Attachment 8 - Exhibits Chillicothe VAMC SOP.pdf

EXHIBITS

CHILLICOTHE VAMC

STANDARD OPERATING PROCEDURES

Construction Risk Reduction and Infection Control Plan

SOP 13

Chillicothe VA Medical Center Chillicothe, OH 45601

Signatory Authority:

Chief, Facilities Management Service

Responsible Owner:

Facilities Management Service (138)

1. PURPOSE AND AUTHORITY

Service Line(s):

Facilities Management Service

Effective Date:

December 13, 2022

Recertification Date:

December 13, 2027

a. The purpose of this standard operating procedure (SOP) is to describe measure for identification and protection of at-risk patients, control of exposure, and prevention of the spread of infection during construction, demolition, renovation, and repair projects at the medical center.

b. It is the policy of this VA facility to proactively reduce the potential of infection resulting from construction, demolition, renovation, and non-routine maintenance, using current technology to protect patients, visitors, and staff. The appropriate staff is involved in all stages including planning, design, procurement of construction, and construction phases.

c. Construction and remodeling are defined as activities that disturb the environment. This may include demolition of existing ceilings or walls; exposure of ceiling spaces by removal of all or part of ceiling; breeching of walls, ceilings, or floors;

removal of uncovered debris from construction areas; and major disturbance of soil in which dust or dirt becomes airborne. The Occupational Safety and Health Administration (OSHA) defines construction and remodeling as the alteration or repair, including painting and decorating of a large scale or high complexity.

d. This SOP set forth mandatory procedures and processes to ensure compliance with VHA Directive 7715, Safety and Health During Construction, dated April 6, 2017.

2. PROCEDURES

a. Contracted projects.

(1) Management of construction related risk for contracted projects, including capital improvement projects, including nonrecurring maintenance (NRM), minor or clinical special initiatives (CSI), begins with the project application. The SOW and project budget define in the project application included consideration for project phasing and infection control measures.

December 13, 2022 SOP 13

(2) Project Managers use approved applications to write the scope of services document for architectural and engineering (A/E) services required for development of complete contract documents. Project Managers include specific requirements in the A/E scope of services that the PCRA and ICRA process is considered in project programming, schematic design, design development and construction documents set for each phase of the project.

(3) Project Managers involve the Infection Control Nurse, or designee, as early as practicable in project programming and in all subsequent phases of project document development. Project Managers ensure that draft PCRA’s and ICRA’s are incorporated into the planning process no later than the schematic design (35%) set and updated throughout the remainder of the planning process, culminating in a completed PCRA and ICRA for all phases of the project with resulting requirements fully integrated into the final plans and specifications.

(4) Prior to forwarding final plans and specifications to Contracting, the Project Manager writes a general requirements specification section to clearly convey commissioning, preoccupancy environmental testing, documentation or any other relevant construction safety or infection control requirements not elsewhere defined in the plans or specifications or that may require additional detail.

(5) Project Managers forward completed plans and specifications to Contracting for action and ensure to the best of their ability that the Contracting Officer understands the significance of construction and infection control risk reduction strategies incorporated into the plans and specifications.

(6) Upon award of a construction contract and commencement of work, the Project Manager and the Infection Control Nurse, or designee, conduct periodic inspections at intervals commensurate with the sequence of work and associated risk, Weekly inspections are conducted in accordance with Engineering Section Standard Operating Procedure (SOP) 12, Construction Project Inspections.

(7) Prior to occupancy, the Project Manager coordinates all environmental testing and clearance activities stipulated in the ICRA or projected documents and ensures that documentation of testing required by the contract is in hand prior to final acceptance of the project.

b. Station level construction, demolition, renovation, and non-routine maintenance activities, as well as installation of equipment by VA staff or contractors require early collaboration between Project Managers and the Infection Control Nurse, or designee, and due to their often less formal project structure, require a high degree of cooperation and communication between all stake holders.

(1) The Project Manager develops a SOW or project plan with input from affected stake holders and the Infection Control Nurse, or designee. The PCRA and ICRA are completed at this time and all related mitigating measures are included in the SOW.

Prior to commencement of work, the Project Manager notifies Infection Control and affected staff that work is beginning. The Project Manager coordinates egress pathway obstructions or critical life safety systems with the Fire Department prior to these activities.

(2) Prior to occupancy/acceptance of work or completion of the contract, the Project Manager coordinates all environmental testing and clearance activities stipulated in the SOW and ensures that documentation of required testing is in hand prior to final acceptance.

3. ASSIGNMENT OF RESPONSIBILITIES

a. The Chief. Engineering Section is assigned the responsibility to ensure that risks associated with construction, demolition, renovation, and non-routine maintenance activities are appropriately assessed and mitigating measures implemented. Risks are assessed and categorized using the Pre-Construction Risk Assessment (PCRA) and Infection Control Risk Assessment (ICRA (VA Form 10-431) or the Quick PCRA (VA Form 10-152) and Quick ICRA (VA Form 10-153). Forms are available on the Construction Safety SharePoint at https://dvagov.sharepoint.com/sites/Chillicothe/projectsafety/default.aspx

b. The Contracting Officer. Is assigned the responsibility to: Enforce contracts for contracted projects.

c. Project Managers. Contracting Officer Representatives (COR), Engineering Section Shop Supervisors, Project Engineers, Interior Designers or other medical center staff responsible for managing construction, demolition, renovation or non-routine maintenance activities performed by medical center staff or contractors: is assigned the responsibility for ensuring that the PCRA and ICRA (VA Form 10-431), have been developed to assess risks associated with the work and to incorporate appropriate phasing plans, mitigating measures and specifications into the work plans, statement of work (SOW) or contract documents. Additional responsibilities include:

(1) Working with Contracting Officers to ensure the terms of the contract are followed, when applicable.

