Atch 14 VA TVHS Confined Space Policy.docx

VA MEDICAL CENTER VA HANDBOOK 1538

NASHVILLE, TN MAY 1, 1998

VA HANDBOOK 1538 VA MEDICAL CENTER

MAY 1, 1998 NASHVILLE, TN

Department of Veterans Affairs ENGINEERING SERVICE Tennessee Valley Healthcare System SOP 138-4, November 11, 2020

VA TVHS CONFINED SPACE POLICY

Department of Veterans Affairs ENGINEERING SERVICE Tennessee Valley Healthcare System SOP 138-4, November 11, 2020

1. PURPOSE: To develop a policy and provide guidelines for VA Tennessee Valley Healthcare System (TVHS) employees confronted with the hazards present in confined spaces, including permit-required confined spaces. To ensure appropriate training has been provided, hazard-specific PPE is available and safe working conditions/practices are established and enforced.

2. SCOPE: All VA staff involved with permit-required confined space entry at TVHS.

3. POLICY: It is the policy of TVHS to establish and maintain a Permit-Required Confined Space Entry Program in accordance with 29 CFR 1910.146. This includes surveying of confined spaces to determine which are permit-required confined spaces, correctly marking all spaces determined to be permit-required, elimination of unauthorized entry, and minimizing hazards associated with entry through use of engineering controls, Personal Protective Equipment (PPE), training, and safe entry procedures. Only those individuals properly trained as attendants, authorized entrants, entry supervisors, and confined space rescue personnel may participate in confined space entry and/or rescue. No authorized entry will occur on station until Engineering Service is notified, and entry procedures reviewed and completed.

**The full regulation that this policy is based on can be found in OSHA 29 CFR 1910.146**

4. RESPONSIBILITIES:

A. The Chief of Engineering Service shall be responsible for ensuring the overall compliance with this program. The Industrial Hygienist or other trained staff shall provide training for Permit Required Confined Space Entry to assure appropriate procedures and documentation are followed. The entry supervisor(s) will be determined by each shop/section, trained by the industrial hygienist, and given responsibility for entry into permit-required confined spaces in that area. The industrial hygienist or other trained staff will be available to assist if necessary.

B. VA contractors will be apprised of any work requiring permit-required confined space entry and to the hazards identified within the space by the Contract Officer Representative (COR). Contract staff will coordinate all entry operations through Engineering Service Safety Personnel and/or the COTR. Contract staff will be required to abide by all OSHA guidelines set forth in 29 CFR 1910.146 or its equivalent for construction activities. The OSHA construction standard states the following:

1926.21(b)(6)(i) All employees required to enter into confined or enclosed spaces shall be instructed as to the nature of the hazards involved, the necessary precautions to be taken, and in the use of protective and emergency equipment required. The employer shall comply with any specific regulations that apply to work in dangerous or potentially dangerous areas.

1926.21(b)(6)(ii) For purposes of paragraph (b)(6)(i) of this section, "confined or enclosed space" means any space having a limited means of egress, which is subject to the accumulation of toxic or flammable contaminants or has an oxygen deficient atmosphere. Confined or enclosed spaces include, but are not limited to, storage tanks, process vessels, bins, boilers, ventilation or exhaust ducts, sewers, underground utility vaults, tunnels, pipelines, and open top spaces more than 4 feet in depth such as pits, tubs, vaults, and vessels Contractors will be required to provide documentation confirming their employees have been trained in confined space entry as defined in CFR 1910.146 (d). Contractors will also adhere to the station policy of carry-in / carry out, removing all trash, tools and extraneous materials. Contractors will also be required to provide Safety Data Sheets (SDS) for all chemicals that will be used in both confined spaces and designated permit required confined spaces to the Safety Section of Engineering Service prior to the confined space work being scheduled. The COR or Safety/IH personnel will perform visual inspections to ensure this practice. This visual inspection will be documented.

5. DEFINITIONS:

Attendant - individual stationed outside the permitted space to monitor the authorized entrants and performs all other duties assigned in the confine space program.

