Loch Raven Boiler Plant Standard Operating Procedure-.pdf

LOCH RAVEN BOILER PLANT STANDARD OPERATING PROCEDURE

SOP 138 ENG-022

VA Maryland Health Care System (VAMHCS) Service Lines:

Baltimore MD, 21201 Facilities & Engineering Service

(FES)

Signature Authority: Effective Date:

Chief, Facilities & Engineering Service January 13, 2023

Responsible Owner: Recertification Date:

Chief, Facilities & Engineering Service January 31, 2028

1. PURPOSE & AUTHORITY

To define local procedure for the safe, reliable, and efficient operation and maintenance of the boiler plant to produce hot water for the medical facility(s) by VHA boiler personnel. Heating Hot Water is critical to Loch Raven Veterans Affairs Medical Center (VAMC) facilities and supports numerous Heating, Ventilation, and Air Conditioning (HVAC) systems. To ensure compliance with VHA Directive 1810(1) Boiler and Boiler Plant Operations at Loch Raven VAMC.

2. PROCEDURES

a. Local Policies and Procedures

This procedure, associated procedures, and documentation forms, etc. will be reviewed annually to ensure accuracy and compliance with the latest VHA Boiler Plant Directive. The date of this procedure shall not exceed five (5) years. If any changes are made to this procedure, the updated procedure shall be shared with all appropriate personnel and supervisors.

b. Safe Boiler Operation

(1) All Utility Systems Repairer-Operator (USRO) personnel and persons entering the boiler plant must be aware of the scope and magnitude of the potential danger of working with boiler equipment. All policies, procedures, actions, documentation, and employees will execute their functions with the understanding that safety is the first priority. At no point shall safety be compromised to maintain hot water service. The following safety actions must be adhered to:

(a) Management will ensure proper tools and personal protective equipment (PPE) are available and appropriate training is provided.

(b) USROs will utilize proper tools and PPE when executing assigned duties.

(c) If a boiler maintenance/repair activity requires equipment to be locked and tagged out, USRO personnel will execute the appropriate lock-out tag-out (LOTO) policy and procedure before performing any work.

(d) At no point will any boiler or ancillary device be operated with a failed safety device unless an approved Interim Safety Measure (ISM) is in place.

(e) The boiler plant contains dangerous chemicals. No chemicals will be handled by USRO personnel unless they have been formally and sufficiently trained.

January 13, 2023 SOP 138/ENG-022

(f) Boiler plants are hot environments with many hot surfaces. USROs will exercise caution when working near boiler plant equipment and will wear appropriate PPE.

(g) Proper lifting technique will be adhered to.

(h) Operators will follow proper fall protection protocol.

(i) USROs are required to always assume electrical circuits are live. No electrical circuit or panel of any voltage will be accessed by USRO personnel without proper PPE or National Fire Protection Association (NFPA) 70E training.

(j) USROs will obtain a hot work permit before performing any hot work.

(k) A confined space entry permit, procedure, and proper training are required to enter a confined space. Confined Space Program, MCP 512-001/OPS-S-008.

(l) This safety procedure is not all encompassing. USRO will follow any additional safety measures deemed appropriate by the USRO supervisor.

(m) USRO will report any situation or occurrence that could possibly compromise safety.

c. Boiler Plant Security

(1) All boiler plant entrance doors will always remain locked. Access will be controlled via keyed access. Any personnel wishing to obtain keyed access may be granted access only with USRO supervisor approval. Any unauthorized personnel wishing to enter the boiler plant must gain access via the on duty USRO or higher management.

(2) Unrestricted access to the utility systems (boiler) plant is limited to the following personnel:

(a) Loch Raven VAMC USRO Supervisors.

(b) Loch Raven VAMC USROs.

(c) Baltimore / Loch Raven VAMC Facility & Engineering Services / Supervisors.

(d) VA Police.

d. Interaction with Office of Healthcare Engineering (OHE)

(1) Per VHA Boiler Plant Directive, only OHE possesses the authority to interpret the contents of the VHA Boiler Plant Directive. OHE alone can issue waiver or exception to any Boiler Plant Directive requirement. When atypical conditions exist, the Medical Center Director must request authorization from OHE to deviate from any Boiler Plant Directive requirement if warranted. As defined previously, it is also the responsibility of the Medical Center Director or designee to notify OHE when required by Directive 1810(1) or this procedure.

(2) OHE will be notified given the following:

(a) There are plans for the installation of new or replacement of high-pressure boilers, hot water generators, installation of new fuel burning equipment on existing boilers, or re-tubing 30 percent or more of a single boiler. Sufficient (determined by OHE) technical and operational information must be provided to OHE for plan evaluation and to obtain approval to proceed with design development. For approved plans, design development documents must be submitted for review by OHE and Office of Construction and Facilities Management (OCFM) at the 30, 60, and 100 percent design stages.

(b) There are plans for changes in equipment sizing, implementation of new technologies, and/or decentralization (partial or total). These events must be evaluated and approved prior to completion of concept development as well as at 30, 60, and 100 percent design stages.

(c) Performance of reviews include, but are not limited to:

1. Non-steam producing fluid filled (e.g.) boilers.

2. Low mass boilers.

3. Combined Heat and Power (CHP) Plants of any type or energy output capacity.

4. Biomass plants of any type or energy output capacity.

5. Any steam generating or boosting equipment that operates in excess of 15 pounds per square inch gauge (PSIG). This includes equipment that uses alternative heating fluid, such as oil or other fluid.

