipe card system. The overhead doors to the loading dock and parkade are accessible on 103 Street and open automatically from 6am – 6pm Monday to

Friday. Outside these hours, a swipe card is required.

Muster point All employees, visitors and contractors must assemble at 102 St. in front of

Manulife Building. Address is 10180 – 102 St.

Fire Department Access

The Fire department access to the building is the locked 103 Street entrance. The key is in the fire department lock box to the left of the doors. Security or a member of the DL safety team will meet at that location, they will be available to escort the Fire Department through the building if required. Depending on the situation the Fire Department may also access the building via the 102 Street DynaLIFE cab door. Ring the doorbell to request access.

Fire Detection & Alarm System

Manufacturer

The building is equipped with a two-stage Vortex fire alarm system. The building

operator is in control of the system. TYCO monitors the system, and Meridian Fire Protection is the maintenance contractor.

The fire alarm control/annunciator panel (FACP) is located in the vestibule of 103

St. entrance. A zone map is posted at the FACP.

Upon activation of an initiating device (i.e. Manual pull station, heat detector, smoke detector etc.) the fire alarm system will automatically sound an alarm signal

throughout the building. Alarm bells will ring and strobe lights will light up.



First Stage First Stage alarm is a pre-evacuation warning stage. The alarm bell rings at a slow pulsed rate of 20 strokes per minute. The alarm system’s 5-minute evacuation timer is initiated. The building operator may cancel the timer and hold the system in first stage if appropriate.

Second Stage Second Stage (building evacuation) alarm is automatically if the 5 minute

evacuation timer is not canceled. The alarm bells ring at a faster 3-3-3 temporal

rate. Building and laboratory ventilation systems (i.e. fume hoods, grossing stations and ventilation exhaust fans) shut down.

Sprinkler

System

The first and second floors and mechanical penthouse have wet-pipe sprinkler

system. The parkade is equipped with a dry-pipe system. The fire alarm system monitors all sprinkler system actuation devices, pre-charge pressures, water flow switches, and control valves. The main shut-off valves are located in the sprinkler room in the Parkade – P2 Level. Zone valves are distributed throughout the building. A Victaulic Vortex 500 Fire Suppression System protects the IT server room on the 2nd floor. A nitrogen cylinder is secured to a metal frame on a wall outside of the server room.

Standpipe System

This building standpipe system is active.

Fire Department

Connection & Fire Hydrants

The sprinkler Fire Department connection is located on 103 St. There is access to municipal fire hydrants on both 102 St. (east) and 103 St. (west) side of the

building.

Fire Extinguishers

5 – 10 lbs. ABC dry chemical fire extinguishers are located throughout the building indicated by placard signage. There is one 30 lbs. ABC in Anatomic Pathology



Fire Hazards Base Lab occupancy classification is F2 - medium hazard industrial occupancy.

The Flammable storage room is located on the south hallway across from Anatomic Pathology (AP) department on the ground floor.

The Gas room is located in the South hallway in the south west corner of the building on the ground floor.

There are five 95L (55 gal) formalin waste storage barrels located in the Compactor Room on the Loading Dock.

The Anatomic Pathology (AP) department contains a large volume of in-use flammable liquids

Flammable liquid storage cabinets are located in Anatomic Pathology (6), Core Lab (2), Microbiology (2), and Materials Management - Receiving area (1) on the ground floor.

Safety Data Sheets (SDSs)

All Safety Data Sheets (SDS) are stored electronically access in the MSDSonline

database at https://msdsmanagement.msdsonline.com/?ID=292DC953-5F2A-4AFD-A534-7BA29ED05E7C.

Building Owner - AIMCO

The Building Owner is responsible for ensuring all requirements in the Alberta Fire Code are met:

assigns supervisory staff their responsibilities

Ensure fire protection and life safety systems are functioning and

maintained as per the Alberta Fire Code as required and documented.

