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Environmental Health & Safety Compliance Michael A. Charlton, Ph.D., CHP, CIH, CSP, CHMM, CFI Director of Environmental Health & Safety The University of Texas Health Science Center at San Antonio 7703 Floyd Curl Dr. San Antonio, TX 78229 Phone: (210) 567-2955

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environmental health safety compliance

Environmental Health & Safety Compliance

Michael A. Charlton, Ph.D., CHP, CIH, CSP, CHMM, CFI

Director of Environmental Health & Safety

The University of Texas Health Science Center at San Antonio

7703 Floyd Curl Dr.

San Antonio, TX 78229

Phone: (210) 567-2955

Email: charlton@uthscsa.edu

Paul D. Pousson, ARM Associate Director Office of Risk Management The University of Texas System 201 West 7th Street Austin, Texas  78701 Phone: (512) 499-4559

Email: ppousson@utsystem.edu

  • Colleges and universities must comply with an astronomical variety of requirements, ranging from issues related to NCAA athletic compliance, student financial aid, to patient medical billing. The implications of non-compliance extend far beyond the mere imposition of penalties and sanctions. Noncompliance can result in escalated enforcement activities, damage to institutional reputation, and can serve to erode overall stakeholder trust. To reduce the risk of instances of non-compliance, systemic institutional compliance programs are being formed and put into place within universities across the country. The creation of such compliance programs represents an excellent leadership opportunity for institutional environmental health and safety programs due to their intimate familiarity with the compliance-driven environment. For example, the Federal Sentencing Guidelines define the essential components of a compliance program to include: written polices and procedures, designated responsible parties, a formalized risk assessment, monitoring plans, training, confidential reporting mechanisms, and a method for disciplinary action in instances of non-compliance. Safety organizations have maintained many of these required programmatic elements through historical regulatory interactions. Therefore, safety personnel can seize the opportunity for a leadership role within the institution by actively relaying their demonstrated experience and expertise to other units in order to bolster the overall institutional compliance effort. By actively engaging in these compliance initiatives, safety programs can better position themselves for improved institutional recognition and resource allocations.
speaker biographies
Speaker Biographies
  • Paul D. Pousson is the Associate Director of the Office of Risk Management for The University of Texas System. He is responsible for directing the environmental health and safety, property and casualty insurance, and risk management services offered to the fifteen (15) component institutions of The University of Texas System. He has over 15 years of experience in the risk management, environmental protection and health and safety fields. Mr. Pousson is Past President of the Texas Campus Safety Association and serves on the Board of Directors of the Risk and Insurance Management Society - Central Texas Chapter and the University Risk Management and Insurance Association.  Mr. Pousson received his bachelors degree in Urban and Regional Planning (environmental management emphasis) from Southwest Texas State University. He also holds the designation of Associate in Risk Management (ARM) from the Insurance Institute of America.
  • Mike Charlton is the Assistant Vice President for Risk Management and Safety at the University of Texas Health Science Center at San Antonio. Mike has experience in academic research, cyclotron particle accelerators, light-water nuclear reactors, and industrial applications. He possesses a B.S. in Physics from Texas A&M University, an M.S. in Health Physics from Texas A&M University, an M.P.H. from the University of Texas at Houston Health Science Center and a doctorate in health physics from Texas A&M. Mike is board certified in health physics (CHP), industrial hygiene (CIH), as a safety professional (CSP), and hazardous waste management (CHMM).
safety and compliance
Safety and Compliance
  • Compliance infers safety
  • Non-compliance
    • infers or connotes unsafe conditions
    • damages image, reputation, morale
    • can result in fines
    • can result in escalated enforcement
    • costs money to defend, refute
    • can erode stakeholder trust
recent institutional compliance emphasis
Recent Institutional Compliance Emphasis
  • Genesis of the Federal Sentencing Guidelines
  • Non-compliance can result in penalties and punitive damages (3x?)
  • Reduction or insulation from punitive damages for organizations maintaining compliance programs meeting established criteria
compliance program criteria
Create and maintain compliance standards and procedures