6. Proposed decentralization of steam systems, process hot water systems, or domestic hot water systems. The proposed actions shall be reviewed for compliance to VA requirements and long-term sustainability and viability. If the requirements of these systems are not defined in other VA documents, the VA medical facility shall request clarification and guidance from OHE.

7. Any upgrades or replacement of boiler controls and safety systems.

8. Within 12 hours of any of the occurrences identified below, notification must be made to

OHE. A thorough investigation by the Veterans Integrated Services Network (VISN) and VA medical facility, including root cause analysis, must be performed, with a written report submitted to OHE within 30 days of occurrence.

a) A rupture or explosion of a boiler or pressure vessel.

b) A furnace explosion or extensive damage from overheating.

c) When boilers and equipment required to meet the VA medical facility redundancy requirements for the supply of the maximum steam demand, exclusive of load shedding, are out of service for more than 24 hours for maintenance or repairs, the N+1 requirement is compromised (N+1 requirement refers to the requirement for the availability and functionality of a redundant system or equipment).

d) Repeated maintenance issues with boilers, safeties, or ancillary equipment.

e) The acquisition and operation of rental boilers to meet any part of the N+1 requirement.

f) Any other unusual occurrence or activity.

(d) OHE will be notified in a documentable manner and be provided all pertinent information so that proper evaluation and guidance can be provided. Boiler plant personnel will notify Engineering in an appropriate documentable manner when any applicable condition occurs. The Chief Engineer will assemble all pertinent information and notify the Medical Center Director or designee of any applicable condition. Per VHA Boiler Plant Directive, following the notification, a thorough investigation, including root cause analysis and risk evaluation, will be performed by Loch Raven personnel as soon as possible.

A copy of the report will be provided to OHE within thirty 30- calendar days from the date of the incident or occurrence.

(e) Required Documentation for Interaction with OHE:

1. Documentation of communication with OHE (Email record).

2. Waiver / Deviation Request Forms.

3. OHE issued Guidance.

4. OHE issued Waivers / Deviations.

5. Any analysis, risk evaluation, and investigation reports generated.

e. National Boiler Plant Quarterly Compliance Survey

(1) VHA Boiler Plant Directive compliance will be assessed and reported quarterly via the National Boiler Plant Quarterly Compliance Survey. Reporting will be accomplished through the web-based survey reporting tool found at the Office of Healthcare Engineering VA intranet site. The survey must be submitted no later than two weeks after the start of each fiscal quarter. The Quarterly Compliance Survey requires answers that reflect the status of the facilities compliance with the VHA Boiler Plant Directive 1810(1). Follow the procedure given in appendix L to complete and submit the survey. If the answer to any question on the survey is no, then an action plan and/or Interim Safety Measure, appendix A, must be in place. The Chief Engineer will verify the accuracy of the Quarterly Compliance Survey before certification. The Medical Center Director must also certify the survey prior to submission to OHE.

(a) Required Documentation for National Quarterly Compliance Survey:

1. Past Certified Quarterly Compliance Surveys.

2. Certification Memos.

f. Testing of Safety Devices

(1) All safety devices on boiler equipment or installed as part of the fuel systems and hot water distribution systems, must be tested in accordance with the VHA Boiler Plant Safety Device Testing Manual “Current Edition” or it’s site-specific equivalent.

(2) Loch Raven USROs will maintain and use site specific safety device testing procedures in accordance with the requirements of the VHA Boiler Safety Device Testing Manual “Current Edition”.

(3) Testing will be conducted on schedule and by a qualified inspector as established by the current

VHA directive. Safety device testing includes monthly, semi-annual, and annual testing. The results of each test will be documented on the appropriate safety device testing documentation forms. Test results must be evaluated via the “Three Question Criteria” found in the VHA Safety Device Testing Manual. A clear Pass/Fail conclusion must be indicated for each test. Loch Raven VA will utilize a third-party review to perform at least one of the required semi-annual tests.

(4) When safety device testing is via a contract, vendors must perform testing in accordance with the

VHA Boiler Plant Safety Device Testing Manual “Current Edition” or sight specific equivalent and provide documentation equivalent to site specific documentation and/or complete site-specific documentation forms.

(5) Vendor testing reports and/or documentation will be reviewed by USRO personnel for accuracy and compliance. An annual review of all safety device documentation will be performed to ensure completion and compliance.

(a) Required Documentation for Testing of Safety Devices:

1. Safety device testing will be documented on site specific documentation forms for each safety device grouped by testing frequency and equipment.

2. Safety Device Testing Summary / Certification sheets for monthly and semi-annual tests must also be completed and signed.

3. Safety device testing documentation must be maintained for the most recent 3 years.

g. Reporting of Non-Functional Safety Devices / Loss of Heating Hot Water Capacity (N+1)

(1) If boiler plant personnel either directly or through oversight of a contractor discovers any safety device to be non-functional and cannot repair immediately, it must be reported in a traceable manner to the Medical Center Director through the Chief Engineer and USRO Supervisor.

(2) Boiler Personnel will document any boiler deficiency and/or safety device failure on the daily boiler log immediately when the issue is found as well send an email with all pertinent information to the USRO supervisor.

(3) It is the responsibility of the USRO supervisor to review the log daily and complete any necessary

Interim Safety Measure (ISM) Forms (Appendix A). Any failed safety device will require an ISM to be generated. The USRO supervisor will certify the ISM and send it the Chief Engineer for certification. The Chief Engineer is responsible for delivering the ISM form to the Associate Director of operations and Medical Center Director for certification.

