Policy Directive

Fire Safety in Health Care Facilities

Summary This policy statement and the attached guide outlines the legal requirements to be met
by public health facilities in relation to fire safety in hospitals and other related care
facilities to ensure compliance with State fire safety requirements.
Document type Policy Directive
Document number PD2010_024
Publication date 27 April 2010
Author branch Business and Asset Services
Branch contact 9424 5867
Review date 30 June 2018
Policy manual Not applicable
File number 08/549
Previous reference N/A
Status Review
Functional group Corporate Administration - Asset Management
Personnel/Workforce - Occupational Health and Safety
Applies to Area Health Services/Chief Executive Governed Statutory Health Corporation, Board
Governed Statutory Health Corporations, Affiliated Health Organisations, Affiliated
Health Organisations - Declared, Public Health System Support Division, Community
Health Centres, Dental Schools and Clinics, NSW Ambulance Service, Public Health Units,
Public Hospitals
Distributed to Public Health System, NSW Ambulance Service, Ministry of Health, Private Hospitals and
Day Procedure Centres
Audience Administration;Chief Executives;Directors;Boards

Secretary, NSW Health

This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory
for NSW Health and is a condition of subsidy for public health organisations.
 POLICY STATEMENT

FIRE SAFETY IN HEALTH CARE FACILITIES

PURPOSE
This policy statement and the attached guide outlines the legal requirements to be met
by public health facilities in relation to fire safety in hospitals and other related health
care facilities to ensure compliance with state fire safety requirements. The attached
guide reflects new models of fire safety management and clarifies ongoing roles and
responsibilities for health facility management.

MANDATORY REQUIREMENTS
Chief Executives, owners, operators and/or boards of private and public health care
organisations are personally accountable and have a duty of care for maintaining a safe
environment for employees, patients and members of the public in their health facilities
under legislation as detailed in section 3 of the attached guide.

It is imperative that chief executives, owners, operators and/or boards have effective
monitoring systems to ensure their legislative obligations as set out in this policy are
implemented and maintained in every facility under their control.

IMPLEMENTATION
This Policy Directive must be implemented in all NSW public health facilities.
NSW private hospitals and day procedures centres and other health and aged care
organisations may choose to use the attached guide as their industry standard where
no other industry specific policies apply.

Roles and Responsibilities

Health Facility managers are responsible for:

 Ensuring the routine maintenance, repair and testing of all fire safety measures
installed in their buildings (section 3.3.4 )
 Annual Fire Safety Statements are completed (section 3.3.4)
 Fire Safety education requirements for Fire Safety Officers and Fire Safety
Managers are met (sections 7 and 8)
 Annual Fire Safety Education is provided for all employees (section 8) this
includes evacuation exercises; use of fire fighting equipment; maintaining a safe
working environment.

All employees have an obligation to familiarise themselves with all fire emergency
equipment and facilities with their workplace and participate in the annual fire safety
education program.

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 POLICY STATEMENT

REVISION HISTORY
Version Approved by Amendment notes
April 2010 Deputy Director-General Rescinds PD2009_062
(PD2010_024) Health System Support The revised policy Guide provides greater clarity in the
operational management process of Fire Safety in
Health Care Facilities with amendments to sections
3.3.4; 4.1.2; 7.5 & 13.1
September 2009 Deputy Director-General Rescinds PD2005_336, GL2005_047, IB2005_015
(PD2009_062) Health System Support and Fire Evaluation Reporting System (FERS).
Updates and clarifies the minimum requirements of
Fire Safety in health facilities
December 2003 Director-General Guidelines for healthcare personnel in relation to fire
(PD2005_336) safety in health care facilities

ATTACHMENT
1. Fire Safety in Health Care Facilities Guide

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Issue date: April 2010

PD2010_024
Fire Safety in Health Care Facilities
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TABLE OF CONTENTS
1 INTRODUCTION .................................................................................................................. 1
2 DEFINITIONS ....................................................................................................................... 1
2.1 FSO .............................................................................................................................. 1
2.2 FSM .............................................................................................................................. 1
2.3 Shall ............................................................................................................................. 1
2.4 Should .......................................................................................................................... 1
3 LEGISLATIVE OBLIGATIONS ............................................................................................ 1
3.1 PRIVATE HOSPITALS AND DAY PROCEDURE CENTRES ACT 1988 ...................... 1
3.2 OCCUPATIONAL HEALTH AND SAFETY (OHS) ACT 2000 AND REGULATION
2001, as amended ................................................................................................................ 2
3.3 ENVIRONMENTAL PLANNING AND ASSESSMENT ACT 1979 (EP&A Act)............... 2
3.3.1 Fire Safety Orders ............................................................................................. 2
3.3.2 Smoke Alarms ................................................................................................... 2
3.3.3 Compliance Certification.................................................................................... 2
3.3.4 Procedures for Seeking Dispensation................................................................ 3
3.3.5 Annual Fire Safety Statements .......................................................................... 5
4 BUILDING FIRE SAFETY - REVIEW PROCESS ................................................................. 6
4.1 PUBLIC AND PRIVATE HEALTH CARE FACILITIES .................................................. 6
4.1.1 Healthcare Buildings (as defined by the BCA) ................................................... 6
4.1.2 Non-Healthcare Buildings where occupants sleep, including Class 1b, 2, 3, 4
and 9c........................................................................................................................... 6
4.1.3 Leased Premises, Public/Private Partnerships .................................................. 6
4.1.4 Review Resources ............................................................................................ 6
5 FIRE SAFETY AND EMERGENCY RESPONSE PROCEDURES ..................................... 10
5.1 Emergency Response Procedures Standards ............................................................ 10
5.2 Emergency Response Procedures Format ................................................................. 10
5.3 Emergency Response Assessment ............................................................................ 10
6 FIRE SAFETY ROLES ....................................................................................................... 12
6.1 EMPLOYEES ............................................................................................................. 12
6.2 EMERGENCY COORDINATORS............................................................................... 12
6.3 FIRE SAFETY PERSONNEL ...................................................................................... 12
6.3.1 Facility Classifications ..................................................................................... 12
6.3.2 Personnel Thresholds ..................................................................................... 12
6.3.3 Position Requirements and Risk Assessment ................................................. 13
6.3.4 Exempt Facilities ............................................................................................. 13
6.4 NATIONALLY RECOGNISED TRAINING STANDARDS ............................................ 13
7 FIRE SAFETY EDUCATION REQUIREMENTS ................................................................. 14
7.1 FIRE SAFETY OFFICERS (Previously FSO1) ............................................................ 14
7.2 FIRE SAFETY MANAGERS (Previously FSO2) ......................................................... 14
7.3 FIRE SAFETY OFFICERS/MANAGERS (EDUCATOR) ............................................. 14
7.4 RECERTIFICATION ................................................................................................... 15
7.5 UTILISATION OF PRIVATE TRAINING PROVIDERS ................................................ 15

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8 ANNUAL FIRE SAFETY EDUCATION .............................................................................. 16

