Body
1.0 Purpose and Scope
This Standard Operating Procedure (SOP) establishes the required process for the creation, tracking, oversight, and documentation of all planned and emergency impairments to life safety systems and high-risk activities.
This SOP applies to the following activities:
- Fire Alarm System Impairments
- Fire Suppression System Impairments
- Building Safety System Generator Impairments
- Hot Work Activities
- Excavation Activities
2.0 Management Tool and visibility
All impairment tracking and management shall be conducted using a dedicated Life Safety Impairment Browse Report within the TMA system.
This process supports the Active Impairment Dashboard within TMA, which shall be visible on every user's homescreen, providing immediate awareness of all current impairments.
3.0 Procedure for Impairment Management
The impairment process requires the creation of two separate work orders: one for tracking/safety protocol (the "Impairment" work order) and one for performing the actual repair/work (the "Execution" work order).
3.1 Trade Shop Manager/Project Manager Responsibility (Impairment Work Order Creation)
The Trade Shop Manager/Project Manager responsible for the work activity shall:
- Request Separate Work Order: Request a separate, unique work order specifically for tracking the impairment in the Life Safety Impairment Browse Report.
- Details on Work Order: This Impairment WO must include:
- Request the work order for Environmental Health and Safety to be assigned Task Code SF001 at the beginning of the request.
- A link to the execution work order or the execution work order number.
- Estimated start date and time of the activity.
- Estimated duration of the activity (system downtime).
- A full description of the activity and the system being impaired.
- All identified safety protocols and plans (e.g., fire watch schedules for suppression systems, required personal protective equipment, isolation plan).
- Attach any required request forms to the work order.
- Initial Status: The initial status of this tracking WO should be "Planned and Scheduled."
3.2 EHSO Safety Coordinator Responsibility
The Safety Coordinator is responsible for managing the Life Safety Impairment Browse Report in TMA and auditing the process.
- Review Plans: The Safety Coordinator shall review the Impairment work orders, including all safety plans and estimated durations.
- Feedback/Approval: The Safety Coordinator has the authority to ask questions, make recommendations or stop any work prior to being executed or the system being taken down.
- Active Impairment: Prior to the system being taken down or the high-risk work being executed, the Safety Coordinator will change the status of the work order to "Work In Progress."
- Dashboard Population: Changing the status to "Work In Progress" automatically signals this work order as an active impairment, populating the Active Impairment Dashboard in the TMA system.
4.0 Emergency Impairment Protocol
In the event of an unforeseen emergency requiring the immediate impairment of a life safety system or high risk work:
- Notification: Any staff member taking a system down or executing emergency high-risk work shall immediately call 9-6111.
- Request: The staff member must clearly state that they are taking a system down and that they need an Impairment work order created, instructing the operator to set the status to "Work In Progress".
- Follow-up: The Trade Shop Manager must follow up to populate the full safety plans and estimated duration in the tracking work order.
5.0 Audit and Review
Auditing and review ensure consistent adherence to life safety protocols and best practices.
5.1 Quarterly Work Order Audit
The Safety Coordinator shall audit 10% of all Impairment work orders created within the preceding quarter to ensure:
- The separate execution Work Order was properly linked to the impairment Work Order.
- The Work Order was fully detailed with all required safety protocols and duration.
- The WO was closed appropriately.
5.2 Annual Field Audit
The Safety Coordinator shall conduct a field audit of 10% of actual high-risk work or system impairment activities annually to ensure best practices were being utilized and all safety plans documented in the Work Order were followed during execution.
6.0 Reporting
The Safety Coordinator shall generate quarterly reports that provide:
- The total number of impairments during that time period by type.
- The cumulative number of impairments over the course of the current year.
- A comparison of these metrics against the previous year's performance, planned versus emergency.
Revision History