Netaji Subhas Medical College and Hospital, Amhara, Bihta, Bihar
(Established by Sitwanto Devi Mahila Kalyan Sansthan)
To establish and maintain a comprehensive fire prevention and fire safety program in the medical college and hospital premises.
To ensure compliance with the National Building Code (NBC) 2016, Fire Safety Act, and all applicable fire safety regulations.
To create and promote a culture of fire safety awareness among all stakeholders through continuous monitoring, education, training, and mock drills.
To identify, assess, and mitigate fire hazards in a proactive manner across all clinical and non-clinical areas.
To ensure readiness for fire emergency response through proper equipment maintenance, trained personnel, and rehearsed evacuation procedures.
To coordinate with local fire department authorities and obtain necessary fire safety clearances and No Objection Certificates (NOC).
To implement systematic processes for fire risk assessment, fire incident reporting, investigation, and corrective action.
To develop, review, and update the Fire Safety Manual and Standard Operating Procedures (SOPs) for fire prevention, detection, alarm, suppression, and evacuation.
To ensure compliance with National Building Code 2016 requirements for fire safety installations including fire extinguishers, hose reels, hydrants, sprinkler systems, fire detection systems, fire alarm systems, and emergency lighting.
To maintain updated Fire No Objection Certificate (NOC) from the concerned State Fire Department and ensure timely renewal.
Clinical areas (wards, ICUs, OTs, emergency, OPD, laboratories, blood bank, radiology): Twice per year
Non-clinical areas (administrative offices, stores, workshops, residential quarters): Once per year
To identify fire hazards including electrical faults, flammable material storage, blocked fire exits, non-functional fire equipment, and any other conditions that could lead to fire incidents.
To ensure proper maintenance of all fire safety equipment and systems with documented preventive maintenance schedules, testing records, and calibration certificates.
To maintain an inventory of all fire safety equipment including fire extinguishers (with type, location, and expiry date), fire hose reels, fire hydrants, sprinklers, fire detection systems, and fire alarm systems.
To ensure appropriate placement and adequate number of fire extinguishers based on fire risk classification (Class A, B, C, D, K fires) and as per NBC guidelines.
To verify that 10% of fire extinguishers are tested annually for functionality and refilling is done before expiry dates.
To ensure fire exit routes are clearly marked, unobstructed, well-lit (including emergency lighting), and lead to designated assembly points.
To ensure fire exit doors remain unlocked during operational hours, open outward, have panic bars where required, and have appropriate fire rating.
To ensure fire exit signage is bilingual (English and Hindi), glow-in-the-dark, and prominently displayed at all critical locations.
To display fire evacuation plans on each floor and in each patient room showing exit routes, fire equipment locations, and assembly points.
To ensure fire doors have proper fire rating, are fitted with self-closing devices, and remain functional.
To monitor functioning of automatic fire detection systems (smoke detectors, heat detectors) and fire alarm systems (manual call points, central monitoring panel).
To ensure fire alarm system is monitored 24x7 at a designated location with trained personnel.
To verify proper functioning of fire suppression systems including sprinkler systems, fire pumps, underground storage tanks, and terrace tanks.
To ensure fire pumps are tested regularly, pressure gauges are calibrated, and appropriate water pressure is maintained in fire hydrant and sprinkler lines.
To ensure proper functioning of fire dampers in HVAC systems to prevent fire spread through ventilation ducts.
To establish and maintain an Emergency Command Centre that becomes operational immediately during fire emergencies with designated personnel and communication protocols.
To constitute Fire Fighting Team and Evacuation Team with defined roles, responsibilities, and 24x7 availability.
To ensure electrical safety including proper earthing, circuit breakers, overload protection, preventive maintenance of electrical panels, UPS, DG sets, and transformers.
To regulate storage, handling, and use of flammable materials including medical gases (oxygen, nitrous oxide), spirit, alcohol, petroleum products, and other combustible materials.
To ensure bulk storage of diesel and flammable materials complies with Indian Explosives Act and has approval from Indian Explosives Department.
To ensure proper ventilation in electrical panel rooms, UPS rooms, DG set rooms, and equipment rooms to prevent overheating.
To verify peripheral road around the building is accessible for fire brigade vehicles in case of emergency.
To coordinate with Hospital Safety Committee on overall facility safety and emergency preparedness.
To receive, investigate, and document all fire incidents, near-miss events, and fire safety violations.
To conduct root cause analysis for fire incidents and implement corrective and preventive actions (CAPA).