These records should be kept on site

Ensure the key box contains keys required to used by authorized personnel

(Fire Dept.) in an emergency

https://msdsmanagement.msdsonline.com/?ID=292DC953-5F2A-4AFD-A534-7BA29ED05E7C

https://msdsmanagement.msdsonline.com/?ID=292DC953-5F2A-4AFD-A534-7BA29ED05E7C



Building Operator - EDON

The building owner uses a building operator to represent them and acts on their behalf to complete their responsibilities. The building operator is responsible for:

Understand and know their duties and responsibilities

Performing required inspections, maintenance and testing of the fire

protection system and equipment

Coordinating fire drills with tenant(s) and other stakeholders

Notify the Fire Department of a temporary shut-down of the fire alarm or

sprinkler system and appropriate alternate measures are arranged

Ensure that the fire alarm and sprinkler system are returned to normal

operator, immediately after maintenance, repairs or an emergency has

taken place

Practice fire prevention

Manages/directs building contractors

Ensure Fire Department connections are kept clear and accessible for the

Fire Department use at all times.

Tenant – DynaLIFE (DL)

As a tenant in the building DL will be responsible for ensuring that the provisions of this plan are implemented within their space including:

Ensure that all employees are trained in fire safety including evacuation procedures, exit routes, fire alarm signal, muster point location, fire prevention

Ensure Chief and department Fire wardens are selected and trained

Ensure any fire hazards, unsafe conditions or equipment are immediately addressed and corrected

Ensure procedures are provided for safe evacuation of all employees, contractors and visitors

Conduct annual fire drills and complete fire drill reports Keep training documents and records onsite

Practice fire prevention

Fire Warden Team

The Base Laboratory Fire Warden Team consists of the Chief Fire Warden, Deputy

Chief Fire Warden, and the Departmental Fire Wardens.



Chief/Deputy Fire Warden Responsibilities

The persons fulfilling the roles of Chief and Deputy Chief fire warden are identified in Appendix B. Duties: When the alarm sounds, assume full control and authority over all occupants in

their designated floor area; Direct the safe evacuation of all personnel in the event of a fire or other

emergency; • Provides leadership to the Fire Warden Team;

• Assigns and maintains a roster of Department Fire Wardens and alternates;

• Trains Department Fire Wardens and ensures that Department Fire Wardens

know their assigned duties and locations in case of an emergency;

• Ensures plans for the evacuation of disabled personnel are in place;

• Supervises the activities of Departmental Fire Wardens during an emergency;

• Maintains liaison with the Fire Department;

• Meets the Fire Department at fire alarm panel in the event of a fire alarm;

• Together with Facilities, administer and maintain this fire plan.

• Recording information on the following:

- Fire incidents;

- False alarms;

- Fire drills;

- Discharge or operation of fire equipment.

Upon hearing the pre-evacuation alarm Chief Fire Warden:

Step Action

1. Proceed immediately to the west entrance vestibule.

2. Collect the two-way radio and establish contact with the Fire Warden Team

3. Obtain information on the location, nature, and extent of the emergency from the fire panel, PA pages, the department fire wardens, Building

Operator, and other sources. 4. Inform Building Operator/Security and the Fire Department of the nature

and extent of the emergency.

5. Receive reports from the Department Fire Wardens and verify that all areas have been evacuated. Record on the Fire Alarm/Drill log.

6. Inform the Executive/Risk Management Team of the nature and extent of the emergency.

7. If appropriate, make a PA announcement(s) to inform staff of the situation's nature. Dial 509 to page.

8. When the Building Operator/Security or the Department gives the “all-clear", instruct the Fire Wardens to allow staff to re-enter the building.



Departmental Fire Wardens Responsibilities

Duties: Advises the Chief Fire Warden of all fire emergencies in their assigned area When the alarm sounds, assume full control and authority over all occupants in

their designated floor area Direct the safe and orderly evacuation of all personnel from their designated

area in a fire or other emergency. In the event of a fire, bomb threat, or similar emergencies, the building's safe and timely evacuation is a priority.

o An evacuation is not undertaken in a bomb threat unless a suspicious package is found.

Step Action

When the first stage (pre-evacuation) alarm sounds:

1. Put on an orange vest 2. Instruct personnel in your assigned area to prepare to evacuate

3. Instruct personnel to assemble at the Department Muster Point 4. Follow any instructions given by the Fire Department or Chief Fire

Warden

When the second stage (evacuation) alarm sounds:

5. Instruct all personnel in your area to evacuate the building in an orderly manner Direct personnel to form a single file line into exits and stairwells and

to exit along the right side of doorways and stairwells

6. Ensure all disabled persons have assistance to evacuate the building

safely

If… Then…

The disabled person can walk down the stairs will assistance

Assist the person in walking down the stairs and to the muster point.