(2) Coordinating utility outages, potential interruptions to critical infrastructure, life safety systems or blocking egress pathways with affected staff and the Fire Department.

(3) Signing completed PCRAs and ICRAs (VA Form 10-431) to acknowledge any mitigation measures or recommendations made by the Safety Office and Infection Control.

d. Contractors. Is assigned the responsibility to: complying with all contract requirements.

e. The Safety Manager. Is assigned the responsibility to: Actively participate in the PCRA and ICRA development process, reviewing project specifications, work plans, SOWs, and contract documents to identify potential health or safety risks, make recommendations for mitigating measures to address risks identified, and to assist Project Managers or the Fires Department in addressing health and safety issues that arise through the course of a project.

f. The Infection Control Nurse, or designee. Is assigned the responsibility to:

Actively participate in the PCRA and ICRA development process, reviewing project specifications, work plans, SOWs, and contract documents to identify potential infection control risks and other impacts to patient care, make recommendations for mitigating measures to address risks identified, and to assist Project Managers in addressing infection control issues that arise through the course of a project.

g. The Fire Chief. Is assigned the responsibility to: Implement and document interim life safety measures (ILSMs) at appropriate stages of construction.

4. DEFINITIONS

a. “None.”

5. REFERENCES

a. VHA Directive 7715, Safety and Health During Construction, dated April 6, 2017.

Occupational Safety and Health Administration (OSHA), 29 CFR 1910.12 Construction Safety SharePoint

6. REVIEW

This SOP will be reviewed every five (5) years, at minimum for recertification or when there are necessary changes to the document or governing documents (for example, national policy or a health care accreditation body mandate), and any regulatory requirement for more frequent review.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of December 2027. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

RYAN

JETER

Digitally signed by RYAN

JETER

Date: 2022.12.14

06:50:22 -05'00'

Ryan Jeter, PE, PS, CHFM Chief, Facilities Management Service Date Approved: December 13, 2022

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Facilities Management Service (138), Planning and Design (138B), Infection control Nurse (11F2) Safety and Occupational Health Manager (001S). SOPs are available at: https://dvagov.sharepoint.com/sites/vhachidcs/default.aspx.

https://dvagov.sharepoint.com/sites/vhachidcs/default.aspx

Confined Space Entry

SOP 20

Chillicothe VA Medical Center Chillicothe, Ohio 45601

Signatory Authority:

Chief, Facilities Management Service

Responsible Owner:

Facilities Management Service (138)

Service Line(s):

Facilities Management Service

Effective Date:

December 12, 2022

Recertification Date:

December 12, 2027

1. PURPOSE AND AUTHORITY

a. To establish guidelines and procedures for working in confined spaces and to provide maximum safety protection for employees and contractors who are performing work in confined spaces.

2. PROCEDURES

a. When entry to a confined space is necessary, the following procedures are followed on a daily basis:

(1) The area is inspected by the work supervisor and the OSH Manager or Industrial Hygienist to determine potential hazards, isolation requirements, types of equipment to be used, number of employees required to enter the space and standby personnel required.

(2) The equipment or area is isolated and allowed to ventilate. Confined entry points are posted with Danger, Do Not Enter signage, until such time as requirements have been met.

(3) The Chief, Engineering Section, or designee, issues the Confined Space Entry Permit, Appendix A. The OSH Manager and Fire Department are notified of the proposed entry permit.

Emergency standby equipment is available at the location of the confined space.

(4) The OSH Manager or Industrial Hygienist conduct atmospheric testing and inspect the job site for general safety, isolation, and standby equipment. Prior to entry, the OSH Manager or Industrial Hygienist completes and signs the Confined Space Pre-Entry Checklist, Appendix B, and documents test results.

(5) Each point of entry must have a completed and signed entry permit posted.

(6) At the conclusion of the workday, the entry permit is removed and Danger, Do Not Enter signage is posted.

(7) Entry to a confined space is not permitted until it has been properly prepared, hazards have been identified, standby equipment has been placed on site, and an entry permit has been completed and posted.

(8) The entry permit details the requirements for entry into the confined space.

December 12, 2022 SOP 20

(9) Prior to entering the confined space, each employee reviews the entry permit for specific requirements, reviews emergency procedures, and inspects the confined space for location of entry and exit points.

(10) Retesting of the atmospheric conditions is completed at lunch break or a four-hour interval.

(11) Every confined space is considered immediately dangerous to life and health until it is tested and proven otherwise.

(12) No compressed gas cylinders are permitted inside of the confined space.

(13) Portable electrical tools, equipment, and lighting are powered through a ground fault circuit interrupter.

b. Entry attendants assigned to remain outside of the confined space are equipped with radios, harness, and lifeline. Entry attendants:

(1) Maintain visual or verbal contact with those in the confined space at all times.

(2) Maintain safety lines, if in use.

(3) Summon rescue personnel, if necessary

(4) Summon a supervisor if entry is made in violation of this policy.

(5) Review the conditions for entry into the space as indicated on the Confined Space Entry Permit, Appendix A.