8.1 THEORETICAL .......................................................................................................... 16
8.2 PRACTICAL USE OF FIRE FIGHTING EQUIPMENT ................................................ 16
8.3 EVACUATION EXERCISES ....................................................................................... 16
9 HOT WORK PERMITS ....................................................................................................... 17
9.1 CLASSIFICATION ...................................................................................................... 17
9.2 DURATION ................................................................................................................. 18
9.3 APPLICABLE STANDARDS ....................................................................................... 18
10 FIRE EXTINGUISHERS ..................................................................................................... 18
11 FIRE SAFETY ADVISORY SERVICES .............................................................................. 19
11.1 FIRE SAFETY EDUCATION....................................................................................... 19
11.2 BUILDING REGULATIONS ........................................................................................ 19
12 APPENDIX 1 ...................................................................................................................... 19
12.1 REFERENCES ........................................................................................................... 19
12.2 NSW HEALTH POLICIES INCLUDING BCA/FIRE RELATED (CIRCULARS)
POLICY DIRECTIVES, INFORMATION BULLETINS AND GUIDELINES .......................... 20
13 APPENDIX 2 ...................................................................................................................... 20
13.1 ALIGNMENT OF HEALTH CARE FIRE SAFETY COMPETENCIES .......................... 20
14 APPENDIX 3 ...................................................................................................................... 21
14.1 SAMPLE FIRE SAFETY OFFICER POSITION DISCRIPTION ................................... 21
15 APPENDIX 4 ...................................................................................................................... 21
15.1 SAMPLE FIRE SAFETY MANAGERS POSITION DISCRIPTION .............................. 21
16 APPENDIX 5 ...................................................................................................................... 22
16.1 WHAT TO DO IN THE EVENT OF A FIRE ................................................................. 22
17 APPENDIX 6 ...................................................................................................................... 25
17.1 PROCEDURAL GUIDELINES FOR THE PREPARATION OF ANNUAL FIRE
SAFETY STATEMENTS ..................................................................................................... 25
17.1.1 Background Requirements .............................................................................. 25
17.1.2 Procedures: ..................................................................................................... 25
17.2 ANNUAL FIRE SAFETY STATEMENT (AFSS) APPENDIX 6.1.................................. 26
17.3 ATTACHMENT TO AFSS – FIRE SAFETY MEASURES APPENDIX 6.2 .................. 28
17.4 ATTACHMENT TO AFSS – BUILDING CERTIFICATION APPENDIX 6.3 .................. 29
18 APPENDIX 7 ...................................................................................................................... 30
18.1 EXTRACT FROM ENVIRONMENTAL PLANNING AND ASSESSMENT
REGULATION 2000 ........................................................................................................... 30
19 APPENDIX 8 ...................................................................................................................... 32
19.1 WORKPLACE FIRE SAFETY INSPECTION .............................................................. 32

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1 INTRODUCTION
Chief executives, owners, operators and/or boards of private and public health care
organisations are personally accountable and have a duty of care for maintaining a safe
environment for employees, patients and members of the public in their health facilities.
The requirements specified in this document provide information for organisations to assist
them to meet their obligations. It is therefore imperative that chief executives, owners,
operators and/or boards have effective monitoring systems to ensure the requirements set
out in this Policy Directive are implemented and maintained in every facility under their
control.
The purpose of this document is to outline minimum requirements pertaining to fire safety
in hospitals and other related health care facilities, ensure compliance with state fire safety
requirements, reflect new models of fire safety management and clarify ongoing roles and
responsibilities.
This Policy Directive applies to:
- All NSW government public health and associated organisations.
- All NSW private hospitals and day procedures centres.
- Other health and aged care organisations may use this document as their industry
standard where no other industry specific policies apply.

2 DEFINITIONS
2.1 FSO
A Health Care Fire Safety Officer as specified in Sections 5 & 6 of this document.
Previously called a Fire Safety Officer Level 1.
2.2 FSM
A Health Care Fire Safety Manager as specified in Sections 5 & 6 of this document.
Previously called a Fire Safety Officer Level 2.
2.3 Shall
Indicates a mandatory action required that must be complied with consistent NSW
Health policy, law or industrial instrument.
2.4 Should
Indicates a recommended action that should be followed unless there are sound
reasons for taking a different course of action.

3 LEGISLATIVE OBLIGATIONS
3.1 PRIVATE HOSPITALS AND DAY PROCEDURE CENTRES ACT 1988
Fire Safety in Private Hospitals and licensed Day Procedure Centres is the
responsibility of the licensee. The Department has the responsibility for monitoring
and ensuring compliance with licensing standards as set out in the Private Hospitals
and Day Procedure Centres Act 1988 and Private Hospitals Regulation 1996 and
Day Procedure Centres Regulation 1996. All these provisions will in time be
replaced by the Private Health Facilities Act and regulations under that Act.

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3.2 OCCUPATIONAL HEALTH AND SAFETY (OHS) ACT 2000 AND

REGULATION 2001, as amended
Fire safety is a part of an OHS management system. Induction and ongoing
training of employees is a requirement of the OHS Regulation. The OHS Act and
Regulation refers to controllers of premises obligations to ensure that their premises
are safe. Refer to the Workplace Health and Safety: Policy and Better Practice
Guide – NSW Health, PD2005_409.

3.3 ENVIRONMENTAL PLANNING AND ASSESSMENT ACT 1979 (EP&A Act)

3.3.1 Fire Safety Orders

The EP&A Act permits Councils and the NSW Fire Brigades to issue a range of
orders in respect of fire safety issues, including orders to cease activities at
premises.

3.3.2 Smoke Alarms

The Environmental Planning and Assessment Amendment (Smoke Alarm)
Regulation 2006 makes it compulsory for smoke alarms to be fitted in all new and
existing homes and other buildings were people sleep. These include private and
public hospitals, nursing homes, hostels etc.
Further information on the requirements for smoke alarms is available from the
Department of Planning at http://www.planning.nsw.gov.au/. For enquiries phone the
Smoke Alarm Helpline on 1300858812 or email [email protected].

3.3.3 Compliance Certification

(1) Development consent is to be obtained from local Council for the erection of
buildings. Issues relating to fire safety are usually included in consent
conditions and a record of the conditions shall be retained on file for reference.
Note that for Crown development conditions cannot be imposed without the
written approval of the Minister or the applicant (replaced 2008 Act no. 36).
Section 89 of EP&A Act.
(2) For other than crown development, construction certificates are to be obtained
from the Project Manager and held on file at the relevant facility.
(3) For Crown development, in accordance with section 109 R, of the EP&A Act,
prior to commencement building work shall be certified to comply with the
technical provisions of the NSW building laws (Building Code of Australia
(BCA) as amended for NSW and referenced Australian Standards). Note
certification shall include referenced plans, schedules and other design
documents. The certification needs to apply to the final construction drawings
noting that design documentation may be a staged process for capital
development.
(4) When a development application is lodged for rebuilding, alteration,
enlargement or extension of an existing building the consent authority may
impose requirements for the building to be upgraded if:
a) The proposed building work, together with any other building work
completed or authorised within the previous 3 years, represents more than

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half the total volume of the building, as it was before any such work was
commenced, measured over its roof and external walls, or
b) The measures contained in the building are inadequate:
i) To protect persons using the building, and to facilitate their egress
from the building, in the event of fire, or
ii) To restrict the spread of fire from the building to other buildings
nearby.
(5) In determining a development application to which this clause applies, a
consent authority is to take into consideration whether it would be appropriate
to require the existing building to be brought into total or partial conformity with
the BCA. (See clause 94(2) of the Environmental Planning and Assessment
Regulation 2000 (EP&A Reg 2000) and note that for Crown development
conditions cannot be imposed without the written approval of the Minister or
the applicant (section 89 of the EP&A Act).
(6) The requirement and method for a development application to be submitted
will need to be checked with the local council.
(7) Prior to the occupation of new or refurbished facilities, an occupancy certificate
or, in the case of Crown development, certification of the completed building’s
compliance with the NSW building laws (BCA as amended for NSW and
referenced Australian Standards) shall be obtained from the Project Manager
and held on file at the relevant facility. Note certification will be more than a
single statement and shall include plans, schedules and manuals of individual
certification documents.
(8) Included with the above documents there shall be a list of requirements for
maintaining fire safety at the facility (a Fire Safety Schedule under clause 168
and a Fire Link Conversion Schedule under clause 168A(4) of the EP&A Reg
2000); a Final Fire Safety Certificate; and documentation on any performance
based solutions utilized in the development.
(9) A copy of the Fire Safety Schedule shall be displayed in a prominent location
within the facility.
(10) A copy of the Fire Safety Schedule shall be forwarded to the NSW Fire
Commissioner and the local Council.

3.3.4 Procedures for Seeking Dispensation

In circumstances where organisations wish to seek dispensation from meeting
recommendations relating to compliance with the current edition of the BCA they
should, in the first instance, contact the local Council. Rights of appeal are
available through the Land and Environment Court.