The disabled person cannot walk

down the stairs even with the

assistance

Escort the person to the Northwest or Northeast

stairwell. Instruct them to remain in the stairwell, and that

help will be coming. Inform the Chief Fire warden

that a disabled person in (NE or NW) stairwell must be carried

down the stairs. The Chief Fire Warden will

inform the Fire Department

7. Inform the Chief Fire Warden at the West vestibule that your area is

evacuated and await further instructions. If a Deputy Chief Fire Warden is positioned at the Cab door and has a

two-way radio, fire wardens exiting the building onto 102 Street may inform him/her.



8. When directed by the Chief Fire Warden, inform personnel from your area that they may re-enter the building

After the emergency or drill is over:

9. When directed by the Chief Fire Warden, inform personnel from your area that they may re-enter the building

10. Close and lock the emergency doors in your area.

Department Managers

Duties:

• Establish procedures to preserve records, confidential material, specimens, and equipment in fire or other emergency cases.

• Pre-determine which equipment and processes must be shut down during the pre-evacuation alarm stage.

• Establish a plan for contacting staff. • Ensure plans are in place to evacuate any disabled staff in your department.

All Personnel Duties:

• The safe evacuation of the building in the event of a fire is dependent on all staff knowing and understanding their responsibilities.

• Be familiar with the procedures to be followed in the event of a fire • Be acquainted with the fire alarm stages and the requirements for each

• React to alarms and follow the directions given by the Fire Wardens • Be familiar with at least two emergency exits from your usual work location

• Know the fire alarm pull stations' location and fire extinguishers in your area and understand their operation and use. Ensure that department staff are

aware of and periodically review the actions to be taken when the fire alarm rings.

Employees with disabilities

• Individual evacuation plans for all disabled employees must be prepared • A disabled employee is any employee who will require assistance during an

emergency evacuation of the building. • Assign two co-workers as monitors to assist the disabled employee

• Practice the planned evacuation procedures for disabled staff during each

evacuation fire drill • The Fire Department will assist the employee in exiting the building.

• A draft plan for the evacuation of persons with disabilities is attached as Appendix C.

• General evacuation plan for disabled employees: o Unless alternate plans are made, an employee who works on the

second floor and who cannot manage to exit the building by the stairs is to wait on the top landing of a stairwell

o One of the Monitors or a Fire Warden is to notify the Chief Fire Warden and Fire Department that an employee is waiting in the stairwell who needs assistance to exit the building



Alarm Activation

In a fire or other major emergency, prompt action on the part of all personnel is

required to ensure the safety of people and minimize property damage. If you discover a fire follow these steps:

Remove any injured personnel and any others who are in immediate danger

Evacuate the area and ensure all doors are closed

Activate the fire alarm from the nearest fire alarm pull box and pull center

tab towards you and downwards

Call 911 and page “Code Red (your location)” from a safe location Dial

“911”. Tell the 911 operator you require fire services to make a P.A.

announcement dial 509. After the tone say “Code Red (fill in your

location)”. Repeat three times

Try to extinguish the fire using a fire extinguisher, but only if you can do so

without put yourself at risk

Fire Evacuation – First stage

When you hear the pre-evacuation alarm:

Step Action

1. Follow all instructions given by a Fire Warden

2. Shut down and power off any equipment that cannot be left unattended

3. Shut off all flammable gases

4. Remove laboratory gowns and gloves. Perform hand hygiene

5. Go to the department muster point

6. Listen for second stage alarm or P.A. announcement

Fire Evacuation – Second stage

Evacuate the building immediately through the nearest safe exit:

Step Action

1. Assemble at the DL muster point – Manulife Place 102St

2. Do Not use elevators or pedway bridges for evacuation 3. Do not attempt to remove your vehicle from the parkade

4. Follow any instructions given by the Fire Wardens

5. Assist any physically disabled persons in exiting the building

6. Do Not re-enter the building until directed to do so by the Fire Wardens



If Building re-entry not permitted

Depending on the incident, building re-entry may not be permitted by the

authorities. Staff should:

Step Action 1. Contact DL Fire Wardens

2. Sign the DL staff roster

Evacuations in other emergencies

The Fire Wardens may be used to direct the building's evacuation in the event of a bomb threat or other non-fire emergency. Whether the fire alarm is used to signal the evacuation or not will be determined by Leadership and/or the Risk Management Team in consultation with the appropriate authorities. Once the evacuation is underway, fire wardens will perform their usual duties.