(6) Do not enter or leave the confined space at any time, unless relieved of standby duties.

(7) Continuously maintain an accurate count of authorized entrants in the permit space.

(8) During an emergency situation, make rescue attempts using lifelines from outside the confined space while awaiting the arrival of rescue personnel.

(9) Remain aware of possible behavioral effects of hazard exposure in authorized entrants.

c. Fire Department personnel accomplish rescue of persons from a confined space Emergency rescue personnel are trained in rescue techniques, self-contained breathing apparatus (SCBA) use, use of rescue equipment, and the procedures contained in this policy. Emergency rescue personnel are utilized as entry attendants for confined spaces that can present special hazards, as determined by the supervisor and/or safety representative. Rescue equipment may include:

(1) Harness.

(2) Lifeline.

(3) SCBA.

(4) Stokes litter.

(5) Tripod retrieval system.

(6) Standard firefighter clothing and personnel protective equipment.

d. Isolating equipment for entry is accomplished by blinding or air gapping lines to and from the equipment. Small, screwed lines are disconnected and plugged. Isolation is made as close in proximity as possible to the equipment to be entered.

(1) Double blocks and bleeders are not permitted as a substitute for blinding, except when approved by the OSH Manager or Industrial Hygienist.

(2) Where several pieces of equipment are isolated as a unit, each piece of interconnected equipment is open to the atmosphere and made safe for entry.

(3) Equipment entered is electrically isolated in accordance with Engineering Section SOP 30, Control of Hazardous Energy (Lockout/Tagout). Tagging without locking out equipment is not sufficient for confined space entry.

(4) A record is maintained of blinds, plugs and/or other types of isolation for each entry. Records are used to validate the removal of any type of isolation device. Removing one point of isolation voids the entry permit.

e. Authorized entrants communicate with the attendant, as necessary, to enable the attendant to monitor entrant status and to alert entrants should the need to evacuate the space arise.

3. ASSIGNMENT OF RESPONSIBILITIES

a. The Chief, Facilities Management Service (FMS), is responsible for ensuring projects, maintenance and repairs in confined spaces utilize only authorized entrants under a properly executed Confined Space Entry Permit, Appendix A, and ensures permit spaces are identified.

a. The Safety and Occupational Health (OSH) Manager, Industrial Hygienist, or designee, provides technical guidance to affected employees for entry into a confined space. Additional responsibilities include:

(1) Inspecting the confined space prior to entry for compliance to this policy.

(2) Performing atmospheric testing and completing the Confined Space Pre-Entry Checklist, Appendix B.

(3) Providing confined space entry training.

b. The Fire Department provides rescue services and emergency rescue personnel to be utilized as entry attendants for confined spaces that can present special hazards. Emergency rescue personnel are responsible for completing annual confined space rescue training.

c. The entry supervisor is knowledgeable of the hazards associated with permit required spaces, including information on the mode, signs or symptoms, and consequences of the exposure. Additional responsibilities include:

(1) Determining when responsibility for a permit space entry operation is transferred and, at intervals dictated by the hazards and operations performed within the space, that entry operations remain consistent with terms of the entry permit and that acceptable entry conditions are maintained.

(2) Ensuring that equipment needed for safe entry into any permit required space is available and in proper working order.

(3) Verifying that rescue services are available and that the means for summoning rescue services are operable.

(4) Removing unauthorized individuals who enter or attempt to enter the permit space during entry operations.

(5) Verifying, by checking that appropriate entries are made on the permit, that tests specified by the permit are conducted and that procedures and equipment specified by the permit are in place prior to signing and approving the permit and allowing entry to begin.

(6) Terminating the entry and cancelling the permit following task completion.

d. Entry attendants are knowledgeable of permit space hazards, prohibited conditions, the role to remain outside and in communication with entrants, prevention of unauthorized entry, procedures to request rescue and emergency services, and performance of non-entry rescue. The entry attendants’ primary duty is to monitor and protect authorized entrants. Entry attendants are trained on the procedures contained in this policy and are knowledgeable of the hazards associated with permit required spaces, including information on the mode, signs or symptoms, and consequences of the exposure.

e. Authorized entrants are trained on the procedures contained in this policy and are knowledgeable of the hazards associated with permit required spaces, including information on the mode, signs or symptoms, and consequences of the exposure. Additional responsibilities include:

(1) Maintaining proficiency in dealing with the hazards of permit required spaces, proper equipment use, communications systems, acceptable entry and prohibited conditions, immediate evacuation conditions, and safe work task performance.

(2) Alerting the attendant when a prohibited condition is detected wo when any warning sign or symptom of exposure to a dangerous situation is recognized.

(3) Exiting the permit space as quickly as possible when:

I. A prohibited condition is detected.

II. An order to evacuate is given by the attendant or the entry supervisor.

III. An evacuation alarm is activated.

IV. Any warning sign or symptom of exposure to a dangerous situation is recognized.

f. Contractors performing work is a confined space at this facility are required to adhere to the requirements of this SOP.

4. DEFINITIONS

a. Confined Space: An enclosed space that is large enough and so configured that an employee can bodily enter and perform assigned work, has limited or restricted means for entry or exit, and is not designed for continuous employee occupancy. Examples of confined spaces are listed in Appendix C, Confined Spaces, and include storage pits, vats, tanks, boilers, ventilation/exhaust ducts, sewers, tunnels, manholes, underground utility vaults or pipelines, and excavations.

b. Permit Required Confined Space:

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

(2) Contains material with the potential for engulfing of an entrant.