(4) Safety device deficiencies must be documented and tracked from discovery to repair with a safety device deficiency tracking sheet. Safety device deficiencies are filed on the Engineering shared drive:

Boiler Deficiencies Tracker, LR.

(5) No boiler will be operated with a non-functional safety device unless an approved ISM is in place.

(6) VISN must also be notified of any ISMs in the form of an Issue Brief.

(7) If the hot water generating capacity of the boiler plant is compromised in such a way that the facility no longer maintains N+1 redundancy, then it will be reported in traceable manner to the Medical Center Director through the Chief Engineer and USRO Supervisor.

(8) N+1 is defined as the ability to meet demand with at least one functional boiler not operating.

(9) Given the loss of N+1, boiler plant personnel will complete the Loss of Heating Hot Water

Capacity (N+1) Notification form found in Appendix B to this procedure and transmit it via email to the USRO Supervisor. The USRO Supervisor will certify the document and deliver it to the Chief Engineer for certification. The Chief Engineer is responsible for delivering the notification form to the Medical Center Director or designee for certification.

(10) If the loss of capacity will persist for more than 24 hours, the Medical Center Director or designee will notify OHE and VISN per Directive 1810(1) within 12 hours in an appropriate manner.

(11) In some circumstances where N+1 redundancy will be compromised for an extended period; it may be necessary to acquire a temporary boiler.

(a) Required Documentation for Reporting of Non-Functional Safety Devices/Loss of N+1:

1. All copies of transmittals to the Medical Center Director informing of a non-functional safety device or loss of N+1 for the most recent three years must be kept in the safety device folder including any interim safety measures if needed. Appendices A and/or B

2. Maintain an updated copy of the Safety Device / ISM Deficiency Tracking Sheet.

h. Interim Safety Measure (ISM) Implementation

(1) In the event a boiler(s) must be operated with a non-functional safety device, an ISM is required.

Any ISM must provide an equivalent or acceptable level of safety as is provided by the functioning safety device it is replacing. The ISM will be a temporary operating procedure developed by boiler plant personnel with support from Engineering. If an ISM is needed, boiler plant personnel will develop the ISM procedure and complete the Boiler Safety Device Interim Safety Measure Form found in Appendix A to this procedure. The completed Boiler Safety Device Interim Safety Measure Form (Appendix A) will then be transmitted to the USRO Supervisor through the Chief FES to the Associate Director for operations to the Medical Center Director for certification. All ISMs must be communicated to VISN via Issue brief. The ISM must remain in place until deficiencies are repaired and documented. Each safety device deficiency must have its own ISM as a separate document. ISMs will be tracked on a centralized spreadsheet that lists all ISMs and repairs with date, status, and comments.

(a) Required Documentation for ISM Implementation:

1. Maintain all Boiler Safety Device Interim Safety Measure Forms (Appendix A) in a folder for record and future reference.

2. Maintain all ISM performance records and logs.

i. Ongoing and New Hire Training / Competency Program

(1) A training program will be in place to ensure all USROs / boiler attendants are properly trained and competent to perform necessary duties. The new hire training program will follow a curriculum focused on boiler related material that will include all necessary aspects to ensure new hires permanent and temporary are competent to stand shift independently. New hire USROs / boiler operators must receive a minimum of three months continuous on the job training under the guidance and supervision of a competent USRO. The new hire training program will include a system to deem a new hire USRO competent to perform their duties independently. All USRO, boiler operator, and /or boiler attendant personnel must complete the new hire training curriculum. The USRO Supervisor and Chief Engineer must certify all new hire USROs before they can independently perform duties. The new hire training program is outlined in appendix D to this document.

(2) In addition to the new hire training program, an ongoing training program will be in place, to develop, maintain, and regularly refresh operator proficiency in safe boiler operations. The ongoing training program will include documented formal and on the job training for the specific boiler equipment and operations at Loch Raven VAMCs. The ongoing training program is outlined in appendix E to this document. The USRO Supervisor is responsible for administering the ongoing training program. The USRO Supervisor or Chief Engineer must certify the completion of required training for each USRO. Per VHA Boiler Plant Directive 1810(1) the USRO Supervisor and Contracting Officer Representative for vendor provided safety device testing will complete triennial refreshers on the Safe Steaming 2 course in TMS. All available USRO members will attend VISN Boiler Safety Device Training provided via contract by OHE when scheduled. The USRO Supervisor and their designee shall be designated as Site Boiler Plant Safety Device Training Champions. The champions shall be responsible for training other staff members in safety device testing. All required TMS training will be completed by all USRO personnel.

(a) Required Documentation for Ongoing and New Hire Training Program:

1. Personal training files for each operator containing all relevant training documentation such as:

a) New Hire Training Program Documentation Form (Appendix E) for new operators contained in their personal file.

b) Memorandum Certifying New Operators to Stand Shift.

c) Ongoing Training Program Documentation Form (Appendix F) for each operator contained in their personal file.

d) Any training certificates obtained by operators.

e) Any written exam results.

f) Completed TMS training documentation.

j. Maintenance of Continuous USRO Attendance

(1) The Loch Raven VAMC is equipped with decentralized hot water generating equipment. Per VHA Boiler Plant Directive 1810(1), boiler equipment will be maintained and operated with at least one qualified USRO/Attendant on station at all times. Loch Raven VAMC USROs /Attendants will not leave the station unattended at any time, nor can they be relieved by unqualified personnel. Further, no boiler of any pressure, operating temperature, or medium will be restarted remotely.