Identified high level executive with overall compliance responsibility

Demonstrate due diligence in not delegating discretionary authority

Compliance communications and worker training

Monitoring, auditing, and reporting systems

Consistent enforcement

Interventions in cases of detected offenses

Compliance Program Criteria
what does this have to do with safety
What Does This Have to do With Safety?
  • Colleges and universities are sites of a myriad of compliance risks
    • Medical billing, NCAA, financial aid, human research subjects, sexual harassment, etc.
  • To develop a compliance plan, a comprehensive risk assessment is necessary
  • Within University of Texas System, EH&S consistently identified as a high risk area
implications of being high risk
Implications of Being “High Risk”
  • Move to top of overall priority list
  • Will be required to address detailed compliance risk plan first
  • Will be subjected to increased internal examination
  • Will reveal weaknesses
  • Increased reporting requirements
opportunities inherent to being high risk
Opportunities Inherent to Being “High Risk”
  • Move to top of overall priority list
  • Will be required to address detailed compliance risk plan first
  • Will be subjected to increased internal examination (show your stuff!)
  • Will reveal weaknesses (recurrent problems!)
  • Increased reporting requirements (improved access to the top!)
creation of risk plan
Creation of Risk Plan
  • Create universe of compliance risks
  • Base on regulations and recommendations (standards of care)
  • Show current status and processes in place
    • monitoring controls
    • oversight controls
  • Assign relative priority ranking
  • Link resource allocation requests to compliance risk ranking
case study life safety code compliance
Potential Exposure

Responsible Party

Operating Controls

Monitoring Controls



Life, property, revenue

Vice President for Operations

Systems and postings

Routine safety audits

Hazard awareness training

Routine status reports

Case Study: Life Safety Code Compliance
overview of fire life safety
Overview of Fire & Life Safety
  • Code Background
  • Fire Alarm Systems
  • Fire Detection
  • Fire Suppression
  • Conducting a Basic Assessment
impact of fires on universities
Impact of Fires on Universities
  • The Overall Fire Picture - 2004
    • There were 3,900 civilians that lost their lives as the result of fire.
    • There were 17,785 civilian injuries that occurred as the result of fire.
    • There were 117 firefighters killed while on duty.
    • Fire killed more Americans than all natural disasters combined.
    • 83 percent of all civilian fire deaths occurred in residences.
  • In 2001, 2,530 fires occurred in dormitories causing 6 fatalities, 82 injuries, and $48M in property damage
  • Introduce the Codes that Drive Fire and Life Safety Compliance
  • Overview of Fire Detection and Suppression
  • Provide Group With the Tools to Conduct a Basic Fire and Life Safety Assessment at Their Business




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



Origin of the IBC






goals of codes
Goals Of Codes
  • 80% of a Building Code’s Provisions Relate to Fire and Life Safety
  • IBC – promulgate a comprehensive and compatible regulatory system for the built environment, through consistent performance-based regulations that are effective, efficient and meet government, industry and public needs.
  • NFPA –reduce the worldwide burden of fire and other hazards on the quality of life by developing and advocating scientifically based consensus codes and standards, research, training, and education.
how are these codes enforced
How are These Codes Enforced
  • Codes are adopted by reference through ordinance.
  • Plans for remodeling or a new construction must be approved by the authority having jurisdiction (AHJ) prior to starting work.
    • State Fire Marshal’s Office
    • Local Fire Department or City Code Officials
    • Designated Local AHJ
  • Take Home Message – Know what code(s) apply to your operation
possible additional code requirements
Possible Additional Code Requirements
  • All codes are minimum requirements
  • Insurance company requirements
  • Company policies
  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
  • State and/or City requirements
features of building fire and life safety