(3) Has internal configurations that could trap or asphyxiate an entrant.

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

c. Hazardous Environment/Atmosphere: An atmosphere presenting a potential for death, disablement, injury, or acute illness from one (1) or more of the following causes:

(1) Less than 19.5 percent or more than 23.5 percent oxygen.

(2) A flammable gas or vapor in excess of 10 percent of its lower explosive limit (LEL).

(3) An airborne combustible dust at a concentration that obscures vision at a distance of five (5) feet or less.

(4) An atmospheric concentration that exceeds the listed numerical value of any toxic, corrosive, or asphyxiant substance listed in the Threshold Limit Value (TLV) book by the American Conference of Governmental Industrial Hygienists (ACGIH) or the permissible exposure limit (PEL) that is reasonably expected to be present.

(5) A biological or radiological hazard or one that is otherwise known to present a safety or acute health hazard.

(6) Any condition immediately dangerous to life or health.

d. Entrapment: An area that contains material with the potential to engulf the entrance.

e. Lower Explosive Limit (LEL): The lowest concentration of gas or vapor (percent by volume in air) that will burn or explode if an ignition source is present.

f. Isolation: A process to remove a confined space from service and to completely protect against the inadvertent release of material by the following:

(1) Blanking: The absolute closure of a pipe, line or duct by fastening a solid plate or cap across the pipe, line or duct capable of withstanding the maximum upstream pressure.

(2) Double Block and Bleed: Isolating a confined space from a line, duct or pipe by locking and tagging two (2) closed in-line valves, and locking and tagging open a drain or bleed in the line between the two (2) closed valves to the outside atmosphere.

(3) Lockout: The placement of a locking device on an energy-isolating device, in accordance with an established procedure, to ensure that the energy-isolating device and the machine or equipment being controlled cannot be operated until the locking device is removed. Lockout devices require a tagging device to be used in conjunction with the locking device unless specifically not required by a documented lockout/tagout procedure. Refer to Engineering Section Standard Operating Procedures (SOP) 30, control of Hazardous Energy (Lockout/Tagout).

(4) Mechanical Isolation: Isolation achieved by disconnecting linkages or removing drive belts or chains of moving parts. Equipment with moving mechanical parts is also blocked in such a manner that there can be no accidental rotation.

g. Permissible Exposure Limit (PEL): Regulatory limits on the amount or concentration of a substance in the air, as established by the Occupational Safety and Health Administration (OSHA).

h. Purging and Ventilation Purging: The method by which gases, vapors or other airborne impurities are displaced from a confined space to adjust the atmosphere to acceptable standards.

This is accomplished by using fluids or vapors (gas, water, steam and/or cleaning solutions) or by forced air ventilation.

i. Ventilation: The movement or circulation of fresh air to keep hazards away after purging.

Ventilation is used after entry is made into a space to:

(1) Supply continuous fresh air for entrants inside to breathe.

(2) Remove potentially hazardous conditions before they become hazardous.

(3) Supply cool air for comfort.

5. REFERENCES

a. SOP NUMBER 30, Control of Hazardous Energy (Lockout/Tagout), dated December 12, 2022.

6. REVIEW

This SOP will be reviewed every five (5) years, at minimum for recertification or when there are necessary changes to the document or governing documents (for example, national policy or a health care accreditation body mandate), and any regulatory requirement for more frequent review.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of December 2027. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

Ryan Jeter, PE, PS, CHFM Chief, Facilities Management Service Date Approved:

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Facilities Management Service (138), Safety and Occupational Health Manager (001S), Industrial Hygienist (001S), Fire Department (07F). SOPs are available at:

https://dvagov.sharepoint.com/sites/vhachidcs/default.aspx.

Appendix A

CONFINED SPACE ENTRY PERMIT

RESCUE/FIRE: Ext. 444 SAFETY: Ext. 17952/17153

PERMIT VALIDATION PERIOD: Date Time From __________ To ________________

LOCATION OF WORK ____________________________________________

DESCRIPTION OF WORK ________________________________________

REQUIREMENT CHECK LIST: RECORDKEEPING:

ITEM YES NO CONDITION

MET

ISOLATION/BLINDING

ELECTRICAL

LOCK/TAGOUT

VENTILATION

MECHANICAL

RESCUE EQUIPMENT

HOT WORK PERMIT

CONTINUOUS

MONITORING

SPECIAL CLOTHING

RESPIRATORS

CLEANING/SLUDGE

REMOVAL

MECHANICAL ISOLATION

OTHER

LIFELINES

FULL BODY HARNESS

RETRIEVAL DEVICE

FIRE EXTINGUISHER

COMMUNICATION

SPECIAL LIGHTING

EMPLOYEES ENTERING AREA:

a. ___________________________________________ b.___________________________________________ c.___________________________________________

SUPERVISOR IN CHARGE:

a. __________________________________________

STANDBY PERSON:

a.__________________________________________

HAZARDOUS CONTANIMATES FOUND:

a.__________________________________________ b.__________________________________________ c.__________________________________________

COMMUNICATION PROCEDURES (to be used by attendants and entrants):

INITIAL EACH TEST COMPLETED AND INDICATE TEST TIME (After initial entry, retest is required after lunch or at 4-hour intervals):

TEST PEL COMPLETION TIME INITIALS RETEST TIME INITIALS

OXYGEN DEFICIENCY (O2) 19.5% - 23%

FLAMMABLE VAPORS (LEL) Any % < 10

CARBON MONOXIDE (CO) 35 PPM

HYDROGEN SULFIDE (H2S) 10 PPM

OTHER TOXINS (specify)

LOCKOUT/TAGOUT

BLINDING/ISOLATION

OTHER

NOTE: STANDBY EQUIPMENT IS REQUIRED AT ALL CONFINED SPACE ENTRIES. STANDBY PERSON IS REQUIRED AT ALL CONFINED SPACE ENTRIES. RESCUE HARNESS MUST BE WORN BY ALL PERSONS ENTERING A CONFINED SPACE.