To organize fire safety training programs for all categories of staff including faculty, residents, nurses, technicians, housekeeping, security, and administrative staff.
To conduct mandatory fire mock drills at least twice per year as per NABH requirements with participation from all departments and shifts.
To document all mock drills with date, time, scenario, participants, observations, gaps identified, time taken for evacuation, and corrective actions.
To educate patients and visitors about fire safety through display of fire safety information, pamphlets, and audio-visual materials.
To implement fire safety codes for announcements and communication protocols (e.g., Code Red for fire emergency).
To submit quarterly reports to the Principal and Managing Committee on fire safety status, inspections conducted, incidents reported, training programs, mock drills, and compliance with regulations.
To liaise with State Fire Department, local fire station, civil administration, and other external agencies on fire safety matters.
To recommend budgetary provisions for procurement, maintenance, and upgradation of fire safety equipment and infrastructure.
To ensure compliance during NMC inspections, NABH accreditation surveys, and other regulatory audits regarding fire safety requirements.
The Fire Safety Committee shall be a multidisciplinary body consisting of the following members:
| S.No. | Designation/Position | Status in Committee |
|---|---|---|
| 1. | Principal cum Dean, Netaji Subhas Medical College | Chairperson |
| 2. | Medical Superintendent, NSMCH Hospital | Vice-Chairperson |
| 3. | Deputy Medical Superintendent, NSMCH Hospital | Member |
| 4. | Fire Safety Officer (to be designated) | Convener |
| 5. | Professor & Head, Department of Forensic Medicine | Member |
| 6. | Professor & Head, Department of Anesthesiology | Member (Clinical) |
| 7. | Professor & Head, Department of Emergency Medicine | Member (Clinical) |
| 8. | Chief Nursing Superintendent | Member |
| 9. | Nursing Superintendent (ICU) | Member |
| 10. | Nursing Superintendent (OT) | Member |
| 11. | Hospital Administrator/Administrative Officer | Member |
| 12. | Chief, Maintenance and Engineering Department | Member |
| 13. | Assistant Engineer (Electrical) | Member |
| 14. | Assistant Engineer (Civil) | Member |
| 15. | Chief of Biomedical Engineering Department | Member |
| 16. | Security Officer/Chief of Security | Member |
| 17. | Housekeeping Supervisor | Member |
| 18. | Chief Pharmacist | Member |
| 19. | Manager, Quality Assurance and Accreditation | Member |
| 20. | Chief Warden, Male Hostel | Member |
| 21. | Chief Warden, Female Hostel | Member |
| 22. | IT Manager | Member |
| 23. | Representative from Local Fire Station | Member (Special Invitee) |
Table 1: Composition of Fire Safety Committee
The Principal cum Dean and Medical Superintendent shall be ex-officio Chairperson and Vice-Chairperson respectively by virtue of their positions.
The Principal shall designate a Fire Safety Officer who shall serve as Convener of the Committee.
The Fire Safety Officer should preferably be from Security Department or Engineering Department and must be trained in fire safety protocols.
The Fire Safety Officer shall report directly to the Principal on all fire safety matters.
The Fire Safety Officer shall be responsible for day-to-day fire safety operations, inspections, training coordination, and emergency response coordination.
The Committee ensures representation from clinical services, nursing services, facility management, security, engineering, support services, and quality assurance to provide comprehensive fire safety oversight.
The Chairperson may invite representatives from State Fire Department, local fire station, civil administration, or external fire safety consultants as special invitees without voting rights.
The Principal/Dean shall be the Chairperson of the Committee.
The Chairperson shall have overall supervision and control of the Committee's functioning and fire safety program implementation.
The Chairperson shall approve major fire safety policies, budgetary provisions for fire safety equipment, and investigation reports of major fire incidents.
In the absence of the Chairperson, the Vice-Chairperson shall preside over meetings.
The Medical Superintendent shall be the Vice-Chairperson of the Committee.
The Vice-Chairperson shall assist the Chairperson in discharge of duties and preside over meetings in the absence of the Chairperson.
The Vice-Chairperson shall oversee day-to-day implementation of fire safety measures in the hospital.
The Fire Safety Officer designated by the Principal shall serve as Convener.
The Convener shall report directly to the Principal on all fire safety matters.
