Emergency action plan: what OSHA requires, and how to keep the plan working

01

The rule: OSHA 1910.38, and when a plan is required

For private employers under federal OSHA, the requirement is OSHA 29 CFR 1910.38, Emergency action plans. It opens with a condition that is easy to miss: "An employer must have an emergency action plan whenever an OSHA standard in this part requires one." In other words, 1910.38 sets out what a plan must contain; other standards decide whether you need one.

OSHA's own Evacuation Plans and Procedures eTool questionnaire, "Am I required to have an emergency action plan?", walks through the triggers. In most ordinary buildings the first is portable fire extinguishers: under 29 CFR 1910.157, Portable fire extinguishers, an employer that chooses total evacuation, provides extinguishers not intended for employee use, or lets only designated employees use them relies on an emergency action plan meeting 1910.38. The questionnaire also asks about total flooding extinguishing systems, delayed fire detection alarms and several process and chemical standards, such as process safety management (1910.119).

OSHA's booklet How to Plan for Workplace Emergencies and Evacuations (OSHA 3088, 2001 revised) is plain: "Not all employers are required to establish an emergency action plan," but compiling one is "a good way to protect yourself, your employees, and your business during an emergency." In practice, a janitorial contractor or security company in someone else's building will be asked for one, or to follow the building's.

The plan must be written down. Under 1910.38(b), it "must be in writing, kept in the workplace, and available to employees for review. However, an employer with 10 or fewer employees may communicate the plan orally to employees."

02

What an emergency action plan must cover

Section 1910.38(c) sets the minimum. An emergency action plan "must include at a minimum":

1. Procedures for reporting a fire or other emergency. Dialing 911, an internal number or a manual pull station; say which is preferred.
2. Procedures for emergency evacuation, including type of evacuation and exit route assignments. Total evacuation, partial evacuation or staying put, and which route each area uses, usually shown on exit diagrams.
3. Procedures to be followed by employees who remain to operate critical plant operations before they evacuate. In an office this may be nobody; elsewhere it may be the building engineer shutting down gas or equipment.
4. Procedures to account for all employees after evacuation. An assembly area, a head count and a way to pass on the names of anyone missing.
5. Procedures to be followed by employees performing rescue or medical duties. Most small organizations rely on the fire department and local hospital.
6. The name or job title of every employee who may be contacted by employees who need more information about the plan or an explanation of their duties under it.

The standard also requires, in 1910.38(d), that the employer "have and maintain an employee alarm system" that "must use a distinctive signal for each purpose and comply with the requirements in § 1910.165." And under 1910.38(e), "An employer must designate and train employees to assist in a safe and orderly evacuation of other employees."

OSHA's eTool page on minimum requirements suggests, though OSHA does not require, a description of the alarm system, including how it alerts employees with disabilities; an alternative communications center; and a secure place for copies of essential records.

A working plan goes further. The eTool's evacuation elements page adds when to evacuate and when to shelter in place, a clear chain of command, procedures for high-rise buildings, and help for visitors and employees who have disabilities or do not speak English. Most plans also cover severe weather, a medical emergency, a utility failure and workplace violence, each with its own protective action. The Ready.gov Emergency Response Plan page puts it as a planning step: "Develop protective actions for life safety (evacuation, shelter, shelter-in-place, lockdown)."

03

Who does what: the coordinator, wardens, and everyone else in the building

OSHA's eTool page on developing and implementing an EAP says it is "common practice to select a responsible individual to lead and coordinate your emergency plan and evacuation." The coordinator decides whether an emergency exists, oversees the response, works with outside emergency services and directs shutdowns; once the fire department arrives, its highest-ranking responder takes command of the incident. Make sure every employee knows who the coordinator is, and that the coordinator has the authority to make decisions during an emergency.

Evacuation wardens do the moving and the counting. OSHA's guidance is specific on numbers: "Generally, one warden for every 20 employees should be adequate, and the appropriate number of wardens should be available at all times during working hours." Wardens may check offices and restrooms before being the last to leave, and close fire doors behind them. They should know the alternative routes, and who may need extra help.

"Available at all times during working hours" is where most plans quietly fail. A warden list drawn up for the day shift says nothing about the second shift, the weekend or a warden's vacation. Name a warden for each shift, by role where possible, with cover arranged in advance.