Authorized Entrant - employee who is authorized by the employer to enter a permit space.

Certification of Hazard Elimination (Attachment A) - Form used to reclassify a permit space as a non-permit space. This form certifies that all hazards have been removed.

Confined Space - a space by design that is:

(1) large enough to allow an employee to bodily enter and perform assigned work; and

(2) has limited or restricted means of entry and exit; and

(3) is not designed for continuous employee occupancy.

Contractor Confined Space Compliance Checklist (Attachment B) - Form used to ensure that the VAMC has provided contractor with the required hazard and safety information and to ensure contractor's compliance with this memorandum and OSHA Standard 1910.146.

COR – VA Contracting Officer’s Representative.

Entry - the action by which a person passes through an opening into a permit required confined space. 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 that space.

Entry Permit (Attachment C) - The written or printed document to allow and control entry into a permit space.

Entry Supervisor - the person responsible (as stated under section 4 part A of this memorandum) for determining if acceptable entry conditions are present at a permit space where entry is planned, for authorizing entry and overseeing entry operations and for terminating entry as required.

Entry Permit - the written or printed document provided by the employer to allow and control entry into a permit and contains the information specified in CFR 1910.146 (f).

Hazardous Atmosphere - an atmosphere that may expose employees to the risk of death, incapacitation, impairment of ability to self-rescue, injury or acute illness from one or more of the following:

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

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

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 this Part and which could result in employee exposure in excess of its dose or permissible exposure limit;

NOTE: An atmospheric concentration of any substance that is not capable of causing death, incapacitation, impairment of ability to self-rescue, injury, or acute illness due to its health effects is not covered by this provision.

(5) Any other atmospheric condition that is immediately dangerous to life or health.

Hot Work Permit - written authorization to perform operations which could provide a source of ignition.

Permit Required Confined Space (permit space) - a confined space that has one or more of the following characteristics:

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

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

(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;

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

6. PROCEDURES:

A. THE FACILITY SAFETY OFFICER, INDUSTRIAL HYGIENIST, OR OTHER TRAINED STAFF will evaluate hazards of the confined space, determine which confined spaces require entry permits and provide initial training on the requirements of this memorandum.

***ALL PERSONNEL INVOLVED WITH PERMIT-REQUIRED CONFINED SPACES AND NON-PERMIT CONFINED SPACES ARE REQUIRED TO KNOW THE HAZARDS THAT EXIST OR COULD POTENTIALLY EXIST IN THAT SPACE***

B. THE ENTRY SUPERVISOR SHALL:

(1) Verify emergency plans and specified entry conditions such as permits, tests, procedures, and equipment before allowing entry into confined spaces.

(2) Terminate entry and cancel permits when entry operations are completed or if a new condition exists.

(3) Take appropriate measures to remove unauthorized entrants.

(4) Ensure that entry operations remain consistent with the entry permit and that acceptable entry conditions are maintained.

(5) Retain copies of canceled entry permits for at least one year.

C. THE ATTENDANT SHALL:

(1) Remain outside permit space during entry operations unless relieved by another authorized attendant. A minimum of two attendants will be stationed immediately outside the opening or entrance. One attendant will constantly monitor the entrant’s activities, the other will remain available to summon rescue assistance should the need arise and to assist the first attendant with rescue using an outside retrieval system.

***AT NO TIME, WILL THE ATTENDANT OR OTHER NEARBY PERSONENLL ENTER THE PERMIT REQUIRED SPACE FOR A RESCUE! PROPERLY TRAINED AND EQUIPPED FIRE DEPARTMENT PERSONNEL WILL CONDUCT ALL INTERNAL RESCUE OPERATIONS. INITIATE VIA 9-1-1***

(2) Maintain communication with and keep an accurate account of those workers entering the permit space.

(3) Order evacuation of the permit space when a prohibited condition exists, when a worker shows signs of physiological effects of hazard exposure, when an emergency outside the confined space exists, and when the attendant cannot effectively and safely perform required duties.