(2) To detect any possible USRO/Attendants’ incapacitation, a method of performing regular checks each shift will be performed. In the event of a lone operator on shift, USRO/Attendants must communicate with VA police prior to leaving to make rounds and upon returning and/or at least every two hours. To reduce the likelihood of operator incapacitation, USRO/Attendants must have an annual physical and audiological examination (see VA Handbook 5019, Pt. II). In the event of USRO incapacitation and no qualified USRO/Attendant is on station, the Nurse On Duty (NOD) and the USRO Supervisor or other relevant personnel will be immediately contacted by calling the following numbers: Loch Raven Boiler Operator at 410-210-7290, USRO Supervisor at 443-986-2593, Emergency on-call USRO at 410-605- 7000 ext. 57020 or NOD at 410-336-9059. Only an individual qualified for Loch Raven boiler operations can restart or attend any change in status of boilers in the interim until qualified personnel arrive.

Documentation and weekly verification for compliance of USRO/Attendant checks is to be performed by the USRO Supervisor. Records must be retained for at least 3 years.

(a) Required Documentation for Maintenance of Continuous Boiler Plant Operator Attendance in Boiler Plant:

1. A copy of the annual physical examination results for each boiler plant USRO/attendant for the most recent three years must be kept in a location where deemed appropriate.

2. Documentation must be kept ensuring the required regular periodic safety checks are occurring each shift. All health and safety check contacts should be logged on a daily log.

k. Provision of Reference Material for Boiler Operators

(1) All pertinent reference material will be organized and maintained by boiler plant personnel. All reference material must be readily available for use in the boiler plant. Change logs / revision dates for single line diagrams and other boiler plant drawings must be maintained. Electronic copies should be maintained as well as hard copies where possible. The required reference material is given by the following:

(a) VHA Directive 1810(1) Boiler and Boiler Plant Operations.

(b) All current normal and emergency operating procedures.

(c) Manufacturer’s literature on all major equipment: boilers, burners, burner management controls, pumps, water softener, emergency generator, combustion controls, instrumentation, schematic boiler control wiring diagrams for troubleshooting.

(d) One - line diagrams of boiler plant systems to include: Process Hot Water systems, Make up and

Water Supply Systems, Primary and Alternate Fuel Systems, Control Systems, and Electrical Distribution Systems.

(e) Current list of connected hot water utilizing equipment, with supplied pressure, temperature, and flow quantity requirements.

(f) Lock Out Tag Out Procedures for all boiler plant equipment.

(g) Confined Space Entry Procedures as applicable.

(h) Load shedding plan.

(i) Links to OHE boiler page.

(j) Links to Technical Information Library (TIL) Master Specification, Standard Details, Design Manuals.

(k) VA Whole Building Commissioning Process Manual, latest edition.

(l) VHA Directive 2010-031 Boiler Plant Safety Education, or subsequent procedure issue.

(m) VHA Directive 1028, Electrical Power Distribution Systems.

(n) VHA Handbook 7701.01, Occupational Safety and Health (OSH) Program Procedures.

(o) VHA Boiler Plant Safety Device Testing Manual, latest edition.

(p) American Society of Mechanical Engineers (ASME) Boiler and Pressure Vessel Code, latest edition.

(q) National Fire Protection Association (NFPA) 85: Boiler and Combustion Systems Hazards Code, latest edition.

(r) NFPA 70E: Standard for Electrical Safety in the Workplace.

(s) NFPA 110: Standard for Emergency and Standby Power.

(t) Boiler Efficiency Improvement Operator Manual.

(u) The Joint Commission, Management of the Environment of Care (EC) Standard 02.05.01, or current equivalent standard.

l. Setting Priority Loads on Loss of Steam Generating Capacity (Load Shedding Plan)

The load shedding procedure must be readily available to all impacted personnel. If boilers for any reason cannot provide the necessary heating capacity, USRO personnel/attendant will notify the USRO Supervisor who then must communicate the situation up the chain of command. Execution and /or deviation from the specified plan requires approval from the Medical Center Director. Critical hot water loads will be determined on a patient care priority basis and approved by the Chief Engineer and Medical Center Director. Site manager / NOD / chief nurse must be notified in the impacted area of load shedding.

A list of priority loads for Loch Raven VAMC is found in Appendix I to this document.

m. Maintenance and Testing of Emergency Electric Power System

(1) The emergency electrical generator(s) serving the boiler equipment will be included as part of the emergency power supply system testing and maintenance program. This shall include the automatic transfer switches. The testing will meet the latest requirement by The Joint Commission, NFPA 99 and

110. All generator testing is conducted monthly by the Electrical Shop. An annual load bank will be conducted in addition to monthly testing if monthly testing cannot be conducted with at least 30% generator load each month. The USRO supervisor will maintain access to generator testing logs. If electrical load shedding is required boiler equipment must have priority over less critical utilities.

(a) Required Documentation for Maintenance and Testing of Emergency Electric Power System:

1. Copies of all monthly emergency generator testing for at least 3 years.

2. Electrical log sheets.

3. Weekly Generator PM sheets.

n. Maintenance and Testing of Emergency Fuel Supply

(1) Per VHA Boiler Plant Directive 1810(1), Loch Raven VAMC will maintain an emergency supply of #2 fuel oil to meet the normal demands of continuous operation under most extreme winter weather conditions for at least 10 calendar days. Fuel storage requirements will be revaluated annually by associate chief or designee against actual total fuel/energy used under most extreme winter weather conditions. Loch Raven VAMC must maintain fuel oil tank at a minimum of the results of the annually calculated 10-day storage requirement. Loch Raven Maintenance Supervisor will perform a weekly inventory of fuel. If fuel level is found to be below adequate capacity, Loch Raven Management personnel must purchase additional fuel oil. Back up fuel will be annually tested for water, algae, other contaminates. If annual testing detects contaminates above action limits, the water shall be mechanically removed, along with other contaminates and the fuel treated with biocide or other treatments to minimize algae growth. USRO personnel will operate every boiler equipped with backup fuel source on backup fuel and pilot for at least one hour each month. The boiler plant will maintain a sufficient supply of propane pilot fuel to fire the boilers when needed.