SIGNATURES:

CHIEF, FACILITIES MANAGEMENT SERVICE (verbal contact after hours) ________________

SUPERVISOR (or designee) IN CHARGE _________________________

TESTING OPERATOR ________________________________

ENTRY CANNOT BE MADE UNTIL ALL CONDITIONS ARE MET AND ALL SIGNATURES OBTAINED.

OP-516 (April 2013)

Appendix B

Confined Space Pre-Entry Checklist

A confined space is either entered through an opening other than a door (such as manhole or side port) or requires the use of a ladder or rungs to reach the working level.

Test results must be satisfactory. This checklist must be completed whenever the job site meets this criteria. See Engineering Services SOP No. 20, Attachment C, Confined Space Listing.

Yes No

1. Did your survey of the surrounding area show it to ( ) ( ) be free of hazards such as drifting vapors from tanks, piping, or sewers?

2. Does your knowledge of industrial or other discharges ( ) ( ) indicate this area is likely to remain free of dangerous air contaminants while occupied?

3. Are you certified in operation of the gas monitor to ( ) ( ) be used?

4. Has a gas monitor functional test (Bump Test) been ( ) ( ) performed this shift on the gas monitor to be used?

5. Did you test the atmosphere of the confined space ( ) ( ) prior to entry?

6. Did the atmosphere check as acceptable (no alarms ( ) ( ) given)?

7. Will the atmosphere be continuously monitored while ( ) ( ) the space is occupied?

Contact the Fire Department (ext. 444) in the event of an emergency.

NOTE: If any of the above questions are answered "no," DO NOT ENTER and contact your immediate supervisor.

Job Location:

Signature Date

Industrial Hygienist or Designee

Appendix C

CONFINED SPACES LISTING

1. Manholes:

ELECTRICAL DISTRIBUTION

SYSTEM MANHOLES

1A 8A 20 30 41

1B 8B 21 31 42

1C 9 22 32 43

2A 10 23 33 44

2B 11 24 34 45

2C 12 24A 34A 46

3 13 25 35 47

4 14 26 36 48

5 15 27 37 49

6 16 27A 37A

6A 17 28 38

7 18 29 39

8 19 29A 40

SIGNAL DISTRIBUTION

SYSTEM MANHOLES

1 11 24 35A

2 12 25 36

2B 13 26 37

2C 14 27 38

3 15 27A 39

4 16 29 40

5 17 29A

6 18 30

7 19 31

7A 20 32

8 21 33

9 22 34

10 23 35

STEAM DISTRIBUTION SYSTEM MANHOLES

1 1H PT17 PT81 5A 11

1A 1I PT18 2 6 13

1B 1J PT41 3 6A 13A

1C 1K PT42 3A 7 13B

1D PT9 PT43 3B 8 13C

1E PT12 PT44 4 8A 15

Appendix C, continued

1F PT13 PT45 4D 9 15A

1G PT16 PT46 5 10 D

STORM MANHOLES

1 19 37 53 71 89

2 20 38 54 72 90

3 21 39 55 73 91

4 22 39A 56 74 92

5 23 40 57 75

6 24 41 58 76

7 25 42 59 77

8 26 43 60 78

9 27 43A 61 79

10 28 44 62 80

11 29 45 63 81

12 30 46 64 82

13 31 47 65 83

14 32 48 66 84

15 33 49 67 85

16 34 50 68 86

17 35 51 69 87

18 36 52 70 88

SANITARY SEWER MANHOLES

1 17 33 49 63B 78

2 18 34 50 63C 79

3 19 35 51 64 80

4 20 36 52 65 81

5 21 37 53 66 82

6 22 38 54 67 83

7 23 39 55 68

8 24 40 56 69

9 25 41 57 70

10 26 42 58 71

11 27 43 59 72

12 28 44 60 73

13 29 45 61 74

14 30 46 62 75

15 31 47 63 76

16 32 48 63A 77

Appendix C, continued

2. Miscellaneous Confined Spaces:

a. Four (4) boilers in Building 261, two chambers in each. Boilers and condensate receiver and deaerator, DA tank, wood chip bins, and feed water tank at Building 261.

b. Crawl space under Building 21.

c. Dust collector outside Building 22.

d. Two (2) water storage tanks on top of the hill.

e. Building 27 tunnel crawl space.

f. Elevator hoistways.

g. Two (2) well access vaults located at the well site.

3. Biomass Boiler Plant Confined Space Inventory:

a. Condensate outside pit – Outside east side, conventional side.

b. DA tank – East side, conventional side.

c. Treated water tank – East side, conventional side.

d. Boiler #1 – Conventional side, front and back.

e. Boiler #2 – Conventional side, front and back.

f. Boiler #3 – Conventional side, front and back.

g. Small brine tank – West wall, conventional side.

h. Large outside brine tank – Outside west side, conventional side.

i. Water softener #A – West wall, conventional side.

j. Water softener #B – West wall, conventional side.

k. Biomass furnace doors – Biomass side.

l. Under grate ash doors – Biomass side.