Rated Corridors

Exit Access

Number of Required Exits

Egress Widths

Occupant Loads

Elevator Recall

Fire Rated Doors & Frames

Smoke Control

Rated Stairwells

Fireproofing Requirements

Electrical Safety

Construction Combustibility

Fire and Smoke Dampers

Emergency Power

Roof Assemblies

Features of Building Fire and Life Safety
fire alarm systems
Fire Alarm Systems
  • Play an Essential Role in Protecting Property and Lives From Fire.
  • Protection Goals Governs System Selection
    • Building Occupant Safety
    • Satisfy Building Codes or AHJ Requirements
    • Property Protection
    • First Responder Safety
    • Environmental Protection
    • Combination
fire alarm systems23
Fire Alarm Systems
  • IBC references NFPA 72 for Installation and Maintenance
  • NFPA 72 – National Fire Alarm Code
  • Basic Components
    • System Control Unit
    • Primary Power Supply
    • Secondary Power Supply
    • Initiating Device Circuits
    • Notification Appliance Circuits
    • Off-Premises Connection for Supervision
basic components
Basic Components













Primary Power


fire alarm systems26
Fire Alarm Systems
  • Fire Alarm System Will Provide Three Types of Signals
    • Alarm
    • Trouble – Indicates a fault in a monitoring circuit or component of the fire alarm system
      • Bad Smoke Detector
      • Ground Fault
    • Supervisory – Indicates that a problem exists with other fire protection systems that are being monitored by the fire alarm system.
      • Water Valve to Sprinkler System Closed
      • Clean Agent System Problem




fire detection
Fire Detection
  • Spark/Ember Detectors
  • Flame Detectors
  • Combination
  • Radiant Energy
      • UV
      • IR
  • Smoke Detector
      • Ionization
      • Photoelectric
  • Heat Detectors
      • Fixed Temperature
      • Rate-of-Rise
manual pull stations
Manual Pull Stations
  • Manual Pull stations devices are located on the wall (usually near an exit).
    • They are activated by pulling on a handle.
    • This sends a signal to the building’s fire alarm system which in turn places the building into alarm.
notification appliances
Notification Appliances
  • Audible alarms (How loud is loud enough?)
    • Public – SPL must be 5 dB above any ambient noise that lasts 60 sec. or more, or 15 dB above the 24-hr average, whichever is greater.
    • Sleeping quarters – Minimum of 75 dBA. Frequency may be important
  • Voice Communication
    • Better to have a larger number of lower SPL units are used vs. a few very loud units.
    • Intelligibility can be a problem
notification appliances30
Notification Appliances
  • Visual alarms
    • Primarily intended to augment audible alarms
    • Device output measured in candela (cd)
      • 15-635 (cd)
  • Common Locations of Visual Alarms
    • Corridors
    • Meeting rooms
    • Restrooms
fire alarm system interfaces
Fire Alarm System Interfaces
  • Heating Ventilation and Air Conditioning (HVAC)
    • AHU Shut-Down
    • Duct Detectors
  • Sprinkler Waterflow Alarms
  • Magnetic Lock Release Mechanisms
  • Door Unlocking Devices
  • Elevator Recall
  • Stairwell Pressurization
sprinkler flow alarms
Sprinkler Flow Alarms
  • Building sprinkler systems have switches inside the piping that will detect water flowing.
    • When a water flow is detected the building fire alarm system will activate.
system reliability
System Reliability
  • Based on Four Elements
    • Design
    • Equipment
      • Underwriters Laboratories Inc.
      • Factory Mutual Global
    • Installation
    • Maintenance
      • Inspection, Testing, and Maintenance are crucial.
      • Unfortunately some problems may be identified after the previous three have been completed.
fire suppression
Fire Suppression
  • Water Based Suppression
  • Clean Agent Systems
  • Fire Extinguishers
water based suppression
Water Based Suppression
  • Sprinkler System Components
    • Insert picture of typical system
  • Sprinkler Systems Fall Into Four Categories
    • Wet-Pipe
    • Dry-Pipe
    • Preaction
    • Deluge
wet pipe system
Wet-Pipe System
  • System contains water under pressure at all times.
  • Series of closed sprinkler heads
  • Heat activates sprinkler head
  • Water is discharged immediately