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BUILDING FIRE SAFETY COMPLIANCE CERTIFICATION

Section 2.3 Compliance Certification & Development Consent

Liaise with the relevant local government authority to determine the zoning status of
the land. Note that development consent may not be required where hospital
specific zoning exists under old an old Town Planning Scheme which preceded the
EP&A Act (See PD2005_036)

Liaise with the relevant local government authority to determine if development

consent is required under their Local Environment Plan

Address the impact of Clause 94 of the EP&A Regulation on projects involving

rebuilding, alteration, enlargement or extension of an existing building. This will
require reference to any fire safety deficiencies identified in the building's Fire Safety
Review Report and may require specialist advice from a properly qualified person as
defined by sections 4.1.1, 4.1.2 and 4.1.3.

Development Application Development Application

Necessary Not Necessary

Lodge Development Application Provide Certification of Compliance

(Note requirements of NSW Health with the State's building laws (BCA
PD2005_036) as amended for NSW and
For projects involving rebuilding, referenced Australian Standards)
alteration, enlargement or extension and for renovations and additions to
of an existing building a report existing buildings, a report showing
addressing the requirements of measures contained in the building
Clause 94 of the EP&A Regulation are adequate to protect persons
should be included. using the building, and to facilitate
their egress from the building in the
event of a fire from the building or
to restrict the spread of fire from the
building to other buildings.

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3.3.5 Annual Fire Safety Statements

(1) An Annual Fire Safety Statement is a statement issued by the owner of a
building or his agent. The statement is written confirmation that fire safety
measures installed in the building have been inspected by a properly qualified
person and found to be capable of performing to the standard to which they
were installed. Fire safety measures are incorporated into the building to
safeguard the building and its occupants in the event of a fire.
(2) Fire safety measures are those measures included on a Fire Safety Schedule
(issued under clause 168 of the EP&A Reg 2000). Where no Fire Safety
Schedule exists for the building a schedule is to be obtained from local Council
or an Accredited Certifier with the Building Professionals Board with the
appropriate level of accreditation for the class of building and performance
requirements included with the building or Accredited Building Surveyors with
the Australian Institute of Building Surveyors.
(3) Facility Managers are responsible for ensuring that the Legislative routine
maintenance, repair and testing of all fire safety measures installed in their
building(s) has been carried out and documented by competent persons to
ensure it is capable of performing to a standard no less than that specified in
any applicable fire safety schedule or to a standard no less that to which the
measure was originally designed and implemented.
(4) In accordance with Part 9, Clause 175 of the EP&A Reg 2000, an Annual Fire
Safety Statement is to be issued by or on behalf of the owner or agent of a
building.
(5) The essential fire safety measures are measures incorporated into the design
of the building that assist to safeguard the building and its occupants in the
event of a fire. The combination of essential fire safety measures and the
annual fire safety statement are designed to ensure that the measures perform
to their operational/installation standard (Clause 182 of EP&A Regulation –
Requires Maintenance).
(6) Part 9, Clause 177, of the EP&A Regulation 2000, requires a copy of the
Annual Fire Safety Statement to be displayed in a prominent location within
the facility and a copy to be submitted to the Local Council and the
Commissioner of the New South Wales Fire Brigade. Local Council has the
power under the EP&A Act to require full compliance with this requirement.
This power extends to all existing buildings, not necessarily undergoing
refurbishment.
(7) Health-care organisations shall ensure Annual Fire Safety Statements are
issued, displayed and forwarded as above for each building they own. They
should also obtain a copy of the Annual Fire Safety Statement for any building
that they operate services from, or locate staff or clients at, that they do not
own.
(8) Refer to Appendix 6, Procedural Guidelines for the preparation of Annual Fire
Safety Statements, for further assistance.

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4 BUILDING FIRE SAFETY - REVIEW PROCESS

4.1 PUBLIC AND PRIVATE HEALTH CARE FACILITIES
4.1.1 Healthcare Buildings (as defined by the BCA)
A regular review of building fire safety requirements in accordance with the
technical provisions of the NSW building laws shall be conducted for each health-
care building. The review shall also include building fire safety requirements in
accordance with the legislation applicable at the time of construction or any of any
subsequent renovations, additions or upgrading works. The report shall include
recommendations for improvement clearly identifying those required for compliance
with the relevant legislation. The frequency of the review may be determined by an
accreditation or licensing body but shall not be less than four years.
4.1.2 Non-Healthcare Buildings where occupants sleep, including Class 1b, 2, 3, 4
and 9c.
A regular review of building fire safety requirements in accordance with the
technical provisions of the NSW building laws should be conducted for each
building in which people sleep. The review should include building fire safety
requirements in accordance with the legislation applicable at the time of
construction or any of any subsequent renovations, additions or upgrading. The
report should include recommendations for improvement clearly identifying those
required for compliance with the relevant legislation. The frequency of the review
may be determined by an accreditation or licensing body but should not be less
than four years.
4.1.3 Leased Premises, Public/Private Partnerships
It is the responsibility of the health care organisation occupying a building, to ensure
that the regular review of building fire safety requirements is undertaken in line with
this section. This clause does not exempt building owners from their responsibility
under NSW law in relation to fire safety in their building. Occupiers and owners
must ensure that there is clear delineation of responsibility relating to this matter in
leases, contracts, agreements, etc.
4.1.4 Review Resources
a) One of the following resources shall be utilised:
i) NSW Fire Brigades - Structural Safety Unit Phone: (02) 97427400.
ii) The Building Department of Local Council.
iii) Private Building Consultants that are Accredited Certifiers with the Building
Professionals Board with the appropriate level of accreditation for the class
of building and performance requirements included with the building or
Accredited Building Surveyors with the Australian Institute of Building
Surveyors.
b) EP&A Act, BCA and referenced Australian Standards identify minimum
standards of fire safety and are subject to regular review and change. Issues of
non-compliance that have been identified may be brought to notice either:
i) Through an involuntary process which may involve local council or the NSW
Fire Brigades Structural Safety Unit issuing Fire Safety Orders, or

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ii) A proactive approach whereby management initiates a review process.

c) Identified deficiencies should, where possible, be acted upon immediately.
However, immediate action to rectify deficiencies may not be possible. If
necessary, required works will need to be prioritised to reflect two primary
factors:
i) Nature and use of the building including circumstances of the occupants.
ii) Nature of the works to be undertaken.
d) Matters which provide higher life safety to occupants should have a higher priority
than matters related to property protection.
e) A regular review of building fire safety requirements in accordance with relevant
legislation should be conducted at all health and associated facilities covered by
section 4.1.1 & 4.1.2. The frequency of the review would normally be
determined by an accreditation or licensing body. In all other cases, 4 years
would be considered a reasonable frequency. The following resources may be
used:
i) NSW Fire Brigades - Structural Safety Unit Phone: (02) 97427400.
ii) The Building Department of Local Council.
iii) Private Building Consultants that are Accredited Certifiers with the Building
Professionals Board with the appropriate level of accreditation for the class of
building and performance requirements included with the building or
Accredited Building Surveyors with the Australian Institute of Building
Surveyors.
f) The approach taken in reviewing a facility may vary but will generally follow one
or a combination of the following:
i) A prescriptive approach that directly compares building circumstance against
requirements deemed to satisfy provisions of the Codes, Regulations and
Australian Standards with the resultant recommendations reflecting those
provisions.
ii) A performance based assessment of building circumstances against the
intent and objectives of the BCA. In this case the recommendation will reflect
the specific need and function of the facility. Performance assessments shall
only be undertaken by building consultants that are accredited, with the
Building Professionals Board or with the Australian Institute of Building
Surveyors, to undertake performance assessments for the particular class of
building. Any modifications to a building which has performance-based
solutions shall undergo a full reassessment to ensure the performance
standards of the original design are not compromised.
g) Organisations shall develop action plans for each facility utilising suitably
qualified fire safety/engineering personnel and where necessary private building
consultants. Action plans need to show each item identified deficient in the
survey, its priority, cost estimates, time frames, proposed funding source and
the person responsible for the rectification. Priorities and time frames should be
justified with supportive documentation utilising the organisation’s risk rating
methodology.

