Investigation of Unwanted Fire Alarm Signals

(UFAS) PROCEDURE SP44

The Council is required to review its approach to fire alarm activations (AFAs) within its non-domestic premises due to the recent Unwanted Fire Alarm Signals (UFAS) policy change from Scottish Fire and Rescue Service (SFRS).

The following procedure is intended to offer the duty holder or responsible person for the premises guidance to enable them to set out the local arrangements needed to respond to unwanted fire alarm signals and to minimise disruption to business from false alarms.

A risk management process and safe system of work has been devised to meet our specific needs, as a duty holder, and the requirements of the new SFRS UFAS policy where “call challenging” will apply in all workplaces, during operational and non-operational/overnight hours. Sleeping accommodation premises are excluded from the policy, such as care homes and hospitals.

The process will give guidance on the following scenarios:

• During occupied/operational hours with Building Manager / Facilities officer or nominated person present
• During non-operational hours
• A lone Worker process for UFAS investigation during operational hours

It is accepted various circumstances exist within the different types of Council buildings therefore there are four key elements of work that need to be completed at a local level after reviewing the EDC UFAS procedure. This local level work should be conducted by the Duty Holder/Responsible person in control of premises, in conjunction with Facilities Management staff where applicable.

These are:

• Adapt the process to suit your building and complete Appendix 1 UFAS Procedure
• Identify persons that will undertake the investigation process (please include all persons covering for any type of absences such as annual leave, medical emergencies, etc.)
• Undertake EDC UFAS training and training at local level – for your building
• Display all information required such as fire alarm panel information sheet.

This procedure applies to all East Dunbartonshire Council premises, operational and non- operational. This procedure is in line with East Dunbartonshire Council’s Fire Safety Policy 2023 and SP29: Duty Holder Procedure.

Chief Executive, Depute Chief Executive, Executive Officers, Service Managers

The East Dunbartonshire Council (EDC) Chief Executive has ultimate responsibility for health and safety and for making sure that a risk assessment process is undertaken to identify potential hazards to employee health and safety and anyone who may be affected by their undertakings, including a fire hazard.

It is important to acknowledge that the Chief Executive’s responsibilities are shared, in that the Depute Chief Executive, Executive Officers and Service Managers will be responsible and accountable within their areas of responsibility for appointing duty holders and responsible persons in control of premises and requiring all persons involved in the UFAS investigation process to be trained accordingly.

Executive Officer - Assets and Facilities

The Executive Officer – Assets and Facilities has a delegated responsibility for making sure this Management Procedure is implemented in respect of premises under the control of or otherwise, occupied by council employees.

The Executive Officer – Assets and Facilities must ensure the following:

• Adequate resources and competent person(s) are allocated to support the implementation of this Management Procedure and relevant associated Health and Safety and Fire Safety legislation
• Duty Holders and Nominated person(s) are supported in the implementation of the measures of this Management Procedure to comply with relevant Health and Safety legislation through adequate instruction, information and training as well as relevant equipment for the purposes on UFAS investigation and raising the alarm in the case of fire.

Estates Team

The Estates Team holds specific Duty Holder responsibilities as manager of the Council estate and will therefore support Duty Holders and other nominated persons with control of premises to fulfil their fire safety responsibilities. 

Estates Management Surveyors will be responsible for tenanted buildings with information on our UFAS procedure made available to tenants as well as local level information for the building.

Facilities Management Team

The Facilities Management Team holds specific Duty Holder responsibilities as the on-site manager of operational buildings, where they have a presence.

Customer Service Receptionists - Comercial Buildings

The Customer Service receptionists are the nominated persons to undertake UFAS investigation procedure for commercial tenanted buildings, where present. Buildings with no customer service receptionist presence will be managed by tenants locally and Estates Management Surveyors.

Health and Safety Team

The Health and Safety Team will advise the management in fulfilling their duties in regards to the implementation of this Management Procedure and associated regulations and guidance.

In respect of this procedure, the Health and Safety Team shall:

• Undertake the Fire Safety Risk Assessment (FSRA) for the premises
• Work with Duty Holders and other responsible persons with control of council premises to provide feedback about actions and control measures that may need to be taken to prevent harm and protect employees in respect of UFAS procedure and to close any outstanding actions in the FSRA
• Advise the Executive Officer, Manager and Team Leaders in fulfilling their fire safety duties under UFAS investigation procedure
• Provide and reinforce training and education on UFAS procedure
• Monitor the compliance with this management procedure and the associated regulations and guidance by carrying out periodical audits and inspections and issuing subsequent reports detailing any possible gaps or issues that need to be addressed.