(4) Summon rescue and other services during an emergency. When possible this should be done without leaving the area.

(5) Ensure that unauthorized persons stay away from permit spaces or exit immediately if they have entered the permit space.

(6) Inform authorized entrants and entry supervisor of entry by unauthorized persons.

(7) Perform no other duties that interfere with the attendant's primary duties.

D. THE AUTHORIZED ENTRANT SHALL:

(1) Use appropriate PPE properly (i.e., face and eye protection, respirators if necessary, and other forms of barrier protection such as gloves, aprons, and coveralls).

(2) As necessary, maintain communication (i.e., telephone, radio, visual observation) with attendants to enable the attendant to monitor the entrant's status as well as to alert the entrant to evacuate.

(3) Exit from permit space as soon as possible when ordered by an authorized person, when the entrant recognizes the warning signs or symptoms of exposure exists, when a prohibited condition exist, or when an automatic alarm is activated.

(4) Alert the attendant when a prohibited condition exists or when warning signs or symptoms of exposure exist.

E. THE DESIGNATED PERSON SHALL CONDUCT INTERNAL ATMOSPHERE TESTING AS FOLLOWS:

(1) The measurements shall be made with a calibrated direct-reading instrument.

(2) The atmospheric conditions shall be tested in this order:

(3) Testing should be prior to and during entry into the permit space. Initial and periodic readings will be recorded on the entry permit.

(4) If entry involves descent into atmospheres that may be stratified, the initial testing shall be made through all layers and four feet in the direction of travel, and to each side of where the entrant will be located.

F. FORCED AIR VENTILATION:

(1) Forced air ventilation is required in permit spaces.

(2) The forced air ventilation shall be so directed as to ventilate the immediate areas where an employee is or will be present within the space and shall continue until all employees have left the space.

(3) The air supply for the forced air ventilation shall be from a clean source and may not increase the hazards in the space.

G. PROCEDURES FOR RECLASSIFYING A PERMIT SPACE AS A NON-PERMIT CONFINED SPACE:

(1) The Entry Supervisor will complete a Certification of Hazard Elimination (Attachment A) for permit spaces which can be reclassified as non-permit confined space. The Certification of Hazard Elimination documents the basis for determining that all hazards have been eliminated.

(2) When there are changes in the use or configuration of a reclassified non-permit confined space that might increase the hazards to entrants, the Entry Supervisor or Industrial Hygienist shall reevaluate that space and, if necessary, classify it as a permit space.

H. PROCEDURE FOR PERMIT SPACES:

(1) Those spaces classified as permit spaces are listed on Attachment D.

(2) The affected employees will receive training to ensure that they do not make an unauthorized entry into a permit space.

(3) All items on the Entry Permit form must be completed and signed by the Entry Supervisor and authorized entrant prior to entry into the permit space. The second copy of the Entry Permit is retained by the Entry Supervisor. The original copy is taken to the work site where continuous readings are recorded during work in the permit space. Any problems encountered during the entry operation are noted on the Entry Permit. The original completed form is returned to the Entry Supervisor at the completion of the work authorized by the permit.

(4) All monitoring, alarms, PPE, ventilation, barriers, communications, lighting, ladders, rescue and emergency equipment, etc, necessary for safe permit space entry operations will be listed on the Entry Permit.

(5) Procedures and /or permits for isolating, inverting, ventilating, lockout/tagout and hot work will be specified on the Entry Permit.

(6) The employees assigned duties as entry supervisor, attendant and authorized entrant will be identified on the Entry Permit. An entry supervisor may also be the authorized entrant or attendant.

(7) The internal atmosphere of a permit space shall be tested using guidelines listed in this memorandum. There may be no hazardous atmosphere within the space, (i.e. oxygen between 19.5-23.5%, lower explosion limit less than 10%, and hydrogen sulfide less than 10 ppm) whenever any employee is inside the space.

(8) Appropriate safety controls and procedures listed on the Entry Permit must be in effect before entry into the permit space is permitted.