(a) Required Documentation for Maintenance & Testing of Emergency Fuel Supply:

1. Weekly Fuel Tank Inventory Log/Tracking Sheet.

2. Monthly Boiler Fueling Station Fuel Tank PM.

3. Annual Fuel Quality Testing Report.

4. Fuel Storage Requirement Calculation.

5. Log/Documentation of Monthly Firing of Back Up Fuel.

o. Providing Hot Water Utility Shut Down for Maintenance

(1) A method for hot water utility system shut down to allow maintenance to be performed will be in place. In the event a shutdown is required, Loch Raven USRO personnel will assemble all pertinent information and follow SOP 138 / ENG-039 Scheduled and Emergency Utility Shutdowns and initiate a Utility Outage Request found in Appendix K to this procedure. The Chief Engineer will approve and acquire Director approval for the outage and then issue a notification directing the required shut down for maintenance. USROs will follow applicable procedures for shutting down the hot water supply for maintenance. Boiler equipment will be locked and tagged out if required.

(a) Required Documentation for Providing Steam Shut Down for Maintenance:

1. A copy of the notification by the Chief Engineer readily available to the operators.

2. A copy of appendix K.

p. Maintenance and Testing of Emergency Water Supply to Boiler

(1) A system for providing and testing emergency water to boiler hot water loops will be in place and will be tested annually. A long-term contract with a mobile water tank or truck provider will be maintained and implemented in the event of loss of primary water. Boiler plant personnel will perform and review the Emergency Water Supply Procedure annually to ensure the ability to utilize a secondary feed is maintained.

(a) Required Documentation for Maintenance & Testing of Emergency Water Supply to Boiler:

1. Documentation forms for Maintenance and Testing of the Emergency Water Supply to Boilers must be retained for at least three years.

q. Purchase and Maintenance of Parts and Supplies (Common and Emergency)

(1) Common and emergency parts will be identified, and a proper inventory of these parts maintained.

An inventory of spare parts especially long lead time parts is critical to compliant boiler operation. The system for purchasing parts and supplies is defined by boiler plant SOP Procedure for Purchase of Boiler Plant Parts and Supplies. A list of recommended spare parts and supplies is located in Appendix G to this procedure.

(a) Required Documentation for Purchase and Maintenance of Parts and Supplies:

1. Inventory tracking for spare common and emergency parts.

2. Tracking information of parts on order.

3. Invoices and Part Receipt Reports.

r. Operating Boilers at Highest Efficiency

(1) USROs will maintain the system at the temperature and pressure necessary for the proper operation of the plant and connected loads as defined by the Chief Engineer. The Chief Engineer will determine an efficient and reliable operating pressure and temperature based on the system design and requirements of processes. Any water leaks must be immediately investigated and reported to the proper personnel. Insulation will be maintained by all utilities personnel to ensure best efficiency. Combustion tuning will be performed by a qualified individual on each boiler on all fuels semi-annually. The boilers will be tuned to ensure the best possible combustion efficiency while maintaining satisfactory reliability and safety requirements. Boiler plant operational parameters will be reviewed and reconsidered annually by boiler plant and engineering staff to ensure the most efficient and reliable operation.

(a) Required Documentation for Operating Boilers at Highest Efficiency:

1. Test result reports from qualified combustion tuning technician for the most current three years

s. Hot Water Conservation Program

(1) USRO personnel will maintain the integrity of the of piping systems and insulation at Loch Raven.

USRO supervisor will assign maintenance and inspection of hot water systems to USRO personnel. All inspections will be documented on the appropriate inspection form. The inspection report for the program is given in Appendix H to this procedure. Inspection reports will include the following:

(a) Name and Title of person performing inspection

(b) Date/Frequency of Inspections

(c) Location of Devices

(d) Device/Equipment Type

(e) Discrepancy found if any

(f) Corrective action

(g) Required Documentation for Hot Water Conservation Program:

1. All inspection reports generated from the Maintenance and Operations personnel for at least three

(3) years.

2. All inspection reports generated from USROs for at least 3 years Appendix H Steam Conservation

Inspection Checklist for Boiler Plant.

t. VHA Boiler Plant General and Directive Required Boiler Plant Equipment Maintenance / Testing / Calibration

(1) The VHA Boiler Plant Directive 1810(1) requires substantial boiler plant equipment maintenance, testing, and calibration. All required action will be performed by a qualified USRO or procured from a qualified vendor if required. All action will be properly documented and retained for reference. Selections of contractors for plant services including boiler inspections, burner adjustments, testing of safety devices, calibration of instruments, and monitoring of water treatment must be based on quality of work and experience as the first priorities. Pressure vessel inspections must be conducted by a Qualified Professional Inspector (QPI). A QPI is any one or combination of the following:

(a) A boiler inspector who has a valid and current certificate from the National Board of Boiler and Pressure Vessel Inspectors.

(b) A boiler inspector who has qualified for licensure by passing a written examination under the laws, rules, and regulations of a jurisdiction of the State and holds a current State license.

