138-18-28 Lock out Tag out.docx

Health Care System Memorandum No. 138-18-28 September 17, 2018

VETERANS AFFAIRS PALO ALTO HEALTH CARE SYSTEM

3801 Miranda Avenue Palo Alto, CA 94304-1207

Effective Date: March 31, 2008 Issue Date: September 17, 2018

HEALTH CARE SYSTEM MEMORANDUM No. 138-18-28

SUBJECT: LOCK-OUT/TAG-OUT

1. SUMMARY: Health Care System Memorandum (HCSM) No. 138-14-28, dated February 20, 2014, is rescinded. Minor changes have been made.

2. PURPOSE: This policy establishes the requirements for isolation of both kinetic and potential electrical, chemical, thermal, hydraulic, pneumatic and gravitational energy, prior to equipment repair, adjustment or removal. The purpose of this policy is to ensure that the VA Palo Alto Health Care System (VAPAHCS) is in compliance with the Occupational Safety and Health Administration (OSHA) Standard 29 Code of Federal Regulation (CFR) 1910.147, The Control of Hazardous Energy, and 29CFR 1910.333, Selection and Use of Work Practices - Electrical.

3. POLICY: It is the policy of VAPAHCS to ensure that machines and/or equipment are isolated from potential hazardous energy, and locked out and/or tagged out before employees perform any servicing or maintenance activities where unexpected energization, start-up, or release of stored energy could cause injury. Hot tapping of natural gas and steam piping is prohibited. Lock-out devices shall be utilized over tag-out devices whenever practical. Tag-out devices will be utilized when energy isolating devices are not capable of being locked out.

4. DEFINITIONS:

a. Affected Employee: An employee whose job requires him/her to operate or use a machine or equipment on which servicing and/or maintenance is being performed under lock-out/tag-out or whose job requires him/her to work in an area in which such servicing or maintenance is being performed.

b. Authorized Employee: A person who locks out or tags out equipment/machines in order to perform servicing and/or maintenance on the equipment/machines.

c. Energy Isolating Device: A mechanical device that physically prevents the transmission or release of energy. Such devices include, but are not limited to: electrical disconnects; double block-and-bleed valves; and line valves. Note: Push buttons, selector switches, and other control circuit type devices are not energy isolating devices.

d. Energy Source: Any source of electrical, mechanical, hydraulic, pneumatic, chemical, thermal, or other energy.

e. Hot Tap: A technique of attaching a mechanical or welded branch fitting to piping or equipment while in service (i.e., live steam or natural gas lines), and creating an opening in that piping or equipment by drilling or cutting a portion of the piping or equipment within the attached fitting.

f. Lock-out: The placement of a lock-out device on an energy isolating device, in accordance with an established procedure, ensuring that the energy isolating device and the equipment being controlled cannot be operated until the lock-out device is removed.

g. Lock-out Device: A device that utilizes a positive means such as a lock, either key or combination type, to hold an energy isolating device in a safe position and prevent the energization of equipment/machine.

h. Periodic Inspection: Annual review of energy control procedures and employee knowledge of the responsibilities pertaining to energy control procedures being inspected. Inspection is conducted by an authorized employee other than the one(s) utilizing the energy control procedures being inspected.

i. Tag-out: The placement of a tag-out device on an energy isolating device, in accordance with an established procedure, to indicate that the energy isolating device and the equipment being controlled may not be operated until the tag-out device is removed.

j. Tag-out Device: A prominent warning device, such as a tag and a means of attachment, which can be securely fastened to an energy isolating device to indicate that the energy isolating device and the equipment/machine being controlled may not be operated until the tag-out device is removed.

5. PROCEDURES: Only the standardized devices supplied by VAPAHCS are to be used for lock-out/tag-out. These devices shall not be used for securing any other device or for any other purpose. All devices used to lock-out/tag-out shall be stored in a secure manner to prevent unauthorized use. OSHA 29CFR 1910.147, The Control of Hazardous Energy, refers generally to hazards associated with the accidental starting of all energy-generating machines, devices or things. This policy shall be understood to include the possibility of injury from working near interconnecting machines or equipment. In situations where exposure to interconnecting machines or equipment is required, the authorized employee is required to shut down and lock out such equipment. This lock-out/tag-out policy applies to all sources of energy including, but not limited to, electrical, mechanical, pneumatic, hydraulic, thermal, and gravitational energy. It also covers stored energy that remains in equipment even after it is isolated from its energy source. This can be, but is not limited to, electrical capacitors, springs, flow lines, or pipes. Some machinery and equipment may be powered from multiple sources.

