Small Site Maturity Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Incident Reporting - SSS 001 Guidance: Locate the current local copy of your procedure. Review for accuracy and proceed to answer the questions.

• Do you have an up-to-date local version of the Incident Reporting (SSS 001) procedure?

  Yes

  No

  N/A

• After reading through the procedure, select the appropriate level of implementation of all the elements

  NA - No Incidents in the past 3 years

  25% - We have missed several incidents in the reporting process

  50% - about half of the incidents have been reported

  75% - Most incidents have been reported

  100% - All Incidents have been reported

• Accident and Incident Reports: What percentage of accidents and incidents have a completed report?

  NA- No accidents to report

  25% or less have a completed report

  50% or less have a completed report

  75% or less have a completed report

  100% have a completed report

• While considering the incidents and accidents that have occurred at the facility, what is the percentage of those that have been entered into MST or ETS? (Honeywell's Electronic incident recordkeeping database)

  NA - No Incidents in the past 3 years

  25% - We have missed several incidents in the reporting process

  50% - about half of the incidents have been reported

  75% - Most incidents have been reported

  100% - All Incidents have been reported

• Incidents requiring to be entered into the electronic system usually require corrective actions to be assigned.<br>Does the site have evidence of the corrective actions resulting from the past incidents?

  0% - We had no incidents

  25% Alerts Completed

  50% Alerts Completed

  75% Alerts Completed

  100% Alerts Completed

• Managers and Supervisors are required to participate in the investigation process. <br>Does the site have evidence of the inclusion of the responsible persons in the investigation process?

  Yes

  No

  N/A

• Have ALL managers and supervisors completed investigation training in the previous 3 years?

  Yes

  No

  N/A

• Cause and Effect or "5-Why" analysis is required to determine root cause(s) for incidents. <br>Does the site include a detailed cause analysis in EACH incident ?

  Yes

  No

  N/A

• Does the site have evidence of completed safety alerts for prior incidents?

  0% - We had no incidents

  25% Alerts Completed

  50% Alerts Completed

  75% Alerts Completed

  100% Alerts Completed

Emergency Response - SSS 002 Guidance: Locate the current local copy of your procedure. Review for accuracy and proceed to answer the questions.

• Do you have an up-to-date local version of the Emergency Response (SSS 002) procedure?

  Yes

  No

  N/A

• Does the site have a specific shelter in place process/procedure outlined in writing?

  Yes

  No

  N/A

• Does the site have a specific Evacuation process/procedure outlined in writing?

  Yes

  No

  N/A

• Does the site have a specific emergency procedure for chemical spills or releases?

  Yes

  No

  N/A

• Does the site have a written Fire Prevention that includes a smoking policy and flammables storage?

  Yes

  No

  N/A

• Does the site have a current list of the Emergency Response Equipment maintenance and inspection records?

  Yes

  No

  N/A

• Cause and Effect or "5-Why" analysis is required to determine root cause(s) for incidents. <br>Does the site include a detailed cause analysis in EACH incident ?

  Yes

  No

  N/A

• Does the site have evidence of completed safety alerts for prior incidents?

  0% - We had no incidents

  25% Alerts Completed

  50% Alerts Completed

  75% Alerts Completed

  100% Alerts Completed

Emergency Response - SSS 002 This section reviews the requirements of the maintenance and inspection records for the sites Emergency Response Equipment

• Does the site have a current list of the Emergency Response Equipment? An example of this registry can be found in Appendix B of the procedure.

  Yes

  No

  N/A

• Is there any equipment requiring shutdown in the event of an emergency? Are there instructions and responsible persons assigned to perform the shutdown of the equipment

  None on site

  Yes, we have equipment but no responsible persons

  Yes and Yes

Sprinkler systems should have quarterly pressure/flow testing and monthly bypass valve inspections. Additionally a clearance area of 36” must be maintained under all sprinkler heads. Diesel fire pumps should be operated at least weekly for 30 minutes; electric fire pumps should be operated at least monthly for 10 minutes. All pumps should be performance tested annually.

• Are all sprinkler systems testing (quarterly) and valve inspections (monthly) being performed?

  Yes

  No

  N/A

• Can the site validate all sprinkler heads have a clearance area of 36"?

  Yes

  No

  N/A

• Are the fire pumps being tested as required?

  Yes

  No

  N/A

Emergency Response - SSS 002 This section reviews the requirements of the maintenance and inspection records for the sites Emergency Response Equipment

• Are Fire Suppression systems maintained and certified by appropriate personnel?

  Yes

  No

  N/A

• Does the site have a schedule for testing emergency lighting that meets manufacturers recommendations?

  Yes

  No

  N/A

• Are Fire extinguishers inspected on a minimum monthly basis? (Can be part of the Small Site weekly inspection sheet)

  Yes

  No

  N/A

• Hoses on reels must be pressure tested or replaced every 5 years. Mark "Yes" if the site can confirm for each hose at the location. If no hoses exists, then select NA.

  Yes

  No

  N/A

• Are the fire pumps being tested as required?

  Yes

  No

  N/A