SOP IH-23 Confined Space Entry (new format).docx

March 30, 2022 SOP – IH 23

CONFINED SPACE ENTRY

SOP – IH 23

March 8, 2022 SOP – IH 23

Aleda E. Lutz VAMC Saginaw, Michigan 48602 Signatory Authority:

Facilities Management Chief Responsible Owner:

Safety Manager and Industrial Hygienist Service Line(s):

Facilities Management Service (FMS) Effective Date:

March 8, 2022 Recertification Date:

March 31, 2027

1. PURPOSE AND AUTHORITY

a. The purpose of this confined space entry standard operating procedure (SOP) is to establish procedures on limiting entry into confined spaces to those individuals experienced in performing work in confined spaces. Provide protection of all persons entering confined spaces. The Medical Center shall provide necessary assistance and protection to employees performing work in confined spaces.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with precautions associated with entry into areas classified as confined spaces by 29 CFR 1910.146.

2. RESPONSIBILITIES

a. Medical Center Director is has the overall responsibility and accountability for the Permit Required Confined Space Entry Program/SOP.

b. Associate Medical Center Director is responsible for supporting the Safety Manager and Industrial Hygienist with the implementation of the Confined Space Entry Program, assuring adequate resources are available to fully comply with its requirements.

c. Chief, Facilities Management Services (FMS), responsibilities include.

1) Ensuring this SOP is implemented and complied with by all FMS personal and contractors performing work at the Medical Center.

2) FMS staff are trained and educated in the requirements of this regulation and will monitor compliance.

d. Contracting Officer’s Representative (COR) responsibilities include:

1) Ensuring contractors performing work at the Medical Center are aware of and follow the responsibilities outlined in this SOP.

2) To notify the FMS when entry is needed so all proper notifications can be made.

3) Ensuring contractors under their supervision have a valid Permit Required Confined Space Entry Program as required by 29 CFR 1910.146. All contractors or subcontractors, prior to entering any confined spaces, must provide copies of their confined space entry program to the Safety Manger or Industrial Hygienist for review.

e. Vendors contracted to perform work which includes PRCS confined space entry must provide proof of confined space training, all equipment necessary for confined space entry, air monitoring equipment and complete entry permit provided by the vendor. Vendors must complete the confined space entry briefing prior to the onset of work (Attachment B)

f. FMS Supervisors are responsible for the actions of their employees. Entry Supervisors are responsible for obtaining Permit-Required Confined Space Entry Permit (Attachment A) and coordinating inspection of the confined space prior to entry.

g. FMS employees will comply with the policies and procedures of this regulation. They have the right to question any rule or hazard involved with this regulation without fear of reprisal.

h. The Safety Manager or trained Facilities Management Service (FMS) staff is responsible:

1) Monitoring and signing off the Confined Space Entry Permit (Attachment A).

2) Reviewing and approving contractors and subcontractors confined space entry programs prior to performing work at the Medical Center.

3) Designated as the Confined Space Program Manager and ensure the implementation of all aspects of this policy.

4) Periodically reviews existing identified Permit Confined Space Entries to ensure appreciate signs/labels have not been discarded and if any changes have manifested.

i. The Industrial Hygienist is responsible for:

1) Monitoring and signing off the Confined Space Entry Permit (Attachment A).

2) Reviewing and approving contractors and subcontractors confined space entry programs prior to performing work at the Medical Center.

3) Designated as the Confined Space Program Manager and ensure the implementation of all aspects of this policy.

4) Periodically reviews existing identified Permit Confined Space Entries to ensure appreciate signs/labels have not been discarded and if any changes have manifested.

3. PROCEDURES

a. Review. The Safety Manager and Industrial Hygienist are the technical advisors on this regulation and will monitor program compliance

b. Permits – Permit Required Confined Space Entry Permit (Attachment A) is required before entering a Permit Required Confined Space (PRCS) and will be posted at the site.

(1) The Safety Manager will maintain permits for at least one year.

(2) Specific Job – Issued for a short period of time, not to exceed one 8hour day, for an area that is not routinely entered where the atmosphere is not hazardous.

(3) Hazardous Space – Issued for a space, which is low in oxygen, or the atmosphere is toxic or flammable. Issued for a short period of time and not to exceed one 8hour day.

c. Monitoring.

(1) Before entering any confined space, the atmosphere will be tested by the Safety Manager, Industrial Hygienist, or trained FMS staff. The work area will be tested periodically during work and before reentering after a break of 30 minutes or longer.

