DO 404 - Fire, Safety and Loss Prevention

CHAPTER: 400

Physical Plant/Facilities

DEPARTMENT ORDER:

404 – Fire, Safety and Loss Prevention

OFFICE OF PRIMARY

RESPONSIBILITY:

OPS

Arizona

Department

Corrections

Rehabilitation

and Reentry

Department Order Manual

Effective Date:

March 10, 2022

Amendment:

N/A

Supersedes:

DO 404 (11/9/18)

Scheduled Review Date:

July 1, 2024

ACCESS

☐ Contains Restricted Section(s)

David Shinn, Director

CHAPTER: 400

404 – FIRE, SAFETY AND LOSS PREVENTION

MARCH 10, 2022

TABLE OF CONTENTS

EXPECTED PRACTICES ................................................................................................................... 1

PURPOSE ...................................................................................................................................... 1

APPLICABILITY .............................................................................................................................. 1

PROCEDURES ................................................................................................................................ 1

1.0 FACILITIES MANAGEMENT RESPONSIBILITIES ........................................................................ 1

2.0 EMERGENCY PREPAREDNESS ADMINISTRATOR RESPONSIBILITIES ......................................... 4

3.0 OCCUPATIONAL SAFETY CONSULTANT (OSC) RESPONSIBILITIES ............................................ 4

4.0 SAFETY AND LOSS PREVENTION COMMITTEES ................................................................... 11

5.0 DEPARTMENT LOSS PREVENTION PROGRAM ELEMENTS ...................................................... 14

6.0 FIRST AID, BIOHAZARD SPILL AND OLEORESIN CAPSICUM MASK KITS AND SUPPLIES ............ 14

7.0 PERSONAL PROTECTIVE EQUIPMENT (PPE) .......................................................................... 15

8.0 EQUIPMENT, POWERED INDUSTRIAL TRUCKS AND HEAVY EQUIPMENT SAFETY ..................... 16

9.0 CONTROL OF HAZARDOUS ENERGY (LOCKOUT/TAGOUT) PROGRAM ..................................... 18

10.0 INMATE WORKERS ............................................................................................................ 22

11.0 FIRE-RELATED CONTRACTS ............................................................................................... 23

12.0 RESPIRATORS AND RESPIRATORY PROTECTION .................................................................. 23

13.0 INSTITUTION/FACILITY EVACUATIONS ................................................................................ 25

14.0 CONFINED SPACE PROTOCOLS .......................................................................................... 26

DEFINITIONS/GLOSSARY .............................................................................................................. 27

ATTACHMENTS ........................................................................................................................... 27

FORMS LIST ................................................................................................................................ 27

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EXPECTED PRACTICES

American Correctional Association (ACA) Expected Practices: 5-ACI-2A-02 (M), 5-ACI-3B-01 (M), 5-ACI-3B-

02 (M), 5-ACI-3B-05 (M), 5-ACI-3B-11 (M), 5-ACI-3B-12 (M), and 5-ACI-3B-14 (M)

PURPOSE

This Department Order establishes procedures to protect the public, Department employees, contractors, and

inmates by ensuring facilities are managed safely by the consistent adherence to applicable fire and life safety

codes and standards from the National Fire Prevention Association (NFPA), Office of Safety and Health

Administration (OSHA), United States (US) Department of Labor, as adopted by the state. This Department

Order also establishes the Department’s Loss Prevention Program procedures to comply with the Arizona

Administrative Code (A.A.C.) Chapter 10, Article 2’s requirement to integrate loss prevention and safety

policy into all Department activities.

APPLICABILITY

This Department Order is applicable to all Department institutions and facilities. Some exceptions for private

prisons are indicated throughout this Department Order or are managed in accordance with Department

contract. Private prison facilities shall refer to Attachment E, Department Order Exempted

Sections/Subsections.

This Department Order is not applicable to structural fire, wildland fire or disaster aid responses, which are

addressed in Department Order #918, Fire Crews/Disaster Aid.

The Department’s Mandatory Exposure Control Plan, part of the OSHA Mandatory Programs, is a unifying

source for this Department Order and Department Orders #116, Employee Communicable Disease Exposure

Control Plan and #1102, Communicable Disease and Infection Control. The Plan outlines the steps to follow

for infectious disease management, control and prevention, in compliance with OSHA Standards general rules

and regulations. The Mandatory Exposure Control Plan is located on the ADCNet on the Office of Safety and

Environmental Services page.

PROCEDURES

1.0 FACILITIES MANAGEMENT RESPONSIBILITIES {5-ACI-2A-02 (M)}

The Assistant Director for Facilities Management or designee shall consult with state regulatory

authorities and the Arizona Department of Administration (ADOA) Risk Management Division

on the following:

1.1.1 Fire and life safety detection and prevention programs, to include inspection and

testing of fire equipment and alarm systems.

1.1.2 Fire and life safety materials/equipment and implementation procedures mandated by

code, standard or rule.

1.1.3 Existing fire equipment and alarm systems repair, replacement, modification and

addition.

1.1.4 Existing structure and infrastructure renovation, demolition, and/or alteration.

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Prior to any structure or system renovations, alterations or modifications, including additions to

Department fire and life safety systems and alterations to a structure’s ingress/egress pattern,

the Engineering and Facilities Administrator or designee shall receive written approval from the

Arizona Department of Forestry and Fire Management (ADFFM) and ADOA Risk Management.

Fire, Life and Safety Administrator Responsibilities – The Fire, Life and Safety Administrator

shall:

1.3.1 Collaborate with the Staff Development and Training Bureau as required in annual fire

and life safety training curriculum development.

1.3.2 Ensure Department Occupational Safety Consultants (OSCs) complete all required

OSHA safety training requirements in accordance with Department Order #509,

Employee Education and Training and this Department Order.

1.3.3 Act as a Department liaison with:

1.3.3.1 The ADFFM and ADOA Risk Management.

1.3.3.2 OSCs.

1.3.3.3 Local jurisdictional fire departments where appropriate or required.

1.3.3.4 Fire Marshals and/or the authority having jurisdiction.

1.3.3.5 The Arizona Departments of Occupational Safety and Health (ADOSH),

Health Services (ADHS), Food Safety, and Environmental Quality (ADEQ).

1.3.3.6 The Arizona Corporation Commission (ACC).

1.3.3.7 OSHA and other applicable regulatory authorities as required or needed.

1.3.4 Coordinate and prepare all Department responses to regulatory agencies relating to

inquiries, inspections or reports of violations/non-compliance issues. In preparing

responses, institution/facility compliance and regulatory comments and/or findings

shall be used. {5-ACI-2A-02 (M)}

1.3.4.1 All responses shall be forwarded for review by the Department General

Counsel.

1.3.5 Collaborate with the Emergency Preparedness Administrator to support fire evacuation

and life safety drills for personnel at the following Department structures:

1.3.5.1 801 South 16th Street, Phoenix

1.3.5.2 1831 West Jefferson Street

1.3.5.3 701 East Jefferson Street, Phoenix

1.3.5.4 3279 East Harbour Drive, Phoenix

1.3.5.5 5601 West Trails End Road, Tucson

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1.3.5.6 Community Corrections Facilities

1.3.5.7 Any Central Office address yet to be determined

1.3.6 As assigned, collect structure evacuation timing and floor compliance data from Floor

Wardens at the conclusion of each drill or event, and document the result on the

Fire/Emergency Evacuation Drill Summary – Central Office Only, Form 404-12, and

the ADOA Risk Management Floor Warden Evacuation Evaluation form.

1.3.7 Update and maintain Department-wide statistics of damages or potential damages to

state structures and/or state personal property as a result of one of the following

incidents:

1.3.7.1 Workplace accident or incident involving near misses and injuries

1.3.7.2 Natural disaster (e.g., inclement weather, heavy rain, flooding, earthquake,

fire, explosion)

1.3.7.3 Technological/accidental incidents (e.g., fire, hazardous material,

foodborne illness)

1.3.7.4 Adversarial/human-caused incidents (e.g., assault, armed assault,

explosives attack, and cyber-attack)

1.3.8 Assist the Engineering and Facilities Bureau with the review of projects of new

construction, demolition, renovation, alteration and additions to include temporary/

emergency housing projects. This is a mandatory code review for fire and life safety

and/or environmental project impacts. {5-ACI-2A-02 (M)}

1.3.9 Ensure Department OSCs submit their institution/facility’s annual Institutional Tier ll

electronically no later than March 1 each year to the Arizona State Emergency

Response Commission (AZSERC) and coordinate with the authority having jurisdiction

for hazardous materials emergency responses for their institution/facility.

1.3.10 Advise the OSCs, Department institutions/facilities, and private prisons when made

aware of unusual or serious incidents or accidents involving the use of equipment,

tools, or machines in a workplace setting.

1.3.11 Assist Department OSCs in:

1.3.11.1 Applying fire and life safety standards, codes, laws, rules and regulations.

{5-ACI-2A-02 (M)}

1.3.11.2 Performing as a consultant on regulatory compliance issues.

1.3.11.3 Providing clear and consistent loss prevention, fire and life safety-related

communications, directions and/or recommendations.

1.3.12 As a member of the Emergency Relocation Group, serve as the Department Safety

Officer for emergency and disaster incidents as prescribed by the Incident Command

System (ICS).

