ATTACHMENTS.pdf

4 Attachments:

Confined Space Entry Program Confined Space_Contractor Acknowledgement (2022.09.17) LOTO (Attachment C) Contractor's Acknowledgement

MCP 138-075

CONFINED SPACE ENTRY PROGRAM

SOP SO-010

VA Connecticut Healthcare System West Haven, CT 06516

Signatory Authority:

Deputy Director

Responsible Owner:

Chief, Safety Office

Service Line(s):

Safety Office

Effective Date:

July 7, 2021

Recertification Date:

July 7, 2026

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures on confined space entry. This SOP must be followed by FMS staff and Contractors who enter confined spaces

b. This SOP sets forth mandatory procedures and processes to ensure compliance with OSHA’s Permit Required Confined Space Standard, 29 CFR 1910.146 in General Industry and 29 CFR 1926.21 in Construction Standard.

2. PROCEDURES

a. This SOP will identify Non-Permit Required Confined Spaces (NPRCS) and PRCS, the types of hazards that may be present in a confined space, the use of various forms to identify hazards and the use of a permit for PRCS.

(1) Marking of Confined Spaces. All confined spaces are marked or labeled with a confined space sign and identification number with the exception of manholes.

Manholes are not labeled at VACT. VA employees are prohibited from entering manholes. Any employee can request that an unlabeled work area be evaluated by Environmental Safety and Occupational Health (ESOH) to determine if it is a confined space.

(2) Preventing Unauthorized Access. All confined spaces (NPRCS and PRCS) shall be protected against unauthorized access by warning signs fixed at entry points and by locking the entry points. AT NO TIME CAN AN OPEN ACCESS POINT TO A

CONFINED SPACE BE LEFT UNATTENDED.

(3) Before any confined space is entered, a Confined Space Survey Form (Attachment A) must be reviewed. These forms are in Building 15A at West Haven, CH&P Control Room Building 19 at West Haven and Building 3 at Newington). This form will describe the spaces’ hazards and the current classification of the space and whether it can be reclassified.

(4) Confined Space Entry Classification: All identified confined spaces are to be considered PRCS until the Confined Space Entry Classification form (Attachment B) is

July 7, 2021 SOP SO-010 completed and indicates that there is or is not a health, safety, or atmospheric hazard.

The completion of the Confined Space Entry Classification form is to aide the Entry Supervisor with reclassifying a PRCS to a NPRCS.

(a) Notification must be made to the VACHS Environmental Safety and Occupational Health Service (ESOH) prior to a planned entry by the Entry Supervisor or Contract Officer Representative (COR) for both PRCS and NPRCS.

NOTE: For NPRCS it is recommended that the buddy system is used with one worker stationed at the space entry, and that worker(s) wear an air monitoring device when inside the NPRCS e.g. oxygen sensor and/or multi gas meter.

b. Preparing for entry.

(1) Surveillance: The surrounding area shall be surveyed to identify hazards such as drifting vapors from tanks, piping, sewers, vehicular traffic, and exhaust vents. Place barricades, as appropriate, to ensure that other workers will be protected.

(2) Isolation: This is also known as Lockout Tag out of Hazardous Energy (LOTO).

(a) Lines that open into a confined space including: water, steam, compressed air, material feed lines, sewer lines, vent and drain lines to common headers, flammable gas, and fuel oil lines shall be isolated according to the VACHS Lockout/Tag out Procedures.

1. Where lines cannot be valved off and safety tagged (LOTO), special procedures for that confined space shall be developed and followed. Procedures for specific confined spaces will indicate if these lines are required to be disconnected and/or blanked off.

2. Any other line not mentioned shall be disconnected and/or blanked off and safety tagged (LOTO). All blanks are to have a visible tag that extends beyond the end of the flange.

(b) If the confined space being entered is equipped with internal movable equipment, which could injure the entrant, the source of power must be disconnected completely.

Follow the VACHS "Lockout/Tag out Procedures".

1. Sources of power may include electric, pneumatic, hydraulic, spring, gravity, and similar types of energy.

2. Disconnecting completely means the switching to the off position, neutralizing the energy, and safety locking and tagging the manual starter, the combination starter, or safety switch using Lockout/Tag out Procedures.

a. The key(s) to LOTO locks are to be kept on the person entering the confined space.

b. Each person entering the confined space must be provided with their own lock(s) and tag(s).

(3) Air Monitoring. The atmosphere in a confined space must be evaluated prior to entry for at least oxygen as % oxygen and flammable/combustible gases as percentage of lower explosive limit (%LEL). (Note: Confined space meters must be bump tested prior to using, span calibrated at least quarterly, and factory calibrated yearly. Ensure that the appropriate gas and regulator is used prior to calibration. The bump test and span calibrations are documented).

(a) Immediately before entry, the space shall be checked using a properly calibrated and bump tested oxygen and combustible gas meter.

(b) The oxygen level must be checked first at the space entrance and must read between 19.5% and 23.5% by volume.

1. The oxygen meter alarm shall sound at and below 19.5% oxygen concentration.

2. The oxygen meter alarm shall sound at and above 23.5% oxygen.

(c) The combustible gas level is checked next and should be less than 10% of the lower explosive limit (LEL) before a person may enter the confined space.

1. The combustible gas meter alarm shall sound at 10% of the LEL and higher (verified by bump test).

(d) Testing stratified atmospheres. When monitoring for entries involving a descent into atmospheres that may be stratified, the atmospheric envelope should be tested a distance of approximately 4 feet (1.22 m) in the direction of travel and to each side. If a sampling probe is used, the entrant's rate of progress should be slowed to accommodate the sampling speed and detector response.