Duty Holders and Nominated Responsible Persons

The Council, in its capacity to nominate one or more competent persons to assist in undertaking measures necessary to comply with fire safety regulations will appoint Duty Holders to each premises (or nominate other responsible persons with control of premises) to fulfil their fire safety responsibilities under UFAS Procedure.

Duty Holders and other nominated responsible persons, in conjunction with Facilities Management staff where applicable, will complete key elements below:

• Adapt the general process to suit your building and complete Appendix 1 UFAS Procedure for the building
• Identify persons that will undertake the investigation process at local level (please include all persons covering for any type of absences such as annual leave, medical emergencies, etc. and non- standard operational hours such as lets and after school clubs)
• Keep a local record of nominated trained persons
• Undertake EDC UFAS training and training at local level – for your own building
• Display all information required such as Fire alarm panel information sheet
• Ensure that local procedures are updated to reflect any changes to the management procedure.

Selecting Persons for UFAS Investigation

Persons selected to take on the UFAS investigation, going forward designated as “Nominated person” should have a good working knowledge of the layout of the building and be physically able to access all areas of the building during an investigation.

There is no expectation that those undertaking investigation duties will undertake any fire-fighting activities. However, Fire extinguisher training is available on request at Health.Safety@eastdunbarton.gov.uk and most Facilities Management staff have been trained. A good understanding of how extinguishers work is helpful in the unlikely event it has to be used to secure escape from a building.

Training required under the Fire Safety Policy will continue to apply:

• Fire Safety Awareness training (local) provided by the Duty Holder, and/or alternatively; Fire Safety Refresher available on EDC Moodle
• Fire Warden training (only assigned Fire Wardens)
• Duty Holder training (only Duty Holders and nominated responsible persons, including Fire Warden Coordinator)
• EDC UFAS Procedure, available on the Hub and Employee zone (only Duty Holders and nominated responsible persons)
• Duty holders must ensure there is local training on the fire panel and its use for UFAS investigation, ensuring an adequate number of additional persons have been trained in the role of nominated person to facilitate an effective response to unwanted fire alarm signals. A TBT49 has been developed and could be used to train and record training at a local level
• Local training should include:
• The interpretation of information displayed on the fire alarm panel
• Disablement of fire alarm panel/reset of panel
• The use of two-way radios and other relevant information as set out in the local arrangements document
• The layout of the premises and any special arrangements for access to specific areas
• The fire protection measures in the premises, including any active fire protection measures that may come into effect on operation of the fire alarm system
• Any special fire hazards within the premises (e.g. presence of gas cylinders)
• Any hazards associated with fire suppression systems in the building
• Training and information may also have to be provided to other tenants in the building and/or to third parties who may respond to alarm activations
• A record of all trained persons.

A reliable method of communication should be established to enable effective communication between the Nominated persons undertaking the investigation and Duty Holders or delegated nominated persons. This may be achieved by two-way radios or mobile phones. In some of the smaller buildings this may well be achieved by simply shouting.

The most suitable and reliable form of communication must be selected taking into account areas of the building where there may be poor mobile and radio reception. Details of the communication method and areas of poor signal should be provided in the local arrangements document, UFAS Procedure which can be downloaded below.

Areas of Particular Fire Risks

Areas of special fire risks include kitchens, chemical storage rooms, plant rooms, boiler rooms, rooms where gas cylinders are stored and electrical rooms etc. A list of these areas can generally be found in the building layout and Fire Safety Risk Assessment for the premises. Any specific details of these areas will be established in Appendix 1 UFAS Procedure and made known to the nominated persons during local training.

External Investigations

Depending on the size and layout of the building it may be possible to conduct an investigation into an unwanted fire alarm signal from the outside of the building rather than from the inside. This will generally be possible in smaller, single or two storey buildings where areas under investigation can be viewed from the outside of the building. This form of investigation will also be default during out of hours Callout Team process.

Lone Working While Investigating UFAS

A Lone worker process has been devised for those undertaking the UFAS investigation alone, whether the building is occupied at the time or not. This will depend n the type of premises, usually smaller building that will allow this process to take ace safely and without added risk. Lone Worker process is embedded in 5.0 Process – How to investigate a Fire Alarm signal.