1.3.13 Ensure compliance tours of each Department institution/facility and private prison

occur: {5-ACI-3B-01 (M)}

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1.3.13.1 Once per calendar year at a minimum.

1.3.13.2 When directed by the appropriate Assistant Director, Bureau

Administrator, or Warden or designee.

1.3.13.3 When an inquiry, violation or citation requires a compliance intervention

by the Fire, Life and Safety Administrator.

2.0 EMERGENCY PREPAREDNESS ADMINISTRATOR RESPONSIBILITIES – The Emergency Preparedness

Administrator shall:

Serve as the Department’s primary Emergency Preparedness Program Manager.

Serve as the Department’s Emergency Preparedness Liaison to the Arizona Division of

Emergency Management and other county, state and federal emergency planning groups as

identified or needed.

Represent the Department at the Capitol Mall Emergency Response and Evacuation Plan

Meetings.

Collaborate with the Fire, Life and Safety Administrator for fire/emergency evacuation and

response planning.

Oversee the publication of building Emergency Action plans and associated preparedness and

planning.

Provide oversight for the Department’s all-hazards comprehensive Emergency Preparedness

program through collaboration with individual complexes, operational areas, and local response

partnering agencies. {5-ACI-3B-14 (M)}

3.0 OCCUPATIONAL SAFETY CONSULTANT (OSC) RESPONSIBILITIES – Department OSCs shall report

directly to the Fire, Life and Safety Administrator. The Fire, Life and Safety Administrator shall work

with Wardens and OSCs to meet the institution/facility’s fire and life safety and loss prevention needs.

The private prison Warden shall identify an OSC or position equivalent to meet the requirements of this

Department Order.

Training Responsibilities – The OSC shall:

3.1.1 Attend quarterly OSC meetings and scheduled trainings. Minimum training shall

consist of four hours classroom safety training quarterly. Refer to Attachment A, OSC

or Equivalent – Required/Recommended Training and Certification for additional

information.

3.1.2 Provide OSHA-related safety training as required.

3.1.3 Where applicable, provide fire apparatus operational training to ensure operating

personnel are proficient in their use in accordance with state vehicular regulations and

Department Order #405, Vehicles/Vehicle Maintenance.

Authority Having Jurisdiction’s Fire Department Responsibilities – The OSC shall:

3.2.1 At a Department institution/facility:

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3.2.1.1 Ensure a proper contractual agreement or municipal boundary

incorporation exists between the institution/facility and an authority having

jurisdiction. Either a legal Intergovernmental Agreement (IGA) or a council

mandate of incorporation shall suffice.

3.2.1.2 Collaborate with the Radio Response Manager to validate that formalized

response communication exists between any ICS staff, firefighters and the

responding resources of the jurisdictional fire department and emergency

medical resources, when on-site.

3.2.2 At a private prison, ensure a formalized response communication exists between any

ICS staff, firefighters and the responding resources of the jurisdictional fire department

and emergency medical resources, when on-site.

Loss Prevention Activities – As the Institutional Loss Coordinator, the Department OSC shall:

3.3.1 Complete a Loss Prevention Program Checklist, Form 404-2, at the beginning of the

first and third fiscal quarters (July and January).

3.3.1.1 Originals shall be maintained on-site in accordance with the current

retention schedule. An electronic version shall be provided to the Fire, Life

and Safety Administrator within five workdays.

3.3.2 Ensure the Fire, Life and Safety Administrator receives an updated list of the

institution/facility's Loss Prevention/Risk Management Liaisons and Property

Managers.

3.3.3 When damages to state structures occur as a result of a major fire or major incident,

submit a Fire/Safety Incident Summary Report, Form 404-6, to the assigned ICS

Safety Officer, Logistics and Finance/Administration Section Chiefs, the Loss

Prevention Liaison, the Risk Management Liaison and the Fire, Life and Safety

Administrator as needed during the incident.

3.3.4 Submit any Fire/Safety Incident Summary Report forms to the Warden or designee

and the Fire, Life and Safety Administrator within five workdays of the conclusion of

the incident.

3.3.4.1 Private prison staff shall provide written origin and cause reports, fire

incident evaluations and completed Fire/Safety Incident Summary forms to

the Fire, Life and Safety Administrator and the Emergency Preparedness

Administrator, through the Contract Beds Operations Director.

3.3.5 At a minimum, document the following elements of the incident:

3.3.5.1 Specific location information.

3.3.5.2 Date and time.

3.3.5.3 Type of construction and occupancy/use type.

3.3.5.4 Area of fire origin, if applicable.

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3.3.5.5 Probable and/or determined causes, including the indicated source.

3.3.5.6 Approximate/anticipated or actual loss values.

3.3.5.7 First aid incidents, near misses, medically serious injuries, and loss of life.

3.3.5.8 Preventative measures, mitigation methods and/or recommended

corrective actions.

3.3.5.9 A 30/60/90 calendar day cycle follow-up for compliance resolution status.

3.3.6 Inform the institution/facility’s assigned ICS Safety Officer, Logistics Section Chief

and the Safety and Loss Prevention Committee chairperson of any incidents of

damage.

3.3.7 Prepare a report for the ADOA Risk Management and the Fire, Life and Safety

Administrator, in consultation with the Physical Plant Manager/ Administrator, of all

property losses, in accordance with the following ADOA Risk Management criteria:

3.3.7.1 Major Incident: Within one workday, any injury to a non-employee or for

the loss of non-state property and/or liability claims, or for state property

loss exceeding a $10,000 estimated value.

3.3.7.2 Property Loss: Within ten workdays of a personal property loss with an

estimated value of less than $10,000.

3.3.8 Upon receiving reports from the institution/facility relating to employee injury or near

miss occurrences involving fire and life safety violations:

3.3.8.1 Document the incident reports as required.

3.3.8.2 Conduct investigative inspections for incidents as directed using the

Incident-Accident Investigation, Form 404-7. The Department OSC shall

determine if a Root Cause Analysis, Form 404-8, is needed. In cases where

a Root Cause Analysis, Form 404-8, is performed, the results shall be

reported in the next Institutional Safety Committee.

3.3.8.3 Provide a copy of the form(s) to the OHN and the Fire, Life and Safety

Administrator electronically as follows:

3.3.8.3.1 Immediately if there is a death or in-patient hospitalization of

any employee or worker, or if the injury involves the loss of

an eye or an amputation. (Reportable Incident to ADOSH)

3.3.8.3.2 By the end of the next workday when there is a recordable

injury or personal property damage not addressed in this

section.

3.3.8.3.3 Within five workdays when there is only first aid, not a

recordable injury or personal property damage, and the

incident is considered a near miss.

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3.3.9 Upon request of the Fire, Life and Safety Administrator, the Occupational Health Nurse

(OHN) and/or the Occupational Health Administrator, review industrial injury/illness

situations to perform an investigative inspection with a Root Cause Analysis, Form

404-8, to determine if corrective actions can be made to avoid future occurrences or

a similar loss.

3.3.9.1 If corrective actions can be made, the Department OSC shall prepare and

provide a report to Warden or designee, the Safety and Loss Prevention

Committee, and the Physical Plant Manager/Administrator. The report shall

contain incident or accident finding-specific information, the resulting

consequences, and recommendations to eliminate future occurrences.

3.3.9.2 Report findings, corrective actions or recommendations to site

management, the Safety and Loss Prevention Committee, and the Fire,

Life and Safety Administrator.

3.3.10 Determine areas that require “slip resistant” footwear. Approval for Medical Waivers

for the footwear shall be in accordance with Department Order #503, Employee

Grooming and Dress.

3.3.10.1 A copy of the approved Medical Waiver shall be provided to the

Department Occupational Health Nurse and the OSC.

Fire and Life Safety Equipment Monitoring and Documentation Responsibilities {5-ACI-3B-01

(M)}

3.4.1 The Department OSC shall ensure appropriate quantities of fire and life safety

equipment are available and maintained in accordance with applicable standards,

codes, laws, rules and regulations. Fire and life safety equipment includes but is not

limited to the following:

3.4.1.1 Fire detection systems, fire extinguishers and extinguishing systems

3.4.1.2 Respirators as outlined in section 12.0

3.4.1.3 Face shields, goggles, and head, hand and foot protection

3.4.2 The Department OSC shall submit a completed:

3.4.2.1 Annual Fire Profile Report, Form 404-4, before March 1 each year to the

Warden or designee and the Fire, Life and Safety Administrator.

3.4.2.2 Detailed report of critical item fire equipment shortages to the Fire, Life

and Safety Administrator on the first Monday of March each year, which

specifies:

3.4.2.2.1 The type and quantity of the equipment needed.

3.4.2.2.2 The reason for the shortage and/or damage.

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3.4.2.2.3 Whether the item identified is a repeat from the last fiscal

budget request. If a repeated request, the reason the item

was not approved in a prior request shall be provided, if

known.

3.4.2.3 Budget request to the Fire, Life and Safety Administrator by March 1 each

year for the repairs, upgrades, replacements, alterations and additions to

facilities, alarm systems, fire detection, prevention and suppression

apparatus, equipment, their related infrastructures, and personal

protective equipment (PPE) in accordance with applicable standards,

codes, laws, rules and regulations.

