MCP 00-190 Control of Hazardous Energy Program.pdf

This is a Medical Center Policy (MCP 190) establishing a Control of Hazardous Energy (Lockout/Tagout) Program for the VA Western New York Healthcare System in Buffalo, New York. The policy became effective September 10, 2024, with recertification scheduled for September 1, 2029.

The policy establishes mandatory energy control procedures for all VAWNYHS personnel, employees, contractors, subcontractors, and vendors who construct, service, or maintain building utility systems and machines where unexpected energization or energy release could cause injury. The program covers all hazardous energy types including electrical, mechanical, pneumatic, hydraulic, chemical, and thermal energy. The policy requires appropriate lockout devices on energy isolating devices and prohibits substitution with tagout procedures alone. Two primary procedures are defined: Simple Lockout for single energy sources with single isolation devices not exceeding 600V, performed only by qualified and authorized employees; and Complex Lockout for multiple energy sources, crews, crafts, locations, employers, disconnecting means, or sequences, requiring documented procedures and controlling agents. The policy mandates energy control procedure development, employee training completion within 45 days of program establishment with annual retraining, and periodic inspections at minimum annually. All employees across classifications must comply, with specific role-based responsibilities assigned to the Medical Facility Director, Chief of Engineering, shop supervisors, Qualified Employees, Authorized Employees, Affected Employees, Controlling Agents, and contractors. The policy references OSHA regulations (29 CFR 1910.147), NFPA 70E electrical safety standards, and VHA directives, and includes detailed definitions, training requirements, hot tap operation exclusions for specific low-pressure systems, and procedures for forcible lockout/tagout removal with documented notification.