(c) A boiler inspector who is currently employed as a boiler inspector/testing by a jurisdiction that has adopted and administers one or more sections of the ASME Boiler and Pressure Vessel Code as a legal requirement and has a representative serving as a member of the ASME Conference Committee.

(d) A boiler inspector who is currently employed by an insurance company that has been licensed or registered by the appropriate authority of a State to write boiler and pressure vessel insurance.

Pressure vessel inspections are high priority inspections and any issues noted on inspection reports must be immediately addressed. A complete list of all required inspections is given in Appendix L to this procedure.

(2) Calibration of Gages and Instrumentation

(a) All temperature and pressure gauges located on boiler equipment will be calibrated annually.

Pressure and temperature gauges must be calibrated with a lab traceable calibrated instrument.

Calibratable instruments will be calibrated by an accredited vendor. Calibration data will be documented on the Pressure and Temperature Gauge Calibration Tracking Sheet given by Appendix M to this procedure. Calibration stickers containing the calibration date will be placed on calibrated pressure and temperature gauges. If any temperature or pressure gauge cannot be calibrated to within an acceptable accuracy, the gauge must be immediately replaced.

(b) Instrumentation used for control system input and data monitoring will be calibrated semi-annually. A qualified vendor will be utilized to calibrate control input and data monitoring instrumentation.

The vender must deliver a calibration report that includes instrument results across an acceptable number of points that spans the full range of the instrument with as found and as calibrated results preferred. If any instrument cannot be calibrated it must be immediately replaced. If the instrument that cannot be calibrated is a critical control system input, the impacted equipment will be taken out of service until the instrument is replaced.

(c) Required Documentation for Calibration of Gages & Instrumentation:

1. Temperature and Pressure Gauge Calibration Tracking Sheet Appendix M.

2. Lab traceable calibration certificates for calibration instruments.

3. Instrumentation calibration reports.

(3) Boiler Water Treatment

(a) Water treatment vendor will be retained to conduct monthly tests and maintenance on all pertinent water quality parameters. Vendor must maintain parameters at recommended levels. Boiler personnel will also maintain records of the tests, adjustments, and the use of chemicals. No chemical treatment systems are to be manual and magnetic water treatment systems are prohibited in VHA boiler plants. Water chemistry records must contain results of chemical residual tests as compared to acceptable levels.

Records must indicate any changes or additions to the system.

(b) Required Documentation for Boiler Water Treatment:

1. The monthly boiler water chemistry logs and all chemical vendor reports for three years.

2. Documentation of any problems and repairs.

(4) Boiler Maintenance

(a) The items listed in table 5.1 are minimum boiler maintenance items and will be performed by boiler plant USROs or a qualified vendor on all boilers at the given frequencies. USROs and vendors must follow applicable procedures when required.

Table 5.1 Boiler Maintenance

Maintenance Item Priority Recommendation Frequency

Blowdown boiler water columns on online and standby boilers Directive Required In house Daily

Monthly Safety Device Testing Directive Required In House / Vendor Monthly

Semi-Annual Safety Device Testing Directive Required In House / Vendor Semi-Annual

Check Vibration of Burner Fans Directive Required Vendor Semi-annual

Combustion Tuning Directive Required Vendor Semi-annual

Annual Safety Device Testing Directive Required In House / Vendor Annual

Internal / External Inspection Directive Required Vendor-QPI Annual

Clean waterside of boilers Directive Required In House Annual Clean Fireside of Boilers and Repair

Refractory Directive Required In House Annual

Tube leak Check Directive Required Vendor Annual

Combustion Fouling and Gas Flow Check Directive Required Vendor Annual

Exercise, maintain, & lubricate valves High In House As needed

Maintain drains and drip pan eels High In House As needed

(b) Required Documentation for Boiler Maintenance:

1. All Directive required boiler maintenance/inspection activities will be documented by the Directive Required Inspection Checklist given in Appendix P to this procedure.

2. Safety Device Testing documentation.

3. Internal / External Pressure Vessel Inspection Certificates and Reports.

4. All vendor reports.

5. Tuning Reports Appendix J.

6. Daily logs.

7. Record of PMs.

u. Maintenance and Review of Daily Logs

(1) USRO / attendant personnel will maintain 4 hourly/daily/weekly/monthly Operational Logs. To be informed of the current boiler operational status, USROs/attendants will review logs from the previous shift and note any entries that will impact their shift. USRO/attendant personnel will enter daily activity into these logs to include:

(a) Time of Entries.

(b) Online equipment.

(c) Offline/down equipment during shift.

(d) Onsite personnel and work being performed.

(e) Official / emergency phone calls.

(f) Problems, unusual occurrences, safety device failures, or other significant issues and impacted personnel.

(g) Health and safety checks.

(2) Boiler plant personnel will also maintain 4 hourly/daily/ weekly/monthly/yearly Performance Data Logs. Operators will enter data into these logs at the proper frequency. Performance Data Logs must be manually collected even if automatic SCADA logging is in place. Table 5.3 gives the required data and frequency.