3.4.3 The Department OSC shall:

3.4.3.1 Record hydrant inspections and testing on the Fire Hydrant Inspection

Report, Form 404-11.

3.4.3.2 Ensure hydrants are flushed at least annually to verify operation, repairs

and reliability.

3.4.3.3 Ensure hydrant flow tests (pressure tests) are conducted every five years.

3.4.3.3.1 Private prisons shall conduct hydrant flow tests (pressure

tests) every five years.

3.4.4 The Department OSC shall: {5-ACI-3B-01 (M)}

3.4.4.1 Update and maintain a fire and life safety equipment maintenance/

replacement record that includes the documentation below. These

documents shall be maintained with Facilities Maintenance and

documented with a hard copy and/or maintenance database (TME):

3.4.4.1.1 Type of inspection and testing required (i.e., hydrostatic

testing, fire detection and fire prevention device testing, and

mandatory hydrant flow tests).

3.4.4.1.1.1 Sprinklers, Standpipes, Hydrants, Tanks and

other Water-Based Extinguishing Systems

Inspections – Water based systems shall be

inspected, tested and maintained per NFPA

25 by qualified Facilities staff or a contractor.

3.4.4.1.1.2 Quarterly main drain tests shall be conducted

by qualified Facilities staff or a contractor on

sprinkler risers.

3.4.4.1.1.3 An annual sprinkler test shall be conducted

by an outside resource (contractor, fire

department, fire marshal, etc.). Other

inspections and tests may be conducted by

qualified Facilities staff.

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3.4.4.1.1.4 Portable fire extinguisher inspections shall be

inspected, tested and maintained per NFPA

10. Annual maintenance may be completed

by qualified staff or a contractor.

3.4.4.1.1.5 Kitchen hoods, duct systems and associated

fixed fire suppression systems shall be

inspected, tested and maintained per NFPA

96.

3.4.4.1.2 Maintenance/replacement schedule in accordance with NFPA

and/or OSHA standards.

3.4.4.1.2.1 Alarm systems shall be inspected, tested and

maintained per NFPA 72 by qualified Facilities

staff or a contractor.

3.4.4.1.3 Date of the last maintenance/replacement and by whom.

3.4.4.2 Conduct random fire and life safety inspections of all institution/facility

structures when directed and a minimum of once per year. This report shall

conform to a format approved by the Fire, Life and Safety Administrator,

which shall be included in a photo-documented finding and

recommendations report.

3.4.4.2.1 The Department OSC shall provide a copy to the Warden or

designee, the Deputy Warden of Compliance and the Fire,

Life and Safety Administrator for all code corrective actions

relating to documented inspection findings and

recommendations.

3.4.4.2.2 The private prison OSC shall provide to the Warden corrective

actions relating to documented inspection findings and

recommendations.

3.4.4.3 Ensure Safety Data Sheets’ (SDS) are updated, readily accessible, and a

centralized location, in accordance with Department Order #407, Chemical

Control. In addition to mirroring the Master SDS List maintained by the

Warehouse Manager in the warehouse, the SDS for the pest and weed

control/eradication products applied in accordance with Department Order

#403, Maintenance, shall be updated and readily accessible.

Fire Prevention and Evacuation Responsibilities – The OSC shall:

3.5.1 Ensure a weekly fire and monthly safety inspection of the institution is conducted by

a qualified Unit Fire/Safety Coordinator or qualified institutional supervisor, who shall

submit a completed Safety/Sanitation Inspection Report, Form 404-13, to the

Department OSC. {5-ACI-3B-02 (M)}

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3.5.2 Ensure fire detection and protection systems are visually inspected (monthly,

quarterly, annually or as required) and qualified testing is completed. The OSC shall

submit a completed Maintenance/Service Work Order Request, Form 403-2, or an

electronic request in accordance with Department Order #403, Maintenance, if

problems are observed. {5-ACI-3B-01 (M)} {5-ACI-3B-02 (M)}

3.5.3 With a minimum of same day notification, with the exception of emergencies, advise

the Warden and the Emergency Preparedness Administrator (as applicable for

Department institutions/facilities) of exercises, drills, tests, or actual alarm activations

when any evacuation is scheduled to occur.

3.5.4 Receive a completed copy of the Use of Force/Incident Command, 804-2, after each

fire evacuation and life safety drill.

3.5.4.1 Announced or unannounced fire evacuations and life safety drills shall

occur in all occupied structures, for each shift they are occupied, at least

quarterly each year. Actual emergency evacuations may count as

evacuations and training.

3.5.5 Coordinate the completion of the Emergency Action/Fire Prevention Action Plan, Form

404-3, and submit the form to the Fire, Life and Safety Administrator the first Monday

in February. Copies shall be provided to the following:

3.5.5.1 Department institution/facility – Copies shall be provided to the Warden or

designee, and posted on appropriate employee bulletin boards.

3.5.5.2 Private prison – Copies shall be submitted to the Warden, who shall

disseminate the Plan as appropriate.

3.5.5.3 The Emergency Preparedness Administrator.

3.5.6 Ensure accurate emergency evacuation routes are posted in all structures and ensure

occupants are familiarized with evacuation procedures. {5-ACI-3B-11 (M)}

3.5.6.1 Automated External Defibrillator (AED), first aid kits, biohazard spill kits,

alarm boxes and portable fire extinguisher locations shall be clearly

indicated on the site’s map.

The Unit Fire/Safety Coordinator shall:

3.6.1 Function as the unit’s liaison to the OSC.

3.6.2 Immediately report critical fire and life safety issues to the OSC or Complex Fire/Safety

Coordinator.

3.6.3 Review the unit's chemical control in accordance with this Department Order,

Department Order #407, Chemical Control, and other regulatory requirements. {5-

ACI-3B-05 (M)}

3.6.4 Ensure monthly inspections of the fire detection and protection systems are completed

by the Facilities Department and report their findings to the OSC or Complex

Fire/Safety Coordinator. {5-ACI-3B-02 (M)}

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3.6.5 Conduct monthly inspections of the chemicals/SDS, and respiratory protection

systems, and report their findings to the OSC or Complex Fire/Safety Coordinator. {5-

ACI-3B-02 (M)}

3.6.6 Attend and participate in the institution/facility’s monthly Safety and Loss Prevention

Committee meetings.

3.6.7 Prior to using a chemical received independently of the warehouse, obtain the SDS,

read them, ensure the OSC has a copy of the SDS or provide one, and inform the OSC

of the quantity of the chemical on-hand. {5-ACI-3B-05 (M)}

3.6.8 Conduct weekly and monthly inspections of all unit buildings using the Safety

Inspection Report and submit reports to the Department OSC.

3.6.9 For units that have a Fire Brigade, serve as a leader for the Brigade.

3.6.10 Attend the OSHA 30 hour training and maintain certification.

Control of Hazardous Energy (Lockout/Tagout) Procedure – The OSC shall monitor the

Lockout/Tagout Program as outlined in section 9.0 and ensure equipment, machinery or systems

are inspected at least annually and the certification documentation for qualified staff is

completed.

4.0 SAFETY AND LOSS PREVENTION COMMITTEES

Department Vehicle Incident Review Committee – The Department Vehicle Incident Review

Committee shall:

4.1.1 Review major traffic accidents or incidents involving Department motor vehicles when:

4.1.1.1 The operator receives a citation for a traffic violation arising from an

accident.

4.1.1.2 There is a death or serious injury requiring hospitalization.

4.1.1.3 A leased, rented or personal vehicle or personal property is involved in an

incident involving a state vehicle.

4.1.1.4 Property damage exceeds $2,500.

4.1.2 Meet at least quarterly.

4.1.3 Meet as expediently as possible (no later than 30 calendar days) after an accident

involving a death and incidents with pertinent information available (e.g., accident,

incident reports and/or the police reports) that resulted in one or more of the following:

4.1.3.1 A serious and possibly debilitating injury.

4.1.3.2 A state vehicle being defective or containing defective equipment.

4.1.3.3 A law enforcement investigation determining a Department driver was at

fault or negligent.

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4.1.4 Be chaired by the Security Operations Administrator with one representative member

appointed by each Assistant Director. Members may include:

4.1.4.1 An ADOA Risk Management representative.

4.1.4.2 Fire, Life and Safety Administrator.

4.1.4.3 A Department Fleet Management Administrator.

4.1.4.4 The Prison Operations Business Manager.

4.1.5 Review each incident as reported from the previous quarter and forward findings and

recommendations to the responsible Assistant Director, Warden or Bureau

Administrator. The findings shall include:

4.1.5.1 Finding the accident was preventable – Good judgment was not used

when operating a state vehicle and the driver was cited for the accident

and/or found to be at fault.

4.1.5.2 Finding the incident was non-preventable – Proper operational judgment

was used in trying to avoid the incident, and the operator was not cited

by law enforcement as responsible for the incident.

4.1.5.3 Recommended action based on the incident and the driver's Motor Vehicle

Division (MVD) operating history to assist disciplinary action

determination.

4.1.5.4 Accident Prevention Training – A vehicle operator with more than one

preventable incident on his/her Arizona Department of Transportation

(ADOT) driving record within a three-year period shall complete a

Department-approved Defensive Driving training program. State driving

privileges may be suspended and/or restored by the Deputy Directors.

