HSE - Risk Based Inspection Programme

8/20/2019 HSE - Risk Based Inspection Programme

1/18

Breede Valley Fire & Rescue Service dcn BVFD MPr FS ENF RBI 05.01.01R Page 1 of 18

:BVFD/MPr/FS/ENF/RBI/05.01.01R

: 1.01

: 24

: 24/07/05 : 01/07/09 01 1

: . : 01/08/11

Responsibility: CFO

ACO: FS&RM

MANAGEMENT PROCEDURE

RISK BASED INSPECTION PROGRAMME

DOCUMENTATION HISTORY

1.0 . 24/07/05

1.01 . 01/06/09 &

2008

3.03.5


2/18


PURPOSEThis Standard Operating Procedure provides an overview of the Breede Valley Fire & RescueService’s procedure of conducting risk based Inspections that provide overall support to theIntegrated Fire Safety & Risk Management Plan [IFSRMP]

EFFECTIVE DATE: August 2005

REFERENCES:

• BVFD: Management Procedure on the Discharge of Fire Safety Duties

• Fire Brigade Services Act, Act 99 of 1987

• Fire Protection Regulations, SANS 10400:Part T• Breede Valley Municipality – Fire Safety By Law

• SANS 10090 – Standard on Community Protection against Fire

• The Constitution of the Republic of South Africa, Section 152(1) (d).

OBJECTIVES:

• To ensure that fire safety duties are conducted in a systematic, transparent and auditablemanner that will enable the achievement of Key Performance Objectives

SCOPE OF APPLICATION:Applicable to all members of staff assigned and delegated to discharge fire safety and fire

prevention duties.

RESPONSIBILITY:

• The Assistant Chief: Fire Safety and Risk Management (or Senior Officer so delegated in

this capacity) is responsible ensuring the implementation and quality assurance of this

Procedure.

• Fire Safety Officers are responsible for ensuring adherence to the guidelines and (any)

prescriptive conditions of this Procedure.

RELATED DOCUMENTS

• /////05.01.01

• ()

• :

BREEDE VALLEY FIRE & RESCUE SERVICE

Management Procedure

RISK BASED INSPECTION

PROGRAMME

BVFD/MPr/FS/ENF/RBI/05.01.01R

DATE OF LAST REVIEW: 01/07/09NEXT REVIEW DATE: May 2011

AUTHOR: PD GOVENDER


3/18


POLICY1.01 Department policy is to adopt, in the first instance, an advisory role rather than to simply

police the legislation for which the Fire Service is responsible with the mindset thatcooperation is generally more effective than confrontation.

INTRODUCTION

1.02 The development and management of a Risk Based Inspection Programme (RBIP) willprovide important data to assist in the development and evaluation of the Service’sIntegrated Fire Safety & Risk Management Plan (IFSRMP) and overall PerformanceManagement System. This will enable Breede Valley Fire and Rescue Service to fulfill itsduty to manage the fire risk in the community.

1.03 The final decision on the level of enforcement to be taken following an inspection andassessment of risk in any workplace will where appropriate embody the principles,expectations and methodology as outlined in the Management Procedure on theDischarge of Fire Safety Duties.

1.04 The use of risk based inspections read together with other Management Procedures andSOP’s on Fire Safety and/or Risk Management will allow the Fire Safety Inspectorate(FSI) to make consistent and fair enforcement decisions based on clear guidelines,which will be robust if challenged, and auditable when required.

1.05 There are three principle areas that will enable the fire service to manage the fire risk inthe community. These are:

1.06 The integrated approach recognizes that activity in one or more of these areas has thepotential to reduce the risk in the community. However in situations where it may notalways be possible to reduce the risk to an acceptable level using Statutory orCommunity Fire Safety initiatives, the information gathered will be used to provide anappropriate level of fire cover in terms of service response.

DETERMINING THE LEVEL OF RISK

1.07 The Risk Based Inspection Programme forms part of the Service’s overall integratedapproach to management by prioritizing the inspection of workplaces. It will initially benecessary to determine the level of risk in the workplace in question.

1.08 This will be determined by the carrying out of an on-site or remote audit, which will, oncompletion necessitate a risk rating.


4/18


1.09 The risk to individual persons will be of concern to Inspectors carrying out the audit;however it will be the potential for the loss of life or serious injury that will have a majorinfluence on the level of risk determined.