Coordinating all activities of the Fire Safety Committee
Convening meetings in consultation with the Chairperson
Conducting regular fire safety inspections and facility rounds
Maintaining inventory of all fire safety equipment with maintenance records
Receiving and documenting fire incident reports and near-miss reports
Investigating fire incidents and preparing investigation reports
Coordinating implementation of corrective and preventive actions
Organizing fire safety training programs and mock drills
Liaising with State Fire Department and local fire station
Ensuring compliance with Fire NOC conditions and renewal
Preparing and circulating agenda and minutes of meetings
Maintaining comprehensive records of all fire safety activities
Preparing quarterly and annual fire safety reports
Handling correspondence on behalf of the Committee
Leading the Emergency Command Centre during fire emergencies
The Committee shall constitute a Fire Fighting Team consisting of 8-12 trained personnel primarily from Security and Maintenance departments.
One supervisor shall be designated as Team Leader.
All members shall be trained in firefighting, use of fire extinguishers, operation of fire hose reels and hydrants, and emergency response.
The Fire Fighting Team shall be available 24x7 on rotation basis to respond immediately to any fire incident.
The Team shall take control of fire situations until fire is extinguished or external help (fire brigade) arrives.
The Committee shall constitute Evacuation Teams for each clinical area (wards, ICUs, OTs, emergency) led by nursing staff with support from security and housekeeping staff.
Evacuation Team members shall be trained in evacuation procedures, patient mobilization techniques (bedridden, critical, pediatric, psychiatric patients), and assembly point protocols.
Evacuation Teams shall conduct floor-wise evacuation during mock drills and actual emergencies.
Special evacuation protocols shall be developed for ICU patients on ventilators, OT patients undergoing surgery, and immobile patients.
The Committee shall establish an Emergency Command Centre that becomes operational immediately during fire emergencies.
Designated location with communication equipment
List of Emergency Command Centre members with 24x7 contact numbers
Written protocol for activation and operation
Communication links with all departments, fire station, police, and civil administration
Emergency Command Centre members shall include Principal, Medical Superintendent, Fire Safety Officer, Security Officer, Engineering Head, and other key personnel.
The Committee shall meet at least once every three months (minimum four meetings per year) as per NABH requirements. Additional emergency meetings may be convened as required.
The Convener shall convene meetings with at least 5 days' prior notice to all members.
The notice shall include the date, time, venue, and agenda for the meeting.
In case of urgent matters (post-fire incident review), meetings may be convened with shorter notice with approval of the Chairperson.
The quorum for meetings shall be one-third of the total members or 8 members, whichever is higher.
The Chairperson or Vice-Chairperson must be present for the meeting to proceed.
If quorum is not present within 30 minutes of the scheduled time, the meeting shall stand adjourned.
Meetings shall be conducted in accordance with established rules of procedure.
All members shall have the right to participate in discussions.
Special invitees may participate in discussions but shall not have voting rights.
Fire safety inspection reports, mock drill reports, and incident investigation reports shall be reviewed in meetings.
Decisions shall ordinarily be taken by consensus after thorough discussion.
Where consensus cannot be reached, matters shall be decided by simple majority vote of members present.
In case of a tie, the Chairperson shall have a casting vote.
All important decisions shall be recorded as resolutions with action points, responsible persons, and timelines.
The Convener shall prepare minutes of each meeting within 7 days of the meeting.
Minutes shall be submitted to the Chairperson for approval and then circulated to all members.
Copies of minutes shall be submitted to the Managing Committee and made available to senior management.
Confirmed minutes shall be maintained in a permanent record book.
The Committee shall conduct comprehensive fire safety inspections as per the following schedule:
Clinical areas (wards, ICUs, OTs, emergency, OPD, laboratories, blood bank, radiology): Twice per year
Non-clinical areas (administrative offices, stores, workshops, hostels, residential quarters): Once per year
Fire safety inspection teams shall consist of Fire Safety Officer, Engineering staff, Security staff, and department representatives.
Fire extinguishers (type, location, accessibility, pressure gauge, expiry date)
Fire hose reels and hydrants (accessibility, water pressure, hose condition)
Fire detection and alarm systems (functionality, battery backup)
Fire exit routes (obstruction-free, signage, emergency lighting)
Fire doors (closure mechanism, fire rating, panic bars)
Electrical safety (panel condition, earthing, overload protection)
Flammable material storage (proper location, ventilation, signage)
Housekeeping (clutter, combustible materials)
Documented findings with photographs shall be submitted to the Convener within 7 days of inspection.
Non-compliance issues shall be communicated to concerned departments with timelines for rectification.
Annual comprehensive fire safety audit shall be conducted covering entire campus.