(e) Measurement of values for each atmospheric parameter should be made for at least the minimum response time of the test instrument specified by the manufacturer.

(f) A calibrated chemical specific meter (e.g. miniRAE 2000 obtained from ESOH) must also be used by the Entry Level Supervisor or appropriately trained worker in gas monitoring for each likely contaminant that may exceed the OSHA Permissible Exposure Limit (PEL) or American Conference of Governmental Industrial Hygienists (ACGIH) Threshold Limit Value (TLV), when possible. These additional tests may be indicated in specific confined space procedures.

(g) If the PEL or TLV is exceeded and cannot be controlled through engineering controls such as ventilation, entry is forbidden until the Program Administrator, or designee, develops a safe entry protocol, requiring special procedures and protective equipment.

(h) NPRCS workers and PRCS Authorized entrants or their representative shall be provided an opportunity to observe pre-entry and continuous monitoring if applicable.

(i) All air monitoring results shall be recorded on the Confined Space Entry Classification form (Attachment B) and/or the PRCS Permit (Attachment C) for:

1. The pre-entry readings

2. Upon return from breaks of more than 15-minutes, prior to re-entry; and

3. Every 60 minutes during the entry.

(j) Continuous air testing is required for PRCS.

1. The space must be monitored continuously for at least oxygen and combustible gas.

2. Air testing must be periodically repeated for other toxic chemicals when there is an unknown concentration during the work.

3. Workers are required to wear a multi gas meters when inside a PRCS.

(4) Communication.

(a) A suitable means of communication (i.e., radio and/or telephone) between entrants and attendants and another person who can summon emergency responders must be provided.

NOTE: Explosive proof communication equipment shall be used in atmospheres with the potential for explosion e.g., flammable gases or vapors, electrically conductive dusts, etc.

(b) Prior to entry into any confined space, the method of emergency communication must be tested to ensure adequate function. Many locations have poor radio and/or cellular service. In such cases, other methods of emergency communication must be established.

(5) Egress and Locks.

(a) When entered, the access and egress point(s) to the confined space must remain held in an open position

(b) Upon exiting a confined space, the access point(s) must be secured and locked to prevent unauthorized access. At no time can an open access point to a confined space be left unattended.

(6) Equipment. Equipment may be needed to safely enter the confined space and is set up prior to entry into the confined space.

(a) Sources of ventilation shall be fresh air. Ventilation must be used where:

1. There is poor natural ventilation that can create an unsafe atmosphere,

2. The operation will generate a hazardous atmosphere, or

3. A hazardous atmosphere may be present without ventilation.

(b) The use of electrical equipment inside a confined space must be approved by the Program Administrator or designee, and shall be equipped with:

1. A ground fault circuit interrupter power supply, or

2. A low voltage (<50 Volts) supply.

3. Explosion-proof electrical fixtures are required in spaces that may exceed 10% of the LEL.

c. All persons entering a PRCS must wear a retrieval device such as a full body harness with lifeline (retrieval line) attached.

1. The lifeline is to be attached to a lifting device or to a point located outside of the confined space.

2. An attendant must be posted outside the confined space.

3. Alternative procedures must be identified for confined spaces where using a retrieval device may be a greater hazard to the entrant than not wearing a device.

d. Other equipment may be required based on potential hazards including:

(1) Protective clothing such as rain suits, coveralls, gloves, goggles, heat resistant suits, and a respirator appropriate for the job.

1. The use of respirators must comply with the VACHS Respiratory Protection

Program.

(2) Retrieval equipment may include retrieval lifting device, tripod or hoist anchoring device, full body harness, wristlets, fall protection device and lifeline.

(3) Air monitoring equipment including oxygen, combustible gas (% LEL), carbon monoxide, and hydrogen sulfide direct read meters and colorimetric indicator tubes.

(4) Ventilation equipment including blowers and flexible tubing with grounding straps.

(5) Lockout/Tagout devices, chains, locks and tags, electrical disconnect devices.

(6) Barriers, barricades and signs to keep unauthorized personnel away from confined spaces.

(7) PRCS Emergencies and Notifications. Emergencies fall into several types including: those requiring an immediate response, those that require a response, but timing is not critical, and those where the entrant can perform self-rescue.

Note: Prior to entry into a PRCS, the local fire department must be notified by the Entry Supervisor and acknowledged by the fire department. Advise the fire department of the location of the entry, the estimated start and stop time of the entry, a brief description of the work to be conducted, the number of persons entering the space, the nature of the hazards in the space, and a contact person and phone number. Upon completion of work and vacating the PRCS, notify the local fire department that the PRCS entry has been completed.

(a) Self-rescue or extraction by the entrant is the most common removal method from a confined space. If a hazard is detected, the entrant becomes ill, or the attendant identifies a hazard, the entrant is directed to leave the confined space.

(b) For emergencies other than self-rescue:

1. Call 203-933-1616 West Haven Fire Dispatch or Newington Fire Dispatch at

860-883-5014 immediately. 911 can be called too.

a. Provide the nature of the incident and the location of the confined space.

b. Stay on the call until the Dispatch tells you to hang up.

2. Notify VA police after calling Fire Dispatch or 911 has been notified.

a. From a VA telephone, dial the appropriate extension:

(1) West Haven: 4911

(2) Newington: 6911

b. From a cell phone you must call the main VACHS number and request the VA Police from the operator.