Evacuation Sequence – Building Operator

• Once the situation is under control and with the fire department's

authorization and direction, the fire alarm can be silenced and the panel reset. The fire alarm panel cannot be reset without authorization from the fire

department. • Reset all alarm conditions and ensure that all alarm signals have cleared.

• Enable the fire alarm system using the complex fire alarm system operating instructions.

• Wait 5 minutes and confirm that the fire alarm system is in a "normal" condition. All trouble and alarm signals should be clear.

• Reset all building systems from the Building Management Control System (BMCS).

• Follow Building Operator incident reporting requirements

• Record the details of the incident in the Building Operator logbook.

False Alarms – Building Operator

DO NOT SILENCE OR RESET the fire alarm system

ENSURE the fire department is aware of the incident

When the fire department is satisfied that the alarm was false, RESTORE

activated manual pull stations and RESET the system (if qualified)

COMPLETE an Incident/Activity Report where a fire has occurred and

damaged the system wiring and/or detection devices A qualified contractor may need to make the necessary repairs. Ensure complex fire alarm system operating instructions, including

contact phone numbers, system identification numbers, and passwords,

are readily available at the facility. Please review and update their

contents as required



Fire Prevention Know the fire emergency preparedness plan for your site

Know what to do in the event of a fire in your area

Know what to do when the fire alarm rings

Know where the fire extinguisher is located and how to use it

Keep an inventory of flammable and combustible materials used in your

area

Take appropriate precautions when working with flammable and

combustible materials. See section 7.4.

Remove all sources of ignition before working with flammable liquids.

These include:

o Open flames (e.g. Bunsen burners)

o Heating elements (e.g. portable electric heaters, water baths,

dryers, heating blocks)

o Electric motors

o Static electricity

Keep portable space heaters at least 90 cm (three feet) away from walls,

draperies, furniture, or any other combustible materials

Keep work areas clean and uncluttered

Decorations: live Christmas trees and candles are not permitted,

decorations must not present a fire hazard

Do not leave lit Bunsen burners or other open flames unattended

Do not overload electrical receptacle outlets

Do not use equipment with frayed or damaged electrical cords. Have the

equipment repaired

Immediately disconnect electrical equipment that smokes or smells burnt.

Have the equipment repaired

Turn off portable space heaters when the room is unoccupied

Do not store any material within 0.5 meters of the ceiling, sprinkler heads

or electrical lights



Fire Safety Considerations

• Use a building telephone only if you are safe from the fire.

• While exiting, walk, and do not run

• Shut all doors behind you and alert those who have difficulty hearing that the

building's emergency evacuation is underway

• Proceed along corridors and through exits in a quiet and orderly manner

• Remain calm, do not pass in the stairwell, and do not push or jostle

• If you must use an escape route where there is smoke, stay as low as possible.

Crawling lets you breathe the cleaner air near the floor as you move toward the

exit

• Before you open a closed door, feel it with the back of your hand. If it is hot,

leave it closed and use your alternate escape route. If it feels normal, brace

your body against the door and open it a crack - be prepared to slam it shut if

heat or smoke starts to rush in

• If all exits are blocked by fire or smoke, enter a room preferably with an

exterior window, and seal the cracks in the door with available materials to

prevent smoke from entering the room. Phone 9-1-1 or to report your situation

and attract the attention of someone outside the building by any possible

means

• When you have reached the outside of the building, move away from the exit

allowing others behind you to emerge.

Fire Drills Fire drill exercises can and will include web based training, instructor led sessions,

and physical evacuations. Fire drills will be conducted quarterly. The Chief Fire Warden will coordinate two physical evacuation drills a year and will ensure day, evening and night shifts participate.

Fire drill exercises will provide the Chief Warden, Deputies, Departmental

Wardens, and occupants with the opportunity to hear the fire alarm and consider their actions if the fire were real. Use the following procedure when conducting

the fire drill: • Notify occupants of the date and time of the drill

• Notify the fire department on their non-emergency phone numbers that you

are planning to have a fire drill and that you will call them back when the drill is

complete

• Fire Warden Team should perform his or her duties as detailed in the plan.