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Action plans need to clearly identify whether each item is required for
compliance with the technical provisions of the NSW building laws or is a
recommendation for compliance with the current edition of the BCA. The later
items are to be a lower priority as per Australian Standard AS/NZS 4360 Risk
Management.

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BUILDING FIRE SAFETY – REVIEW PROCESS FLOW CHART

Section 4; Building Fire Safety – Review Process

Building fire Safety Review Report

Recommendations separately identified those require for compliance with:

- State building laws
- Current edition of BCA

Prepare Action Plan with Deemed-To-Satisfy or Performance Based Solutions to

recommendations

Prioritise action plan utilising Consider seeking dispensation for

organisational risk rating methodology recommendations where Deemed-To-
with higher priority to actions related Satisfy and/or Performance Based
to compliance with State building laws Solutions are overly onerous or where
there is no practical solution

Complete Actions in order of priority Prepare report with clear statement

that dispensation will not put at risk
the safety of persons who occupy the
building

Seek dispensation through local

Council

Report Progress on Action Plan Report progress with dispensations on

Action Plan

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5 FIRE SAFETY AND EMERGENCY RESPONSE PROCEDURES

5.1 Emergency Response Procedures Standards
All buildings shall have formalised fire safety and emergency response procedures.
These procedures shall be designed around the special needs of the facility
concerned. The procedures should be reviewed at least annually and as required
and where necessary updated to reflect any changes to installed systems,
emergency response protocols or regulatory change. Procedures shall comply with:
i) Australian Standard (AS4083) - “Planning for Emergencies - Health Care
Facilities” for Classes 9a, 9c and 3 used as aged care and/or
ii) Australian Standard (AS3745) “Emergency control organisation and
procedures for buildings, structures and workplaces” for all other facilities.
5.2 Emergency Response Procedures Format
Procedures will generally take two forms:
i) A detailed document containing aims, objectives, building systems/information,
roles and responsibilities, evacuation procedures and so on applying to both
fire and other internal emergencies as identified in the Australian Standards.
Suitable numbers of the document should be provided so that all employees
have ready access to the information.
ii) A summary flip chart or poster providing brief detail on fire emergency
responses as well as other internal emergencies and which is colour coded to
accord with the requirements outlined in the Australian Standard AS 4083
“Planning for Emergencies - Health Care Facilities”
Fire/Smoke Red
Medical Emergency Blue
Bomb Threat Purple
Internal Emergency Yellow
Personal Threat Black
External Emergency Brown
Evacuation Orange
Copies of the flip chart should be displayed at each staff station and throughout
the facility for easy access by employees.
5.3 Emergency Response Assessment
(1) In New South Wales the acronym RACE is a generally accepted term for
assessing the initial fire emergency response:

Remove (persons in immediate danger if safe to do so)

Alert (Inform occupants and facilities emergency number)
Confine (the fire and smoke by closing all doors if safe to do so on exit)
Extinguish (the fire if safe to do so)

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The above actions should, depending on the availability of employees, be

undertaken simultaneously or in an order that provides for the highest level of
life safety.
(2) Attached at Appendix 5 is a minimum model that may be used as a guide when
developing localised emergency response procedures in Health Care Facilities.
(3) For assistance in developing Emergency Response Procedures, advice should
be sought from the following sources:
i) Persons currently qualified as a Fire Safety Manager; and
ii) The New South Wales Fire Brigades ComSafe Training Services.
(4) In addition to written procedures, all facilities shall have wall mounted localised
evacuation diagrams giving a graphical representation of a floor or area of a
facility, shall be legible and in produced in colour.
(5) The diagram shall be at least A4 (210 x 297 mm) in size. If any additional
information is included, then the minimum size of the whole sign shall be A3
(297 x 42 mm) in size.
Evacuation diagrams shall display the following minimum elements:
• Titled ‘Evacuation Diagram’
• Exit routes and exit points
• Fire and smoke doors
• Manual and emergency call points
• Firefighting equipment (Incl type)
• Fire alarm indicator and mimic panels
• EWIS panel and WIP phones
• Assembly areas
• You are here reference point
• A legend
Optional elements:
• Site plan
• First aid stations/kit
• Hazardous chemical/flammable liquid store
• Spill response kits
• Isolation valves
• Hydrant systems
(6) Evacuation diagrams are to be properly orientated to avoid any confusion in
interpreting displayed information. Evacuation diagrams are to be located at
each nurse’s station, reception area and in highly visible locations throughout
facilities.
(7) In the event of a fire or emergency occurring, CE/Facility Managers are
reminded of their obligation under NSW Health Policy Directive PD2007_061,
Incident Management Policy that under Section 7, Reportable Incident Briefs
(RIB) Fire is listed in 7.1.2 Corporate and a RIB is required for a fire incident.
(8) Licensees of private health facilities are reminded of their obligations under the
relevant licensing legislation

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6 FIRE SAFETY ROLES

The management of fire safety at Area Health Service level is typically a function of
Asset management/Facility management and or Risk management business areas.
Further information with respect to specific roles and responsibilities are outlined
below.

6.1 EMPLOYEES

Employees have an obligation under the Occupational Health & Safety Act to
familiarise themselves with all fire emergency equipment and facilities within their
workplace and participate in the annual fire safety education program.

6.2 EMERGENCY COORDINATORS

Emergency coordinators are those employees that as a part of their normal duties
attend and take the lead role at fire and other emergencies at their place of work in
line with AS 3745 and AS4083. These standards give different titles to those in
charge during an emergency. The roles are essentially the same for Chief Wardens
AS3745 and Emergency Coordinators AS4083.
These personnel are to undergo additional education from an appropriately qualified
person as outlined in Appendix 2.
A Fire Safety Officer/Manager if on site at the time of a fire or other emergency
would assist by providing information and advice to the Emergency Coordinator.
However, the Emergency Coordinator is the person with overall control of the
facilities’ emergency management organisation. The above does not preclude the
Fire Safety Officer/Manager from acting in the role of Emergency Coordinator when
they are on site and officially appointed by the facilities management to perform this
role.

6.3 FIRE SAFETY PERSONNEL

6.3.1 Facility Classifications

Facilities, incorporating Patient/Resident Care (Class 9a, Class 9c or Class 3 used
for aged care occupancies as defined by the BCA) shall appoint a member of their
permanent employees to act as the site’s Fire Safety Officer/Manager. Generally,
the number of employees that the Fire Safety Officer/Manager is required to train
annually, the size and nature of facilities and their occupancy (ie Nursing Home,
Major Hospital, Day Stay Unit) will determine the level of fire safety related
experience required, the number of and whether the role/s should be full time or as
part of other duties of a permanent employee.
6.3.2 Personnel Thresholds
The thresholds at which the level and time commitment of fire safety personnel in
each facility needs to be identified. The following indicates the methodology an
organisation could use to determine the level of expertise their facilities may require:
< 1,000 Employees - Part Time FSO,
> 1,000 Employees - Part Time FSM,

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> X,XXX Employees - Full Time FSM and X FSO’s

> XX,XXX Employees - X Full Time FSM’s and X FSO’s
6.3.3 Position Requirements and Risk Assessment
FSO/M position requirements are determined through a risk assessment process
which as a minimum takes into consideration the following:
o Number of employees
o Educational expectations
o Number of facilities
o Physical size and complexity of buildings
o Geographic location of employees and facilities etc.
The appointed Fire Safety Officer/Manager will perform the duties as outlined in
Appendices 3 and 4. These duties should be included in the employee’s Job
Description/Statement of Duties. Salary levels for Fire Safety Officers/Managers
are determined in the Health Employees (State) Award.
6.3.4 Exempt Facilities
Facilities where there is no provision of Patient/Resident Care are not required to
appoint a site Fire Safety Officer/Manager. Examples of these are: Community
Health Centres, Administrative Offices, Warehouses, Linen Services and the like. A
person from these facilities shall be appointed to oversee in the event of an
evacuation and be appropriately trained. (OHS Regulations 2001 Chapter 2
Section 17). Annual fire safety training in line with this Policy Directive is required to
be conducted for all employees. Components related to patient/resident care areas
may be omitted.
The above does not remove the requirement for an Emergency Control
Organisation in line with AS 3745 in all facilities and services.