(1) VA CT Operator: (203) 932-5711

(8) Post-Entry Procedures. When the job inside any confined space (NPRCS and PRCS) is completed, the responsible supervisor or designee shall ensure that the space is returned to operating condition.

(a) Ensure space is secure. No confined space is to be left unattended without securing/locking access to the space.

(b) Reverse Isolation Methods: Reverse lockout/tag out procedures (closing lines, removing tags, debris is picked up etc.).

(c) Supervisor Verification: For PRCS the responsible Entry Supervisor is to certify the confined space is back in service by signing the entry permit form.

(d) Maintain Permits: All confined space paperwork and permits shall be returned to ESOH, building 15A and maintained in a file by the Program Administrator for review. Permits will be stored for a minimum of one year.

(9) Contractors. Outside contractors who need to enter a PRCS as part of their work at the VACHS must adhere to the OSHA requirements for confined space entry in Construction 29 CFR1926.21(b)(6)(i) and (ii) and General Industry 29CFR1910.146.

(a) Contractor Oversight: The Contracting Officer Representative (COR) or COR designee is responsible for outside contractors' compliance with this policy and permitting requirements.

1. Inform the contractor that the confined space entry involves permit requirements.

2. Inform the contractor of known physical and chemical hazards associated with the confined space to be entered. Issue to the contractor the written Confined Space Survey Form for the space that the contractor will make entry into.

3. Coordinate entry operations with site personnel and with other workers and work crews in the area.

4. Provide a safety data sheet (SDS) for hazardous chemicals known to be in the confined space.

5. Debrief the contractor at the end of the job regarding any hazards confronted or created in the PRCS.

(b) Contractor Responsibility:

1. The contractor must be qualified to perform the work in a confined space.

2. Have a Program for entry into confined spaces.

3. For PRCS, have a trained Confined Space Entry Supervisor, Entrant, and

Attendant and provide the documentation of training to the VACHS COR or COR designee.

4. Provide all required equipment for a safe confined space entry.

5. Have a permit form used for the entry obtained from the COR.

6. For PRCS, establish who the confined space rescue team will be for their employees. Local Fire Department may perform this service; however, it is the responsibility of the contractor to provide verification to VACHS of this agreement.

7. If the Contractor is going into an IDLH environment, a rescue team must be stationed outside the confined space being entered.

8. Provide a copy of the completed Permit to ESOH, Building 15A via the

COR.

(c) Additional Provisions:

1. VACHS will not provide air-testing equipment or retrieval equipment to outside contractors required to use such equipment for confined space entry.

2. VACHS reserves the right to not allow a contractor into a VACHS confined spaces who:

a. Does not have proper equipment;

b. Does not have a permit;

c. Has not provided documentation of being confined space trained; or

d. Is working unsafely in or around a VACHS confined space.

e. Does not have a rescue team agreement for PRCS entry.

(10) Training:

(a) General awareness training is required for all NPRCS Workers conducting

NPRCS operations

1. All employees who may participate in a confined space operation shall be trained. The training will address how to:

a. Review of the OSHA Confined Space standard

b. The VACHS Confined Space Entry Program

c. Definitions applicable to confined spaces

d. Hazards found in confined spaces

e. Identify and locate confined spaces

f. Recognize potential hazards

g. Recognize the effects of confined space hazards

h. Use personal protective equipment

i. Follow evacuation and rescue procedures

(b) Additional training is required for employees conducting permit-required confined space operations:

1. All employees who may participate in a permit-required confined space operation must additionally be trained in permit-confined space duties (i.e. in the roles of authorized entrants, attendants, and entry supervisors). The training will address:

2. Training content by roles:

a. Authorized entrants are employees who have been trained and approved to enter a confined space. These employees must have had training regarding the potential hazards of the confined space, as well as the signs and symptoms of overexposure to any of the hazards. They should be familiar with all equipment, know if the equipment is explosion-proof, and know how to tell when it is properly grounded.

Authorized entrants must know how to communicate with the attendant, especially if a prohibited condition or a hazardous situation arises. Entrants must agree to exit immediately if an order is given to do so or an alarm goes off. Entrants must wear full -body harnesses with retrieval lines attached to the center of their backs or above their heads or wristlets if full-body harnesses are shown to be infeasible.

b. Authorized attendants must be able to monitor situations inside and outside confined spaces so they can order entrants to evacuate a space if a dangerous situation arises in either place. Attendants must be well aware of the hazards of the confined space and also aware of the physical and behavioral effects of hazard exposure so that they would notice the effects in any of the entrants. If an emergency situation arises in the confined space, the attendant is the person responsible for summoning emergency services and performing whatever rescue operation he or she has been trained and equipped to perform. Another responsibility is keeping all unauthorized entrants out of the confined space. Under no circumstances is an attendant permitted to leave the space until replaced by another attendant or all entrants have come out of the space.

c. Entry supervisors must know the hazards of confined spaces and the signs and symptoms of overexposure to those hazards. They must verify that permits are filled in, the appropriate testing and procedures have been completed, and all equipment is in place. The supervisor is the person responsible for knowing when and under what conditions to cancel a permit and terminate the work. Supervisors must also remove unauthorized persons. Finally, they are responsible for making sure rescue services are available and the means for calling them are operable. Trained on how to use air monitoring equipment and air sampling.

d. Rescue training is not applicable to VACHS workers, since the policy is to use West Haven/New Haven or Newington Fire Department for rescue services.

