Combustible liquid: Any liquid having a flashpoint at or above 100 F (e.g. kerosene, fuel oil)

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1 HOSPITAL NAME INSTITUTIONAL POLICY AND PROCEDURE (IPP) Department: Manual: Section: TITLE/DESCRIPTION POLICY NUMBER Handling of Flammable Material EFFECTIVE DATE REVIEW DUE REPLACES NUMBER NO. OF PAGES APPROVED BY APPLIES TO PURPOSE DEFINITION Combustible liquid: Any liquid having a flashpoint at or above 100 F (e.g. kerosene, fuel oil) Extremely Flammable Material: Any flammable material with a flashpoint below 0 F (e.g. ethyl ether, acetone). Fire Area: An area of a building separated from the remainder of the building by construction having a fire resistance of at least one hour. Flammable Compressed Gas: A compressed gas which forms a flammable mixture when 13 percent or less (by volume) is mixed with air, or a compressed gas having a flammable range with air wider than 12 percent, regardless of the lower limitation. These limitations shall be determined at atmospheric temperature and pressure. Flammable gases do not have flashpoints. Flammable Liquid: Any liquid having a flashpoint below 100 F and having a vapor pressure not exceeding 40 psia at 100 F (e.g. gasoline, alcohols). Flammable Material Storage Cabinet: A storage cabinet which is constructed in accordance with NFPA and BOCA standards. Flammable Liquid Storage Room: A room used for the storage of large quantities of flammable and combustible liquids which meets the construction requirements of the Baltimore City Building Code and NFPA #30- Flammable and Combustible Liquids Code. Flammable Solid: A solid which has an ignition temperature below 212 F. Flash Point: The minimum temperature in degrees Fahrenheit at which a flammable liquid will give off sufficient vapors to form an ignitable mixture with air near the surface or in the container, but will not sustain combustion. HSE: Health, Safety and Environment Liquefied Petroleum Gases (LP-Gas or LPG): A gas that has been converted to a liquid by pressure. Examples are propane, propylene and butane. LPG container capacity is determined by either its water capacity or its LPG capacity. A cylinder with a 12-pound water capacity will hold 5 pounds of LPG. A propane cylinder for a typical outdoor grill has a LPG capacity of 20 pounds. Standards Page 1 of 5

2 RESPONSIBILITY Health, Safety and Environment Facilities Supervisors CROSS REFERENCES Provide direction In handling of flammable materials. Provide interpretation regarding the contents of this document. Ensure that affected outside contractors abide by the requirement outlined in this policy. Provide guidance and training to person in their charge regarding this policy. POLICY It is the policy of the Hospital that all employees shall handle, use and store flammable material in accordance with applicable federal, state and local codes and the requirements of this policy. These requirements are established to ensure the safety of all staff, faculty, students, contractors and visitors in the Hospital; to reduce fire and explosion hazards associated with the improper use and/or storage of flammable or combustible materials; and to protect the interest of the Hospital. PROCEDURE INTERPRETIVE GUIDELINES I. STORAGE OF FLAMMABLE MATERIALS A. An approved flammable storage cabinet is required 1. Should the aggregate volume of flammable liquids in an individual fire area exceed 10 gallons. 2. For containers of flammable materials that exceed one gallon in size. 3. If an approved flammable storage cabinet is provided, it shall be used for the storage of all flammable material not in immediate use. B. Flammable Material Storage Cabinet 1. Cabinets must be marked in conspicuous lettering: "FLAMMABLE-KEEP FIRE AWAY." 2. The capacity of a single flammable storage cabinet shall not exceed 60 gallons of flammable liquids, unless exception is granted by HSE 3. All new flammable storage cabinets should be capable of being vented. 4. Any existing flammable material cabinet that is not vented shall receive periodic evaluation by HSE to confirm that unhealthful vapors are not present. If venting of the cabinet is required by HSE the ventilation will be constructed in accordance with NFPA standards. These flammable cabinets should be ventilated through the fume hood exhaust system at 5-10 cubic feet per minute. 5. The required three-point latch mechanism on the cabinet door must operate properly. 6. All cabinets installed after September, 1997 must have self-closing self-latching devices on the doors. 7. No more than three flammable material storage cabinets shall be located within a single fire area. C. Bulk Flammable Liquid Storage 1. Containers of flammable materials with a capacity greater than 5 gallons must be stored in a flammable liquid storage room, unless a flammable liquid storage room is unavailable and approval is granted by HSE. 2. Any storage in flammable liquid storage rooms must not obstruct exhaust ventilation. Standards Page 2 of 5