1.10 Whilst the risk to the employees and other persons that may be present is the primeinfluence. An assessment of the risk in the workplace and its inclusion in the inspectionprogramme can be made for a number of other purposes, such as:

• /

•

•

•

•

1.11 The findings of the audit process and any risk rating applied to a workplace will beinfluenced not only by life safety considerations but also the potential loss or risk to thecommunity.

1.12 When determining the risk presented by a particular workplace the following factors will

be considered. The following list is not exhaustive each must be assessed on anindividual basis using all relevant factors:

•

•

•

•

• ,

• /

• ( )

•

•

• •

•

•

•

•

•

•

•

: ,

.

1.13 When considering these factors it will also be necessary to utilize information fromcurrent firefighting practice. Current fire intelligence and a review of the historicalexperience of the premises will be taken into account before a final determination of riskrating can be made.


5/18


1.14 Professional judgement will be taken into account as part of the overall process.Examples might include:

• 5, . , .

,

.

•

, ,

.

.

1.15 An initial estimation of the levels of risk, for most occupancy types, can be undertakenaccording to variations in the following:

• /

• ,

•

1.16 Using the provision of active and/or passive fire safety systems that would normally beexpected in any particular occupancy type as the “bench mark” then the level of riskcould be varied as follows:

•

•

•

•

•

1.17 As increasingly sophisticated community risk models are developed to support IFSRMP,the audit process for a workplace must be compatible across all areas of fire service

activity, particularly a correlation between the levels of risk for a Fire Safety InspectionProgramme and the Risk Categorization Review Process (SANS 10090).

1.18 It is critical that at every stage the processes by which the levels of risk and the resultinginspection activity have been determined are reasonable, are recorded, transparent andauditable.

ASSESSMENT OF RISK: EMPLOYER RESPONSIBILITY

1.19 The risk from fire in the workplace should be assessed by the employer (either as part ofa general review of health and safety risks or as a specific exercise). The following

checks should be included:• ,

• ,

• ,

• ,

• , .


6/18


1.20 The Municipal Fire Safety By Law , Part C; Section 37 states that the Chief Fire Officermay designate certain premises as those requiring emergency evacuation plans.

1.21 Premises that are deemed to be of high fire or high population risk will usually bedesignated as such; and it will be required that such premises are scheduled for regularinspections as part of the continuous risk assessment of high risk occupancies.

1.22 In cases where premises have been designated to have emergency plans in place; theFSI is to ensure that such plans are up to date and that such plans are implemented bythe employer.


7/18


INTRODUCTION

2.01 The process for carrying out the fire safety inspection of workplaces in Breede Valley is

determined by the level of risk presented by those workplaces regardless of what otherlegislation might apply to them. The principle of audit will form the basis of theinspections.

2.02 Whilst the Table 1: Compliance levels/Risk Rating Matrix give general guidance ondetermining the level of risk for a workplace, that level can be varied according to localcircumstances such as:

•

•

•

•

• ,

( ).

THE 3-STEP FIRE SAFETY & RISK AUDIT PROCESS FOR WORKPLACES

2.03 As part of the integrated approach to Fire Safety & Risk Management; Departmentstrategy is to strengthen the working relationships between internal Divisions andSections as well as to ensure that other responsible Municipal Departments and externalagencies also play a meaningful role in this integrated approach.

2.04 To achieve this, a 3-Step Fire Safety Audit approach is utilized.

2.05 STEP 1- THE REMOTE AUDITa. A Remote Audit is done in office by gathering as much information about the

premises about to be formally inspected. Information is usually gathered from pastrecords, Building Control or Town Planning, or from external enforcementagencies.

b. The Remote Audit is further supported by the allocation of a “file” (i.e. internal orexternal request to conduct a specific audit of a premise.

c. On first allocation of a file or upon data collected, the FSI will carry out a remote

audit of the premises and apply an initial risk rating using Table 1: ComplianceLevel/Risk Rating Matrix.

d. This initial risk-rating will generally be equivalent to a medium risk (3) for therelevant purpose group column and will change accordingly once an actual FireSafety Audit (Regulatory Inspection) is conducted.


8/18


CL-5 Priority 1

CL-4 Priority 1-2

CL-3 Priority 2-3

CL-2 Priority 4

CL-1 Priority 4


9/18


2.06 STEP 2- OPERATIONAL PRE-FIRE PLANNING RISK VISITa. It is the responsibility of the Division: Fire Safety & Risk Management to generate

regular risk visits sheets for the Operations Division.

b. The Operational Risk Visits(ORV) Form must be generated as part of theCompany Routine for the month and must take into account the :

• Nature of risk

• Priority Code• Level of Complexity for Company /Platoon to handle.

c. The Company Officer must ensure that the ORV is carried out as per scheduleunless impractical to do so in terms of operational constraints.

d. Once complete the ORV must be signed and returned to FSRM together withany recommendations.

e. The ORV must be captured and filed in the FSRM.