(2) Atmospheric testing will be completed with a direct reading instrument capable of detecting percent oxygen, percent of the lower explosion limit (LEL), and levels of toxic gas concentration.

(3) A person, who has been trained in the use of the equipment, understands the instrument, and its shortcomings will complete atmospheric testing.

(4) Hazardous atmosphere means an atmosphere that may expose employees to a risk of death, incapacitation, and impairment of ability to self-rescue (that is, escape unaided from a permit space), injury, or acute illness from one or more of the following causes:

(a) Flammable gas, vapor, or mists in excess of 10 percent of the lower explosion limit (LEL).

(b) Airborne combustible dust at a concentration that exceeds its LEL.

(c) Atmospheric oxygen concentration that is less than 19.5 percent or greater than 23.5 percent.

(d) Atmospheric concentration of any substance for which Permissible Exposure Limit (PEL) could be exceeded.

(e) Any other atmospheric condition recognized as immediately dangerous to life or health.

(5) An area atmospheric monitor will be used to monitor for percent oxygen and percent of lower explosion limit and sound an alarm when conditions deteriorate below allowable levels.

(6) Testing of the Stratified Atmospheres – Atmospheres involving a descent will be tested at a distance of every four feet and to each side.

(7) The Safety Manager and/or Industrial Hygienist will conduct a space re-evaluation if it is determined that space configurations, modifications, or environmental changes have occurred. This includes a change in atmosphere, ventilation system, or other physical hazards, which previously did not exist in the space.

d. Training:

(1) All employees entering any type of confined space will meet health-screening requirements in accordance with Medical Center Memorandum 00-31, Respirator Program if they are to use a respirator in entering.

(2) All employees entering any type of confined space will be trained in the work that has to be done, the hazards of the operation, how to use the assigned equipment and how to operate under the rescue plan.

(3) If a hazard atmosphere develops during entry all entrants shall leave the any type of confined space immediately.

e. Equipment.

(1) All respirators and breathing equipment must be National Institute for Occupational Safety and Health (NIOSH) approved and its use must comply with Medical Center Memorandum 00-31.

(2) All electrical equipment must be properly grounded and equipped with ground fault interrupters and will have explosion-proof electric motors or be air-powered equipment for use in hazardous space.

(3) All equipment for hazardous confined space entry must be explosion-proof and non-sparking.

f. Identification.

(1) All PRCS entries with the exception of manholes, must be identified by a permanently affixed sign at the confined space entrance. The signage will state "Danger Confined Space Entry by Permit Only".

(2) The list of confined spaces is attached to this policy.

g. Procedures.

(1) Before entering a PRCS, first test the atmosphere with a long probe to the bottom of the confined space (See Monitoring.). If the atmosphere is toxic or there is inadequate oxygen, the area must be forced-ventilated for 30 minutes. After that time, another atmospheric test will be made. If the atmosphere still does not meet minimum requirements, the area will be considered hazardous and continuous forge air ventilation shall continue until all employees have left the space.

(2) Prior to entering a PRCS, notify VA Police to monitor local fire department activity. Police will notify FMS to restrict entry into a permit required confined space if the local fire department becomes unable to respond due to a community emergency.

(3) To enter a PRCS, employees must use a fullbody harness with a lifeline connected unless:

(a) Use will make the entry more hazardous.

(b) Use will not contribute to non-entry rescue.

(4) Hot work will be done in any type of confined space only after a Hot Work Permit has been obtained and the proper precautions taken. Refer to SOP 138-14 Hot Work Operations. Hot work is any work that involves burning, welding, using fire or spark producing tools, or that produces a source of ignition. Hot work is prohibited if meter readings indicate 10% of the lower explosive limit or above and/or oxygen levels above 23.5%.

(5) An attendant will, without exception, be posted while any employee is in any confined space. The attendant will always maintain in contact and communication with the employee in the space and will not enter the space or leave the watch. The second observer (Entry Supervisor) will be in the general area and be ready and able to relieve or assist the attendant.

h. Extraction/Rescue Procedures.

(1) A briefing will be held prior to entry into and work in any type of confined space. The briefing will review the work to be done, the hazards and the emergency procedures to be followed. All employees will be trained in the work that has to be done, the hazards of the operations, how to use the assigned equipment and how to use emergency extraction equipment.

(2) All rescues will be non-entry rescues using extraction equipment (tripod, harness, and lifelines). Extraction Procedures will be preplanned and tested and will include equipment needed, notification methods, training, and rescue procedures.