6.4 NATIONALLY RECOGNISED TRAINING STANDARDS

(1) This document specifies that the fire safety education training should be
aligned with the nationally recognised training standards. The intention of
including these standards is to provide a framework to guide educators.
Compliance with meeting the competencies or time frames is not required.
(2) In relation to general employee education, the standards specified in Appendix
2 do not increase the content requirement of existing health care fire safety
education. It is an alignment of the current content with the relevant Public
Safety Training standards.
(3) The new role of emergency coordinator equates to the position of Chief
Warden specified in Australian Standard AS3745. The additional level of
education specified for this role meets that standard.
(4) Persons who are currently appointed/employed, as Health Care Fire Safety
Officers/Managers do not have to upgrade their current training qualifications.
Any adjustments to Fire Safety Officers/Managers levels of competence with
the standards will be addressed at their 3 yearly re-certification.

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7 FIRE SAFETY EDUCATION REQUIREMENTS

To ensure an informed and standard approach to fire safety advice and training in
NSW health care facilities, appointed Fire Safety Officers are to attend either a Fire
Safety Officer (FSO) or Fire Safety Manager (FSM) training program provided by:
• Suitably qualified Fire Safety Manager (See Appendix 2)
• NSW Fire Brigades’ ComSafe Training Services.
• A private provider as outlined in Sect 7.5

Sample Duties Statements are included at Appendix 3.

7.1 FIRE SAFETY OFFICERS (Previously FSO1)

(1) FSO training is attended by employees with limited or no fire safety experience
and who are fulfilling a secondary appointment role. Appropriate for smaller
facilities or at a department level in a large facility. The smaller facility may
rely on specialist advice and support through their Area Health Service’s or
organisation’s Fire Safety Manager. In the absence of these, NSW Fire
Brigades’ ComSafe Training Services or a commercial fire safety consultants
should conduct the training (refer to sect 7.5).
(2) A FSO training program should be aligned with the nationally recognised
Standards as outlined in Appendix 2.

7.2 FIRE SAFETY MANAGERS (Previously FSO2)

FSM shall meet the National Competency Standards as outlined in Appendix 2.

(1) Fire Safety Manager training is attended by an employee or private provider

who has had considerable fire safety management experience and/or
qualifications. See Appendix 2. This training program is designed for
employees, working in health care facilities, who have a full time or part time
fire safety management role or is a private provider. Participants would be
expected to be able to demonstrate previous experience in a professional fire
safety management role (Fire Brigade, Fire Safety Consultant) or have
completed FSO fire safety training and had at least one year’s practical
experience in the FSO role. This qualification is appropriate for larger
facilities, major hospitals and health service organisations, which require
ongoing specialist fire safety management skills.
(2) Providers of FSM training shall meet the National Competency Standards as
outlined in Appendix 2. If using outside providers they shall meet the
requirements of Sect 7.5

7.3 FIRE SAFETY OFFICERS/MANAGERS (EDUCATOR)

(1) Prior to performing face-to-face education, the educational requirements of
FSO and FSM should be aligned to those outlined in Appendix 2.
(2) Fire Safety Officers (Educator) are permitted to deliver fire safety training to
employees and emergency coordination personnel within their own single
facility regardless of size. Where FSOs are employed within a group of similar

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small facilities, having a total of less than 1,000 employees, they are permitted
to deliver fire safety training across those facilities.
(3) Fire Safety Managers (Educator) can deliver training to all employees within
the health care/aged care system throughout NSW.

7.4 RECERTIFICATION
Every Health Service Fire Safety Officer/Manager shall undertake “recertification” at
intervals of not greater than 3 years to maintain their qualifications.
(1) FSO - Full day session comprising:
Assessment of current competencies in line with Appendix 2 Updating on:-
 Fire Detection Systems
 Latest/legislation/guideline requirements
 Emergency Warning Communication System (EWIS)
 First Attack Fire Fighting Equipment (Fire extinguishers, hose reels and
fire blankets)
 Workshop issues relating to position

(2) FSM - Full day session comprising:

Assessment of current competencies in line with Appendix 2 Updating on:
 Level 1 items above
 Protection Systems
 Risk Assessments
 Emergency Response
 Building Code of Australia
 Review of Fire Safety Training
 Workshop issues relating to position

7.5 UTILISATION OF PRIVATE TRAINING PROVIDERS

Prior to entering into any agreements with private providers the manager
responsible shall sight evidence, which demonstrates their suitability in conducting
training of employees and Emergency Controllers. As a minimum, providers should
supply the following:
i) Evidence of being certified/recertified as a Fire Safety Manager as per the
competencies outlined in Appendix 2 within the last 3 years.
ii) Records of attendance at Health Care Fire Safety seminars, conferences or
special interest groups
iii) Certificate IV in TAA or equivalent.
iv) References from health care organisations where they have conducted training
programs
v) Where private providers conduct courses for FSO/FSM’s they shall also provide
evidence of certification as a Registered Training Organisation.

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8 ANNUAL FIRE SAFETY EDUCATION

Healthcare organisations management are responsible for the provision of a suitably
qualified person to conduct fire safety education to all employees in line with the
relevant components of the competencies as outlined in Section 7.5 and Appendix 2.
This education falls into 3 general components: Theoretical, practical use of fire-
fighting equipment and evacuation exercises. All new employees upon
commencement and all employees, at least annually, shall participate in the
theoretical and practical components. An evacuation exercise/drill shall be carried out
in all departments of health care facilities annually.
Where it is not possible for 100% of staff to attend training, a healthcare
organisation needs to demonstrate that reasonable efforts have been made to
ensure that all staff receive training. There should be a policy for managing chronic
non-participants in training and drills, with evidence of actions to follow-up.
Healthcare facilities and/or buildings where this will apply shall be consistent with
the BCA definition below.
From the BCA
Health-care building means a building whose occupants or patients undergoing
medical treatment generally need physical assistance to evacuate the building
during an emergency and includes:
(a) a public or private hospital; or
(b) a nursing home or similar facility for sick or disabled persons needing full-
time care; or
(c) a clinic, day surgery or procedure unit where the effects of the predominant
treatment administered involves patients becoming non-ambulatory and
requiring supervised medical care on the premises for some time after the
treatment.

8.1 THEORETICAL
Fire and emergency prevention (maintaining a safe working environment), evacuation
theory and installed sound systems for emergency purposes. Theoretical
components of the education may be delivered in a number of ways, e.g. E-
learning, self directed learning packages, face to face lectures, etc. Emphasis shall
be on outcomes of knowledge assessments

8.2 PRACTICAL USE OF FIRE FIGHTING EQUIPMENT

A practical demonstration in the operation of the portable fire-fighting equipment.
Hands on use should be encouraged where and when practical to do so. Practical
instruction should include all equipment located within the employees’ area of work.
Including fire extinguishers, fire blankets, fire hose reels, etc.

8.3 EVACUATION EXERCISES

Evacuation exercises/drills shall, as a minimum, involve employees working through
a stage 2 evacuation for patient/resident care area employees and full stage 3
evacuation for all other employees. The exercise/drill need not necessarily be on a
large scale, although in larger establishments this is desirable. Irrespective of the size

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of the exercise/drill it should simulate a fire or other emergency situations in order to

test the following:
o Action taken by employees
o Communication
o Existing emergency response procedures
o Installed fire protection systems

(1) Exercises/drills in patient care areas need only include primary elements
(workshop/walkthrough exercise). Actual patient transfer and building
evacuation are not required. However, the utilisation of employees to act
patient/residents for the practice of removal techniques is encouraged, subject to
risk assessments and supervision by the site Fire Safety Officer/Manager. The
Fire Officer/Manager shall provide instruction and guidance to assist the
department/unit to carry out exercises/drills. This training may provide other
unique fire safety information relevant to the unit or department receiving the
training.
(2) The Private Hospitals Regulation 1996 and Day Procedure Centres Regulation
1996 currently require organisations covered under these regulations to have
all employees undergo evacuation exercises once every 6 months. All other
health care organisations should have all employees undergo an evacuation
exercise at least annually.
(3) Managers shall ensure that new employees receive a departmental orientation
specific to their workplace immediately on commencement of duty. Generic fire
safety education provided by an FSO/FSM should be given to new employees
as an integral part of their organisations orientation at the earliest possible
opportunity. In small organisations these 2 components may be combined.
(4) All employees who may act in the role of Emergency Coordinator shall complete
all components of fire safety education referred to in this section. In addition they
shall undergo the additional Emergency Controller components specified in
Appendix 2, annually.