Fire Watch Period

There may be instances where a “fire watch period” is utilised in which the nominated person investigating UFAS alone waits outside the building for a period of time to observe if there are obvious signs of fire. The precise details of the arrangements for dealing with unwanted fire alarm signals should be set out in the UFAS building procedure. This could be for areas with no access for checks to be carried out, like ceiling voids. Where detectors activate in this zone, there is no way of checking, unless there are indeed obvious signs of fire.

This process is based on a “Safety First” approach and at any time if the person investigating an alarm signal feels unsafe or, there are other signs that lead to believe there might be a fire currently not stated in the process, they must evacuate immediately and call 999.

If a fire has been discovered by someone who has evacuated the premises this information must be passed by radio to the Building Manager/Facilities Officer or other nominated person carrying out the investigation. At this point the investigation can be called off and 999 should be dialled.

The investigation can be called off/not started for other reasons, mainly:

• Where nominated persons (or other persons) are able to confirm signs of fire. This information should be passed on during the 999 call
• Where a manual call point has been activated accidentally and a Fire Warden or other member of staff is able to pass on the information to the person undertaking the investigation via hand held radio from Duty Holder or other delegated responsible person
• Sprinkler system is activated, more than one detector activated in one zone.

Operational Hours/Occupied Premises

• Fire Alarm activates
• ARC is notified – 25 minutes to escalation process starts
• Premises is evacuated according to evacuation plan
• Nominated persons obtain handheld radios and test (One for Duty Holder or delegated responsible person and the other Building Manager/Facilities Officer or other nominated person who has been trained in UFAS)
• Nominated person report to fire alarm panel and establishes zone indicated
• Nominated person dons ear defenders
• Nominated person informs outside radio they are going to investigate inside building
• Nominated person proceeds to zone indicated, to investigate. The aim is to sweep the building in a methodical manner working towards the exits if possible.

If at any time the nominated person feels their own personal safety is compromised, they should evacuate to the assembly point and inform the outside radio to dial 999. Personal safety of individuals, through continual dynamic risk assessment, is the priority in this process.

• Lifts should not be used
• Outside radio should be informed if the nominated person changes floor level or enters another compartment
• When you investigate, use your senses.
  • Look for smoke or smell of smoke
  • Listen for unusual crackling noises
  • Is it unusually hot?
• Remember you are looking for signs of a fire, not a fire itself

If you are investigating ALONE and there is no one taking second handheld radio:

• Once at the alarm panel, check the zone and leave the building to do a 360° of the building, especially checking the zone from outside
• Go back to the panel and check it is still showing only one zone activated
• Do a dynamic risk assessment: depending on the size and complexity of the building – IF YOU FEEL UNSAFE PHONE THE FIRE SERVICE or ERC
• Phone ERC and advise you are investigating an alarm activation and you are doing so alone - lone worker process open - 5 MINUTES OPEN.

Door Procedure:

Check door for heat. This can be done by using the back of the hand against the door to feel for heat. Feel the handles as well. This will indicate a possible fire behind the door.

Check which way the door opens. Toward you or away from you. This can be checked by looking for hinges. If you can see hinges it generally indicates the door opens toward you. If you cannot see hinges this generally indicates the door opens away from you.

Door opens toward you: Stay low and come to the hinge side of the door. The door will protect you in the event of a reaction. Place the foot nearest the door about six inches from the door. This acts to block the door should there be an extreme reaction. Take control of the handle and “crack” the door. If there is no reaction (fire, heat or flames) take a quick look inside the room you are preparing to enter including the floor area. If there is no sign of fire it is safe to enter and continue. If there is evidence of fire it can be extinguished if small enough however if it is any larger than a wastepaper basket shut the door and radio to outside to dial 999. Evacuate yourself from the building by the nearest exit and report to fire assembly point.

Door opens away from you: Stay low and take shelter on the opposite side of the hinge side of the door. Effectively you will be protected by the wall with the door handle close to you. Using the wall as protection “crack” the door. If there is no reaction (fire, heat or flames) take a quick look inside the room you are preparing to enter including the floor area. If there is no sign of fire it is safe to enter and continue. If there is evidence of fire it can be extinguished if small enough however if it is any larger than a wastepaper basket shut the door and radio to outside to dial 999. Evacuate yourself from the building by the nearest exit and report to fire assembly point.