• Restore the manual fire alarm pull station, and then reset the fire alarm system

• Notify the alarm monitoring company (when applicable) and the fire

department that the fire drill is complete

• Discuss the drill with occupants to identify concerns and gather feedback



Fire Safety Training

Fire safety training for new employees includes: Fire safety training during new employee safety orientation

Safety Manual Part 15 sections 1 – 6 as required

Fire SOP module via SABA

Fire safety training for all employee include: Fire SOP module via SABA

Quarterly fire drill exercises

Fire Warden training include: Initial training session – instructor led or web base

Read & Sign 1.3 Base Lab Fire Warden team

Annual web base module

Fire Extinguishers

Portable fire extinguishers are helpful only if you know how to use them, suitable for the fire you are fighting, and if the fire is discovered immediately. You should not attempt to fight even a small fire until people have been evacuated from the area and the Fire Department has been called. Never attempt to fight a fire if any

of the following is true: • You are uncertain about how to use the extinguisher.

• The fire is spreading beyond the immediate area where it started.

• The fire could block your escape route.

• You are alone.

• The fire could spread and block your escape route.

• The fire is growing rapidly.

• The fire has developed or is developing a lot of smoke.

• You have not been trained in the use of the extinguisher.

If you doubt that you can extinguish the fire, leave immediately, close off the area and leave the firefighting to the Fire Department. Read and follow the directions on the fire extinguishers within your building. Most portable fire extinguishers work according to the following directions (PASS):

• PULL the pin.

• AIM low... pointing the extinguisher nozzle at the base of the fire

• SQUEEZE the handle. This releases the extinguishing agent

• SWEEP from side to side at the base of the fire until it appears to be out.

Watch the fire area. If a fire breaks out again, repeat the use of the extinguisher



Portable Fire Extinguishers Checklist – DL Facilities

Portable Fire Extinguishers inspections is completed monthly by DL Facilities and is documented electronically.

Portable Fire Extinguisher Checklist 1. Is the gauge within the green zone ☐ Yes ☐ No

2. Is the hose clear? ☐ Yes ☐ No

3. Are portable fire extinguishers inspected annually by certified technician?

☐ Yes ☐ No

Fire Hose Occupant use hose has been removed from all wall cabinets

Fire System Inspection – Building Operator

Fire System Inspection Checklist

1. Have the fixed extinguishing systems (sprinkler

system) been inspected by certified technician

annually?

☐ Yes ☐ No

2. Are the remote activation devices (IT Server

Room) free of obstructions and visible?

☐ Yes ☐ No

3. Is each system inspected monthly as per the

manufacturer's instructions?

☐ Yes ☐ No

4. Are all discharge heads secure and unobstructed? ☐ Yes ☐ No

Disabling the Fire Alarm System

• Contact Building Operator to disable fire alarm system

• Maintain fire watch for the entire time that the fire alarm system is disabled

Shut down of Fire Detection System – Building Operator

Increased walkthrough of building by Building Operator Security team.

A notice must be visibly posted in the main entrance to the building; as well as notices posted at access points including elevators and stairs, when fire protection systems are out of service for an extended period of time. All building occupants shall be notified when any portion of a fire protection system is temporarily shut

down.

Enabling the Fire Alarm System – Building Operator

Notify tenant that the fire alarm system is fully functional.



Appendix A: Evacuation maps



Support Documents

Document name Document ID Appendix A: Evacuation maps N/A

Appendix B: 1.2.2 Base Laboratory Fire

Warden Team

Policy – RM - 20095

Appendix C: Individual Emergency Evacuation Plan

Form – SAF - 24110

Appendix D: Hot Work Procedure Policy – SAF - 1526

Appendix E: 1.3.1 Base Laboratory – Infrastructure Failure

Policy – RM - 2706

Appendix F: 4.2c Incident Reporting Portal

– OHS Procedure

Procedure – SAF - 1542

Appendix G: OHS Fire Safety Inspection

Checklist

Form – OHS - 56324

Appendix H: Inspection, Maintenance & Testing of Fire Equipment

Policy – FA - 56071

Appendix I: OHS Gas Room & Flammable Storage Room Inspection Checklist

Form – OHS - 56323

Appendix J: Emergency Phone numbers N/A