(9) Rescue and Emergency Services:

(a) Non-Entry rescue, retrieval systems or methods shall be used whenever an authorized entrant enters a permit space.

(b) Each authorized entrant into an Electric Manhole or Sewer Manhole shall use a chest or full body harness with a retrieval line attached at the center of the entrant's back near shoulder level, or above the entrant's head. The other end of the retrieval line shall be attached to a mechanical device in such a manner that rescue can begin as soon as the rescuer becomes aware that rescue is necessary.

I. ANNUAL PROGRAM REVIEW: An annual review covering all entries performed during the previous calendar year will be completed during the month of January by the Entry Supervisor and Industrial Hygienist. The review will utilize the canceled Entry Permits and Certification of Hazard Elimination forms and the program revised as necessary.

J. CONTRACTORS:

(1) Only contractors who have a permit space program which complies with the OSHA Standard 1910.146 will be allowed to work in permit spaces.

(2) The Contractor Confined Space Compliance Checklist (Attachment B) will be completed by the Contracting Officer's Technical Representative prior to the contractor's entry into a permit space. The checklist covers the basic requirements of a confined space program the contractor must comply with and information the VAMC is required to provide to the contractor.

(3) Contractors are required to supply all equipment to perform the necessary work. This includes personal safety equipment and any equipment needed to monitor working environment conditions for safety and compliance purposes.

K. TRAINING: The Industrial Hygienist will provide initial training on contents of this memorandum and the use, calibration and maintenance of the atmosphere testing equipment. Thereafter, training will be the responsibility of departmental supervisors. For non-routine extraordinary entry procedures, the training will be provided by the Industrial Hygienist and the Entry Supervisor.

(1) Training will include, but is not limited to:

(a) The contents of this memorandum.

(b) Potential hazards and methods of controlling those hazards.

(c) Signs, symptoms and consequences of exposure to hazards.

(d) PPE and work practices needed for safe entry and exit.

(e) The use of external barriers.

(f) Steps taken in the case of an emergency.

(2) All exposed employees shall receive training of the existence, location, and danger posed by permit confined spaces.

(3) Employees who perform duties as Entry Supervisor, attendant and authorized entrant shall be provided with training to acquire the understanding, knowledge, and skills necessary for the safe performance of those duties.

(4) Training shall be provided prior to first performing these duties, before there is a change in assigned duties, when there is a change in permit space operations that presents a new hazard about which an employee has not previously been trained, and when there is reason to believe that permit space entry procedures have not been followed or there are inadequacies in the employee's knowledge or use of permit space procedures.

(5) Training documentation shall contain the employees name, the signatures or initial of the trainers, and the dates of training and documentation maintained by the departmental supervisors.

(6) Training documentation shall be available for inspection by employees and their authorized representative.

L. PROCEDURE FOR WORK IN NON-PERMIT CONFINED SPACES:

(1) Some of the non-permit confined spaces are identified on Attachment D.

(2) Employees working in remote areas must notify their supervisor before they enter an identified remote work area.

(3) If an employee working in a remote area encounters a situation or environmental condition that is suspicious or potentially hazardous they will stop work immediately, leave the remote area, and notify their supervisor, who will initiate an investigation with the assistance of the Industrial Hygienist or anyone else that he/she feels appropriate to investigate the situation.

8. SUMMONING RESCUE AND EMERGENCY SERVICES:

Rescue and emergency services will be conducted by outside personnel. No Engineering or Engineering M&O personnel will be trained or authorized to perform any rescue or emergency services inside a permit-required confined space.

In the event an emergency should arise, incapacitating the entrant or preventing self-rescue, the following procedures will be implemented:

A. The attendant will summon help, by not leaving the area if possible, by calling 9-11 notifying the medical center operator. VA Police and the local fire department will be notified immediately by the medical center operator, followed by issuing a “Code Blue” (medical emergency adult).

B. Responding VA emergency room personnel will NOT be permitted to enter the permit-required confined space. Only rescue team members from responding police and fire departments will be authorized entry into the confined space to perform rescue procedures.