9 HOT WORK PERMITS

9.1 CLASSIFICATION
All “Hot Work” such as welding, oxyacetylene cutting, paint stripping, vinyl laying etc.
that is conducted outside the confines of a dedicated workshop should be the subject
of an approval process managed by a suitably qualified person. Permit detail should
include the following as a minimum:

(a) Date and time operation commenced and expected duration.

(b) Name of contractor/employee.
(c) Nature of work and location:
(i) Fire alarm system isolated - employees in area notified Yes No
(ii) Fire fighting equipment available Yes No
(iii) Operator knows how to use equip. Yes No
(iv) Operator knows how to raise alarm Yes No

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(v) All combustible material removed/made safe Yes No

(d) Approval signature block Yes No
(e) Completion check detail. Time work completed
(i) Area checked Yes No
(ii) Fire alarm reset Yes No
(f) Completion signature block Yes No
(g) Ventilation adequate Yes No
(h) Sparks and flash screen in place Yes No
(i) If required, has a fire watch been organised Yes No
(j) Has site been isolated or roped off to all unauthorised persons Yes No
(k) All gas in the area has been turned off or isolated Yes No

9.2 DURATION
Hot Work permits are to be retained at the site for the duration of the approved activity.
A register of all Hot Work permits should be retained for a minimum of 12 months.

9.3 APPLICABLE STANDARDS

Australian Standard AS1674.1 – 1997 “Safety in Welding and Allied Processes”
provides additional detail in relation to this matter and should be used as a reference
point where necessary.

10 FIRE EXTINGUISHERS
This section supersedes NSW Health Guideline: GL2005_047 “Fire Extinguishers to
be used in Health Care Facilities”.

The following fire extinguishers shall be the only types located in patient/resident
care areas. These are:
• Carbon Dioxide
• Stored water (Where fire hose reels are not installed)
• 3M NOVEC 1230 FIRE PROTECTION FLUID (MRI Units Only)

The definition of patient care areas includes portions of a building used for the
treatment, care, accommodation, recreation, dining and transit of patients (Building
Code of Australia).

Other types of fire extinguishers may be considered for areas other than patient/
resident care areas after a risk assessment has been conducted. For the
installation of Fire Extinguishers refer to Australian Standards AS2444 as amended,
Portable Fire Extinguishers and Fire Blankets – Selection and location.

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11 FIRE SAFETY ADVISORY SERVICES

11.1 FIRE SAFETY EDUCATION
The primary source for advice on standards of fire safety education is the New
South Wales Fire Brigade. Contact detail is as follows:

NSW Fire Brigades, ComSafe Training Services

Amarina Avenue
Greenacre NSW 2190
Phone: 1800787848

11.2 BUILDING REGULATIONS

Enquiries regarding building regulations should be directed to:
 Local Council

 NSW Fire Brigades, Structural Fire Safety Unit

Armarina Avenue,
GREENACRE NSW 2190
Phone 97427400

 Private Building Consultants as outlined in Section 3.1.3

12 APPENDIX 1
12.1 REFERENCES
• Environmental Planning and Assessment Act 1979
• Environmental Planning and Assessment Regulation 2000
• The Building Code of Australia
• Occupational Health and Safety Act 2000
• Occupational Health and Safety Regulation 2001
• Private Hospital Regulations 1996
• Day Procedure Centres Regulation 1996
• Private Hospitals and Day Procedure Centres Act 1988
• Australian Standard AS/NZS 4360 Risk Management
• Australian Standard AS4083 Planning for Emergencies - Health Care Facilities
• Australian Standard AS3745 Emergency control organisation and procedures for
buildings, structures and workplaces
• Australian Standard AS1674.1 1997 Safety in Welding and Allied Processes
• Australian Standard AS 2444-2001 Portable fire extinguishers and fire blankets -
Selection and location

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12.2 NSW HEALTH POLICIES INCLUDING BCA/FIRE RELATED (CIRCULARS)

POLICY DIRECTIVES, INFORMATION BULLETINS AND GUIDELINES

IB2005_024 Building Code of Australia and its application to Public and Private
Health Care Facilities
PD2005_080 Use of Nylon Carpet in Health Care Buildings
IB2006_016 Environmental Planning and Assessment (Smoke Alarms)
Regulation 2006
PD2007_061 NSW Health Policy Directive PD2007_061, Incident Management
Policy
PD2005_409 Workplace Health and Safety: Policy and Better Practice Guide
PD2007_030 NSW Health, Occupational Health Safety & Injury Management
Profile, Sections 2.4 Emergency Response and Management & 3.7
Fire safety and Evacuation
PD2005_339 Protecting People/Property: NSW Health Policy/Guidelines for
Security Risk Management in Health Facilities, Ch 24 Fire Security
PD2005_592 Fire Safety Officers

13 APPENDIX 2
13.1 ALIGNMENT OF HEALTH CARE FIRE SAFETY COMPETENCIES
Except where otherwise stated, the competencies referred to are from the Public
Safety Training Package. Further information can be obtained from:
NSW Public Sector Industry Training Advisory Body (PSITAB)
PO Box 107. Gordon NSW 2072
Phone: 02 9499 3168 Web site: http://www.psitab.com.au

ROLE COMPONENTS OF TRAINING PACKAGES UNIT CODE OF

PERFORMED TO MEET ROLE REQUIREMENTS TRAINING
PACKAGE

All Employees Identify, prevent and report potential workplace PUAWER001A

emergency situations
Respond to workplace emergencies PUAWER004A
Confine small workplace emergencies PUAWER008A
Emergency As above plus: PUAWER006
Coordinators Lead an emergency control organisation
FSO As above plus: PUAWER002
(excluding education) Ensure workplace emergency prevention procedures,
systems & processes are implemented.
Operate as part of an emergency control organisation PUAWER005
FSM As above plus: PUAWER003
(excluding education) Manage & monitor workplace emergencies, procedures,
equipment and other resources. PUAWER007
Manage an emergency control organisation. PUAWER0011
Manage workplace emergency response teams
FSO/M (Educator) As above for FSO or FSM plus:

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Providers of education The Module of Certificate IV in Workplace Assessment

to employees and and Training(TAA);
emergency Provide training through instruction and demonstration TAADEL301A
coordinators of work skills
National Training Information Service Web site
provides a list of all Registered Training Organisations,
which could provide this module.
http://www.ntis.gov.au/Default.aspx
or,
An equivalent basic educational technique
qualification.
Providers of education As above for FSM plus:
to FSO’s and FSM’s Certificate IV TAA or equivalent. All modules

14 APPENDIX 3

14.1 SAMPLE FIRE SAFETY OFFICER POSITION DESCRIPTION

A person who meets the Fire Safety Officer competencies and has been
appointed as the Fire Safety Officer of a site would undertake the following
duties:
• Ensure that appropriate written fire safety and fire emergency response
procedures are available.
• Provide advice and assistance to management to ensure that all employees
participate in fire safety education and that records of education are maintained
• Liaise with maintenance and service personnel and/or contractors to ensure all
fire safety equipment and fire protection systems are tested and maintained in
accordance with relevant standards and regulations. Ensure related records are
maintained.
• Monitor day-to-day fire prevention, protection and fire safety functions within the
facility. (Regular utilization of the Workplace Fire Safety Inspection, Appendix 7,
or similar should be used.)
• Develop a working relationship with the local Fire Brigade and related emergency
services.
• Conduct practical evacuation exercises/drills.
Fire Safety Officer (EDUCATOR) who has attended FSO training would also:
• Conduct mandatory annual and orientation fire safety training of employees, in
line with Section 6.3.2, where they meet the competencies outlined in Appendix
2.