External fire safety consultants may be engaged for independent audit.
Audit reports shall be reviewed by the Committee and submitted to the Principal and Managing Committee.
Recommendations from audit reports shall be implemented with defined timelines and budgetary provisions.
All fire safety equipment shall have documented preventive maintenance schedules.
Maintenance records shall be maintained with date of last service, next scheduled service, and name of service provider.
Stickers showing last maintenance date and next due date shall be affixed on all equipment.
10% of fire extinguishers shall be tested annually for functionality.
Fire pumps shall be tested monthly for pressure and flow rate.
Fire detection and alarm systems shall be tested quarterly.
Emergency lighting shall be tested monthly by simulating power failure.
All new employees shall undergo mandatory fire safety orientation within one week of joining.
Fire prevention and causes of fire
Fire triangle and fire classification (Class A, B, C, D, K)
Types of fire extinguishers and their appropriate use
Operation of fire extinguishers, hose reels, and hydrants
Fire alarm activation and Code Red announcement
Evacuation routes and assembly points
Evacuation techniques for patients (bedridden, critical, pediatric)
Emergency Command Centre activation
Responsibilities during fire emergencies
Specialized training shall be provided to Fire Fighting Team and Evacuation Team members.
Training records shall be maintained with date, participants, topics covered, and trainer details.
Hands-on training with actual fire extinguisher operation shall be provided periodically.
Fire mock drills shall be conducted at least twice per year as mandated by NABH standards.
At different times (day shift, night shift)
In different locations (wards, ICUs, OTs, OPD, administrative block)
With varying scenarios (electrical fire, kitchen fire, chemical fire, cylinder leak)
Fire detection and alarm activation
Code Red announcement
Fire Fighting Team response
Initial fire suppression attempts
Evacuation Team activation
Floor-wise patient evacuation
Assembly at designated points
Roll call and accountability
Emergency Command Centre activation
Communication with fire station (simulated)
Date, time, location, and scenario
Participants (departments and number of staff)
Time taken for alarm activation
Time taken for Fire Fighting Team response
Time taken for complete evacuation
Observations on staff response and coordination
Gaps identified and areas for improvement
Corrective actions to be implemented
Debriefing sessions shall be held immediately after mock drills to discuss observations and learning points.
Mock drill reports shall be reviewed in Committee meetings and submitted to senior management.
Fire safety information materials shall be displayed in patient waiting areas, wards, and corridors.
Educational materials shall be in bilingual format (English and Hindi) with pictorial representation.
Topics shall include fire prevention tips, what to do in case of fire, and importance of not blocking fire exits.
Audio-visual materials on fire safety may be played in OPD waiting areas and common areas.
All fire incidents, near-miss events, and fire safety violations shall be reported immediately to the Fire Safety Officer.
Incident reporting form shall be filled with details of date, time, location, cause, extent of fire, response actions taken, injuries/casualties, and property damage.
No fire incident (false alarm)
Minor fire incident (controlled within 5 minutes without fire brigade)
Major fire incident (required fire brigade response or caused significant damage)
Near-miss event (potential fire hazard identified before fire occurrence)
All fire incidents shall be investigated by a team constituted by the Fire Safety Officer.
Investigation team shall include members from relevant departments based on the location and nature of fire.
Cause of fire (electrical, chemical, gas leak, smoking, arson, etc.)
Contributing factors (poor housekeeping, equipment failure, human error)
Adequacy and effectiveness of fire safety systems
Timeliness of response and effectiveness of Fire Fighting Team
Evacuation effectiveness and time taken
Injuries, casualties, and property damage assessment
Investigation report shall include findings, root cause analysis, and recommendations for corrective and preventive actions (CAPA).
Major fire incidents shall be reported to State Fire Department, police, insurance company, and regulatory authorities as required.
The Committee shall review investigation reports and approve CAPA.
CAPA shall be implemented with defined timelines and responsible persons.
The Convener shall monitor implementation and verify effectiveness.
Follow-up review shall be conducted to assess whether implemented actions have prevented recurrence.
The Committee shall develop and maintain a comprehensive Fire Safety Manual approved by the Chairperson and senior management.