(c) Retraining: Will be provided every year or more frequently for Entrants, Attendants, and Entry Supervisors and when:

1. There is a change in Permit Required Confined Space operations that present a new hazard; or

2. There is reason to believe that there are deviations to or inadequacies with the permit system or procedures.

(11) Annual Program Review:

An annual program review will be conducted by the Program Administrator. The review will cover all entries during the previous 12-month period. Based upon the findings, the Confined Space Entry Program will be updated or revised, if necessary.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Program Administrator.

(1) The Chief, Environmental Safety and Occupational Health Service, shall be the Program Administrator.

(2) Oversees the Confined Space Procedures to ensure that they are being properly applied at VACHS. They can designee other employees to assist in program implementation.

(3) Ensures that employees supervising, entering or attending a confined space are properly trained on safe confined space entry procedures.

(4) Ensures that Rescue Services have agreed to provide support to the VACHS and have an opportunity to conduct rescue training at VACHS.

(5) Ensures that an air monitor calibration log is maintained.

(6) Maintains a copy of all confined space survey, classification, and permit forms.

(7) Maintains training documentation for general awareness, entry supervisors, attendants, and entrants.

(8) Provides oversight of contractor’s confined space programs and procedures.

b. Entry Supervisor (See Section M for training requirement).

(1) Ensures that the Confined Space Entry Classification and/or Permit is properly completed and signs the Classification (NPRS or PRCS) and/or Permit form to authorize work.

(2) Receives Entry Supervisor appropriate confined space training to understand and identify the hazards of the confined space being entered.

c. Entrant (See Section M for training requirement): (Applicable only to PRCS).

(1) Receives Entrant appropriate confined space training to understand and identify the hazards of the confined space being entered.

(2) Recognizes the hazards in the confined space being entered and leaves the confined space, if a new hazard is identified, is created, or the attendant directs the entrant to leave.

(3) Follows the requirements of the permit.

d. Attendant (See section M for training requirement): (Applicable only to

PRCS).

(1) Receives Attendant appropriate confined space training to understand and identify the hazards of the confined space being entered.

(2) Recognizes hazards within and near the confined space and directs the entrant to leave the confined space if a new hazard is identified.

(3) Directs the entrant to leave the confined space if the entrant is not responding to communication or appears to be having a difficulty in the confined space.

(4) Calls the emergency rescue service and the VACHS Police Department if an entrant has an emergency where medical assistance or rescue is needed.

(5) After calling for emergency services, will attempt to retrieve the entrant from outside the confined space. The attendant is to NEVER ENTER a confined space to try to rescue a worker.

4. DEFINITIONS

a. [Definition 1]. Attendant. means a trained individual stationed outside one or more Permit Required Confined Space(s) who monitors the authorized entrants and who performs all attendant's duties assigned in the employer's Permit Required Confined Space (PRCS) program.

b. [Definition 2]. “Authorized entrant. means an employee who is authorized by the employer to enter a PRCS.

(1) Has a valid need to enter a confined space

(2) Has been trained as required by this procedure;

(3) Has been briefed on the hazards of the confined space and is properly protected from all such hazards by the use of engineering controls or personal protective equipment.

c. [Definition 3]. Blanking or blinding. means the absolute closure of a pipe, line, or duct by the fastening of a solid plate (such as a spectacle blind or a skillet blind) that completely covers the bore and that is capable of withstanding the maximum pressure of the pipe, line, or duct with no leakage beyond the plate.

d. [Definition 4]. Confined space. means a space that:

(1) Is large enough and so configured that an employee can bodily enter and perform assigned work; and

(2) Has limited or restricted means for entry or exit (for example, tanks, vessels, silos, storage bins, hoppers, vaults, and pits are spaces that may have limited means of entry.); and

(3) Is not designed for continuous employee occupancy.

e. [Definition 5]. Double block and bleed. means the closure of a line, duct, or pipe by closing and locking or tagging two in-line valves and by opening and locking or tagging a drain or vent valve in the line between the two closed valves.

f. [Definition 6]. Emergency. means any occurrence (including any failure of hazard control or monitoring equipment) or event internal or external to the PRCS that could endanger entrants.

g. [Definition 7]. Engulfment. means the surrounding and effective capture of a person by a liquid or finely divided (flowable) solid substance that can be aspirated to cause death by filling or plugging the respiratory system or that can exert enough force on the body to cause death by strangulation, constriction, or crushing.

h. [Definition 8]. Entry. means the action by which a person passes through an opening into a PRCS. Entry includes ensuing work activities in that space and is considered to have occurred as soon as any part of the entrant's body breaks the plane of an opening into the space.

i. [Definition 9]. Entry supervisor. means the person (such as the employer, foreman, or crew chief) responsible for determining if acceptable entry conditions are present at a PRCS where entry is planned, and for authorizing entry and overseeing entry operations for terminating entry, and for reclassification of a PRCS to a Non- Permit Required Confined Space (NPRCS).

j. [Definition 10]. Hazardous atmosphere. means an atmosphere that may expose employees to the risk of death, incapacitation, impairment of ability to self-rescue (that is, escape unaided from a PRCS, injury, or acute illness from one or more of the following causes:

(1) Flammable gas, vapor, or mist in excess of 10 percent of its lower explosive limit

(LEL);

(2) Airborne combustible dust at a concentration that meets or exceeds its LEL;

NOTE: This concentration may be approximated as a condition in which the dust obscures vision at a distance of 5 feet (1.52 m) or less.