9. TRAINING:

A. Initial training will be provided to those M&O employees, designated by the M&O Supervisor, who have potential access to confined spaces. The intent of this training is to provide employees with the understanding, knowledge, and skills necessary for the safe performance of their assigned duties. This training will consist of such topics as:

· Types of hazards that may be encountered

· How to recognize signs and symptoms of exposure

· Components of the entry permit system

· Duties of the attendant, entrant and entry supervisor

· Personal protective equipment required

· Methods for the control or elimination of any atmospheric hazard

· Rescue procedures—whenever possible, rescue training will be conducted by the local fire department.

· Entry equipment - requirements and use

· What to do in the event a hazard is recognized

B. Follow up training will be conducted on an as needed basis to reiterate such points as a) Certain types of work in any confined space has the potential to create hazardous atmospheres for the employee and b) summoning rescue and emergency services, review of basic procedures and SOP’s.

10. REFERENCES:

A. 29 CFR 1910.146 - Confined Space Entry Standard

B. 29 CFR 1910.134 - Respiratory Protection Standard

C. NIOSH Criteria for a Recommended Standard - "Working in Confined Spaces”

11. RESPONSIBILITY AND REVIEW DATE: This memorandum will be reviewed annually by the Chief, Engineering Service and VA TVHS Safety Section.

/s/ Craig Hrobak

ATTACHMENT A

CERTIFICATION OF HAZARD ELIMINATION FOR CONFINED SPACES

Date: / / Location of Confined Space:

1. Are all non-atmospheric hazards eliminated? Yes___ No___

Method(s) used to eliminate non-atmospheric hazards: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Are all atmospheric hazards eliminated? Yes___ No___

Method(s) used to eliminate atmospheric hazards: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. TVHS Atmospheric readings: O2(19.5%-23.5%)______ H2S(<10ppm)______ LEL(<10%)______ CO(50ppm)______

Instrument used: ________________________ Serial #: ____________________

Instrument calibration date: __/__/____

4. Contractor Atmospheric readings: O2(19.5%-23.5%)______ H2S(<10ppm)______ LEL(<10%)______ CO(50ppm)______

Instrument used: ________________________ Serial #: ____________________

Instrument calibration date: __/__/____

5. Who is performing work? TVHS __ Contractor __

1910.146(c)(7)(i) If the permit space poses no actual or potential atmospheric hazards and if all hazards within the space are eliminated without entry into the space, the permit space may be reclassified as a non-permit confined space for as long as the non-atmospheric hazards remain eliminated.

All actual and potential atmospheric hazards and all other hazards have been eliminated in accordance with CFR 1910.146. This permit required confined space will be declassified to a non permit confined space for this entry only. Future entries will require retesting and elimination of all hazards.

Signature of Safety Representative: _________________________ Date: __/__/____

Signature of Entry Supervisor: _____________________________ Date: __/__/____

ATTACHMENT B

CONTRACTOR CONFINED SPACE COMPLIANCE CHECKLIST

1. Date: Location of Confined Space ___________________________

2. Contractor Entering the Confined Space: _____________________________________

3. Purpose of Entry:

4. A check mark indicates that the VAMC has provided the contractor with the following information:

__ Information on the hazards and experience with this confined space which make it a permit space.

__Precautions and procedures implemented for the protection of employees in or near this permit space while contractors employees are working.

5. A check mark indicates that the contractor has met the following requirements prior to permit space entry:

__Entry operations have been coordinated between VA employees and the Contractor working in or near the permit spaces __Written Permit-Required Confined Space Program __Rescue Equipment for Non-Entry Rescue __Trained Rescue Service available to enter confined space for rescue __All Equipment Necessary for Employee Safety __Entry Permit Meeting OSHA Requirements

6. The following hazards were confronted or created in the permit space by the contractor during permit space entry operation:

Contracting Officer’s Technical Representative Signature: _________________________

Contractor Signature: _____________________________________________________

ATTACHMENT D

Confined Space Classification The Nashville and Murfreesboro Safety Specialist will each maintain a confined space inventory.

