Memorandum Interstitial Space.pdf

DEPARTMENT OF VETERANS AFFAIRS Policy Memorandum 007-15-04 South Texas Veterans Health Care System San Antonio, Texas 78229-4044 May 11, 2015

WORKING SAFELY IN INTERSTITIAL SPACES

1. PURPOSE: To ensure that all employees and contractors brought into the South Texas Veterans Health Care System (STVHCS) take every precaution to ensure safety while working in interstitial spaces at Audie L. Murphy VA Hospital (ALMD).

2. POLICY: Each person working in the interstitial spaces will reduce or eliminate the possibility of people and/or equipment from falling through the ceiling into spaces below. This only includes working above specified floors and does not include the pipe space.

3. ACTION:

a. Definitions:

(1) Construction – OSHA defines as construction, alteration, and/or repair, including painting and decorating of a large scale or high complexity.

(2) Routine Maintenance – an activity such as making or keeping a structure, fixture, or foundation in proper condition in a routine, scheduled, or anticipated fashion as well as keeping equipment working in its existing state. Does not include replacement of significant components.

b. Accountability:

(1) The Chief, Safety Service, is responsible for ensuring that all work is done safely in interstitial spaces. Maintenance and Operations (M&O), Biomedical Engineering, Office of Information Technology (OIT), computer and communication installation service contractors, and ALL contractors’ employees are responsible to be trained in this policy and perform the safety requirements contained herein.

(2) Engineering and the Contracting Officer’s Representative (COR) are responsible for training employees and ensuring the requirements are followed. Contractors will not be issued keys for interstitials until a record of training is on file.

(3) Contractors working at ALMD are responsible to train their employees as well as subcontractor employees and ensure that the requirements are followed.

(4) Logistics and Contracting are responsible for including these requirements in contracts where work will occur in interstitial spaces.

(5) Employees are responsible for following these guidelines and to report any infractions by themselves and/or others. Violations of this policy should be reported to the Chief, Safety Service.

b. Procedures:

(1) All work in the interstitial space will be performed within the confines of the catwalk or a properly secured platform and appropriate fall protection when working outside the confines of the catwalk.

(2) When a work platform cannot be secured, or is impractical, a risk assessment must be conducted to determine the appropriate fall protection plan for the task. For routine maintenance the M&O supervisor will be responsible for ensuring a risk assessment is completed prior to the task being conducted. For construction projects the risk assessment will be complete as part of the Pre-Construction Risk Assessment (PCRA) process.

POLICY MEMORANDUM 007-15-04

(a) The design and construction of working platforms and fall protection must be approved by the Safety Office, and COR, M&O Foreman, OIT, or Bio-med for their respective projects prior to use.

(b) Fall protection must be inspected by a competent person before each use, for strength and reliability. This will be the section supervisor and/or his designee.

(3) All M&O personnel will be required to obtain an interstitial work permit from their supervisor for all routine maintenance, preventive maintenance, and work orders. In the event that their supervisor is not available they can obtain this permit from the M&O Foremen or any other supervisor. Permits can be obtained for the duration of the job.

In the event of an emergency, an interstitial work permit can be obtained after the emergency has been secured. All personnel will notify their supervisor verbally of the location of the work being performed and the nature of the emergency.

(4) Contractors must obtain interstitial permits for daily entry 24 hours in advance. Only the Chief, Safety Service, and/or his designee may grant exceptions to this timeframe based on the recurring task being performed. The contractor must provide date, time, interstitial and floor location to the COR prior to the start of work.

(5) The COR, M&O Foreman, OIT, and Bio-med will notify nurse managers and supervisors of the work being done above their area no later than 24 hours, or as soon as possible prior to the start of work. All employees, patients, and visitors will be relocated from the area by the COR, M&O Foreman, OIT, and Bio-med if core drilling is being conducted in the space above.

(6) All personnel working in the interstitial space will wear the appropriate Personnel Protective Equipment (PPE) when performing construction and maintenance work as previously defined. In areas where there are potential head strike hazards only head protection complying with OSHA Standard 1926.100 will be recognized as proper PPE. Bump caps do not meet the standard and are unauthorized at ALMD.

(7) All employees and contractors shall conduct themselves in a professional manner with respect for occupants below while in the interstitial space. This includes, but is not limited to, verbal interactions and music in the interstitial space as well as job activities on the floor above.