(3) Atmospheric oxygen concentration below 19.5 percent or above 23.5 percent;

(4) Atmospheric concentration of any substance for which a dose or a permissible exposure limit is published in Subpart G, Occupational Health and Environmental Control, or in Subpart Z, Toxic and Hazardous Substances, of CFR 1910 and which could result in employee exposure in excess of its dose or permissible exposure limit;

(5) Any other atmospheric condition that is immediately dangerous to life or health (IDLH). NOTE: For air contaminants for which OSHA has not determined a dose or permissible exposure limit, other sources of information, such as Safety Data Sheets (SDS) that comply with the Hazard Communication Standard, section CFR 1910.1200, published information, and internal documents can provide guidance in establishing acceptable atmospheric conditions.

k. [Definition 11]. Hot work permit. means the VACHS written authorization to perform operations (for example, brazing, riveting, welding, cutting, burning, and heating) capable of providing a source of ignition. Hot work performed in a confined space requires a permit for both hot work and confined space entry.

NOTE: If space was reclassified from a PRCS to a NPRCS prior to the introduction of hot work, the space must be reclassified by the Entry Supervisor through the Confined Space Entry Classification process

l. [Definition 12]. Immediately dangerous to life or health (IDLH). means any condition that poses an immediate or delayed threat to life or that would cause irreversible adverse health effects or that would interfere with an individual's ability to escape unaided from a PRCS.

m. [Definition 13]. Inerting. means the displacement of the atmosphere in a PRCS by a noncombustible gas (such as nitrogen) to such an extent that the resulting atmosphere is noncombustible.

NOTE: This procedure produces an IDLH oxygen-deficient atmosphere.

n. [Definition 14]. Isolation. means the process by which a PRCS is removed from service and completely protected against the release of energy and material into the space by such means as: blanking or blinding; misaligning or removing sections of lines, pipes, or ducts; a double block and bleed system; lockout or tagout of all sources of energy; or blocking or disconnecting all mechanical linkages.

o. [Definition 15]. Non-permit confined space. (NPRCS) means a confined space that does not contain or, with respect to atmospheric hazards, have the potential to contain any hazard capable of causing death or serious physical harm.

p. [Definition 16]. Oxygen deficient atmosphere. means an atmosphere containing less than 19.5 percent oxygen by volume.

q. [Definition 17]. Oxygen enriched atmosphere. means an atmosphere containing more than 23.5 percent oxygen by volume.

r. [Definition 18]. Permit required confined space (PRCS). means a confined space that has one or more of the following characteristics:

(1) Contains or has a potential to contain a hazardous atmosphere; or

(2) Contains a material that has the potential for engulfing an entrant; or

(3) Has an internal configuration such that an entrant could be trapped or asphyxiated by inwardly converging walls or by a floor which slopes downward and tapers to a smaller cross-section; or

(4) Contains any other recognized serious safety or health hazard.

s. [Definition 19]. Permit. The written document, which must be properly completed prior to any PRCS entry; and must be made available or posted at or near the confined space entrance in use. When the Permit is completed, a PRCS entry is in effect and all appropriate precautions must be taken.

t. [Definition 20]. Prohibited condition. means any condition in a PRCS that is not allowed by the permit during the period when entry is authorized.

u. [Definition 21]. Rescue service. means the personnel designated to rescue entrants from PRCS.

v. [Definition 22]. Retrieval system. means the equipment (including a retrieval line, chest or full-body harness, wristlets, if appropriate, and a lifting device or anchor) used for non-entry rescue of persons from PRCS.

w. [Definition 23]. Testing. means the process by which the hazards that may confront entrants of a PRCS are identified and evaluated. Testing includes specifying the tests that are to be performed in the PRCS.

NOTE: Testing enables employers both to devise and implement adequate control measures for the protection of authorized entrants and to determine if acceptable entry conditions are present immediately prior to, and during, entry

5. REFERENCES

a. OSHA 1910.146, OSHA 1926.21(b)(6)(i) and (ii)

b. The National Institute for Occupational Safety and Health (NIOSH), “Chemical Listing and Documentation of Revised IDLH Values”.

6. REVIEW

At recertification, and when there are changes to the governing document.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of July 2026.

In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

John Callahan Deputy Director Date: July 7, 2021

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: MC SOPs are available at:

https://dvagov.sharepoint.com/sites/VHACONQMS/Policy%20Management/Policies/Form s/Active.aspx

Attachments A-C

Attachment A to MC SOP SO-010

Confined Space Survey Form Confined Space Identity: ###

Date of Survey: Permit Required: Yes No Location of Space:

Description of Space:

Possible Atmospheric Hazards: Oxygen deficiency Enrichment Flammable Toxic Comments:

Possible Content Hazards: Previous contents Content fill or removal Shifting contents Fluid levels Dust https://dvagov.sharepoint.com/sites/VHACONQMS/Policy%20Management/Policies/Forms/Active.aspx

Potential Energy: Electrical Hydraulic Pneumatic Mechanical Fire Control

Environment in the Space:

Slippery surfaces Ambient temperature high or low Surface temperatures high or low Noise Comments:

Configuration of Space:

Interior shape & slope Low overhead clearance Drop offs Complex layout Structural integrity

External Hazards: Traffic Machinery Equipment Processes Terrain

Other Hazards: Animals Insects Biological organisms Non ionizing radiation ionizing radiation

Confined Space Permit Required Confined Space (PRCS) Can be bodily entered? Yes No Hazardous

Atmosphere?

Yes No

Limited or restricted entry? Yes No Potential for Engulfment?

Yes No

Not designed for continuous human occupancy

Yes No Internal configuration hazard?

Yes No

Other serious safety hazard?

Yes No

Reasons for entering space & typical activities:

Who usually enters space? Maintenance Production Contractors Other Frequency of entry? Number of entry points?