• Investigate the area indicated by the fire alarm panel
• If no fire is found/false alarm, inform outside and ask them to standby.

If false alarm activation, phone back advising of UFAS - lone worker process closed.

• Nominated person returns to main fire alarm panel and resets fire panel
• If fire panel resets, inform outside and reoccupy the building. Remember to inform the ARC
• Record in Fire Logbook and inform Health and Safety of incident
• If fire alarm panel does not reset, further investigation may be carried out however if there are any doubts dial 999.

Flowchart: Operational hours with a BM or Nominated person present

Non - Occupied Hours/Unoccupied Premises/ Partially Occupied

• Fire alarm actuates
• ARC will be notified immediately
• The ARC will notify the Emergency Response Centre
• The Emergency Response Centre will notify the Call Out Team
• The Call Out Team will respond in teams of 2 – in no circumstance will enter the building until both present – although the exterior of the building should be checked and if any sign of fire, then dial 999
• Call Out Team will ensure that they have handheld radio and test to ensure they are sending and receiving
• Call Out Team don ear defenders
• Call Out Team reports to fire alarm panel
• One member of the Call Out Team to investigate the zone/area that is shown on the fire alarm panel to find the detector head(s) that has been actuated whilst the other member stays at the fire panel
• If fire is discovered, either tackle with a fire extinguisher if safe to do so OR, close the door, evacuate and dial 999
• If person’s safety is compromised, or evidence of fire, they should evacuate premises and contact the other Call Out Team member to contact 999
• If there is no fire discovered, radio to other member and attempt to reset
• If fire alarm resets and no evidence of fire, the Callout Team can lock up the premises OR, allow persons to re- enter the building, if it was still occupied.
• If the fire alarm panel doesn’t reset, further investigation may be carried out.  However, if there is any doubt, dial 999

Partially Occupied Premises

There are circumstances where a building will come under non-operational hours although persons or groups might still be using the building regularly, such as EYCs and Primary schools after 4pm. Operational hours have been assessed per building type and use, and hours vary. Duty Holders should check the operational hours for their building. This has been done to support non-FM employees’ safety who will not normally carry out the UFAS investigation.

If a building is under non-operational hours, which vary according to building type and use, but there are people trained in UFAS present, the UFAS investigation could be undertaken and Callout team de-escalated by contacting ERC after investigating.

School and Public Holidays

Non-Operational hours will apply during school and public holidays

If not connected to the ARC, the alarm will be reset in the morning OR, if a member of the public wishes to report the alarm during non-operational hours, the external sign with emergency number can be contacted.

Non-operational hours Flowchart

There will be occasions when the nominated person investigating UFAS will find no signs of fire. Whilst this will be taken by many as enough to permit reoccupation of the building, the Duty Holder or delegated responsible person may seek further reassurance.

This reassurance will be sought from the Building Manager, Facilities Officer or nominated person who carried out the UFAS investigation. Where a single nominated person and lone worker call has been used, then a Fire Watch period can be considered for reassurance, normally no less than 20 minutes, as defined in the UFAS Procedure for Building.

It should be noted that on some occasions an internal investigation may not be possible for a number of reasons, e.g., lack of knowledge about a building, access to certain areas not possible or support calls cannot be established etc., on such occasions an external investigation and a fire watch period may be all that can be utilised.

As part of the EDC Health and Safety Management System, the EDC Health and Safety Team will conduct regular audits and inspections to monitor the implementation of this management procedure.

The EDC Health and Safety Team will review this management procedure every 6 months from the date of implementation or sooner as a result of any changes to staff feedback, policy change or some other event i.e. a major incident or accident.

The EDC Health and Safety Team will provide feedback in the form of a report following any audits and inspections. When necessary the procedure will be amended and reissued with an updated version number.

All Duty Holders must ensure that local procedures are updated to reflect any changes to the management procedure.

HSE Guidance and Regulation

• Health and Safety at Work Act 1974
• Fire (Scotland) Act 2005
• The Management of Health and Safety at Work Regulations 1999
• Fire (Scotland) Regulations 2006 also applies.

East Dunbartonshire Council: Health and Safety Policy / Procedures

• HSP03 Fire Safety Policy 2023
• SP29 Duty Holder Procedure.

East Dunbartonshire Council: Health and Safety Forms

• HS1a Health and Safety Accident/Incident/fire alert form
• HS1b Health and Safety Near miss form.