Appendix C, Continued

m. Under grate ash doors – Biomass side.

n. Biomass boiler economizer door – Biomass side.

o. Biomass boiler cyclone #1 door – Biomass side.

p. Biomass boiler cyclone #2 door – Biomass side.

q. East fuel bunker – Biomass bunker room.

r. West fuel bunker – Biomass bunker room.

s. Vibrating conveyor doors – Biomass side.

t. Ash dumpster – Outside east biomass side.

u. ESP north ash conveyor – Outside east biomass side.

v. ESP south ash conveyor – Outside east biomass side.

w. Fuel oil tank #1 – Outside east biomass side.

x. Fuel oil tank #2 – Outside east biomass side.

4. Elevator Pits

Building Number

1 P1

1 P2

7 F1

7 F2

9 P1

23 F1

24 P1

24 P2

Building Number

31 P1

31 P2

31 P3

31 P4

210 P1

210 P2

211 P1

211 P2

26 P1

26 P2

27 P1

27 P2

30 P1

30 P2

212 P1

35 P1

35 P2

28 P1

Control of Hazardous Energy (Lockout/Tagout)

SOP 30

Chillicothe VA Medical Center Chillicothe, Ohio 45601

Signatory Authority:

Chief, Facilities Management Service

Responsible Owner:

Facilities Management Service (138)

Service Line(s):

Facilities Management Service

Effective Date:

March 4, 2025

Recertification Date:

March 4, 2030

1. SUMMARY OF CHANGES

a. Major changes are as follows:

(1) Item 2 Procedures, Section f Exceptions; Removing all of paragraph (2) -

“Minor tool changes that take less than 20 minutes and where the disconnecting means is clearly visible from the machine are locked out but a tagout device is not required.

(2) Item 2 Procedures, Section f Exceptions; Remove a portion of paragraph (3) –

“and work where isolating energy sources is more hazardous than performing the required work does not require lockout or tagout.

(3) Adding to Item 2 Procedures, paragraph (7) –

“For work on steam generation equipment and distribution systems, work is conducted behind two independent isolation valves when a total system depressurization cannot be accomplished.

(4) Replacing all the generic equipment procedures that were attached as Appendix B through Appendix YY. The equipment specific procedures that are attached to each machine will be available in binders in each shop as per guidance in the new Appendix B of this document.

2. PURPOSE AND AUTHORITY

a. To establish minimum energy isolation requirements and procedures for an effective program for the safe management and control of hazardous energy.

b. This policy applies to employees who service or maintain machines or equipment;

operate or use a machine or equipment on which servicing, or maintenance is being performed under lockout/tagout; and those whose job requires work in an area in which servicing, or maintenance is being performed.

March 4, 2025 SOP 30

c. Contractors comply with the lockout/tagout procedures in accordance with this policy and other applicable regulations.

d. This policy does not apply to work on cord and plug-connected electric equipment if the hazards of unexpected energization or startup of the equipment is controlled by unplugging the equipment and the plug is under the exclusive control of the employee performing the service or maintenance.

2. PROCEDURES

a. Only trained authorized employees may lockout/tagout utilizing the following procedures:

(1) Identify energy-isolating devices requiring lockout/tagout to ensure effective control of hazardous energy. More than one energy source may be involved. In the event multiple energy sources are present, consult equipment specific procedures. If no equipment specific procedure is documented for equipment or machinery with multiple energy sources or you do not fully understand the equipment specific procedures, stop work, and notify your direct supervisor.

(2) Determine the type and magnitude of the energy that the machine or equipment utilizes.

(3) If the machine or equipment is operating, shut it down by the normal operating procedures.

(4) Notify affected employees that a lockout/tagout system is being utilized and the purpose for utilizing the system.

(5) Operate the energy-isolating devices, such as a switch or valve, so that the machine or equipment is isolated from its energy sources and follow the documented process if one has been developed for the subject equipment. Always stand to the side of electric panels when opening the main disconnect switches as panels can explode when disconnected under a load.

(6) Stored energy such as springs, elevated members, rotating flywheels, hydraulic systems, and air, gas, steam, capacitors, or water pressure is dissipated or restrained by repositioning, blocking, or bleeding down as specified.

(7) For work on steam generation equipment and distribution systems, work is conducted behind two independent isolation valves when a total system depressurization cannot be accomplished.

(8) Affix lockout and tagout devices to energy-isolating devices. If lockout is not physically possible, affix tagout devices. Lockout is always the preferred method.

(9) After ensuring employees are not exposed, operate the push button or other normal operating control to make sure that equipment cannot operate. Return operating controls to the neutral or off position. Check electrical circuit with a meter or similar device to verify that power is off. If working on conductors, test for no voltage on phase-to-phase and phase-to ground before beginning any work.

(10) After the servicing or maintenance is complete, prepare the machine or equipment for normal operations. Replace guards and safety devices and remove personnel, tools, blocking and equipment.

(11) Notify affected employees that lockout and/or tagout devices are being removed.

(12) Remove lockout/tagout devices.

(13) Operate the energy isolating devices to restore energy to the machine or equipment.