Eligible for alternate procedure Yes No Eligible for reclassification?

Yes No

External connections to space?

Comments:

Surveyed by: Reviewed by: Date Reviewed:

Note: Attach photos of entry point(s)

Attachment B to MC SOP SO-010

CONFINED SPACE ENTRY CLASSIFICATION Entry/Permit #:__________ Space ID: ______________ Space Name: ____________________

HAZARDS (Based on the “Confined Space Survey Form” and current condition of the confined space, list all hazards applicable and means that the hazard was eliminated)

Hazard Yes No Hazard Elimination Method (circle and explain as needed)) Atmospheric Lockout/Tagout

Ventilate Purge Other, explain.

Engulfment e.g., water, chemical, fluids, dry bulk material

Lockout/Tagout Drain Empty Contents Other, explain:

Configuration (May Cause Entrapment) e.g., inwardly converging walls, floors that slop downward and/or tapers to a smaller cross section

Staging/Scaffolding Temporary Flooring Fall Protection Other, explain:

Other Serious Safety or Health Hazard e.g. hot work, painting, fall hazards, heat/cold stress, chemical, noise, trip hazards, unguarded equipment, hazardous energy (electrical), hazardous energy (mechanical, pressure, pneumatic/hydraulic)

Lockout/Tagout Fall Protections Purge Ventilate Depressurize Drain Vent Temporary Flooring Wash/Rinse Other, explain:

Atmospheric Monitoring Data

Constituents Permissible Entry Levels Monitoring Results Oxygen 19.5%-23.5% Lower Explosive Limit (<10% LEL Carbon Monoxide (<35PPM) Hydrogen Sulfide (<10PPM) Other, if applicable: <25% of occupational exposure limit

Monitoring Performed By:_______________ Date and Time: ____________________

NOTE: If hazards cannot be eliminated, space shall be entered utilizing PRCS Entry .

FINAL CLASSIFICATION OF SPACE FOR THIS ENTRY (Check box):

Non-Permit Required Confined Space (VA workers can enter)

Permit Required Confined Space (VA workers cannot enter, and a Permit must be completed (Attachment C)

Entry Supervisor Signature: _____________________ Date: ___________________

FMS Chief or designee Signature: _______________ Date: ___________________

Safety Chief or designee Signature: _______________ Date: ___________________

Attachment C to MC SOP SO-010 Entry/Permit #:__________

CONFINED SPACE ENTRY PERMIT

1. Conf ined Space ID No:

2. Location:

3. Description of Space:

4. Purpose of Entry:

5. Entry Date: 6. Authorized Duration:

7. Authorized Entrant(s) (Print name)

8. Authorized Attendant(s) (Print name)

9. Authorized Entry Supervisor (Print name)

Types of Hazards Hazards of Confined Space Yes No Measures to Isolate Hazards Yes No

Carbon Monoxide Hot Work Permit

Combustible Dust Lines broken, capped, or blanked Combustible Gas/Vapor Lockout/Tagout

Electrical Purge-Flush and Vent Engulfment Secure Area-Post and Flag

Entrapment Traf f ic Control Hydrogen Sulf ide Ventilation

Mechanical Other:

Oxygen Def icient Special Equipment Oxygen Enriched Breathing Apparatus-Respirator

Skin-chemical Escape Harness Slips, Trips, and Falls Explosion proof (Lighting)

Steam Explosion proof (Tools) Temperature Extreme (Hot / Cold) Fire Extinguisher

Toxic Fumes Lifelines Toxic Gas/Vapors Lighting

Toxic Fumes PPE: Goggles, Gloves, Clothing

Toxic Gas/Vapors Tripod, Hoist, Barriers Other: Other:

Communication System With Entrants: Radio Channel #: Verbal Phone #:

With Rescue Team Radio Channel #: Verbal Phone #:

Other: Radio Channel #: Verbal Phone #:

Rescue / Emergency Services Agency notif ied: Phone #: Name of contact notif ied: Time notif ied:

West Haven Fire Dept. 203-733-

Newington Fire Dept. 860-883-

Other

VA Police Notified West Haven 4911 Dispatch (Name): Time notif ied:

Newington 6911 Dispatch (Name): Time notif ied:

Attachment C to MC SOP SO-010 Cont.

Air Monitoring Equipment

#1 #2 #3

Instrument

Manufacturer

Model No.

Serial No.

Calibration Date:

Calibrated By:

This form shall be posted at the site until cancelled by the Entry Supervisor

Atmospheric Testing Confined Space work is not authorized when levels exceed the stated acceptable limits

Sample Time

Oxygen (O2)

19.5 % - 23.5

Flammability Less than 10%

LEL

Carbon Monoxide

(CO)

Less than 35 ppm

Hydrogen Sulf ide (H2S) Less than 10 ppm

Other (if Applicable)

Permit Authorization Entry Supervisor Name: (Print)

Signature Date: Time:

FMS Chief or Designee: (Print)

Safety Chief or Designee: (Print)

Permit Cancellation/Completion (Signed by Entry Supervisor) Name: (Print)

CONTROL OF HAZARDOUS ENERGY LOCKOUT/TAGOUT PROGRAM

MCP 138-075

VA Connecticut Healthcare System West Haven, CT 06516

Signatory Authority:

VA Connecticut Healthcare System Director

Responsible Owner:

Facility Management Service

Rescinded Document:

MCP 138-075, Control of Hazardous

Energy Lockout/Tagout Program, dated September 10, 2020

Effective Date:

January 9, 2023

Revised Date: March 31, 2023

Recertification Date:

January 9, 2028

1. POLICY

It is VA Connecticut Healthcare System’s (VACHS) policy to protect all employees from injuries caused by unexpected energizing or start-up of machines or equipment, or release of stored energy during service, repair, maintenance, operation, adjustment, removal and associated activities.