* Not recommended if system could be exposed to temperatures below 40ºF.

wet pipe system37
Wet-Pipe System
  • Indicating Valve
  • Alarm Check Valve
  • Fire Department Check Valve
  • Fire Department Connection
  • Water Motor Alarm
  • Automatic Sprinkler
  • Inspector’s Test Valve
how do sprinklers work
How do Sprinklers work?

Sprinkler head

Water is released and deflected in a spray pattern

As temperature rises the bulb will shatter

  • only the sprinkler heads directly heated by the fire activate
  • A fire sprinkler sprays approximately 18 gallons of water per minute to provide early fire control
dry pipe system
Dry-Pipe System
  • System contains air under pressure
    • Compressor on system keeps pressure up
  • Sprinkler heads hold the pressure
  • A dry-pipe valve holds back the water supply
  • Valve opens when pressure falls below a predetermined level
  • Sprinkler head activation – pressure drop – valve opens – water sent to all heads – water discharged from activated sprinkler heads.

* Recommended for areas that could experience freezing temperatures

dry pipe system42
Supply Check Valve

Indicating Valve

Dry Pipe Valve

Fire Department Check Valve

Dry Pipe System
  • Fire Department Connection
  • Water Motor Alarm
  • Automatic Sprinkler
  • Inspector’s Test Valve
how do dry pipe systems work
How do Dry-Pipe Systems Work?
  • Heat Activated
  • Pressure Drop
  • Valve Opens
  • Water sent to all sprinkler heads
  • Water Discharges from activated head
preaction system
Preaction System
  • System contains air under pressure
    • Compressor on system keeps pressure up
  • Water held back by preaction valve
  • System equipped with supplemental detection
  • Operation of detection system allows preaction valve to open and water fills the system.
  • Water not discharged until fire has generated sufficient heat to activate a sprinkler head.

* Typically found in computer rooms, museums, communication rooms

pre action system
Pre-Action System
  • Supply Check Valve
  • Indicating Valve
  • Water Control or Deluge Valve
  • Fire Department Check Valve
  • Fire Department Connection
  • Water Motor Alarm
  • Sprinkler (closed)
  • Detector
  • Electrical Bell
  • Manual Release Station
  • Control Panel
  • Inspector’s Test Valve
how do pre action systems work
How do Pre-Action Systems Work?
  • Smoke Detected
  • Valve Opens
  • Water sent to all sprinkler heads
  • Water Discharges from activated head
deluge systems
Deluge Systems
  • System designed to deliver large quantities of water over a specified area in a short period of time.
  • All piping is at atmospheric pressure
  • All sprinkler heads are in the open position
  • Deluge valve keeps the water back
  • Supplemental detection activated deluge valve
  • Water is discharge from all heads immediately

* Typically used to protect against rapidly spreading fires

fire pumps
Fire Pumps
  • Fire pumps are utilized when the hydraulic demand exceeds public supply capacity.
  • Components
    • Pump and motor
    • Controllers (Fire pump and jockey pump)
    • Jockey pump
    • Water Tank
water supply
Water Supply
  • Standpipe System
    • Class I – 2 ½ inch hose connection intended for fire department use.
    • Class II – 1 ½ inch hose connections intended for first-aid fire fighting
    • Class III – Provided with both 2 ½ inch and 1 ½ inch hose connections.
  • Fire Department Connection
suppression without water
Suppression Without Water
  • Halon – NFPA 12A
    • Being phased out as per 1987 Montreal Protocol
  • Carbon Dioxide – NFPA 12
  • Clean Agent – NFPA 2001
    • Inert gas formulation

* Many times these systems are not recognized as allowable substitute for water suppression.