2.07 STEP 3 - THE ON-SITE: REGULATORY FIRE SAFETY INSPECTION & AUDITa. The regulatory fire safety inspection is a process that is not wholly dependent on

Steps 1 and 2; as it also depends on the Priority Code allocated once a complaintis registered and may be conducted immediately by the Inspector.

b. However, regardless of whether the audit is done after Steps 1 and 2 or is doneas urgent following a Priority Code allocation; the Inspector will need to considerfire intelligence data concerning external factors, which may affect the overall riskprofile presented by the premises.

c. This audit of a workplace will be carried out using the

• Risk Evaluation Audit Data Form [READ ], and the

• Regulatory Fire Inspection Checklist as per occupancy classification.

d. The results of the workplace audit will determine the final risk rating. Indetermining the final Risk Rating, the Inspector must use Table 3: EnforcementExpectation.

This table may be used to provide additional guidance to the Inspector to verifythe correct risk rating is allocated during the course of any remote audit,operational risk visit or regulatory inspection.


10/18


DESCRIPTION

5

U N A C C E P T A

B L E

R I S K

High level risks

that have NO

control measures

and place life

/property at

immediate risk

from fire outbreak

• Dangerous conditions resulting inserious risk to persons in case of fire

Follow Up Audit Always Required ProhibitionNotice to

Cease Activity

4

S E R I O U S R I S K S T H A T R E Q U I R E

I M M E D I A T E

A T T E N T I O N

High level risks

that are lacking inadequate control

measures

Medium risks

that have no

effective control

measures

• Generally workplace risk rating veryhigh/high

• Serious deficiencies that requirestructural alterations

• Requirement for comprehensivemajor systems

• Poor management with numeroushigh/medium contraventions of fire

safety legislation.

• Disregard for fire safety issues withbad housekeeping and no risk

assessment or records of training or

testing.

• Following a fire where greateremphasis is required to address

deficiencies

• History of previous enforcement orinformal action

Follow Up Audit Always Required

Enforcement

Notice- FOTC

[ Final Order to

Comply on First

Inspection]

-OTC may range

from 24 hours to

7 days

3

R I S K S R E Q U I R I N G

A T T E N T I O N

Medium level

risks that are not

adequately

controlled

High level risks

that could bereduced further

by technology

• Generally workplace risk ratingmedium

• Numerous low level deficienciespossibly with history of other minor

issues

• Poor management evident andinspector has lack of confidence that

matters will be adequately

addressed

• History of previous enforcement orinformal action.

• Consider referral to Building Control ifappropriate

Follow Up Audit Always Required

Enforcement

Notice[ 1 st or 2nd OTC-

14 days with

possible

extension]

Notification ofFire Safety

Deficiencies


11/18


12/18


3.01 AUDIT PRINCIPLESThe following paragraphs are provided to give guidance on audit principles to those

Inspectors who may be unfamiliar with this type of inspection. Instruction on the carryingout of a fire safety audit can be found in the following sections of this Part.

a. The process of audit is designed to allow the Inspector to determine if the process orprocedure, subject to the audit, is in practice a true reflection of theory. It is the system,process or procedure that is subject to audit and not the people within that system,process or procedure. For example, the audit of staff training procedures will look at thesequence of events, detailed in writing, being performed in reality. If the procedurestates that ‘all staff will receive comprehensive fire safety training on a quarterly basis’,the Inspector will expect to see evidence that this is true. The efficiency with which thetask is completed may be of relevance but is not what the Inspector is looking for. Only ifthe task is not carried out will reasons be looked for.

b. The Fire Safety Inspector will start by looking at a system and frequency for review, toensure it is actually in place. Following this each element of the system will then bechecked, including the review process.

c. The important factors to be considered when on site are:• Establish that a system exists (policy or procedure)

• Check each element (hazard identification, risk assessment, controlmeasures, review)

• Only check samples (select particular components of each element)

• Check by observation and communication (look and listen for evidence,talk to persons)