(14) Notify affected employees that servicing, or maintenance has been completed and the machine or equipment is back online.

b. If more than one authorized employee is involved in the servicing or maintenance of a machine or equipment, the following group lockout/tagout procedures are used:

(1) Utilizing the procedures as described above, each authorized employee places his/her own personal lockout or tagout devices on the energy-isolating devices. When an energy-isolating device cannot accept multiple locks or tags, a multiple lockout or tagout device is used.

(2) A single lock is used to lockout the machine or equipment with the key placed in a lockout box or cabinet that allows multiple locks to secure it. Each authorized employee uses his/her own lock to secure the box or cabinet. As each authorized employee no longer needs to maintain his/her lockout protection, that employee removes his/her lock from the box or cabinet.

(3) For work involving multiple authorized employees, multiple shop disciplines, multiple shifts, or complex, long duration projects, and as deemed necessary by involved shop supervisors, the supervisor(s) of authorized employees affix locks as described above in addition to locks being placed by the authorized employees. The supervisor lock is the primary means of securing hazardous energy in these situations.

Each authorized employee independently verifies the equipment or machinery has been properly isolated and affixes his/her own lock and tag before starting work. When authorized employees finish a portion of the work or leave the job site for an extended period, s/he removes their lock and tag. Only the supervisor who placed the primary lockout/tagout device may remove the final lock and tag and reenergize the equipment or machinery.

c. Contractors comply with the lockout/tagout procedures as established by this procedure. Engineering employees do not violate contractor’s lockout/tagout.

d. Emergency lock removal.

(1) Under normal conditions only the authorized employee who placed the lockout/tagout device may remove the device. When it is necessary for a lockout or tagout device to be removed by someone other than the authorized employee who placed the tag, it is removed by the authorized employee’s supervisor under the following conditions:

(a) The authorized employee and supervisor have determined that the equipment or machinery is safe to reenergize but the keys to the lockout device have been lost.

(b) The supervisor has determined that the equipment or machinery is safe to reenergize but the authorized employee who placed the lockout or tagout device is unavailable and cannot return to the work site within a reasonable timeframe. Prior to removal, the supervisor tries to contact the authorized employee using the standard call-in procedures. Upon return work, the supervisor who removed the authorized employee’s lockout and/or tagout device immediately notifies the affected employee that the device was removed and the conditions under which the device was removed.

e. Unsafe to Operate Locks:

(1) Unsafe to operate locks are identified by the gold color. The shop supervisor maintains control of the unsafe to operate locks and keys. Unsafe to operate locks meet all the physical requirements of a lockout lock. Unsafe to operate locks are not used for any other purpose than securing unsafe equipment that is currently not being serviced or maintained. They are NEVER substituted for a lockout device.

(2) Unsafe to operate tags are yellow and constructed of the same types of materials as tagout devices to allow for use of a grease pencil to document the name of the person who placed the tag and the date and reason for placing the tag. Unsafe to operate tags are NEVER substituted for a tagout device.

f. Exceptions:

(1) Lockout/tagout is not required for routine maintenance of domestic, fire suppression or irrigation water systems.

(2) Troubleshooting, work that cannot be done while the equipment or machinery is locked or tagged out.

(3) Recharging or evacuating refrigerant from HVAC units, refrigerators, freezers, and similar equipment does not require lockout or tagout.

g. A review of the energy-control procedures for machines or equipment in the lockout/tagout program is conducted annually.

(1) The review is conducted by the respective Engineering Section shop supervisor or a designated authorized employee other than the employee whose energy-control procedures are being reviewed.

(2) The reviewer and each authorized employee analyze the employee’s responsibilities under the energy-control procedures being reviewed.

(3) If tagout is used for energy control, the review also includes the limitations of tags.

h. Employee training:

(1) Authorized employees receive training in the recognition of applicable hazardous energy sources, the type and magnitude of the energy known to be present in the workplace, and the procedures necessary for energy isolation and control. Authorized employees are not permitted to implement lockout/tagout procedures until training is completed.

(2) Affected employees whose job requires the operation or use of a machine or equipment on which servicing or maintenance may be performed under lockout or tagout are instructed in the purpose and use of the energy control procedures.

(3) Other employees whose work operations are or may be int eh area where energy control procedures may be used are instructed about the applicable procedures and prohibited attempts to restart or reenergize machines or equipment that are locked out or tagged out.

(4) Employees receive instructions regarding the limitations of tags. Tag limitations include:

(a) Tags do not provide physical restraint on devices.

(b) Tags are only to be removed by the authorized person who installed them.

(c) Tags are legible and understandable.

(d) Tags and the means of attaching tags are appropriate for conditions in the workplace.

(e) Tags are one part of the overall tagout program.

(f) Tags are securely attached.

(5) Retraining is provided to authorized and affected employees whenever there is a change in job assignment; a change in machines, equipment, or presses that present a new hazard; or whenever a supervisor has reason to believe that there are inadequacies in the employee’s knowledge or use of the energy control procedures.

(6) Training is documented to include the date of training and employee names.

i. Hazardous energy sources are listed in Appendix A, Hazardous Energy Inventory.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Engineering Section shop supervisors are responsible for ensuring their employees implement procedures in accordance with this policy for isolating energy sources for machines or equipment prior to any service or maintenance and ensure that contractors under their control comply with procedures for lockout/tagout. Additional responsibilities include:

(1) Developing written standard operating procedures (SOPs) for isolating energy sources for machines or equipment on which employees may be working or performing service or maintenance. Specific procedures need not be documented in writing if the machine or piece of equipment meets the following:

(a) The machine or equipment has no potential for stored or residual energy or re-accumulation of stored energy after shutdown which could endanger employees.