Permit-Required Confined Spaces – entry permit required

· Electrical, signal, steam, or sewer manholes – Various Locations

· Kitchen grease traps – Outside Kitchen Area

· Mechanical chases – Various Locations

· Old water tank vault – Boiler Plant

· Solar hot water tank - ACRE building

· Blow down pit – Boiler Plant

· Fire/Hot box – Boiler Plant

· Plant boiler – water side – Boiler Plant

· De-aeration tank – Boiler Plant

· Flash tank – Sub-basement

· Hot well – Boiler Plant

Non Permit Confined Spaces (unless a hazard is introduced)

· Storage vault beneath backup generators/above diesel fuel vault – Boiler Plant

· Ceiling spaces above plaster ceilings where access is limited

· Crawl spaces – Sub-basement

· Air handlers – Various Locations

· Elevator wells – Various Locations

· Fall-out shelters – Sub-basement

· Diesel fuel tank vault – Boiler Plant (Nashville)

Error! Main Document Only.

Microsoft_Excel_97-2003_Worksheet.xls Sheet1

CONFINED SPACE ENTRY PERMIT ATTACHMENT C

DATE ISSUED: __/__/____ TIME ISSUED: __:__ a.m. p.m.

DATE EXPIRES: __/__/____ TIME EXPIRES: __:__ a.m. p.m.

NOTE: IN THE EVENT OF AN EMERGENCY, CALL 911

NOTE: IF THE CONDITIONS OR PROCEDURES SPECIFIED ON THIS PERMIT CHANGE, STOP

WORK IMMEDIATELY AND NOTIFY THE SAFETY OFFICE

CONFINED SPACE ID:

CONFINED SPACE LOCATION:

DESCRIPTION OF CONFINED SPACE:

DESCRIPTION OF WORK TO BE PERFORMED:

MATERIALS OR CHEMICALS LOCATED AND/OR BROUGHT INTO THE CONFINED SPACE:

EQUIPMENT LOCATED OR TO BE BROUGHT INTO THE CONFINED SPACE:

CHECK ALL POTENTIAL HAZARDS

HAZARDOUS ATMOSPHERS

FLAMMABLE IRRITANT OXYGEN-DEFICIENT

TOXIC CORROSIVE OXYGEN-ENRICHED

OTHER:

PHYSICAL HAZARDS

TEMPERATURE VIBRATION SPARK PRODUCING

CHEMICAL ABSORPTION ELECTRICAL EQUIP. OPERATIONS

NOISE MECHANICAL EQUIP. ENGULFMENT

ENTRAPMENT SPILLED LIQUIDS RADIATION

OTHER:

Yes No Is lockout/tagout required? List isolation points:

Yes No Are GFCI's required on all electrical power?

Yes No Is explosion-proof equipment required?

Yes No Are barriers required?

Yes No Is communication equipment required?

Yes No Is telephone or 2-way readio for summoning rescue available?

Yes No Are MSDS's for all materials in the confined space attached?

Yes No Have supervisors, entrants and attendant personnel been trained?

CHECK REQUIRED EMERGENCY EQUIPMENT:

Fire Extinguisher Life Line Retrieval Line

Emercency Shower / Eyewash Tripod and Winch

Safety Harness Other:

Special entry and/or work procedures?

List required personal protective equipment:

PART 3 - PERMIT REVIEW

Yes No Has appropriate air monitoring been identified

Yes No Are respirators required? List types:

Yes No Are hazard controls and PPE appropriate and adequate?

Yes No Has the safety office approved the operating procedure?

Yes No Is continuing air monitoring required?

PART 4 - AIR SAMPLING RESULTS

Air monitoring equipment used

Model Serial Number Date Calibrated User Name

Air monitoring results

Date Time Location Oxygen % LEL H2S CO

Has all required air monitoring been done throughout the confined space? Yes No

Test done by:

PART 5 - LIST ALL AUTHORIZED ENTRANTS AND ATTENDANTS

(completed by the Entry Supervisor and initiated by Entrants and Attendants)

Entrants Signature

Attendants Signature

PART 6 - CERTIFICATION

We have reveiwed the work authorized by this permit and the information contained here-in. Written instrcutions and procedures have been received and are understood. This permit is not valid unless all appropriate items are complete.