(8) All construction helpers, apprentices, and laborers will be under direct supervision of a competent person and/or supervisor while working in the interstitial space. Training will be conducted by the competent person/supervisor during annual PPE review. Non-authorized personnel (family, patients, friends, etc.) are prohibited from entry into the interstitial space.

(9) There will be NO EATING, DRINKING, USE OF TOBACCO PRODUCTS, OR URINATING while working in interstitial spaces. Contractors violating any of these rules will result in being asked to immediately leave the premises. Employees who violate these rules will be subject to disciplinary action.

(10) The COR, M&O Foreman, OIT, and Bio-med will conduct a daily safety walk-through inspection of all interstitial spaces where work is being performed. Weekly inspections will be conducted for all Class III & IV construction projects by a multidisciplinary inspection team during construction rounds.

(11) All personnel working in the interstitial space will practice the buddy system to the greatest extent possible.

(12) Any Architect/Engineering (A/E) firm and their contractors must be accompanied by Engineering staff. Private firms and or companies must comply with all safety procedures while conducting architectural, engineering, and/or design surveys in the interstitial.

(13) Outside the boundary of the catwalk, metal containers will not be used to hold tools. Plastic containers or canvas buckets should be used. All power/cordless tools and other material greater than 2lbs will be secured by tie off ropes. All tanks, (i.e. Acetylene) will remain on the catwalk.

(14) CORs, M&O Foreman, OIT, Bio-med, and Safety will document non-compliance of safety procedures in the interstitial. Administrative action may be taken for repeat offenders.

(15) All fall protection must be in good operating condition, and must be inspected prior to use.

If equipment is found to be unsafe, it must be taken out of service.

4. REFERENCES:

a. VHA Directives 7701 and 7701.1, Occupational Safety and Health (OSH)

b. VHA Directive 2004-012, Safety and Health During Construction Activities

c. 29 CFR 1926 OSHA Construction Industry Regulations, Current Edition

5. RESPONSIBILITY: Chief, Safety Service (007)

6. RESCISSION: STVHCS Policy Memorandum 007-12-04 dated November 6, 2012

7. RECERTIFICATION: May 2020

(Signature on file)

JULIANNE FLYNN, MD

Acting Director Attachment

DISTRIBUTION: A & B

Audie L. Murphy VA Hospital Division Permit for Interstitial Entry (April 1, 2015)

All general contractors and sub-contractors must obtain a permit for DAILY entry into interstitial space from Safety Service. Only the Chief, Safety Service, and/or his designee may grant exceptions to this timeframe based on the recurring task being performed. M&O, Biomed, OIT are required to obtain a permit for interstitial entry for construction and routine maintenance.

Interstitial doors provide a barrier and must be closed at all times (including smoke wall hatch doors) and absolutely NO food, drink, or tobacco products are permitted.

• Before entering the interstitial space all personnel must complete one-time fall protection training and comply with STVHCS Policy Memorandum 007-15-04 (Working Safely in Interstitial Spaces). Fall protection training will be conducted by the competent person.

• Contractors will NOT route wire or cable through wire chases, pipe chases, and/or fire/smoke barriers without written authorization from the COR or Safety Service. The COR will record the location of penetrations of all wire chases or fire/smoke barriers, and ensure penetrations are sealed correctly with a NFPA/JC approved method/material. M&O staff must notify the Foreman of wire routing, fire/smoke barrier, and chase penetrations. The COR, M&O Foreman, Biomed, and OIT will be responsible to inspect all work completed in the interstitial by a contractor prior to acceptance.

1. Contractor/Section/Department Name:

2. Date:

3. Name of Foreman/Competent Person and Contact Number:

4. Floor of Interstitial:

5. Nearest Stairwell/Elevator to Interstitial:

6. Type of work being accomplished:

a. Does work involve routing cabling, conduit, piping in interstitial space, specify smoke/fire barriers:

YES / NO

(CIRCLE ONE)

b. Does work involve routing cabling, conduit, piping via chase from floor to floor:

YES / NO

(CIRCLE ONE)

7. Will work be done on catwalk only: YES / NO

(CIRCLE ONE)

8. COR/M&O Foreman/Biomed/OIT that will inspect the interstitial work area (Initials & Date):

9. Reviewed by Safety Office (Initials & Date):

Attachment

For off catwalk work:

1. Fall Protection is REQUIRED: ___________

2. Catch material must be in place for possible dropped material: ___________