•

Identify deficiencies (in the areas selected for audit)• Address deficiencies

3.02 THE FIRE SAFETY AUDITa. A fire safety audit is, as its title implies, an inspection that uses the principles of audit as

its base, but not as its sole methodology. The process of auditing a workplace,assessing risks and making enforcement decisions will embody the principles,expectations and methodology as contained in 1.05.

b. The Fire Protection Regulations and the Occupational Health & Safety Act, Act 85 of1993 are based upon the unequivocal responsibility of the employer to assess andmitigate the risk to those employees who could be affected by fire. It is not appropriate

for the Fire Service to provide a prescriptive solution as the sole means of addressingdeficiencies, except where communications have broken down and formal methods arenecessary.

c. It is important for Inspectors to recognize that any enforcement action taken must be firstverified against the Enforcement Expectation Table.

d. Any enforcement action must be detailed enough for the employer to act upon, and itmust make clear the required objective.


13/18


3.03 CONDUCTING THE AUDIT

3.03.1 Responsible Persona. The Inspectors initial objective is to identify the responsible person(s). In multi-

occupied premises the first point of contact should normally be the buildingmanager (owner and/or agent) who will normally have responsibility for the

building overall and in particular the common parts and common fire safetysystems.

b. Where possible at least 1 weeks’ notice should be given in writing prior tocarrying out a fire safety audit using a standard notification letter.

c. An individual employer’s responsibility for safety in the workplace extends beyondthe part(s) of the premises they occupy to a place of ultimate safety. This willinclude (as a minimum) some responsibility for the common parts.

d. In multi-occupied premises employers have a responsibility to co-operate witheach other and any other person who has control overall of the premises toensure adequate fire safety measures are in place. This process will inevitablyrequire action by the owner, as a person having control (and responsibility). It isnot acceptable for an individual employer in multi-occupied premises to simplytolerate inadequacies in the common parts of the premises on the basis that athird party has principal control.

3.03.2 Prior to the Inspectiona. Time must be taken to prepare for the audit. If the premises are known, then

careful research of the file should be undertaken.

b. Particular attention must be given to all factors that will affect the overall riskrating of the premises; these will include not only life risks but also those tofacilitate IFSRMP, compliance with parts of the current Building Regulations, fire-fighter safety and the effect of any fire in the premises on the environment.

Note: When an Inspector ’s competence prevents completion of any area,consultation with Fire Service Senior Management shall take place.

3.03.3 Employers Fire Safety Management Plan (or Equivalent)a. Every employer shall make arrangements as appropriate, having regard to the

nature of their activities and the size of their undertaking, for the effectiveplanning, organisation, control, monitoring and review of the preventive andprotective measures.

b. In order to develop and maintain the safety of the building and that of employeesand others expected to be there, the building management team should haveformulated and documented a fire safety strategy.

c. The workplace fire safety strategy may include a fire safety manual in whichtechnical specifications for all aspects of the workplace are included, i.e.:

• , ,

.


14/18


.

• .

• .

• .

• .

• .• .

• .

• .

• .

• .

• ,

.

3.03.4 Risk Assessment

a. The workplace fire safety audit should commence with an examination of the firesafety risk assessment and emergency plan. These documents underpin therationale for the fire safety strategies within the workplace. The Inspector mustuse professional judgement to form an initial view regarding the safety casepresented and decide to what extent these matters will require verification.

b. Past experience has shown that there are a considerable number of employerswho are unaware of their responsibilities to carry out a risk assessment.However, even where there is no risk assessment available most responsiblepersons do have a general, if incomplete or imprecise, understanding of theirresponsibilities for fire safety in the workplace. In many cases they may havetaken some action to meet these obligations.

c. In the absence of a written fire risk assessment, the Inspector must establishwhat, if any, control measures are in place. This will form the starting point for theaudit.

d. This process will enable the Inspector to gauge the extent of the employersunderstanding of their responsibilities and provide an opportunity to educate andinform. Understanding and acceptance of responsibility should be seen as one ofthe primary purposes of the fire safety audit.

3.03.5 Emergency Plan***Refer to Schedule 1 of the Fire Safety Bylaws

a. The responsible person should ensure that:• People in the workplace know what to do if there is a fire,

• the workplace can be safely evacuated,

• there is a written plan where five or more people are employed, and• the written plan is available for inspection by the fire authority.

b. In drawing up the emergency plan, the employer should take the results oftheir risk assessment into account. If the workplace is in a building, which isshared with other employers or occupiers, the emergency plan should be drawn


15/18


up in consultation with those employers and the owner(s) or other people whohave any control over any part of the building.