Department Worker Injury Reduction Committee – The Department Worker Injury Reduction

Committee is the Agency Loss Prevention Committee. The Fire, Life and Safety Administrator,

as the Agency Loss Prevention Coordinator and ex-officio member of the Committee, shall be

the Chairperson of the Committee.

4.2.1 The Department Worker Injury Reduction Committee shall:

4.2.1.1 Review the following:

4.2.1.1.1 Department property losses, accidents, workplace injuries

and disturbances, negligence, or thefts involving claims of

more than $2,500, to include fatalities and losses from

incidents outlined in section 1.0.

4.2.1.1.2 Incidents forwarded from the Institutional Safety and Loss

Prevention Committee.

4.2.1.1.3 The minutes from each Institutional Safety and Loss

Prevention Committee meeting, including their findings,

recommendations and problem resolution from the previous

meeting.

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4.2.1.1.4 Completed Loss Prevention Program Checklist, Form 404-2.

4.2.1.1.5 SafeT Management Systems (SMS) metrics and evaluate

effectiveness.

4.2.1.2 Recommend corrective action(s), if appropriate.

4.2.2 Each Assistant Director or designee shall appoint one Committee member for each

major area of responsibility, who shall have a term not to exceed three consecutive

calendar years.

4.2.3 The Fire, Life and Safety Administrator shall ensure minutes are distributed to the

following:

4.2.3.1 Director and Deputy Directors

4.2.3.2 Assistant Directors

4.2.3.3 Regional Operations Directors and Bureau Administrators

4.2.3.4 Emergency Preparedness Administrator and the Occupational Health

Administrator

4.2.3.5 Committee members

Institutional Safety and Loss Prevention Committee

4.3.1 The Warden shall appoint Committee members for a one year term, which may be

extended at the discretion of the Warden.

4.3.2 The Committee shall:

4.3.2.1 Be comprised of:

4.3.2.1.1 A Deputy Warden or designee, who shall be the Committee

Chairman.

4.3.2.1.2 The Unit Fire/Safety Coordinator.

4.3.2.1.3 The OHN and Department OSC.

4.3.2.1.4 Representatives of the total site workforce and all major

areas within each area of responsibility.

4.3.2.2 Meet a minimum of once monthly to review the following:

4.3.2.2.1 Key performance indicators as measures of safety

performance (i.e., worker’s compensation injury claims,

injuries with workdays lost, and inmate worker injuries).

4.3.2.2.2 Workplace incidents involving fatalities, injuries and/or near

misses including those involving only first aid.

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4.3.2.2.3 Received Employee Safety Suggestions, Form 404-1.

Employees may submit these forms to the Safety Committee

Chairman to convey suggestions on how to improve

Department safety.

4.3.2.2.4 Institutional compliance with ADOA’s mandatory Loss

Prevention Program using the Loss Prevention Program

Checklist, Form 404-2, and make recommendations to

improve the program(s).

4.3.2.2.5 Equipment loss and property damage claim trends.

4.3.2.2.6 Recommendations for recognition of safety-related actions or

activities.

4.3.2.2.7 The adequacy of the locations and types of first aid kids,

biohazard kits, AEDs, and PPE. Modifications shall be in

accordance with section 6.0.

4.3.2.2.8 Special projects planning, implementation and follow-up.

4.3.2.3 Discuss vehicle incidents not meeting the criteria for review by the

Department’s Vehicle Incident Review Committee.

4.3.3 The Deputy Warden or designee shall ensure:

4.3.3.1 A Meeting Agenda is developed and used that contains the minimum

elements in Attachment D, Safety and Loss Prevention Committee Agenda

Guidelines.

4.3.3.2 The Fire, Life and Safety Administrator receive a copy of all Committee

meeting minutes.

4.3.3.3 Findings and recommendations are provided to the Warden, the OHN, and

Department OSC.

4.3.3.4 The Warden is provided status update reports upon the successful

completion of Committee activity.

5.0 DEPARTMENT LOSS PREVENTION PROGRAM ELEMENTS – The Institutional Safety and Loss

Prevention Committee and the Department Worker Injury Reduction Committee, the Fire, Life and Safety

Administrator and/or individuals designated by the Director shall develop, implement, measure and

monitor the Department Loss Prevention Program, the SMS Core Elements and any active occupational

health and safety programs. Refer to Attachment C, Department Loss Prevention Program Elements,

for additional information.

6.0 FIRST AID, BIOHAZARD SPILL AND OLEORESIN CAPSICUM MASK KITS AND SUPPLIES

The Warden, Administrator or designee shall:

6.1.1 Purchase components and supplies for first aid, biohazard spill and Oleoresin Capsicum

(OC) Mask kits, and AED, and provide them to the Department OSC to restock kits.

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6.1.2 Ensure Department employees submit a completed Information Report, Form 105-2,

to the Department OSC when a first aid kit, biohazard spill kit seal or OC Mask kit is

broken or contents are used, along with the opened first aid and/or biohazard spill kit.

The Occupational Health Administrator and the Fire, Life and Safety Administrator shall identify

kit contents in accordance with the Exposure Control Plan.

The Institutional Safety and Loss Prevention Committee shall determine the location of first aid

and biohazard spill kits and OC mask kits in each structure and identify each kit’s contents in

accordance with the Exposure Control Plan.

The Department OSC shall stock the kits and the individual items of the kits for distribution as

needed, and ensure the Unit Fire/Safety Coordinator:

6.4.1 Inspects tamper seals of first aid and biohazard spill kits and installs or replaces kits

when missing, damaged or broken.

6.4.2 Exchanges kits having broken seals for sealed kits with the OSC.

6.4.3 Provides the OSC a monthly report documenting the unit’s overall fire and safety

compliance, including the completeness of first aid and biohazard spill kits.

Vehicle First Aid Kits – Vehicle first aid kits shall be mandatory in vehicles used to transport

Department and private prison inmates, and offenders.

Medical emergencies outside the scope of Correctional Analysis and Response to Emergencies

(CARE) requiring treatment by a trained health professional or a trained Emergency Medical

Technician shall not be considered first aid. In emergencies, stabilizing efforts may be provided

by trained First Responders until Emergency Medical Technicians or health staff arrive on-scene.

No one shall render aid beyond their level of training.

7.0 PERSONAL PROTECTIVE EQUIPMENT (PPE)

Project/Work Crew supervisors, when scheduling work that involves new construction,

demolition, renovations, maintenance, and hazardous chemical usage that may create hazards,

shall:

7.1.1 Consult with the OSC and the Physical Plant Manager/Administrator to determine if a

Job Hazard Analysis, Form 404-10, needs to be completed. If determined necessary,

Project/Work Crew supervisors shall complete the form in consultation with the OSC

for the selection, inspection, and maintenance of PPE.

7.1.2 Receive OSHA 10-Hour General Industry and/or Construction Training.

The OSC shall ensure PPE designated for a specific hazard/area is in accordance with the

following:

7.2.1 OSHA standards and fire and life safety codes

7.2.2 The Department’s Exposure Control Plan requirements

7.2.3 Job Hazard Analysis form, if applicable

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PPE shall include, but not be limited to the following:

7.3.1 Appropriate eye protection, as determined by health staff as necessary and hearing

protection, if needed

7.3.2 Gown, coveralls and aprons

7.3.3 Face shields and hard hats

7.3.4 N-95 respirators and other “N”, “R” or “P” rated respirators

7.3.5 Air purifying respirators (APR) and SCBA

7.3.6 Work boots or strap-on metatarsal guards

7.3.7 Gloves, including disposable, latex-free gloves

Anyone assigned to duties, or in the proximity of, inmates with a known or suspected

contagious disease shall use the PPE protocols as outlined in this section, Department Order

#1102, Communicable Disease and Infection Control, and the Department’s Exposure Control

Plan.

8.0 EQUIPMENT, POWERED INDUSTRIAL TRUCKS AND HEAVY EQUIPMENT SAFETY

For power and pneumatic tools and equipment, the assigned Tool Room Officer, Project/Work

Crew supervisor or Inmate Program Specialist shall:

8.1.1 When a new or reassigned tool is received:

8.1.1.1 Verify an operations manual was included with the tools/equipment. If the

equipment is custom manufactured, an operational set of guidelines shall

be developed and implemented.

8.1.1.2 Do an inspection to ensure the manufacturer/distributor has met use

requirements and the tool/equipment operates as required.

8.1.1.3 Review Department Order #712, Tool Control, to determine the

classification of the equipment.

8.1.1.4 Identify necessary PPE and available safety training information (e.g.,

safety training programs, videotapes, etc.). This may include specialized

training provided by the equipment provider or manufacturer.

8.1.2 Prior to equipment use:

8.1.2.1 Ensure the identified PPE is being worn and equipment is used in

accordance with manufacturer’s operator’s manual or operational

guidelines.

8.1.2.2 Perform a visual safety check to ensure the safety features are in working

order and document it on the Tool Checkout, Form 712-4 or 712-4A.

8.1.3 Upon return:

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8.1.3.1 Ensure PPE and/or safety training information is returned with the

tools/equipment.