Accounting for people is the element most often left vague. OSHA 3088 suggests designating assembly areas; taking a head count after the evacuation; identifying "the names and last known locations of anyone not accounted for" and passing them to the official in charge; and establishing a method for accounting for non-employees such as suppliers and customers. Some employers use the visitor and contractor sign-in list for this.

Custodial crews, day porters and security officers are often a contractor's staff, working when the building is nearly empty. OSHA notes that you "may find it beneficial to coordinate the action plan with other employers when several employers share the worksite, although OSHA standards do not specifically require this." In a multi-tenant building or a contracted site, settle in writing:

• whose plan the contractor's staff follow, the building's or their employer's, and that the two agree on alarms, routes and assembly areas;
• who counts contractor staff at the assembly area, and who is told they are there;
• what the evening custodian or overnight security officer does when alone in the building;
• how the contractor hears about changes to the building's plan.

04

Alarms, training, review and drills

The alarm. 29 CFR 1910.165, Employee alarm systems says the alarm "shall be capable of being perceived above ambient noise or light levels by all employees in the affected portions of the workplace," and "shall be distinctive and recognizable as a signal to evacuate the work area or to perform actions designated under the emergency action plan." Its maintenance and testing rules apply to any local fire alarm signaling system used to alert employees:

• non-supervised employee alarm systems must be tested for reliability and adequacy every two months, using a different actuation device in each test of a multi-device system;
• supervised systems must be tested at least annually;
• back-up means of alarm, "such as employee runners or telephones," must be provided when the system is out of service;
• under 1910.165(e), manual pull stations must be "unobstructed, conspicuous and readily accessible."

With 10 or fewer employees, 1910.165(b)(5) accepts direct voice communication, "provided all employees can hear the alarm." A building fire alarm system also has fire code testing requirements; ask the authority having jurisdiction.

Training and review. Section 1910.38(f) requires the employer to review the plan with each employee it covers "(1) When the plan is developed or the employee is assigned initially to a job; (2) When the employee's responsibilities under the plan change; and (3) When the plan is changed." If the plan relies on a fire prevention plan, 29 CFR 1910.39, Fire prevention plans adds that employees must be told, on initial assignment, of the fire hazards they are exposed to. OSHA's eTool adds: "Consider retraining employees annually."

Drills. OSHA's EAP standard does not set a drill frequency. OSHA's guidance calls practice drills "a good idea," to be held "as often as necessary to keep employees prepared," with a debrief afterward: "After each drill, gather management and employees to evaluate the effectiveness of the drill."

Drill frequencies are usually set by the fire code, and vary by occupancy and jurisdiction. Under Chapter 4 of the New York City Fire Code, Emergency Planning and Preparedness, certain large and high-rise office buildings must have a comprehensive fire safety and emergency action plan; Table 401.7.6 sets fire and non-fire emergency drills for all occupants of Group B offices semiannually, and quarterly in the two years after a plan is accepted; and FC 401.7.8 requires drills and education to be "documented by entries in the logbook" kept under FC 401.8. Other jurisdictions and occupancies set their own; ask the fire marshal which code and edition apply.

05

Keeping the plan true to the building, and what the record should show

An emergency action plan describes a building on the day it was written. OSHA's guidance is blunt about what happens next: "Operations and personnel change frequently, and an outdated plan will be of little use in an emergency." The part that goes stale first: "The most common outdated item in plans is the facility and agency contact information."

The routes on the diagram only work if they are passable, and 29 CFR 1910.37, Maintenance, safeguards, and operational features for exit routes sets the standard: exit routes "must be free and unobstructed," with no materials or equipment placed in them "either permanently or temporarily"; safeguards such as sprinkler systems, alarm systems, fire doors and exit lighting "must be in proper working order at all times"; and each exit must be clearly visible and marked "Exit." Routine checks that support the plan usually include:

• exit routes and stairwells clear, exit doors free to open, exit signs lit;
• the posted evacuation diagrams present, current and matching the floor as it is now;
• manual pull stations unobstructed and fire extinguishers in their places;
• the assembly area clear and usable, not a parking lot now fenced off for construction;
• emergency contact and warden lists up to date on each floor;
• shelter-in-place rooms and evacuation chairs accessible.