(b) The machine or equipment has a single energy source, which can be readily identified and isolated.

(c) The isolation and locking out of the energy source completely de-energizes and deactivates the machine or equipment.

(d) The machine or equipment is isolated from the energy source and locked out during service or maintenance.

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

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

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

(h) In addition to items (a) through (g) above, the facility has had no accidents involving the unexpected activation or re-energization of the equipment or machine during servicing or maintenance per Section 1910.147 (c)(4)(i) of the OSHA Lockout/Tagout Standard. Authorized employees on lockout/tagout procedures or requirements contact their immediate supervisor. Unresolved questions or questions from affected or other employees are directed to the Safety Office at extension 17153.

(2) Identifying authorized employees to perform servicing or maintenance on machines or equipment when lockout or tagout is required.

(3) Providing training as outlined in this policy to authorized employees. Training is documented and maintained to include date of training and employee names.

Supervisors work with other services and the Safety Office to assure that affected employees are included in this training.

(4) Ensuring that the annual review is conducted in accordance with this policy for the procedure for each machine or piece of equipment in the lockout/tagout program.

Documentation is maintained with each supervisor. Supervisors work with other services and the Safety Office to assure that affected employees are included in the annual review.

b. Authorized employees are responsible for implementing the procedures in accordance with his policy for isolating energy sources for machines or equipment prior to any service or maintenance.

c. Contracting Officer Representatives (COR’s) are responsible for informing contractors of this hazardous energy control procedure and obtaining a copy of the contractor’s internal policy.

(1) The contractor’s internal policy must be equal to, or more stringent than, the procedures contained therein.

(2) The COR provides a copy of the contractor’s policy to shop supervisors if concurrent work in contractor occupied spaces is required.

d. The Assistant Chief, Engineering Section is responsible for:

(1) Ensuring that supervisors and COR’s have received instructions sufficient to allow them to carry out their duties and responsibilities under the lockout/tagout program.

(2) Working with the shop supervisors to develop and maintain an inventory of sources of hazardous energy by type and magnitude.

4. DEFINITIONS

a. Affected employee: An employee whose job requires the operation or use of machines or equipment or to work in the same area in which servicing, or maintenance is being performed under lockout/tagout.

b. Authorized employee: A properly trained employee who implements the lockout/tagout procedures on a machine or piece of equipment to perform service or maintenance.

c. Other employee: An employee, other than an affected or authorized employee, who may work near or pass-through areas where energy control procedures may be used.

d. Energy isolating device: A mechanical device that physically prevents the release of energy; for example, a manually operated electrical circuit breaker, a disconnect switch, a line valve, or any similar device used to block or isolate energy. It does not include push buttons, selector switches or other circuit type devices.

e. Energy source: The origin of any type of energy to include electrical, mechanical, hydraulic, pneumatic, chemical, and thermal.

f. Hazardous energy: Any energy source associated with a machine or piece of equipment whose unexpected energization or startup could cause injury to employees or identified chemical, physical, or biological hazard. Examples include, but are not limited to, the following.

(1) Electrical sources greater than 50 volts AC or DC.

(2) Licensed radiation sources.

(3) Heated liquids or surfaces exceeding 114 degrees Fahrenheit, excluding potable, fire suppression and irrigation water systems.

(4) Any stored mechanical energy.

(5) Pneumatic energy exceeding 30 PSI pressure or vacuum.

(6) Ignitable liquids or gases.

(7) Corrosive liquids with pH outside the range of 6-8.

(8) Cold liquids or surface less than 32 degrees Fahrenheit.

(9) Hydraulic pressure exceeding 30 PSI, excluding potable, fire suppression and irrigation water systems operating at less than 150 PSI.

(10) Materials (solid, liquid, or gas) which, if released, could cause injury or concentrations in the immediate area of the release exceeding exposure limits established by OSHA.

g. Lockout: The placement of a lockout device on an energy-isolating device, in accordance with an established procedure, to ensure that the energy-isolating device and the machine or equipment being controlled cannot be operated until the lockout device is removed. Lockout devices require a tagout device to be used in conjunction with the lock unless specifically not required by a documented lockout tagout procedure.

h. Lockout device: A uniquely identifiable device that utilized a positive means such as a lock operated by a key to hold an energy-isolating device in a safe position and to prevent the energizing of a machine or piece of equipment. The lockout device can withstand the environment to which it is exposed. Lockout devices used at this facility are padlocks painted safety red. No lockout device is installed at this facility without an accompanying tagout device, except where expressly permitted by this procedure.

i. Normal production operations: Utilization of a machine or equipment to perform its intended production function.

j. Service and/or maintenance: Workplace activities on a machine or equipment where an employee may be exposed to the unexpected energization of startup of the equipment or machine or may be exposed to the release of hazardous energy. These activities include lubrication, cleaning, un-jamming of machines, utilization, making adjustments, and performing tool changes.

k. Tagout: The placement of a tagout device on an energy-isolation device, in accordance with an established procedure, to indicate that the energy-isolating device and the machine or equipment being controlled may not be operated until the tagout device is removed. Tags do not deteriorate in the environment in which they are placed and are printed such that environmental conditions do not cause the tag or message on the tag to become illegible. When a tagout device is permissible for use without an accompanying lockout device, the tagout device is attached to prevent inadvertent or accidental removal.