8.1.3.2 Perform a visual safety check as outlined in this section.

8.1.4 When found broken or inoperable:

8.1.4.1 Immediately tag the item as “Out of Service” and remove it from use until

repaired or replaced.

8.1.4.2 Where possible, place a Department Lock Out/Tagout Tag on the

equipment, which shall include the name of the person performing the lock

out/tag out and the date it was performed.

8.1.4.3 Use a single-keyed lock to disable the device and render the equipment

inoperable.

8.1.4.4 Document both the Lock Out/Tag Out and return on an Information Report,

to the Shift Commander. Refer to section 9.0 for specific Control of

Hazardous Energy (Lockout/Tagout) Program requirements.

Equipment and machinery shall be monitored for proper use, repair and storage.

8.2.1 Misuses may result in disciplinary action. All suspected and verified attempts to

circumvent/modify/eliminate safety devices or procedures shall be reported to the unit

Chief of Security using an Information Report form in accordance with Department

Order #105, Information Reporting. A copy shall be given to and maintained by the

OSC.

Repairs and Modifications of Power and Pneumatic Tools and Equipment

8.3.1 Repairs may be completed utilizing Authorized Personnel or technician with the use of

original equipment manufacturer or authorized replacement parts.

8.3.2 Modifications shall be completed by authorized technicians unless approved by the

OSC and the Physical Plant Manager/Administrator.

Powered Industrial Trucks and Heavy Equipment (PIT/HE)

8.4.1 PIT/HE usage shall comply with OSHA standards found in CFR 1910.178 and 1910

Subpart F. For the purposes of this section, PIT/HE consists of fork trucks, tractors,

platform lift trucks, man lifts, motorized hand trucks, and other specialized vehicle

mounted industrial equipment powered by electric motors and/or internal combustion

engines.

8.4.2 PIT/HE shall only be operated by persons who:

8.4.2.1 Are proficient in their operation, safe use, and inspection of the particular

working platform to be operated.

8.4.2.2 Successfully complete a PIT/HE Operator Training program and evaluation

equivalent to that of construction operators as outlined in Department

Order #405, Vehicles/Vehicle Maintenance.

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The Tool Room Officer or the supervisor shall not reissue any tools/equipment until after repairs

are completed or the item is replaced.

9.0 CONTROL OF HAZARDOUS ENERGY (LOCKOUT/TAGOUT) PROGRAM – In accordance with 29 Code

Of Federal Regulations (CFR) Part 1910.147, OSHA Control of Hazardous Energy Standard (Standard)

the Department’s Lockout/Tag Out Program establishes positive control methods used by Department

employees and contractors to prevent the accidental starting or activating of equipment, machinery or

systems being repaired, cleaned and/or serviced. The Inmate Program Supervisor supervising an Arizona

Correctional Industries owner-operated work program that utilizes energized equipment within a prison

complex shall administer the equipment’s lockout/Tag Out Program. In situations where the Department

Order and the Standard conflict, the Standard shall be followed.

The Physical Plant Manager/Administrator or designee shall update and maintain an electronic

record of employees and outside personnel/contractors who are Authorized Personnel for

Lockout/Tagout Procedures.

Supervisor Responsibilities – The supervisor of employees and contractors performing a

maintenance or service activity shall ensure:

9.2.1 Department employees and contractors comply with Program requirements and

procedures.

9.2.2 Only those listed in the electronic record, updated and maintained by the Physical

Plant Manager/Administrator or designee, implement any Lockout/Tagout procedures

outlined in this section.

9.2.3 Prior to completing Lockout/Tagout procedures, Authorized Personnel complete the

Authorized Personnel Training, which shall:

9.2.3.1 Include the following:

9.2.3.1.1 The identification of applicable hazardous energy sources.

9.2.3.1.2 The type and magnitude of energy available in the work area.

9.2.3.1.3 Methods and means for energy isolation and control.

9.2.3.2 Be documented on the Lockout/Tagout Certification of Training, Form 404-

17. Completed certifications shall be kept on file by the OSC.

9.2.4 All persons working in the area of the equipment, machinery or systems (affected

persons) shall be instructed on the equipment’s current status. For the purposes of

this Department Order, affected persons are those whose job functions require them

to:

9.2.4.1 Operate or use a machine or equipment on which servicing or maintenance

is being performed under Lockout or Tagout.

9.2.4.2 Work in an area in which such servicing or maintenance is being

performed.

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9.2.5 Though prohibited from attempting to restart or re-energize equipment, machinery or

systems that are locked out or tagged out, affected persons shall be provided general

instruction on the purpose and use of the Lockout/Tagout procedure.

9.2.6 Lockout Tagout Energy Control – Equipment/Machine/System, Form 404-20, is

completed, updated and maintained as necessary.

Authorized Persons Performing Maintenance or Service Activity Responsibilities – To ensure

compliance with the standard and employee safety, Authorized Personnel performing the

maintenance or service activity shall identify the energy sources (or sources) and shut off or

disconnect the energy means in the following sequence.

9.3.1 For electrical (most common form) shut off:

9.3.1.1 Electric power to the machine, equipment or system and ensure it is

disconnected (i.e., locked or tagged).

9.3.1.1.1 Disconnection may include the following: power cord, power

panels (look for primary and secondary voltage), breakers,

the operator's station, motor circuit, relays, limit switches,

and electrical interlocks, motor isolating shut-off and a

control isolating shut-off.

9.3.1.1.2 If the electrical energy is disconnected by simply unplugging

the power cord, the cord shall be kept under the control of

the authorized employee or the plug end of the cord must be

locked out or tagged out.

9.3.1.2 Press start button to ensure the correct machine, equipment systems is

locked out.

9.3.1.3 Drain capacitors of stored energy, if applicable.

9.3.1.4 Return controls to their safest position (e.g., off, stop, standby, inch, jog,

etc.).

9.3.2 For hydraulic/pneumatic:

9.3.2.1 Shut off all energy sources (pumps and compressors). If the pumps and

compressors supply energy to more than one piece of equipment, lockout

or tagout the valve supplying energy to the piece of equipment being

serviced.

9.3.2.2 Drain/bleed stored pressure from hydraulic/pneumatic lines when any

release of stored energy could cause injury to employees.

9.3.2.3 Return controls to their safest position.

9.3.3 For fluid and gas:

9.3.3.1 Identify the type of fluid or gas and the necessary PPE.

9.3.3.2 Close valves to prevent flow, and lockout/tagout.

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9.3.3.3 Determine the isolating device, then close and lockout/tagout.

9.3.3.4 Drain and bleed lines to zero energy state.

9.3.3.5 Ensure systems with electrically controlled valves are shut off and

locked/tagged out.

9.3.3.6 Check for zero energy state at the equipment.

9.3.4 For mechanical energy (including gravity activation, energy stored in springs, etc.):

9.3.4.1 Block out or use die ram safety chain.

9.3.4.2 Lockout or tagout safety device.

9.3.4.3 Shut off, lockout or tagout electrical system.

9.3.4.4 Check for zero energy state.

9.3.4.5 Return controls to safest position.

9.3.5 Prior to releasing equipment, machine or system from Lockout/Tagout:

9.3.5.1 Remove affected persons from the work area or, if they remain, ensure

they are safely positioned and notified of the release.

9.3.5.2 Ensure work is completed.

9.3.5.3 Replace guards when required.

9.3.5.3.1 Adjustment guards shall be replaced as soon as adjustments

occur.

9.3.5.4 Account for all tools and equipment used.

9.3.5.5 Ensure the area involved is clean (i.e., removing of all debris, towels, rags,

work-aids, etc.).

9.3.5.6 Check all controls and return them to their safest position.

9.3.6 When servicing or performing maintenance on a machine, equipment or system with

other Authorized Personnel concurrently:

9.3.6.1 If capable of being locked out, each person shall use a multiple lock

scissors clamp and place his/her own lock or Lockout/Tagout Tag on the

energy-isolating source.

9.3.6.2 If incapable of being locked out, each person shall place a Lockout/Tagout

Tag on the equipment, machine or system.

Required Written Procedures – Each work area containing machines, equipment or systems

shall ensure written procedures exist for the following:

9.4.1 Removal of a Lock or Lockout/Tagout Tag by Other Authorized Personnel

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9.4.1.1 Though normally the Authorized Personnel who place a lock or

Lockout/Tagout Tags on equipment, machines or systems are responsible

for their removal. Each work area requiring the Lockout/ Tagout Program

shall develop emergency removal procedures, which at a minimum contain

the following:

9.4.1.1.1 Verification that the Authorized Personnel who applied the

device is not on-site at the facility.

9.4.1.1.2 Assurance the Authorized Personnel who placed the lock or

Lockout/Tagout Tag is advised of the removal upon their

return to the work area.

9.4.1.1.3 Verification by the employer that the authorized employee

who applied the device is not at the facility.

9.4.2 Lockout/Tagout Procedures Spanning Shift or Personnel Changes – Written procedure

shall be specific to the needs and capabilities of the work area and detail how

continuity will be ensured at all times.

Procedures for Outside Personnel/Contractors – The Project Manager shall inform the OSC when

outside personnel/contractors need to work in an area with machines, equipment or systems.