Table 5.3 Performance Data Log Parameters and Frequency

Parameter Frequency

Total Fuel Consumed Daily / Monthly / Annually

Make Up Water Quantity / % make up water 4-Hourly

Minimum and Maximum Fuel Demand Daily

Boiler Efficiency Daily

Water treatment data Daily

Outside Air Temperature 4-Hourly

Boiler Flue Gas Oxygen 4-Hourly

Boiler Inlet Air Temp 4-Hourly

Boiler Stack Temperature 4-Hourly

Firing Rate 4-Hourly

Boiler Combustion Efficiency 4-Hourly

Fuel Train Regulated Pressure 4-Hourly

Equipment Tag # 4-Hourly

Hot Water Flow 4-Hourly

DA Tank Inlet Temperature 4-Hourly

Loop Pump Inlet Water Temperature 4-Hourly

Loop Pump Outlet Water Temperature 4-Hourly

Loop Pump Inlet Pressure 4-Hourly

Loop Pump Outlet Pressure 4-Hourly

Hot Water Supply Temp 4-Hourly

Hot Water Return Temp 4-Hourly

(3) The USRO Supervisor will review all logs on a weekly basis. The USRO supervisor will sign off on logs after review with signature or initial.

(a) Required Documentation for Maintenance and Review of Daily Logs:

1. Historical Operational Logs for at least 3 years.

2. Historical Performance Data for at last 3 years.

v. Boiler / Pressure Vessel Repair

(1) Repair of boilers and pressure vessels will comply with ASME Pressure Vessel Code. All weld repairs must be performed by certified R stamp welders using code approved procedures. Hydrostatic testing of boilers and pressure vessels must be conducted after a repair or tube replacement, or when boiler pressure vessel integrity is in doubt. Hydrostatic pressure must be limited to 150% of normal operating pressure of the boiler or pressure vessel.

(a) Required Documentation for Boiler/Pressure Vessel Repair:

1. Repair and Certification Records must be retained for a minimum of 3 years.

w. Boiler Plant Equipment Replacement

(1) All boiler plant equipment will be monitored for useful life. When Boilers are within 3 years of their life expectancy, a useful life study must be performed. No equipment shall be in service beyond the useful life expectancy without an engineering evaluation of the reliability, efficiency, and cost effectiveness of continued operation. The equipment replacement program is based on the following useful life expectancies:

(a) Equipment Useful Life Expectancy (in years)

1. Fire tube boilers and burners - 30

2. Water tube boilers and burners - 40

3. Feed water Deaerator - 30

4. Economizers - 15

5. Burner management controls - 20

6. Combustion controls - 20

7. Instrumentation - 20

8. Boiler feed and condensate pumps - 20

9. Condensate and blow-off tanks and heat recovery - 40

10. Fuel oil pumps - 40

11. Fuel oil tanks - 40

12. Valves; shut off and control - 20

13. Water treatment equipment – 20

(b) Required Documentation for Boiler Plant Equipment Replacement:

1. A completed Appendix O for the most recent three years.

2. Documentation of all life expectancy studies and extension shall be kept on file until the extension date has been exceeded.

x. Lock Out Tag Out (LOTO)

(1) Before any work or maintenance is performed on any machine, equipment, tool, or electrical system, they must be made totally safe before work starts by removing any source of energy or power to them. The LOTO Program provides for a safe method of working on, near, or in machinery or equipment that can cause serious injury. This program shall be used to ensure that the machine or equipment is stopped, isolated from all potentially hazardous energy sources, and locked out before employees perform any servicing or maintenance where the unexpected energization or start-up of the machine or equipment, or release of stored energy, could cause injury. Examples of such energy include electrical, air pressure, hydraulic pressure, chemical, thermal, steam, or springs under tension. If an energy control switch/valve can be locked out, then lockout procedures must be used. Otherwise, a tagout system must be used. Lockout and tagout devices will be singularly identified, used only for this purpose, and will be durable, standardized, substantial, and identify the employee applying the lockout. This program does not apply to cord and plug connected equipment if the plug is unplugged and controlled by the employee performing the maintenance, or to hot tap work. Also, normal production operations are not covered unless a guard/safety device is removed, or the employee is exposed to a point-of-operation hazard.

(2) Loch Raven VAMC will establish a program consisting of written lockout/ tagout procedures and documentation, employee training, and periodic inspections. USRO personnel will notify all appropriate personnel in a trackable manner before locking and tagging out equipment for maintenance. Only the VA employee(s) and or contractor(s) who placed the locks and tags may remove the locks and tags. Special permission must be obtained if the person(s) who placed the locks and tags cannot remove them. Boiler plant personnel and/or contractors will use site specific Boiler Plant LOTO Procedures and complete the corresponding documentation forms. Written lockout/tagout procedures for controlling hazardous energy will consist of the following:

(a) These procedures must clearly outline the scope, purpose, authorization, rules, techniques to be utilized, and means to enforce compliance, for the lockout/tagout procedure.

(b) The procedures must be specific for each affected machine/equipment and outline specific procedural steps for shutting down and/or isolating the machine from its energy source, specific steps for applying and removing the lock(s) or tag(s), and specific steps for verifying the effectiveness of the isolating measures. Inherent to these procedures is identifying the sources of energy.

(3) Boiler Plant personnel must be trained to ensure they understand the purpose and function of the program, that they can recognize applicable lockout/tagout situations, and that they have acquired the knowledge and skills required for applying, using, and removing the lock(s) and tag(s). The Boiler Plant USRO supervisor must conduct at least an annual inspection of each specific written lockout/tagout procedure to ensure that the procedure and the requirements of the standard are being met. An inspection certification must identify the machine/equipment, date of inspection, employees included in the inspection, and the person performing the inspection.

(4) Certain single-energy-source equipment can be exempted from the written procedure requirement only if all the following conditions are met:

(a) There is no potential for stored or residual energy or re-accumulation of stored energy after shut down.

(b) There is only a single energy source which can be readily identified and isolated.