15 APPENDIX 4

15.1 SAMPLE FIRE SAFETY MANAGERS POSITION DESCRIPTION

A person who meets the Fire Safety Manager competencies and has been
appointed as the Fire Safety Manager would undertake the following duties:

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• Perform and/or oversee the duties performed by Fire Safety Officers.

• In conjunction with other stakeholders, review and update, as required,
procedures and manuals for fire safety and emergency situations with others.
• Develop and implement regular Fire Safety, First Attack Fire Fighting and
Evacuation training programs, to all employees.
• Highlight and initiate corrective action to correct unsafe or potentially dangerous
fire risk situations.
• Oversee fire prevention, protection and fire safety functions.
• Conduct regular fire safety reviews, participate in fire risk management activities
and provide fire safety advice as required.
• Provide guidance to facility Disaster Planning Committee/s and Emergency
Control Organisation/s on fire safety matters (where formed).
• Provide guidance to OHS committee/s on fire safety matters(where formed).
• Monitor the production of Annual Fire Safety Statements and their submission to
local council and NSW Fire Brigade.
• Guide and assist Fire Safety Officers within the organisation.
Fire Safety Manager (EDUCATOR) who has attended FSM training would also:
• Conduct mandatory annual fire safety training of employees, in line with Section
6.3.3, where they meet the competencies outlined in Appendix 2.

16 APPENDIX 5
16.1 WHAT TO DO IN THE EVENT OF A FIRE
Health and aged care facilities and their associated services are required to develop
as part of their Emergency Management Policy a local Emergency Response
Procedure. This is a minimum guide for staff in the actions they are required to
follow when responding to fires and other emergencies that may occur in the facility.

Reference to Australian Standards AS 4083 Planning for emergencies – Health

care facilities when developing emergency response procedures in patient/resident
care areas and AS 3745 Emergency control organisation and procedures for
buildings, structures and workplaces in creating emergency response procedures
for all other associated areas.

The following is the minimum framework from which facilities and services should
develop their site-specific procedures:

• Evacuation:
In the event of a fire employees should remember the acronym R.A.C.E
 Remove people from immediate danger (if safe to do so)
 Alert anyone close to the fire and alert the switchboard operator, who will
contact the Fire Brigade, or dial 000 and ask for the Fire Brigade. Tell them:
- The facility name, address and the caller’s telephone extension number
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- The exact location of the fire or smoke, nearest cross street and entry
point
 Confine the fire and smoke by closing all doors and windows (on exit).
 Extinguish the fire if safe to do so.

The above actions should, depending on the availability of employees, be

undertaken simultaneously or in an order that provides for the highest level of
life safety.

The authority to order the evacuation of an area or building is generally vested

with Supervisors and Managers. However, any employees discovering an
incident necessitating the immediate evacuation of an area, should ensure life
and safety is not compromised by seeking the authority to evacuate.

“IF IN DOUBT – EVACUATE”

Evacuation of an entire facility would be decided in consultation with the senior

emergency service personnel on site and the most senior facility manager
available (or their delegate). This would then be communicated via the
predetermined emergency management system.

• Evacuation Guidelines:
Patients will be prioritised, transferred and assembled under the direction of
clinical employees. The situation should be assessed before the decision to
evacuate is made. Consideration should be given to:

- Location of the fire/incident, seriousness and extent of the incident

- Proximity to flammable/hazardous materials and
- Nature and type of patient in the area.
- Layout of the facility

Note:
1. If there is any doubt, evacuation procedures should commence.
2. Where patients are mentioned this will also refer to residents.

• Stages in Evacuation in patient care areas:

Evacuation of patients, employees and others should be conducted in three
stages according to the severity of the emergency. These are:

 STAGE 1: Removal of people from the immediate danger area Patients,

employees and others in the immediate fire/incident area need to be
assembled at a safe distance from the fire and smoke. Once the area has
been evacuated, doors should be closed, not locked, to localise the fire and
smoke /incident.

 STAGE 2: Removal of persons to a safe area

Should the severity of the fire and smoke/incident warrant further evacuation
patients, employees and others should be moved through the fire doors or

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smoke doors to safe areas. This may be to an adjoining compartment protected

by fire or smoke doors on the same level or to another level.

Note: When evacuating a complete floor, patients should be generally moved to

a floor on a lower level.

 STAGE 3: Complete evacuation of the building

Should the emergency necessitate evacuation of the entire building, the
resources of all available employees are required to assist in the movement of
patients, employees and others to a place of safety.
• Prioritisation of patients to be evacuated:
Clinical employees are responsible for prioritising the order in which patients are
evacuated from wards. Generally the following priorities apply:

1. Ambulatory patients, requiring a employees to guide or direct them to a

place of safety
2. Semi-ambulant patients, requiring some physical assistance
3. Non-ambulant patients who need to be physically moved or carried
4. Aggressive, violent or resistive persons

Clinical employees shall predetermine the most suitable method of evacuating

each type of patient/resident depending on their conditions and the severity of
the situation and type of emergency, with due consideration given to their
ongoing medical needs, particularly priority high care patients/residents.
Where, following the incident, the unit/facility remains unsafe to be re-entered,
relevant local contingency plans need to be activated to ensure ongoing care of
patients/residents, and restoration of services and security of the affected
premises.

Strategies should be in place to handle aggressive, violent or resistive persons

during evacuation.
• Assembly areas:
Patients, employees and others should be assembled in predetermined
locations that do not impinge on emergency service access or operations.
Flying debris from the affecting building also needs to be considered when
determining locations. Assembly Areas can be located inside buildings
separated from those affected by the incident to provide shelter to evacuees.
• Lifts:
A lift should not be used during a fire emergency unless it is a designated and
signposted fire isolated lift constructed for evacuation purposes or the Fire
Brigade personnel on site have authorised its use. Fire isolated stairs and
escapes should be used.

Lifts may be appropriate for use in other types of emergencies.

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17 APPENDIX 6
17.1 PROCEDURAL GUIDELINES FOR THE PREPARATION OF ANNUAL
FIRE SAFETY STATEMENTS

17.1.1 Background Requirements

An Annual Fire Safety Statement is a statement issued by the owner of a building or
his agent. The statement is written confirmation that fire safety measures installed
in the building have been inspected by a properly qualified person and found to be
capable of performing to standard. Fire safety measures are incorporated into the
building to safeguard the building and its occupants in the event of a fire.

17.1.2 Procedures:
1. The Facility Manager is to refer to the Fire Safety Schedule for the building/s on
their site/s. Refer to section 3.3.3 COMPLIANCE CERTIFICATION of this
Policy Directive.
2. The Facility Manager, in consultation with the facility Fire Safety Officer/Manager
and responsible Assets/Maintenance staff, is to collate evidence of inspection /
assessments for each Fire Safety Measure listed in the Fire Safety Schedule.
Appendix 6.2
2.1 For contracted services this should be an Attachment Certificate provided by
the contractor within the previous three months and detailed service reports
and/or log books.
2.2 For services carried out by in-house staff this should be an Attachment
Certificate and detailed service records and/or log books.
3. The facility’s Fire Safety Officer/Manager or other suitably qualified person is to
carry out an inspection of the facility to determine if the condition of the building
discloses any grounds for prosecution under Division 7 of Part 9 of the
Environmental Planning and Assessment Regulation 2000. Completion of
Appendix 7 not only meets the above requirements but addresses various other
issues of fire safety. It is recommended that this form is completed at regular
intervals, not just for the Annual Fire Safety Statement (AFSS).
4. Once the information and certification above is available, the AFSS pro-forma at
Appendix 6.1 is to completed and forwarded to the building owner or their
representative (Area Chief Executives in Public Health Services) for signing.
5. Once signed, copies of the Annual Fire Safety Statement will be forwarded to the
Commissioner of New South Wales Fire Brigades and the local Council.
6. The Facility Manager is to arrange for a copy of the Annual Fire Safety
Statement and the Fire Safety Schedule to be displayed in a prominent location
at the facility.