a. Employee Involvement:

(1) Authorized employees: Performance of the lock-out/tag-out of the equipment may only be performed by authorized employees and may only be performed on authorized equipment. VAPAHCS designates authorized employees as the following engineering employee groups: Electricians; Plumbers; Maintenance Mechanics; HVAC Mechanics; Electronic Mechanics, and Biomedical Engineering.

(2) Affected employees: These employees operate equipment or work in an area where a lock-out is taking place. While they do not perform the lock-out, they must be notified of the lock-out before the lock out procedure begins.

(3) Other employees: These employees are not directly affected by the lock-out but need to recognize when a lock-out is in place. In some cases, the affected employee and the authorized employee may be the same person. An authorized employee, as listed by job title in this policy, is the only one permitted to perform energy shut downs and lock-out procedures.

b. Authorized employees shall follow the Basic Rules of Using Lock-out or Tag-out System Procedures:

(1) All identified equipment/machines capable of causing personal injury upon the unexpected energizing, start-up or release of stored energy shall be locked out or tagged out. Mechanically locking out equipment is required for all situations. If the equipment is not capable of being mechanically locked out, a full review of the equipment and tag-out procedure is required by the supervisor prior to equipment being tagged out. A written explanation as to why a mechanical lock-out device could not be used and the procedure to be used that will provide a level of safety equivalent to that of a mechanical lock-out device shall be filed in the lock-out/tag-out log.

(2) DO NOT ATTEMPT TO OPERATE ANY SWITCH, VALVE OR OTHER ENERGY ISOLATION DEVICE WHERE IT IS LOCKED OUT OR TAGGED OUT.

(3) Preparation for lock-out/tag-out: Locate and identify all isolating devices to be certain which switches, valves or other energy isolating devices apply to the equipment to be locked or tagged out. More than one energy source (electrical, mechanical or others) may be involved. Follow the energy control procedures in Attachment A as needed.

(4) Sequence of Lock-out / Tag-out System Procedure:

(a) Notify all affected employees associated with the equipment or machinery that a lock-out or tag-out system is going to be utilized and the reason for its use. The authorized employee shall know the type and magnitude of energy that the machine or equipment utilizes and shall understand the hazards thereof.

(b) If the machine or equipment is operating, shut it down by the normal stopping procedure (depress stop button, open toggle switch, etc.).

(c) Operate the switch, valve, or other energy isolating device so that the equipment is isolated from its energy source(s). Stored energy (such as that in springs, elevated machine members, rotating flywheels, hydraulic systems and air, gas, steam or water pressure, etc.) must be dissipated or restrained by method such as repositioning, blocking, bleeding down, or other approved methods.

(d) Lock-out/tag-out the energy isolating devices with the designated individual lock(s) and/or tag(s). Multiple lock-out/tag-out devices shall be used when more than one shop is performing service/maintenance on the equipment/machine.

1. Lock-out devices shall be affixed in a manner to ensure the energy isolating device is in a "safe" or "off" position.

2. Tag-out devices shall be affixed in a manner to clearly indicate that the operation or movement of energy isolating devices from the "safe" or "off" position is prohibited.

3. Tag-out devices shall be located as close as safely possible to the energy isolating device in a position that will be immediately obvious to anyone attempting to operate the device.

4. All tags shall be filled out completely and correctly (i.e., name, date, trade, and the reason for the lock-out).

(5) After ensuring that no employees are exposed, and to verify energy sources are disconnected, operate the push button or other normal operating controls to make certain the equipment will not operate.

(6) The equipment/machine is now locked out or tagged out.

CAUTION: Return operating control(s) to “neutral” or “off” position after test.

c. Procedures Involving More Than One Authorized Employee:

(1) Follow steps in paragraphs 5.a. (4) (a-d), listed above.

(3) As each authorized employee no longer needs to maintain his/her lock-out protection, that employee will remove their lock from the box.

d. Restoring Equipment/Machines to Normal Production Operations:

(1) After the servicing and/or maintenance is complete and equipment/machine is ready for normal production operations, check the area around the equipment/machine to ensure that no one is exposed.