2. JUSTIFICATION

U.S. Department of Labor, OSHA regulations, 29 CFR 1910.147, "Control of hazardous energy sources (lockout/tagout)" standard: U.S. Department of Labor, OSHA regulations, 29 CFR 1910.145, "Specifications for Accident Prevention Signs and Tags" standard.

U.S. Department of Labor, OSHA regulations, 29 CFR 1910.269, 1910.333, 1910.417, 1910.702.

ANSI Z 244.1-2003 “Control of Hazardous Energy - Lockout/Tagout and Alternative Methods”

ANSI Z 535 “Safety alerting standards”

VHA Directive 1028, “Facility Electrical Power Systems”, February 24, 2020

NFPA 70E “Electrical Safety in Workplace” current Edition

3. RESPONSIBILITIES

a. Director. All VACHS employees must take ownership of our Safety Culture.

Everybody should report hazards to their supervisors or appropriate staff, keep each other safe, attentively attend training sessions, and comply with safety procedures and policies established in our Safety System.

January 9, 2023 MCP 138-075

To set this expectation with regard to LOTO, the Director of the VA Connecticut Healthcare System will:

(1) Ensure all Service Chiefs understand this Policy and effectively lead their respective Services to maintain the highest quality health care environment and a safe workplace.

(2) Ensure the Medical Center’s Safety Service receives the training, education, and resources to meet their responsibilities within this Policy.

(3) Ensure resources are available to each Service to maintain compliance with this Policy.

(4) Consult the Chief of Safety for questions, concerns and assistance related to this Policy.

b. Chief of Environmental Safety & Occupational Health Service. The Safety Chief is responsible for:

(1) Maintaining a base of OSH subject matter expertise by leading, managing, and training/educating the Safety Service staff.

(2) Providing advice, assistance, coordination, oversight for Supervisors and Service Chiefs to ensure they understand their responsibilities under this Policy and maintain a compliant and effective safety culture.

(3) Certifying and submitting Lockout/Tagout Permits (Attachment A). Certifying means that Safety Service SME has reviewed the information on the LOTO permit, noting any discrepancies, and ensuring discrepancies and other unaddressed hazards are communicated to the requesting authorized employee with instructions to correct the hazards and discrepancies before work begins.

(4) Reviewing new or edited LOTO procedures to ensure compliance with this Policy.

(5) Providing oversight and guidance to a supervisor if a LOTO padlock needs to be cut.

(6) Providing advice and guidance for procedures in which multiple authorized employees will work on the same piece of equipment concurrently. Note: this can be a confusing evolution especially on complex machines so extra oversight and subject matter expertise should be available and provided when needed.

January 9, 2023 MCP 138-075

(7) Ensuring planned and potential Lockout scenarios during construction are identified through the Pre-Construction Risk Assessment (PCRA) and the contractor’s Accident Prevention Plan (APP).

(8) Ensuring the VA’s Contracting Officer’s Representatives are made aware of Lockout scenarios identified in the PCRA and APP and required LOTO Permit process.

(9) Ensuring Service Chiefs, Supervisors, Employees and Hospital Education are aware of employee training requirements for lockout/tagout

(10) Providing a professional review of all newly written LOTO procedures to ensure the procedure meets the regulatory requirements.

(11) Reviewing and signing the LOTO permit when required by the Medical Center Leadership, a Service Chief, or Supervisor. The signature will indicate that a competent Safety professional reviewed the permit for errors or deficiencies and communicated any hazards which they are aware of and have not been identified on the permit.

(12) Conducting periodic evaluations of work sites to check for compliance with lockout/tagout procedures.

(13) Periodically reviews this policy to ensure compliance with applicable regulations, directives, and standards.

(14) Providing awareness of risks to the appropriate level of management or leadership.

(15) Immediately stopping work if an imminent risk of severe injury or damage to government property is identified.

c. Chief, Facilities Management Service. The FMS Chief is responsible for:

(1) Administering and managing the VACT LOTO program. While LOTO is used by other service lines, one service line must “own” the program to facilitate standardization and therefore the program’s effectiveness.

(2) Consulting the Chief of Safety for questions, concerns and assistance related to LOTO.

(3) Coordinating with other Service Line Chiefs to ensure the program addresses their specific requirements.

(4) Setting the LOTO program standards for VACT and maintaining an effective and current policy and/or standard operating procedure.

January 9, 2023 MCP 138-075

(5) Maintain and provide required LOTO training to all VACT employees who have any rolls within the LOTO program.

(6) Providing standardized Lockout devices and padlocks to all service lines which participate in the LOTO program. Note: specialized lockout devices and locks which are required by a service line to maintain unique equipment will be purchased and maintained by the individual service lines, in which case the specialized devices must meet the general VACT lockout device color schemes.

(7) Communicating requirements to the Supervisors when the Safety Office is required to certify a LOTO Permit and when a Lockout Supervisor is required based on risks involved with the proposed work.

(8) Providing approval or denial of a LOTO Permit for high-risk maintenance and servicing tasks such as Locking out a boiler, steam line, AC electrical power sources over 480 volts, Tagout, or any work in a permit required confined space.

d. Service Chiefs. The Service Chiefs are responsible for:

(1) Coordinating with the FMS Service Line to ensure any work by their employees requiring Lockout meets the requirements of this Policy.