The OSC or designee shall:

9.5.1 Advise the outside personnel/contractors of Lockout/Tagout procedures and their

enforcement.

9.5.2 Obtain information from the outside personnel/contractors about their Lockout/Tagout

procedures and advise affected persons of this information.

9.5.3 Ensure the appropriate training is completed and documented prior to working in an

area with machines, equipment or systems as outlined in this section.

Periodic Inspection

9.6.1 Machines, equipment and systems that are part of the Lockout/Tagout Program shall

be inspected at least annually.

9.6.2 Inspections shall be conducted by the supervisor of Authorized Personnel or another

qualified designee in consultation with the OSC.

9.6.2.1 In accordance with best practices, supervisors shall inspect machines,

equipment and systems they are familiar with, but do not normally operate.

9.6.3 Inspections shall be documented on the Periodic Lockout/Tagout Inspection

Certification, Form 404-19, and include the following:

9.6.3.1 A review between the inspector and each Authorized Personnel with

Lockout/Tagout procedure responsibilities. The inspector shall be the

Authorized Personnel on the inspected piece of equipment or device.

9.6.3.2 A physical inspection while in use by Authorized Personnel.

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9.6.3.3 A demonstration by the authorized employee of the equipment’s proper

use.

9.6.4 The supervisor shall retain inspection forms in his/her Inspection Record File and make

them available upon request.

10.0 INMATE WORKERS – Project/Work Crew Supervisors assigned to new construction, demolition,

renovations, maintenance, motorized vehicles and hazardous chemical usage that may create hazard

shall:

Prior to hiring inmates to perform specific tasks, conduct an evaluation and determine inmates’

skill/knowledge level by:

10.1.1 Reviewing their Department work history.

10.1.2 Interviewing inmates to determine their knowledge of and/or skill in the work to be

performed.

10.1.3 Observing and/or verifying their ability to perform claimed skills.

Prior to allowing inmates to perform specific tasks, ensure:

10.2.1 Inmates receive training on the potential job hazards and have appropriate PPE in

accordance with the appropriate Job Hazard Analysis form and any other appropriate

safety information.

10.2.2 Inmates receive tools/equipment training and demonstrate their ability in its usage.

Document training provided to the inmate workers relative to their assigned duties, and forwards

the training documents to the appropriate Program Area Supervisor, who shall maintain the file.

Ensure the following:

10.4.1 The proper tools/equipment assigned for tasks are in good working order/condition.

10.4.2 Inmates use safe working practices, including the usage of appropriate PPE.

Supervise work from implementation through completion, ensuring all inmate workers comply

with 29 CFR Parts 1910 and 1926 or remove unsafe inmates from tasks.

Report all inmate serious physical injuries by completing a Significant Incident Report form in

accordance with Department Order #105, Information Reporting. The OSC shall receive a copy.

Report any incident involving unsafe work practices to the Physical Plant Manager/

Administrator and the OSC for appropriate action. Department employees who knowingly

observe and do not report a safety procedure violation or condone unsafe practices may be

subject to disciplinary action in accordance with Department Order #601, Administrative

Investigations and Employee Discipline.

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10.7.1 Vicarious liability and deliberate indifference laws also apply. A person observing but

not reporting violations may be held personally liable when an unqualified inmate

worker performs tasks resulting in the injury of the inmate or another person.

Initiate Work Program assignment changes due to poor performance, disruptive behavior, and/or

security threats, in accordance with Department Order #903, Inmate Work Activities.

11.0 FIRE-RELATED CONTRACTS {5-ACI-3B-01 (M)}

Department institutions/facilities shall establish Procurement-approved contracts for the routine

inspection, testing and maintenance of fire detection and suppression systems.

11.1.1 The Fire, Life and Safety Administrator, the Emergency Preparedness Administrator

and ADOA Risk Management shall review Procurement contracts for state liability and

recommend approval or disapproval to the Director or designee.

Private prisons shall enter into agreements as specified by their Department contract and this

Department Order, which ensures a fire department or an authority having jurisdiction provides

the fire and asset protection.

12.0 RESPIRATORS AND RESPIRATORY PROTECTION – The Department’s written Respiratory Protection

Program shall comply with OSHA 1910.134. Respirators and devices shall be purchased from state

contractors and clearly marked as being approved by the National Institute of Occupational Safety And

Health (NIOSH) and/or meet NFPA Standards, as applicable.

All Correctional staff members that have physical contact with inmates who have or are

suspected of having a communicable disease shall wear an approved NIOSH rated N-95

Respirator, disposable latex free gloves, and appropriate eyewear.

In order to be fit tested for a respirator (half face, full face or an N-95 Particulate), employees

or inmates shall be free of facial hair that comes between the sealing surfaces of the face-piece

and the face, or where it interferes with valve function.

12.2.1 Staff members assigned to Tactical Support Unit, Complex/Statewide Transportation,

and Canine may wear facial hair (i.e., goatee and mustache), if in compliance with the

requirements set forth above. Full beards are not authorized.

12.2.2 All other Correctional Officers (e.g., Correctional Officer II, Sergeant, Lieutenant, and

Captain) shall undergo fit testing once per year and must be free of facial hair that

comes between the sealing surfaces of the face-piece and face, or where it interferes

with the valve function.

Medical Evaluation and Clearance

12.3.1 Employees and inmates assigned to a job or a position requiring a respirator, as

outlined in Attachment B, Respirators, shall be medically evaluated and cleared for

respirator usage prior to being assigned to a job or a position requiring a respirator

(initial medical evaluation and clearance) and on an annual basis within 30 calendar

days of the expiration of their previous fit test.

12.3.2 The Respirator Confidential Medical Questionnaire, Form 404-26, (Respirator

Questionnaire) shall be used to document the initial medical evaluation and clearance

and every two years thereafter.

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12.3.3 Employees and inmates may use the Annual Supplemental – Respirator Medical

Evaluation Questionnaire, (Annual Supplement), Form 404-27, the first year after the

initial medical evaluation and clearance and on alternating years thereafter.

12.3.3.1 Disqualification from using the Annual Supplement form include the

following:

12.3.3.1.1 Required usage of a respirator that has never been fit tested

before.

12.3.3.1.2 The employee or inmate is experiencing adverse health

issues.

12.3.3.1.3 The employee or inmate has had significant facial feature

changes (i.e., 10% weight loss or gain, scar, etc.).

12.3.3.1.4 The employee or inmate did not meet the 30 calendar day

requirement.

12.3.3.2 When disqualified from using the Annual Supplement, employees and

inmates shall use the Respirator Questionnaire.

12.3.4 Employee Medical Evaluations and Clearances

12.3.4.1 Employees shall complete their portion of the appropriate questionnaire

and schedule a health appointment with the OHN in the time frames

specified in this section. The appropriate questionnaire shall be

confidentially submitted to the OHN prior to or during the appointment.

12.3.4.2 The OHN shall evaluate the respirator questionnaire to determine medical

clearance.

12.3.4.3 If additional medical evaluation is required to determine clearance for

respirator:

12.3.4.3.1 The OHN shall provide a copy of the employee’s appropriate

questionnaire and the Authorization and Information for

Respiratory Evaluation, Form 404-25, in a sealed envelope to

take to the contracted Occupational Health Provider.

12.3.4.3.2 The employee shall be directed to the appropriate

Occupational Health Provider.

12.3.4.3.3 Upon the completion of the appointment, the Occupational

Health Provider shall note his/her disposition on the form and

return the form to the OHN.

12.3.4.3.4 The OHN shall document the disposition in the employee’s

medical file and provide written notification of medical

clearance to the Department OSC.

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12.3.4.4 Occupational Health Unit (OHU) staff shall ensure confidential medical

forms are placed in an employee’s appropriate Occupational Health Record.

12.3.5 Inmate Medical Evaluations and Clearances

12.3.5.1 Inmates shall complete their portion of the appropriate questionnaire and

schedule a health appointment with the Health Unit in the time frames

specified in this section. Inmates shall bring the appropriate questionnaire

with them to their Health Unit appointment.

12.3.5.2 During the appointment:

12.3.5.2.1 Inmates shall discuss their questionnaires confidentially with

the appropriate Health Unit staff and answer questions and/or

have a medical examination if needed and appropriate.

12.3.5.2.2 The appropriate Health Unit staff shall evaluate the respirator

questionnaire to determine medical clearance. An

Authorization and Information for Respirator Evaluation form

shall be completed if additional medical examination for

medical clearance is needed.

12.3.5.3 After the appointment, the appropriate Health Unit staff shall:

12.3.5.3.1 Provide written notification of medical clearance to the

Department OSC within five workdays of the appointment’s

completion.

12.3.5.3.2 Ensure confidential medical forms are placed in the

appropriate Inmate Medical Record.

Fit Testing

12.4.1 Fit testing and certification shall be in accordance with Respiratory Protection

Standard, 29 CFR 1910.134, state fire standards, codes, laws rules, regulations.

12.4.2 Fit testing certification shall only be valid for one year from the date of the fit test.

12.4.3 SCBA and Air Purifying Respirators shall be fit tested using the Quantitative Fit Test

method. All other types of respirators may be fit tested using the Qualitative Fit Test

method.

12.4.4 All respirator users shall possess a current Respirator Card for the respirator they are

using or be cited in violation in accordance with OSHA regulations.