(3) In the event any type of confined space must be entered to perform a rescue, it will be done by calling the Saginaw Fire Department.

i. Prescribed Form. Entry into PRCS will be assigned by a FMS Supervisor. All items on the PRCS form (Attachment A) will be completed by the PRCS Entry Supervisor (who may be the Attendant per CFR 1910.146) and the Safety Representative or Industrial Hygienist prior to entering the confined space. The Safety Manager will maintain the original of the form. A copy will also be posted at the location of the confined space entry until completion of work.

3. DEFINITIONS

a. Attendant. An individual stationed outside a confined space who monitors authorized entrants and performs other duties relative to the entry procedures.

b. Authorized entrant. An employee or contractor who is trained and authorized to complete a confined space entry permit and enter a confined space.

c. Confined space. A confined space meets all the items below:

(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 (limited egress); and

(3) Is not designed for continuous employee occupancy.

d. Engulfment. The surrounding and effective capture of a person by a liquid or finely divided solid substance that can be aspirated to cause death by filling or plugging the respiratory system or that can exert force on the body to cause death by strangulation, constriction, or crushing.

e. Entry. The action by which a person passes through an opening into a permit-required confined space. Entry includes all 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.

f. Entry Supervisor. The person (such as the employer, foreman, or crew chief) responsible 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 by this section. NOTE: An entry supervisor also may serve as an attendant or as an authorized entrant, as long as that person is trained and equipped as required by this section for each role he or she fills. Also, the duties of entry supervisor may be passed from one individual to another during an entry operation.

g. Hazardous Atmosphere. An atmosphere that may expose an employee to the risk of death, incapacitation, impairment of ability to self-rescue (that is, escape unaided from a permit space), injury, or acute illness from one or more of the following causes:

(1) Flammable gas, vapor, or mist greater than 10 percent of its lower explosion limit (LEL).

(2) Oxygen concentration less than 19.5% or greater than 23.5%.

(3) Concentration of any substance greater than its permissible exposure limit (PEL).

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

h. Non-permit confined space. 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.

i. Permit-required confined space (permit space). A confined space that has one or more of the following characteristics:

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

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

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

4. REFERENCES

a. OSHA 29 CFR 1910.146. Permit-Required Confined Spaces

b. OSHA, 29 CFR 1910.134, Respiratory Protection

c. Medical Center Memorandum 00-31, Respirator Program dated November 2019.

d. SOP 138-14 Hot Work Operations dated March 2021.

5. REVIEW

Frequency of required review is yearly, at recertification, and including any changes to the governing document, national policy, or a health care accreditation/regulatory requirement for more frequent review.

6. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of March 2027 – 5 years from effective date. In the event of contradiction with national policy, the national policy supersedes and controls.

7. SIGNATORY AUTHORITY

Kevin Russell, PE, CFM Chief Facilities Management Service Date Approved: March 8, 2022 NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Rural Review, and published on the central repository https://dvagov.sharepoint.com/sites/VHASAG/MCM/Active%20MCMs/Forms/AllItems.aspx

Attachment A – PERMIT-REQUIRED CONFINED SPACE ENTRY (PRCS) PERMIT Attachment B – CONFINED SPACE ENTRY BRIEFING Attachment C – CONFINED SPACE LIST

Attachment A

Attachment B CONFINED SPACE ENTRY BRIEFING (for Vendor use ONLY)

1. Date: ____________________________

2. Confined Space Entry Location: ___________________

3. Permit-Required Confined Space: _____________ (YES/NO)

4. Hazards of the Space:__________________________________________________

5. Purpose of Entry: ________________________________________________________________________________________________________________________________________

6. Vendor Performing Confined Space Entry: ___________________________________

VENDOR CONFINED SPACE AND PROTECTIVE EQUIPMENT INFORMATION (check applicable items)

TRAINING

o Evidence of Confined Space Program o Evidence of Confined Space Training

EQUIPMENT

OBSERVATION

o Attendant o Monitor/Recorder

PERMIT

o Permit-required confined space permit provided by vendor

CONCERNS/COMMENTS/ADDITIONAL INFORMATION

7. Signature/Date VA representative: _________________________________________

8. Signature/Date Vendor Representative: _____________________________________

Post this paper at Engineering Board during work.

9. At conclusion of entry VA and Vendor will conduct post entry evaluation (comments required):

EMERGENCY NUMBERS: FMS 13870/13884 SAGINAW FIRE DEPT. 911 SAFETY 13903

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