(2) Ensuring all Service Line supervisors understand their responsibilities for maintaining the highest quality health care environment and a safe workplace.

(3) Maintaining professional awareness of their respective services’ responsibilities within this Policy.

(4) Conducting periodic review of service-specific safety training with each of their supervisors.

(5) Periodically check their employee’s work practices and completed tasks for expected levels of compliance and workmanship. Communicate these observations with appropriate staff to correct deficiencies and recognize high quality work.

(6) Consulting the Chief of Safety for questions, concerns and assistance related to

LOTO.

(7) Ensuring resources are properly managed to meet their Service’s training, education, and resource requirements.

(8) Ensuring that employees do not perform service or maintenance activities on any energized systems.

January 9, 2023 MCP 138-075

- Should there be a compelling reason to conduct work on energized systems, that work plan requires the written approval of the Medical Center Director.

- AN ENERGIZED ELECTRICAL WORK PERMIT in Attachment D must be completed and approved by the Medical Center Director.

e. Supervisor. The Supervisor (or Acting Supervisor) is responsible for:

(1) Ensuring all employees under their supervision understand and comply with this policy and maintain a safe workplace.

(2) Consulting the Chief of Safety for questions, concerns and assistance related to LOTO.

(3) Maintaining current and proficient working knowledge of their employees’ responsibilities under this policy.

(4) Providing, tracking completion of, and maintaining records for required training, evaluations, and proficiencies of each of their employees.

(5) Ensuring that only trained and designated “Authorized” employees conduct servicing and maintenance activities on equipment and that such work activities are performed in accordance with this policy.

(6) Ensuring that only trained authorized employees and affected employees are allowed to approach any equipment and equipment controls which are Locked out.

(7) Prohibiting work on any energized systems. Should there be a compelling reason to conduct work on energized systems, the Supervisor shall ensure an Energized Electrical Work Permit (Attachment D) is approved by the Medical Center Director prior to commencing work.

(8) Ensuring annual inspections/audits of energy control procedure(s) are performed within 364 days prior to their employees work on the equipment.

(9) Ensuring all authorized employees are provided access to valid copies of the written lockout/tagout procedure(s), properly trained on the lockout/tagout procedure for that equipment, and are issued appropriate locks, ID tags, and lockout devices.

(10) Assigning a LOTO Supervisor when directed by the FMS Chief or when necessary, based on the risks involved with the proposed work.

(11) Assessing an employee’s knowledge and abilities if that employee demonstrated a lack of knowledge of LOTO requirements or did not perform LOTO in accordance with requirements. The supervisor will determine is the

January 9, 2023 MCP 138-075 employee needs on-the-spot refresher training or attend a thorough training course.

(12) Providing employees with all required LOTO devices and protective equipment. This includes providing proper storage, maintenance, disposal, and replacement.

(13) Ensuring resources are requested to meet their employees’ training, education, and equipment requirements.

(14) Cutting a LOTO lock and device attaches to a piece of equipment. This requires:

(a) Urgent need to use the equipment,

(b) The authorized employee who attached the lock will not be at the worksite before the equipment use is required.

(c) The supervisor reviewed all existing documentation relating to the attached lock, ensured the LOTO procedure was completed up to the point where the equipment is safe to work on, there were no changes to the procedure or equipment since the lock was attached, and reenergization of the equipment will not create further hazards.

(15) Ensuring contractors and VA staff counterparts coordinate the requirements of each of their LOTO programs and procedures.

(16) Providing approval or denial of a LOTO Permit for routine maintenance and servicing tasks.

f. Employee. The Employee is responsible for:

(1) Complying with all standard operating procedures and LOTO requirements.

(2) Informing supervisors of identified hazards or deficiencies.

(3) Maintaining professional competency with applicable requirements of this policy

(4) Working on energized systems only after the Director has authorized the work on a completed Energized Electrical Work Permit.

(5) Safely stopping all work, establishing a time-out and notifying the supervisor if a defect in the written isolation procedure is identified.

(6) Never attempting to start, energize, or use Locked out machines or equipment.

January 9, 2023 MCP 138-075

(7) Safely stopping all work, establishing a time-out and notifying the supervisor if they observe another employee or a contractor doing LOTO improperly.

g. Contracting Officer’s Representative (COR). CORs are responsible for:

(1) Actively engaging in a Pre-Construction Risk Analysis (PCRA) and reading the contractor’s Accident Prevention Plan to determine possible LOTO requirements during the project.

(2) Ensuring LOTO program coordination and requirements are part of a contract when a contractor may need to use Lockout procedures. In the event that this is not specified in the contract, the COR must ensure that LOTO program coordination and requirements occur per 29 CFR 1910.147, this Policy, and other mandatory standards specific to the contract tasks

(3) Ensuring the Contractor’s site manager understands the Medical Center’s LOTO policy and ensures compliance with the most restrictive elements from each policy.

(4) Coordinate the LOTO process with the contractor as delineated in the Attachments.

(5) Stop the contractor’s work if they do not meet compliance with this Policy or any other LOTO requirements. The COR should contact the Safety Service if they have questions or need a SME at the worksite to verify non-compliance.

4. OTHER PARAGRAPHS

a. Scope. This policy:

(1) defines a program to maintain compliance with required regulations, codes and standards, the primary of which is 29 CFR 1910.147, The Control of Hazardous Energy. However, several other sections of 29 CFR 1910 and 1926 apply as well as NFPA codes and standards, ANSI/ASSE standards, VA directives, and equipment manufacturers’ directions and instructions.