13.0 INSTITUTION/FACILITY EVACUATIONS {5-ACI-3B-11 (M)}

Institutional security and safety procedures for fire and evacuation instructions shall be in

accordance with this Department Order and as outlined in National Incident Management

System (NIMS) and the Incident Command System (ICS). Refer to Department Order #706,

Incident Command System (ICS), for additional information.

CHAPTER: 400

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404 – FIRE, SAFETY AND LOSS PREVENTION

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During emergencies all employees, visitors and any other persons not assigned emergency-

specific responsibilities shall follow safety and evacuation procedures as outlined in Employee

Emergency/Fire Prevention Plans and Emergency Operations and Response Plans. {5-ACI-3B-12

(M)}

Responding agencies shall be:

13.3.1 Incorporated into a Unified Command Structure for management of all incidents.

13.3.2 Assigned an institution/facility liaison with radio communications capability.

13.3.3 Allowed immediate access to the area of the alarm or call, when security is assured.

13.3.3.1 The institution/facility shall secure the area and responding

vehicles/equipment from inmates at all times during a fire emergency.

13.3.3.2 First responders may elect not to enter areas of conflict, where their

personal safety is at risk, or where they cannot be guaranteed safe

operational areas.

The Central Office Emergency Operations Center shall provide all supporting coordination and

resources necessary to manage emergencies when the scope exceeds the institution/facility’s

resources or capabilities and effectively manage the incident.

During unit evacuations, the Incident Commander shall ensure public safety; inmate

accountability and operational security are not compromised.

14.0 CONFINED SPACE PROTOCOLS

A confined space meeting OSHA Protocols 29 CFR 1910.146 as a “permit space”, shall be

designated with markings and/or a sign stipulating “DANGER - PERMIT REQUIRED CONFINED

SPACE, DO NOT ENTER” and shall be locked and/or otherwise secured to prevent unauthorized

entries.

Only persons trained and qualified in confined space extractions shall be permitted entrance to

an area designed as a confined space, as defined in the Glossary of Terms. Any entries into

these areas shall require:

14.2.1 The presence of persons trained and qualified in confined space entry and extractions.

14.2.2 An extraction attendant, a qualified extraction team and/or fire rescue personnel

present at all times when someone is within the confined space with equipment

necessary to perform an extraction rescue. No entry shall occur unless these entry

parameters are met.

14.2.3 The notification of the OSC and the Physical Plant Manager/ Administrator at least 24

hours in advance of the required entry or work commencing until a Confined Entry

Permit, Form 404-9, is issued.

In emergencies, prior to the entry of a confined space:

14.3.1 The OSC and Physical Plant offices shall be notified.

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404 – FIRE, SAFETY AND LOSS PREVENTION

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14.3.2 Confined space rescue shall not commence until an extraction team is present. A

trained confined space extraction team or fire department shall be present during the

extraction.

Person(s) entering confined spaces shall monitor for hazardous or toxic atmospheres using

OSHA/NIOSH-approved oxygen meters and/or four gas meters to determine if sufficient oxygen

levels exist or other hazardous atmospheres are present.

Other confined space hazards shall be evaluated before entry (i.e., electrical shock hazards,

chemical burn potential, the presence of toxic gases, etc.).

DEFINITIONS/GLOSSARY

Refer to the Glossary of Terms for the following:

 Confined Space

 Confined Space Entry Permit

 Contagion

 Declared State of Emergency

 Deliberate Indifference

 Entry

 Extraction Attendant

 Hazardous Atmosphere

 Hazardous Substance

 Healthcare Facility

 Healthcare N-95 Particulate Respirator and Surgical Mask

 Near Miss

 Oxygen Deficient Atmosphere

 Permit-Required Confined Space (Permit Space)

 Personal Protective Equipment (PPE)

 Qualitative Fit Test

 Quantitative Fit Test

 Respirators

 Safety Data Sheet (SDS)

 Tight-Fitting Face Piece

 Vicarious Liability

ATTACHMENTS

Attachment A, OSC or Equivalent Required/Recommended Training and Certification

Attachment B, Respirators

Attachment C, Department Loss Prevention Program Required Elements

Attachment D, Safety and Loss Prevention Committee Meeting Agenda Guidelines

Attachment E, Department Order Exempted Sections/Subsection

FORMS LIST

404-1, Employee Safety Suggestions

404-2, Loss Prevention Program Checklist

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404 – FIRE, SAFETY AND LOSS PREVENTION

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404-3, Emergency Action/Fire Prevention Plan

404-4, Annual Fire Profile Report

404-6, Fire/Safety Incident Summary Report

404-7, Incident-Accident Investigation

404-8, Root Cause Analysis

404-9, Confined Space Entry Permit

404-10, Job Hazard Analysis

404-11, Fire Hydrant Inspection Report

404-12, Fire/Emergency Evacuation Drill Summary – Central Office Only

404-13, Safety/Sanitation Inspection Report

404-17, Lockout/Tagout Certification of Training

404-19, Periodic Lockout/Tagout Inspection Certification

404-20, Lockout Tagout Energy Control – Equipment/Machine/System

404-21, Employee Respirator Training Certification

404-22, Inmate Respirator Training Certification

404-25, Authorization and Information for Respiratory Evaluation

404-26, Respirator Confidential Medical Questionnaire

404-27, Annual Supplemental – Respiratory Medical Evaluation Questionnaire

AUTHORITY

A.R.S. §13-2513, Failure to Discharge Duties; Classification; Definition

A.R.S. §26-302, General Powers of Governor

A.R.S. §26-303, Emergency Powers of Governor, Termination; Authorization for Adjutant General; Limitation;

Extension; Report; Notices; Appeals

A.R.S. §31-107, Emergency Removal of Prisoners

A.R.S. §34-461, Applicability of Local Codes; Exception; Definition

A.R.S. §35-192, Authorization for Declaration of Disaster, Authorization for Liabilities and Expenses; Priorities

and Limitations; Review and Report of Expenditures

A.R.S. §41-1609, Agreements with Federal or Private Agencies and Institutions; Contract Review; Emergency

Contracts

A.R.S. §49-108, Hazardous Materials Emergency Response Operations

A.R.S. §49-123, Hazardous Materials Emergency Management Program; Arizona Emergency Response

Commission; Emergency Planning and Community Right To Know

A.A.C. R2-10-101 et seq., Coverage and Claims Procedure

A.A.C. R2-10-201 et seq., Loss Prevention

A.A.C. R2-10-206, Agency Loss Prevention Program Management

A.A.C. R2-10-207, Agency Loss Prevention Program Elements

A.A.C. R4-36-201 et seq., Arizona State Fire Code

29 CFR Part 1910, Occupational Safety and Health Standards

29 CFR Part 1910.38, Employee Emergency Plans and Fire Prevention Plans

29 CFR Part 1910.134, Respiratory Protection

29 CFR Part 1910.146, Permit-Required Confined Spaces

29 CFR Part 1910.147, The Control of Hazardous Energy (lockout/tagout)

29 CFR Part 1910.1030, Bloodborne Pathogens

29 CFR Part 1926, Safety and Health Regulations for Construction

NFPA 10, Standard for Portable Fire Extinguishers

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Extinguishing System

NFPA 72, National Fire Alarm Code

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations

CHAPTER: 400

404 – FIRE, SAFETY AND LOSS PREVENTION

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ATTACHMENT A

OSC OR EQUIVALENT REQUIRED/RECOMMENDED TRAINING AND CERTIFICATION

Department OSC Requirements

Type

Certification

Fire Inspector I

Fire Inspector II

NFPA 10: Portable Fire Extinguishers

NIMS IS 100/200/700/800 Training

NIMS IS 300/400 Classroom Training

OSHA 501 General Industry Train the Trainer

OSHA 511 Occupational Safety and Health Standards for General Industry

Quantitative Fit Tester Certification

Respirator training for all respirators which may be used

Private Prison OSC (or equivalent) Requirements

Type

Certification

NIMS IS 100/200/700/800 Training

NIMS IS 300/400 Classroom Training

OSHA 501 General Industry Train the Trainer

Qualitative Fit Tester Certification

Respirator training for all respirators which may be used

State Fire Code Inspector I Training IFC (2003 edition)

Recommend for all OSCs or equivalent

Type of Training and/or Certification

Fire and Life Safety Educator I

Fire Origin and Cause for First Responders

NIMS All Hazards Safety Officer Training FEMA IS-954

NFPA 13: Standard for Installation of Fire Sprinklers

NFPA 25: Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems

NFPA 72: National Fire Alarm and Signaling Code

NFPA Health and Safety Officer

NFPA 1500: Fire Department Occupational Safety and Health Program (For Structural Fire Crew OSC)

OSHA 510 Occupational Safety and Health Standards for Construction

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404 – FIRE, SAFETY AND LOSS PREVENTION

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ATTACHMENT B

RESPIRATORS AND DEVICES

RESPIRATORS

Name/Type

Photo(s)

Dept. Usage

Staff Usage/Requirements

Initial/Annual

Requirements

Half Mask

(Tight-fitting*)

Painter’s Cartridge

Respirator

Primarily in painting and coating jobs,

maintenance applications, using organic and

particulate cartridges.