(c) The isolation and locking out of that energy source will completely de-energize and deactivate the machine or equipment.

(d) The energy source is isolated and locked out during servicing or maintenance.

(e) A single lockout device will achieve a locked-out condition.

(f) The lockout device is under the exclusive control of the employee performing the servicing or maintenance.

(g) The servicing or maintenance does not create hazards for other employees.

(h) Required Documentation for Lock Out Tag Out:

1. Lock Out Tag Out Documentation forms for the equipment being locked/tagged out.

2. Training Records for any Lock Out Tag Out training received.

y. Records and Documentation

(1) Maintenance and testing records are required for all VHA Boiler Plant Directive required maintenance and testing. Maintenance and testing records must be retained for at least 3 years. Records and archives must be in compliance with VHA records control schedule 10-1 Section 5.400 Engineering Service. https://www.va.gov/vhapublications/rcs10/rcs10-1.pdf Refer to Appendix P to this procedure for a complete list of required documentation. These maintenance and inspection records must include the following minimum information:

(a) Date of test, inspection, or maintenance.

(b) Results of test, inspection, or maintenance procedures.

(c) Name of individual(s) performing the maintenance.

(d) Parts installed if applicable.

(e) Any Repairs or adjustments made if applicable

(2) Training records must be retained for each Boiler Plant USRO Operator. Ongoing training records must be retained for at least 3 years. New Hire Training records must be maintained perpetually. These training records must include the following:

(a) Name and position of individual being trained.

(b) Name and qualification of trainer.

(c) Specific training item/task and method.

(d) Verification method.

(e) Appropriate certification.

z. Review of Boiler Plant Procedure, Procedure, Documentation

(1) The USRO Supervisor shall annually review for completeness and accuracy and prepare a summary report of all procedure, procedure appendices, references, and documentation required by this procedure for the Chief Engineer’s review. The summary report will note any discrepancies found. All documents relevant to the Quarterly Compliance Survey should be reviewed by the USRO supervisor and other appropriate personnel at the time the survey is completed.

3. ASSIGNMENT OF RESPONSIBILITIES

NOTE: Table 4.1 lists all actions required by the procedure and the person(s) responsible for the actions.

https://www.va.gov/vhapublications/rcs10/rcs10-1.pdf

Table 4.1. Actions and Responsible Person(s)

Action Responsible Person(s)

1. Implementing local Policies and Procedures that meet the intent of Directive 1810(1), Boiler Plant Operations and ensuring they are current and accurate.

Medical Center Director Chief Engineer USRO Supervisor USRO / Attendant

Action continued Responsible Person(s)

2. Safe Boiler Plant Operation

Medical Center Director Chief Engineer USRO Supervisor USRO / Attendant

3. Boiler Plant Security Chief Engineer USRO Supervisor USRO / Attendant

4. Interaction with Office of Healthcare Engineering

Medical Center Director Chief Engineer USRO Supervisor USRO / Attendant

5. Quarterly Compliance Survey Medical Center Director Chief Engineer USRO Supervisor

6. Testing of Safety Devices

Medical Center Director Chief Engineer USRO Supervisor USRO / Attendant

7. Reporting of Non-Functional Safety Devices / Loss of N+1 Redundancy

Medical Center Director Chief Engineer USRO Supervisor USRO / Attendant

8. Interim Safety Measure Implementation

Medical Center Director Chief Engineer USRO Supervisor USRO / Attendant

9. Ongoing / New Hire Training and Competency Programs

Chief Engineer USRO Supervisor

USRO

10. Maintenance of Continuous Boiler Plant Operator Attendance in Boiler Plant

Medical Center Director Chief Engineer USRO Supervisor USRO / Attendant

11. Provision of Reference Material for Boiler Operators USRO Supervisor

USRO

12. Setting Priority Loads on Loss of Steam Generating Capacity

Medical Center Director Chief Engineer USRO Supervisor

USRO

13. Maintenance and Testing of Emergency Electric Power System

Chief Engineer USRO Supervisor

Table 4.1. Actions and Responsible Person(s)

Action Responsible Person(s)

14. Maintenance and Testing of Emergency Fuel Supply to Boiler

Medical Center Director Chief Engineer USRO Supervisor

USRO

15. Providing Steam Shut Down for Maintenance Chief Engineer USRO Supervisor

USRO

16. Maintenance and Testing of Emergency Water Supply to Boiler

Chief Engineer USRO Supervisor

USRO

17. Purchase and Maintenance of Parts and Supplies (Common and Emergency)

USRO Supervisor

USRO

18. Operating Boilers at Highest Efficiency Chief Engineer USRO Supervisor USRO / Attendant

19. Heating Hot Water Conservation Program Chief Engineer USRO Supervisor USRO / Attendant

20. Directive 1810(1) ES-2018-001 Required Boiler Plant Equipment Maintenance / Testing / Calibration

Chief Engineer USRO Supervisor

USRO

21. Maintenance / Review of Daily Logs USRO Supervisor USRO / Attendant

22. Boiler Repair USRO Supervisor

USRO

23. Boiler Plant Equipment Replacement Chief Engineer USRO Supervisor

24. Lock Out Tag Out Chief Engineer USRO Supervisor USRO / Attendant

25. Records / Documentation Chief Engineer USRO Supervisor USRO Attendant

26. Review of Boiler Plant Procedure and Records Chief Engineer USRO Supervisor

NOTE: The detailed responsibilities of the different personnel for the above actions are listed below.

a. Chief Engineer/Facility Manager. Per Directive 1810(1) and this procedure, the Chief…