Permit prepared by: (Supervisor)

Approved by: (Safety Office)

This permit to be kept at job site. Return job site copy to Safety Office following job completion.

Sheet2

Sheet3 image2.emf

Microsoft_Excel_97-2003_Worksheet1.xls Sheet1

CONFINED SPACE ENTRY PERMIT ATTACHMENT C

DATE ISSUED: __/__/____ TIME ISSUED: __:__ a.m. p.m.

DATE EXPIRES: __/__/____ TIME EXPIRES: __:__ a.m. p.m.

NOTE: IN THE EVENT OF AN EMERGENCY, CALL 911

NOTE: IF THE CONDITIONS OR PROCEDURES SPECIFIED ON THIS PERMIT CHANGE, STOP

WORK IMMEDIATELY AND NOTIFY THE SAFETY OFFICE

CONFINED SPACE ID:

CONFINED SPACE LOCATION:

DESCRIPTION OF CONFINED SPACE:

DESCRIPTION OF WORK TO BE PERFORMED:

MATERIALS OR CHEMICALS LOCATED AND/OR BROUGHT INTO THE CONFINED SPACE:

EQUIPMENT LOCATED OR TO BE BROUGHT INTO THE CONFINED SPACE:

CHECK ALL POTENTIAL HAZARDS

HAZARDOUS ATMOSPHERS

FLAMMABLE IRRITANT OXYGEN-DEFICIENT

TOXIC CORROSIVE OXYGEN-ENRICHED

OTHER:

PHYSICAL HAZARDS

TEMPERATURE VIBRATION SPARK PRODUCING

CHEMICAL ABSORPTION ELECTRICAL EQUIP. OPERATIONS

NOISE MECHANICAL EQUIP. ENGULFMENT

ENTRAPMENT SPILLED LIQUIDS RADIATION

OTHER:

Yes No Is lockout/tagout required? List isolation points:

Yes No Are GFCI's required on all electrical power?

Yes No Is explosion-proof equipment required?

Yes No Are barriers required?

Yes No Is communication equipment required?

Yes No Is telephone or 2-way readio for summoning rescue available?

Yes No Are MSDS's for all materials in the confined space attached?

Yes No Have supervisors, entrants and attendant personnel been trained?

CHECK REQUIRED EMERGENCY EQUIPMENT:

Fire Extinguisher Life Line Retrieval Line

Emercency Shower / Eyewash Tripod and Winch

Safety Harness Other:

Special entry and/or work procedures?

List required personal protective equipment:

ATTACHMENT C

PART 3 - PERMIT REVIEW

Yes No Has appropriate air monitoring been identified

Yes No Are respirators required? List types:

Yes No Are hazard controls and PPE appropriate and adequate?

Yes No Has the safety office approved the operating procedure?

Yes No Is continuing air monitoring required?

PART 4 - AIR SAMPLING RESULTS

Air monitoring equipment used

Model Serial Number Date Calibrated User Name

Air monitoring results

Date Time Location Oxygen % LEL H2S CO

Has all required air monitoring been done throughout the confined space? Yes No

Test done by:

PART 5 - LIST ALL AUTHORIZED ENTRANTS AND ATTENDANTS

Who is performing the work? TVHS ___ Contractor ___

Entrants Signature

Attendants Signature

PART 6 - CERTIFICATION

We have reveiwed the work authorized by this permit and the information contained here-in. Written instrcutions and procedures have been received and are understood. This permit is not valid unless all appropriate items are complete.

Permit prepared by: (Supervisor)

Approved by: (Safety Office)

This permit to be kept at job site. Return job site copy to Safety Office following job completion.

Sheet2

Sheet3 image1.emf