(2) After all tools have been removed from the equipment/machine, guards have been reinstalled and employees have been notified and in the clear, remove all lock-out/tag-out devices. Operate the energy isolating devices per manufacturer instructions to restore energy to the equipment/machine.

(3) In the event an authorized employee is not available (i.e., absent) to remove his/her lock/tag in a multiple lock-out/tag-out:

(a) Contact shall be made with absent employee's supervisor, who will become the authorized employee and will be capable of removing the lock/tag;

(b) Before removal of the lock/tag, the absent employee's supervisor shall attempt to locate the absent employee; and

(c) The supervisor shall notify the absent employee as soon as practical that their lock/tag has been removed.

(4) Notify affected employees associated with the equipment or machinery that the lock-out/tag-out has been removed and equipment/machine is returned to service.

e. Supervisor Actions:

(1) Train Authorized Employees. The training program will include:

(a) Review of facility lock-out/tag-out policy.

(b) Review of service procedures developed for equipment/ machine and/or energy type-specific energy control procedures.

(c) Location and identification of designated equipment used in the lock-out/tag-out procedure.

(d) Documentation of training, to include attendance, date, training content, and signature of trainer.

(e) Conducting training of authorized employees as follows:

1. Upon initial assignment.

2. Whenever there is a change in the employee's job assignment.

3. Whenever a new hazard is introduced due to a change in equipment, machines, or process.

4. Whenever there is a change in the energy control procedure.

(2) Logbooks shall be kept for the recording of lock-out/tag-out use. Logbooks shall include start and stop dates, times, location, name of authorized employee performing lock-out/tag-out procedure and work performed (maintenance, repair, or modification).

(3) Create equipment specific procedures for equipment that:

(a) There is potential for stored or residual energy, or re-accumulation of stored energy after shutdown and lockout.

(b) The equipment has multiple energy sources.

(c) The isolation and lockout will not completely de-energize or de-acivate the equipment.

(d) The equipment is not isolated from that energy source and locked out.

(e) Multiple lockout devices are required.

(f) The lockout device is not under the exclusive control of the authorized employee performing the service.

(g) Servicing or maintenance creates a hazard for other employees.

(h) There have been previous accidents involving unexpected activation during servicing.

(4) Conducting periodic inspections in the energy control procedures:

(a) Select an auditor. The inspections are to be performed by an auditor who has been trained in lock-out/tag-out procedures and who is not involved with the process under audit.

(b) Perform inspections annually.

(c) Document inspection, to include identification of equipment/machine, date of inspection, employees included in the inspection, and signature of inspector.

(d) Initiate and follow up on corrective actions taken for deficiencies noted during periodic inspections.

6. RESPONSIBILITIES:

a. The Chief, Engineering Service, is responsible for:

(1) Reviewing all lock-out/tag-out procedures.

(2) Reviewing the annual inspection/audit and taking corrective action as appropriate.

(3) Retaining lock-out/tag-out procedures and audits. Audits are to be retained for three years.

b. The Project Engineer is responsible for:

(1) Obtaining copies of lock-out/tag-out procedures from contractors where implementation of such practice, may affect health care system operations.

(2) Informing all affected health care system employees of contractor lock-out/tag-out operations.

(3) Informing outside contractors of this health care systems lock-out/tag-out policy where such practice may affect contractor or health care system operations.

c. Supervisors are responsible for:

(1) Identifying all equipment/machines requiring inclusion into the lock-out/tag-out program to protect employees from injury during service and maintenance activities.

(2) Developing equipment/machine and/or energy type-specific energy control procedures.

(3) Training authorized employees.

d. Authorized employees are responsible for following the procedures as outlined and described in this policy in sections 5.a. (4) (a-d).

7. REFERENCE:

a. OSHA Control of Hazardous Energy Regulations/LockOut/Tagout: 29 CFR 1910.147.

b. ANSI A10.44-2014: “Control of Energy Sources (Lockout/Tagout) for Construction and Demolition Operations.”

8. RESCISSION DATE: September 30, 2021.

9. RESPONSIBLE OFFICIAL: Chief, Engineering Service .

Thomas J. Fitzgerald III Director