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17.2 ANNUAL FIRE SAFETY STATEMENT (AFSS) APPENDIX 6.1

Organisation Logo

ANNUAL FIRE SAFETY STATEMENT

Name owner/agent
I

Address
Of

Telephone

Certify:
(a) that each essential fire safety measures specified in this statement have been assessed by a
property qualified person and was found, when it was assessed, to be capable of performing:
(i) in the case of an essential fire safety measure applicable by virtue of a fires safety
schedule, to a standard no less than that specified in the schedule, or
(ii) in the case of an essential fire safety measure applicable otherwise than by virtue of a
fire safety schedule, to a standard no less than that to which the measure was originally
designed and implemented, and
(b) that a properly qualified person (whether the person referred to in a paragraph (a) or another
person) has inspected the building and has certified that, as at the date of the inspection, the
condition of the building did not disclose any grounds for a prosecution under Division 7 of
Part 9 of the Environmental Planning and Assessment Regulation 2000, and
(c) the information contained in this certificate is, to the best of my knowledge and belief, true
and accurate.

Identification of building
Location

Street

Suburb

Nearest cross street

House/unit no. or name

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APPENDIX 6.1 (Continued)

Fire Safety Measures
Fire Safety Measure Date of Minimum Standard Minimum Standard
Assessment / of Performance of Performance
Inspection (Design & (Maintenance)
Installation)
List here each essential List dates of the List Standards applicable List Standards
fire safety measure from inspections done for the respective fire applicable for the
the schedule (shall be within 3 safety measure respective fire safety
month period) measure

Date of Statement

Day Month Year

Signature of Owner/Agent

Signature Name

A copy of this certificate together with the relevant fire safety schedule shall be forwarded to
the Council and the Commissioner of the New South Wales Fire Brigades.
A copy of this certificate together with the relevant fire safety schedule shall be prominently displayed
in the building.

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17.3 ATTACHMENT TO AFSS – FIRE SAFETY MEASURES APPENDIX 6.2

ATTACHMENT TO ANNUAL FIRE SAFETY STATEMENT

Name of Assessor
Of

Address

Telephone

Certify:
That each of the Fire Safety Measures listed below have been assessed by me, a properly qualified
person, and was found, when it was assessed, to be capable of performing to a standard no less
than that specified in the schedule below. I also certify that the information contained in this
attachment is, to the best of my knowledge and belief, true and accurate.

Fire Safety Measures

Fire Safety Measure Minimum Standard of Performance

Signature of Assessor

Signature
Identification of building

House/unit no. or
name

Street

Suburb

Nearest cross street

Date of assessment

Date

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17.4 ATTACHMENT TO AFSS – BUILDING CERTIFICATION APPENDIX 6.3

ATTACHMENT TO ANNUAL FIRE SAFETY STATEMENT

Name of Officer
I

Address
of

Qualification

Telephone

Certify:
That I have inspected the building below and certify that, as at the date of the inspection, the
condition of the building did not disclose any grounds for a prosecution under Division 7 of Part 9 of
the Environmental Planning and Assessment Regulation 2000. I also certify that the information
contained in this attachment is, to the best of my knowledge and belief, true and accurate.

Signature of Officer (qualified person)

Signature

Identification of building
Location
Street

Suburb

Nearest cross street

House/unit no. or
name

Date of inspection

Date

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18 APPENDIX 7

18.1 EXTRACT FROM ENVIRONMENTAL PLANNING AND ASSESSMENT

REGULATION 2000

Division 7 Miscellaneous fire safety offences

183 Fire safety notices (cf clause 80GG of EP&A Regulation 1994)
(1) If:
(a) a building's fire exit includes any fire isolated stairway, passageway or
ramp, and
(b) a notice in the form at the end of this clause is not at all times
displayed in a conspicuous position adjacent to a doorway providing
access to, but not within, that stairway, passageway or ramp, the
occupier of the part of the premises adjacent to the stairway,
passageway or ramp is guilty of an offence.
Maximum penalty: 100 penalty units.
(2) The words ``OFFENCE RELATING TO FIRE EXITS'' in the notice referred
to in subclause (1) (b) shall be in letters at least 8 millimetres high, and the
remaining words shall be in letters at least 2.5 millimetres high.
(3) A notice in the form prescribed under the Local Government Act 1919 or
the Local Government Act 1993 for the purposes of a provision
corresponding to this clause is taken to comply with the requirements of
this clause.

OFFENCE RELATING TO FIRE EXITS

It is an offence under the Environmental

Planning and Assessment Act 1979:

(a) to place anything in or near this fire exit

that may obstruct persons moving to and
from the exit, or

(b) to interfere with or obstruct the

operation of any fire doors, or

(c) to remove, damage or otherwise

interfere with this notice.

184 Fire exits (cf clause 80GH of EP&A Regulation 1994)

A person shall not:

(a) place anything that may impede the free passage of persons:
(i) in a stairway, passageway or ramp serving as or forming part of a
building's fire exit, or
(ii) in a path of travel leading to a building's fire exit, or

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(b) interfere with, or cause obstruction or impediment to, the operation of any
fire doors providing access to a stairway, passageway or ramp serving as
or forming part of a building's fire exit, or
(c) remove, damage or otherwise interfere with a notice referred to in clause
183.

Maximum penalty: 100 penalty units.

185 Doors relating to fire exits (cf clause 80GI of EP&A Regulation 1994)

A person shall not:

(a) without lawful excuse, interfere with, or cause obstruction or impediment
to, the operation of any door that:
(i) serves as or forms part of a building's fire exit, or
(ii) is situated in a path of travel leading to a building's fire exit, or

(b) without lawful excuse, obstruct any doorway that:

(i) serves as or forms part of a building's fire exit, or
(ii) is situated in a path of travel leading to a building's fire exit.

Maximum penalty: 100 penalty units.

186 Paths of travel to fire exits (cf clause 80GJ of EP&A Regulation 1994)

The owner of a building:

(a) shall ensure that:
(i) any stairway, passageway or ramp serving as or forming part of a
building's fire exit, and
(ii) any path of travel leading to a building's fire exit, is kept clear of
anything that may impede the free passage of persons, and

(b) shall ensure that the operation of any door that:

(i) serves as or forms part of a building's fire exit, or
(ii) is situated in a path of travel leading to a building's fire exit, is not
interfered with, or otherwise obstructed or impeded, except with
lawful excuse, and shall ensure that any notice required by clause
183 to be displayed is so displayed.

Maximum penalty: 100 penalty units.

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19 APPENDIX 8
19.1 WORKPLACE FIRE SAFETY INSPECTION
DEPARTMENT/FACILITY......................….……. DATE....……… (Print Name)...................……...………
No: ITEM DESCRIPTION Yes No N/A ISSUE
IDENTIFIED
1 Is all Corrective/Preventative Action from last month’s inspection complete?
2 Are staff aware of and do they have access to relevant policies and procedures?
3 Is the following documentation in locations accessible to all staff? Emergency Telephone Numbers, Emergency
Procedures, Wall Mounted Evacuation Plans,
4 Emergency vehicle access clear and unimpeded
5 Is “Housekeeping” to acceptable standards (internal & external)?
6 Are floors/corridors in a satisfactory state and free of obstacles?
7 Is there unobstructed vision at corridor intersections?
8 Does all electrical supply equipment (outlets & switches) appear to be in good condition?
9 Does all electrically powered equipment & cords appear to be in a safe condition? Including torches?
10 Are all fire exits, passageways, smoke/fire doors and fire-fighting equipment clearly marked and free from
obstructions?
11 Is fire equipment clearly marked and in good condition? Have inspection tags been stamped in last 6 months?
12 Do departmental records show that all staff has attended mandatory training within the required timeframes?
13 Exit Latches maintained in accordance with original installation?
14 Other issues:

ACTION PLAN
Issues identified Action Required Person Completion Date
Responsible

SIGNATURE…………………………………………………
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