When a regulator, client or insurer asks how the plan is working, the evidence is dated and specific:

• The plan itself, with a version date and a record of each review and change.
• Employee reviews: who was taken through the plan, when, and why (new hire, changed duties, changed plan), matching the three triggers in 1910.38(f).
• The warden roster by floor and shift, with the date it was last confirmed and who covers absences.
• Alarm tests: the date, the device used, the result and who tested, at the interval 1910.165(d) requires.
• Drills: the date, scenario, areas involved, how long evacuation and the head count took, and what changed as a result.
• Defects and their close-out: a blocked exit, a failed exit light or a missing diagram, who was told, and when it was put right.

A plan without records like these is a document that may once have been right.

06

Where the record fails, and what SiteClara does about it

Emergency action plans rarely fail in the binder. They fail in the routine around them: the exit route walk that is signed off without anyone walking it, the corridor used for storage the week after the check, the evacuation diagram that still shows a door since walled over, the blocked exit a custodian mentioned to whoever was passing and nobody wrote down. Asked later whether the stairwell was clear on a given night, the answer is a row of initials added the same afternoon.

SiteClara puts a printed QR poster at each place a check is due, such as an exit door, a stairwell landing, an alarm panel or the assembly area, with an optional NFC tag behind it. Staff scan the code or tap the tag on their own phone, with no app to install, and sign in with a link. They see the checks due there, such as the nightly exit route walk, and mark each one done or say what stopped them. A problem, such as a blocked exit, a failed exit sign or a missing evacuation diagram, is reported there with a photo and goes onto the team's list of jobs until someone closes it.

The supervisor sees what is due, done and missed at each location, and can record why a check was missed; a job that needs the building manager can be escalated to them to answer. Each day the supervisor reviews and approves a report that goes to nominated management or client contacts at 8 a.m. the next morning, showing what was reported, completed and still open, and how the scheduled checks went, for example 14 of 14 completed.

07

Questions people ask

What should an emergency action plan include?

At a minimum, OSHA 29 CFR 1910.38, Emergency action plans requires six things: procedures for reporting a fire or other emergency; procedures for emergency evacuation, including the type of evacuation and exit route assignments; procedures for employees who remain to operate critical plant operations before they evacuate; procedures to account for all employees after evacuation; procedures for employees performing rescue or medical duties; and the name or job title of every employee who may be contacted for more information about the plan. The same standard adds an employee alarm system, trained staff to help with evacuation, and a review of the plan with each employee it covers.

What are the 5 steps to an emergency plan?

No federal rule fixes a set number of steps. The Ready.gov Emergency Response Plan page sets out ten for a business: review the program's performance objectives; review the hazard or threat scenarios from the risk assessment; assess the resources available for incident stabilization; talk with public emergency services about their response time; check which regulations apply to emergency planning; develop protective actions for life safety; write hazard-specific emergency procedures; coordinate the plan with public emergency services; train personnel in their roles and responsibilities; and hold exercises to practice the plan.

08

Where to read more, and a list to take away

Start with the standard itself, 29 CFR 1910.38, and with OSHA's Evacuation Plans and Procedures eTool, with a checklist, the "fight or flee" decision and shelter-in-place procedures. OSHA's booklet How to Plan for Workplace Emergencies and Evacuations (OSHA 3088) covers it in print. Ready.gov's Emergency Response Plan page sets out ten steps for a business plan. If you are in a state plan state, read your state's version, such as California's 8 CCR 3220, and ask your fire prevention bureau which fire code edition and local amendments apply.

Before you sign off an emergency action plan for a building, check that:

• it is written, kept at the workplace and available to employees, unless you have 10 or fewer;
• it covers all six elements in 1910.38(c), for every type of emergency you can foresee, including shelter in place;
• it names a coordinator with authority to order evacuation, and wardens for every shift;
• it says how visitors, contractors and people who need help evacuating are accounted for;
• the alarm is distinctive and tested at the interval 1910.165 and the fire code require;
• every employee has been taken through it at hire, on a change of duties and on a change of plan;
• drills are held, debriefed and followed by changes where needed;
• exit routes, diagrams and contact lists are checked on a routine, with the checks recorded as they are done.