Policy statement on fire safety
Fire risk assessment and hazard identification
Fire prevention guidelines
Fire safety systems and equipment inventory
Fire detection and alarm activation
Code Red announcement protocol
Fire Fighting Team response
Evacuation procedures (floor-wise, department-wise)
Emergency Command Centre activation
Communication protocols
Fire station and emergency services contact
Maintenance schedules for fire safety equipment
Inspection protocols and checklists
Responsibilities of different departments during fire emergencies
Electrical safety guidelines
Flammable material storage and handling guidelines
Training program outline
Mock drill protocols and frequency
Fire incident reporting and investigation procedures
Fire exit plans for each floor
Contact list of Fire Safety Committee members, Fire Fighting Team, and emergency services
The Fire Safety Manual shall be reviewed annually and updated as necessary.
Copies of the Fire Safety Manual shall be available with all Committee members, department heads, and security office.
Key SOPs shall be displayed prominently at strategic locations.
Hospital Safety Committee (for overall facility safety integration)
Disaster Management Committee (for emergency preparedness)
Hospital Infection Control Committee (for infection control during evacuation)
Medical Equipment Committee (for equipment safety and maintenance)
Electrical Safety Sub-Committee (for electrical hazard mitigation)
The Committee shall submit quarterly reports to the Principal and Managing Committee covering:
Fire safety inspections conducted and findings
Fire incidents reported and investigated
Fire safety equipment maintenance status
Training programs and participants
Mock drills conducted and outcomes
Fire NOC renewal status
Non-compliance issues and corrective actions
Budgetary requirements for fire safety
Overall fire safety performance
Analysis of fire incidents and near-miss events
Fire safety inspection and audit outcomes
Equipment procurement and maintenance
Training programs and coverage
Mock drill statistics and effectiveness
Compliance with NBC, Fire Safety Act, and NABH standards
Challenges faced and recommendations
Future plans and budgetary proposals
The Committee shall be accountable to the Managing Body for all fire safety matters and compliance with regulations.
The Fire Safety Officer (Convener) shall report directly to the Principal on matters requiring immediate attention or emergency situations.
Fire Safety Manual and SOPs
List of Committee members with contact details
Fire NOC and renewal certificates
Inventory of all fire safety equipment with specifications
Maintenance records of all fire safety equipment
Fire safety inspection reports with photographs
Fire safety audit reports
Fire incident reports and investigation reports
Root cause analysis documentation
CAPA implementation records
Training program records and attendance sheets
Mock drill reports, attendance, and debriefing notes
Copies of all agendas and minutes of Committee meetings
Correspondence with Fire Department and other authorities
Electrical safety testing and earthing records
Flammable material storage licenses and permits
All records shall be maintained for a minimum period of 5 years or as required by applicable regulations and insurance requirements.
Records related to fire incidents causing casualties or major damage shall be maintained confidentially and disclosed only to authorized persons or regulatory/legal authorities.
Fire Safety Committee - Incident Reporting Form
Incident No.: ______________________ Date of Report: __________________
Name: ________________________________________________
Designation/Department: ________________________________________
Contact Number: ____________________ Email: _____________________
[ ] Fire Incident [ ] Near Miss [ ] Fire Safety Violation [ ] False Alarm
__________________________________________________________
__________________________________________________________
__________________________________________________________
[ ] Electrical [ ] Gas Leak [ ] Chemical [ ] Smoking [ ] Kitchen [ ] Unknown [ ] Other: ______
[ ] Smoke Detector [ ] Heat Detector [ ] Manual Discovery [ ] Other: ________________
[ ] Fire Alarm Activated [ ] Code Red Announced [ ] Fire Extinguisher Used
[ ] Fire Hose Reel Used [ ] Fire Brigade Called [ ] Evacuation Conducted
Alarm activation: ______ mins | Fire Fighting Team arrival: ______ mins | Fire controlled: ______ mins
[ ] None [ ] Minor injuries [ ] Major injuries [ ] Fatalities
Details: _______________________________________________________
[ ] None [ ] Minor [ ] Moderate [ ] Major
Estimated value: Rs. ______________________
_______________________________________________________
_______________________________________________________
Signature of Reporter: _________________________
Date: __________________
Received by Fire Safety Officer: ____________________ Date: __________________
Incident Category: [ ] No Fire [ ] Minor Fire [ ] Major Fire [ ] Near Miss
Investigation Required: [ ] Yes [ ] No
Investigation Team: _____________________________________________
Dr. __________________ [Name & Signature] Principal/Director Netaji Subhas Medical College & Hospital Date: _______________ Seal:
Prof. _________________ [Name & Signature] Chairperson, Governing Body Date: _______________
Sitwanto Devi Mahila Kalyan Sansthan
Secretary: _________________ [Name & Signature] Date: _______________