  • NFPA 10 Standard for Portable Fire Extinguishers
  • Select Appropriate Extinguisher For Area
    • Class A, B, C, D, and K.
  • Identify Hazard Occupancy (Depends on amount of combustible materials present)
    • Light Hazard
      • Offices, churches, schools, assembly halls
    • Ordinary Hazard
      • Mercantile storage, auto showrooms, parking garages
    • High Hazard
      • Woodworking area, aircraft servicing hanger, warehouses
extinguisher ratings
Extinguisher Ratings
  • Extinguisher UL listing example


      • This extinguisher is good for Class A,B, & C fires.
      • It will extinguish twice as much class A fire as a

2-A rated extinguisher.

      • It will extinguish 20 times as much class B fire as a

1-B rated extinguisher.

      • Suitable for class C fires.
extinguisher comparison
Extinguisher Comparison
  • 2.5 gal water 2-A
  • 20 lb CO2 10-B:C
  • 10 lb dry chemical 2-A:10-B:C
  • 100 lb CO2 20-B:C
  • 33 gal film-forming foam 20-A:160B

Conducting a Basic Assessment

Determine Your Building Occupancy Type First

  • IBC Occupancy Classifications
    • Assembly: Group A-1, A-2, A-3, A-4 and A-5
    • Business: Group B
    • Educational: Group E
    • Factory and Industrial: Groups F-1 and F-2
    • High Hazard: Groups H-1, H-2, H-3, H-4, and H-5
    • Institutional: Group I-1, I-2, I-3 and I-4
    • Mercantile: Group M
    • Residential: Groups R-1, R-2, R-3 and R-4
    • Storage: Groups S-1 and S-2
    • Utility and Miscellaneous: Group U

Conducting a Basic Assessment

Additional Detailed

Requirements Based on Use and Occupancy

  • Covered Mall Buildings
  • High-Rise Buildings
  • Atriums
  • Underground Buildings
  • Motor-Vehicle-Related Occupancies
  • Motion Picture Projection Rooms
  • Stages and Platforms
  • Special Amusement Buildings
  • Aircraft-Related Occupancies
  • Combustible Storage
  • Hazardous Materials
  • Drying Rooms

Know Your Building

  • Once occupancy is determined codes will give you guidance
    • What type of construction is required
    • Is a sprinkler system required
    • Is a fire alarm system required
    • Exiting and egress
    • Emergency power required
    • Is a smoke control system required
    • Is a standpipe system required
some hints
Some Hints
  • Nomenclature difficulties: “compliance risk” versus “safety risk”
  • Explain risk ranking process:
    • Bona fide safety risk?
    • Local emphasis issue?
    • Previous non-compliance?
    • Common issued violation?
  • Who is the “responsible party”
  • Avoid overload: “Rome wasn’t built in a day”
our experience
Our Experience
  • The Compliance Program has served to improve and elevate the status of EH&S programs within our institutions
  • Impressed with our
    • Documentation processes
    • Monitoring and oversight control systems in place
    • Willingness to freely share information
    • Relative comfort with inspection and peer review
our experience62
Our Experience
  • Process has improved ability to identify needs to the highest level of the organization
  • Process has served to focus attention on previously unresolved and persistent issues
  • A catalyst for collaborative arrangements within the University system: ex. computer based training
  • Improved overall institutional support
our experience63
Our Experience
  • Institutional Compliance Committee - Diverse experience
  • External Peer Reviews - Important compliance monitoring tool
  • Others?
  • Powerful Self-Assessment/Monitoring Tool
  • Establishes lines of communication
  • Includes many controls already in place
  • Equalizes regulatory non-compliance for various departments
  • Involves a diverse group with an interest in maintaining (or attaining) compliance