3.03.6 Documentationa. Any effective management system will be supported by a range of

documentation. The Inspector will inspect available documents to obtainevidence that effective systems are in place.

b. In addition to the written risk assessment this evidence should include theemergency plan, service records, staff training records, fire drill records and thecompany policies and procedures relating to fire. The inspection of documentsneed not be exhaustive; the Inspector should record those documents seen,including the date of each document. The aim is to establish the current position,raise management awareness and assist in forming a view about how detailedthe physical inspection of the workplace will need to be.

3.03.7 Verification of Standardsa. Verification is completed by a physical inspection of some or all of the workplace

to check compliance with the Regulations.

b. The extent of the verification will depend upon a number of factors but mustalways include the risk critical constituent and may include a sample constituent.

3.03.8 Risk Critical ElementThe fire safety audit will include a physical inspection of at least one of thefollowing parts of the building.

• Common parts and fire safety systems of multi-occupied premises

• Final exits• Protected/external staircases

• External routes

• Areas licensed for public entertainmentNote: Where major deficiencies are found in the sampled risk critical elements a

full inspection of all risk critical elements is to be made.

3.03.9 Sample Elementa. The selection of the sample element will follow when the risk critical constituent

has taken place.

b. By this stage the Inspector will have enough information to form a comprehensiveview regarding the standard of the workplace and must now exercise professional

judgement to decide the extent of the additional sample constituent to beinspected.

c. When making this decision Inspectors should include the areas that appear topresent the greatest risk.

d. In a single occupied building no further verification may be necessary.

e. When considering the sample to be inspected, Inspectors should take intoaccount any relevant history on the premises file. Particular account should be


16/18


taken of records that indicate a higher level of risk in a certain area of thepremises.

f. Where areas of high fire risk are noted during the risk critical element t theInspector may wish to include these in the sample constituent e.g. industrialkitchen, spray booth, highly flammable store, vulnerable occupants etc.

g. In a multi-storey single occupied premise where the risk profile is uniform, therecommended approach is to randomly sample enough floors to satisfy theprofessional judgement of the Inspector.

h. In multi-occupied buildings a different approach is required. Multi-occupiedbuildings will contain a number of individual premises, and as such a number ofemployers.

i. When carrying out a verification inspection, an audit of the workplace or areaswith the highest risk should be sampled but all individual workplaces are to bevisited in order to assess, educate and inform the employers. Part A of the D- READ form will be completed for each occupier.

j. If in the professional judgement of the Inspector, there remain areas of concernfollowing the sampling and verification process, a full top to bottom inspectionshould be carried out.

3.04 Risk Ratinga. As part of the fire safety audit process the Inspector will be required to decide the

workplace risk rating.

b. This rating will be used to determine the frequency of future fire safety audits.

c. The Inspector will use the information entered on the READ form and from theOccupancy Regulatory Inspection Form to determine the compliance level (1 to5). This compliance level is then applied to the Compliance Level/Risk RatingMatrix using the appropriate premises use group column to determine the initialrisk rating.

3.05 Educating and Informinga. Educating and Informing employers and others about their duties under the Fire

Protection Regulations and Municipal Fire Safety Bylaws is a fundamental part ofthe enforcement regime of Breede Valley Fire and Rescue Service.

b. In this context, educating and informing serves two purposes:

• To provide an initial level of enforcement activity where a premises givesno immediate cause for concern but no risk assessment has beencompleted.

• To provide an efficient method for dealing with a predictable need, i.e.lack of knowledge concerning responsibilities under the Regulations orBylaws


17/18


3.06 AFTER THE AUDITa. When the audit has been completed, the overall Compliance Level will be compared

with the Initial Enforcement Expectations which will offer the range of enforcementoptions to be considered.

b. A meeting with the responsible person is to be held where possible, to discuss theareas of non-compliance, and the possible enforcement options available.

c. Regardless of discussion and arrangements made, the appropriate Order To Complymust be issued if there are any non-compliances.

d. Just as important as enforcement action, encouragement should also be given forcompliance. If appropriate, observations should also be made to encourage theprocess of continuous improvement.

e. The Inspector will, on return to the fire safety base, ensure that appropriate recordsare filed and that all information pertaining to the audit and inspection is capturedand appropriately filed; and that follow up dates are programmed.


18/18

Breede Valley Fire & Rescue Service dcn BVFD MPr FS ENF RBI 05 01 01R Page 18 of 18

HSE - Risk Based Inspection Programme

Documents

Transcript of HSE - Risk Based Inspection Programme