When stipulated on a SDS for chemical use in

an known atmospheres.

Coating operations where eye

protection is less of a hazard

Medical Evaluation

Respirator Training

Fit-Testing

Certification

Full-Face

(Tight-Fitting*)

Air Purifying

Cartridge Respirator

(Gas Mask)

Water/WWTF

chlorine gas canister

In known atmospheres, environments with

gasses, chemicals, dust, vapors, etc. or as

medically required. NOTE: Hazardous

atmospheres shall be avoided at all times

unless extreme handling procedures are

prepared and approved in advance of use or

activity by a qualified OSHA individual or

jurisdictional fire department.

Rescue operations and evacuations from

structures or areas involving gasses.

When stipulated on a SDS.

Gas Mask –

Used by Tactical Support Unit

(TSU) only.

Chlorine Gas Canister –

Used by Water Treatment/

Wastewater Treatment only

Medical Evaluation

Respirator Training

Fit-Testing

Certification

Particulate

Filter**

(Tight-fitting*)

N95 most commonly

used.

When PPE is needed.

Protection from toxic particles, dusts, fibers,

fumes, mists, and, as determined by health

staff, biological materials (i.e., bacteria,

infectious diseases and viruses, etc.)

High risk health staff, qualified

hospital posted officers,

investigators, and qualified

transportation staff.

Medical Evaluation

Respirator Training

Fit-Testing

Certification

CHAPTER: 400

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404 – FIRE, SAFETY AND LOSS PREVENTION

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RESPIRATORS

Name/Type

Photo(s)

Dept. Usage

Staff Usage/Requirements

Initial/Annual

Requirements

Self-Contained

Breathing

Apparatus

(SCBA)

(Tight-fitting*)

SCBA shall be code compliant.

Additional requirements include users being

able to demonstrate their knowledge, skills and

ability to competently use a SCBA.

Situations involving fire, smoke, gasses,

unknown atmospheres for extraction and

emergency rescue and fire suppression

activities.

Fire-resistive clothing is required with use.

Qualified fire brigade crew

members and qualified rescue

personnel and Rapid

Response Team members.

Medical Evaluation

Respirator Training

Fit-Testing

Certification

Fire Brigade Training or

Rescue Training

DEVICES

Emergency

Escape

Breathing Device

(EEBD)

Part of safety equipment in each housing unit

Control Room.

May be staged elsewhere for staff escape, as

designated by the Warden in consultation with

the OSC.

Used only for the purposes of escaping away

from the source of the gas, smoke or fire and

moving towards the closest safe exit.

Provides only 10 minutes of breathing time.

Control Room Officers

Respirator Training

CHAPTER: 400

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404 – FIRE, SAFETY AND LOSS PREVENTION

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ATTACHMENT C

DEPARTMENT LOSS PREVENTION PROGRAM ELEMENTS

Each agency loss prevention committee or individuals designated by the agency head shall develop, implement, and monitor the following

loss prevention program elements of an occupational health and safety program (as applicable to their agency):

Requirement

Department Order and/or Documentation

The agency loss prevention policy statement

404, Fire, Safety and Loss Prevention

New employee and continuous in-service training programs

404, Fire, Safety and Loss Prevention

509, Employee Training and Education

Documentation and recordkeeping of employee training

404, Fire, Safety and Loss Prevention

509, Employee Training and Education

An emergency plan for each agency location that establishes procedures to

follow in the event of serious injury, fire, or other emergency that can be

reasonably foreseen at the specific agency location

105, Information Reporting

404, Fire, Safety and Loss Prevention

706, Incident Command System (ICS)

918, Fire Crews/Disaster Aid

Procedures for scheduled safety inspections of buildings, grounds, equipment,

and machinery. An agency shall document the results of each inspection and

forward notice of any deficiencies to the Fire, Life and Safety Administrator for

corrective action. The agency loss prevention committee or coordinator shall

follow-up on inspection recommendations to ensure action is taken to remedy a

noted deficiency. The agency loss prevention committee or coordinator shall

bring an uncorrected deficiency to the attention of the agency head.

401, Prison Construction

403, Maintenance

404, Fire, Safety and Loss Prevention

606, Quality Assurance and Improvement (QA&I) Program

703, Security/Facility Inspections

Procedures for accident and incident investigations.

404, Fire, Safety and Loss Prevention

405, Vehicles/Vehicle Maintenance

519, Employee Health – State/Federal Programs and

Assignment

A maintenance program for state-owned vehicles, equipment, and grounds

under the control of that agency.

403, Maintenance

404, Fire, Safety and Loss Prevention

405, Vehicles/Vehicle Maintenance

A fire protection program that complies with the Arizona State Fire Code,

located in A.A.C. Title 4, Chapter 36. This program shall incorporate best

practices and standards that protect state of Arizona employees, the general

public, and resources entrusted to the agency.

404, Fire, Safety and Loss Prevention

918, Fire Crews/Disaster Aid

OSHA mandatory program (OMP) and Safety advisory.

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404 – FIRE, SAFETY AND LOSS PREVENTION

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Requirement

Department Order and/or Documentation

Systems and procedures to protect the personal security of each employee and

prevent loss of or damage to state property.

202, Public Access - Tours and Board Hearings

205, Contractor and Program Associate Security

304, Equipment and Inventory System

404, Fire, Safety and Loss Prevention

707, Inmate Escape Prevention/Response

718, Stun and Stun Lethal Electrified Fences

A land, facility, equipment, or process environmental protection program.

404, Fire, Safety and Loss Prevention

407, Chemical Control

An industrial hygiene program that encompasses an existing or potential health

hazard within an agency, or that agency personnel may be exposed to during

the course of work.

105, Information Reporting

116, Employee Communicable Disease Exposure Control Plan

401, Prison Construction

403, Maintenance

404, Fire, Safety and Loss Prevention

407, Chemical Control

706, Incident Command System (ICS)

1102, Communicable Disease and Infection Control

OMP and Computer Based Training – Ergo Smart – Your Guide

to Comfortable Computing http://10.6.0.30/training/ergo/

Motor vehicle safety program. For the purpose of this Section, an authorized

driver is an employee whose job position description questionnaire or similar

document requires the use of a vehicle; an employee who operates a state

vehicle; or an employee who operates a leased, rented or personal vehicle where

the state provides 100% of that vehicle lease, rental or operational costs.

404, Fire, Safety and Loss Prevention

405, Vehicles/Vehicle Maintenance

509, Employee Training and Education

A safety and security standard for a construction site where state employees

work.

404, Fire, Safety and Loss Prevention

CHAPTER: 400

404 – FIRE, SAFETY AND LOSS PREVENTION

MARCH 10, 2022

ATTACHMENT D

SAFETY AND LOSS PREVENTION COMMITTEE MEETING AGENDA GUIDELINES

1. Call to order by Chairperson

2. Roll call of attendees (sign in roster)

3. Review and approve the last meeting minutes

4. Discussion of unfinished business (old business)

a. Reports on pending matters from last meeting

b. Solutions/corrective action recommendations

c. Discussion of unresolved safety suggestions

5. Discussion of new business

a. Review of key performance indicators (metrics and scorecard)

i. Near miss = first aid only/Injury = visit to provider/recordable/reportable to ADOSH

ii. Workers compensation report (YTD frequency and severity)

iii. Injury Rate (rate of occupational injuries and illnesses per 100 full-time workers)

iv. DART (Days Away from work/Restricted duty/Transfer to other job)

b. Report on incident(s) of injured or ill – follow-up welfare

c. Incident Investigation (each incident)

i. What was the incident?

ii. Where did the incident occur (be specific)?

iii. What conditions contributed to the incident?

iv. Why did the conditions exist?

v. What can be learned from this incident?

vi. What can be done to mitigate or prevent another such incident?

d. Report on safety related to incidents

i. Follow-up action taken by management and/or committee

6. Committee/Subcommittee reports

7. Suggestion box

a. Discussion of submitted safety suggestions

b. Assignment of safety suggestions for action

8. Inspection/Tour/Audit reports

a. Assignment for corrective action

9. Training/Guest Speakers

10. Announcement of next meeting date

11. Adjournment

CHAPTER: 400

404 – FIRE, SAFETY AND LOSS PREVENTION

MARCH 10, 2022

ATTACHMENT E

DEPARTMENT ORDER EXEMPTED SECTIONS/SUBSECTIONS

The following sections and/or subsections of Department Order #404, Fire, Safety and Loss Prevention are

not applicable to the operation of private prison facilities.

1.0

Private prisons are exempted from the entire section, with the exception of 1.3.10 and 1.3.13

2.0

Private prisons are exempted from the entire section

3.0

Private prisons are exempted from the following:

3.3 through 3.3.10.1 (unless any loss involves State property and/or State equipment, or if

otherwise directed)

3.4 through 3.4.3.3

3.6 through 3.6.9 (at those one-unit “stand-alone” facilities, where the described duties may be

performed by the OSC)

4.0

Private prisons are exempted from the entire section

5.0

Private prisons are exempted from the entire section

6.0

Private prisons are exempted from the entire section

11.0

Private prisons are exempted from the entire section, with the exception of 11.0, 11.2

12.0

Private prisons are exempted from the entire section