3 3. Labels on containers must be readily visible. If not, a proper label or signage must be added. 4. The entrance to flammable liquid storage rooms should be labeled in accordance with NFPA 704 "Identification of the Fire Hazards of Materials". 5. Doors to flammable liquid storage rooms must remain closed and latched at all times. 6. Trash containers are prohibited within flammable liquid storage rooms. D. Refrigerated Storage 1. Flammable material shall be stored in approved flammable material refrigerators only. 2. See Policy HSE 803: Laboratory Refrigerators for more details. E. Storage and Handling Practices 1. Extremely flammable materials are NOT to be used near open flames or other sources of ignition within the possible path of vapor travel. 2. Flammable and combustible liquids must be segregated from oxidizers. 3. Oil soaked rags must be stored in a metal container with a self-closing lid due to the possibility of spontaneous combustion. 4. The use of ether for anesthesia is prohibited. F. Dispensing 1. Flammable liquids shall not be dispensed by gravity from drums. Approved pumps which take the suction from the top of an upright drum shall be used. 2. Containers of flammable liquids must be electrically interconnected (bonded) before liquid is transferred. II. LIQUEFIED PETROLEUM GAS (LPG) A. Containers of LPG shall be located outside of buildings, with the following exceptions: 1. For temporary demonstration purposes, a container with a maximum water capacity of 12 pounds (5 pound LPG capacity) may be utilized. 2. Hand torches with a 2 ½ pound water capacity (1 pound LPG capacity). 3. Other uses as approved by HSE. B. Outdoor cooking appliances are permitted provided that the conditions outlined in Enclosure II: "Outdoor Cooking Appliances" are strictly adhered to, and prior approval is obtained from Facilities and the Department of HSE. III. FLAMMABLE GASES A. Extremely flammable agents for anesthesia are prohibited. B. Flammable gases shall not be stored within 20 feet of oxidizing gases. C. Flammable gas cylinders shall not be stored in a corridor, stairway or any means of egress. D. Flammable gas cylinders should be limited to the smallest practical size. E. Acetylene cylinders shall be stored in an upright position at all times. F. All compressed gas cylinders shall be properly secured by a chain, strap, approved base or special bench mount. All compressed gas cylinders shall be shut off at the cylinder head. See Hospital Policy :Compressed Standards Page 3 of 5

4 Gas Cylinders for complete information. IV. EMERGENCY PROCEDURES IN EVENT OF FIRE A. Evacuate yourself and others needing assistance from immediate danger. B. Close the door to contain smoke and fire. C. Activate the building fire alarm system. D. Call the emergency phone number. Give pertinent details such as building and room location, material involved, magnitude of event, injuries, etc. E. Portable fire suppression equipment (fire extinguishers) is provided throughout hospital. 1. Certain employees have been trained by HSE in the use of this equipment. Employees who have not been trained in the use of fire extinguishers are not to utilize this equipment. 2. All laboratories shall have a 5 pound CO2 fire extinguisher accessible to the lab. CO2 extinguishers are provided in labs because they do not leave residue, which could damage equipment and/or experiments, when discharged. 3. In areas which contain fixed fire suppression equipment (e.g. sprinkler system), maintain at least an 18 inch clearance between the bottom of any sprinkler head and the top of all equipment, furnishings or stored items. V. SPILL CONTROL A. Spills of flammable materials that are beyond the clean-up capabilities of the persons using the material shall be handled by Health, Safety and Environment (HSE). B. Refer to Policy HSE 703: Management of Hazardous Chemicals for complete information on spill management. VI. OUTDOOR COOKING APPLIANCES A. Outdoor cooking appliances, such as charcoal, electric, or gas grills, are permitted, provided the following conditions are strictly adhered to: 1. These appliances must be so located outdoors that there is no less than a 36 inch clearance on the side and no less than a 48 inch clearance at the front. They must be placed on a non-combustible surface, and in no case may they be located under overhead combustible construction. 2. Outdoor cooking appliances must be in proper working order and sturdy, to prevent tipping. 3. Under no circumstances shall propane gas bottles be permitted inside a building, structure or unit. Only approved charcoal lighter in its original container is permitted. Follow the manufacturer's guide or manual for safe operating procedures. 4. Outdoor cooking appliances shall be located in such a manner so they do not obstruct a means of travel or egress. 5. Ensure charcoal is completely extinguished before emptying ashes into a trash container. To be certain the charcoal is extinguished, it is best to wait until the next day to empty ash from the grill. B. Other additional safeguards may be necessary. FORMS Standards Page 4 of 5

5 EQUIPMENT REFERENCES The BOCA National Fire Prevention Code/2000 The BOCA National Building Code/2000 Code of Federal Regulations, Title 29 Part Revised July 1,1995- Flammable and Combustible Liquids National Fire Protection Association (NFPA) Standard # Flammable and Combustible Liquid Code National Fire Protection Association (NFPA) Standard # Fire Protection for Laboratories Using Chemicals APPROVAL: Prepared by Reviewed by Approved By Approved By Latest Revision Approved By Name Signature Date Standards Page 5 of 5

6 SELF-INSPECTION CHECKLIST for Flammable Materials Fire Extinguishers: Proper fire extinguishers provided, mounted and unobstructed Means of Egress: Fire doors closed and latched Emergency exits unobstructed and unlocked Corridors unobstructed Flammable liquids/gases not stored in corridors, stairways or other means of egress Hazardous Materials: Fume hood functioning properly All container labels in English as to contents Proper labeling (refrigerators, storage room, dispensing areas, flammable cabinets, etc.) Containers of flammable liquids greater than 1 gallon in flammable storage cabinets Liquids in proper containers/proper cabinets Flammable and corrosive materials in separate cabinets Proper liquid dispensing procedures in place LPG not exceeding capacity requirements Proper personal protective equipment available Safety showers, emergency eye washes and related equipment working properly and unobstructed Bulk Liquid Storage Rooms: Bulk rooms properly labeled per NFPA 704 Containers of flammables in excess of five gallons stored in bulk rooms Explosive-proof electrical fixtures in place Fire doors closed and latched Liquids with flashpoints <1000F not being dispensed by gravity Exhaust ventilation unobstructed General Requirements: Oil soaked rags in self-closing metal containers Proper housekeeping maintained 18" clearance between top of storage and bottom of sprinkler heads Personnel aware of emergency procedures for fire, spills and exposures