DHA Procedures Manual for Medical Gases.pdf

Defense Health Agency

PROCEDURES MANUAL

NUMBER 6040.06

October 18, 2021

DHA MEDLOG

SUBJECT: Medical Logistics (MEDLOG) Medical Gas Services

References: See Enclosure 1.

1. PURPOSE. This Defense Health Agency-Procedures Manual (DHA-PM), based on the authority of References (a) and (b), and in accordance with the guidance of References (c) through (ae), establishes the Defense Health Agency’s (DHA’s) procedures to provide guidance and regulatory requirements to DHA Military Medical Treatment Facilities (MTFs) and DHA Dental Treatment Facilities (DTF) on the management of medical gas in a manner which minimizes occupational exposure, protects both the environment and the public, and ensures compliance with appropriate Federal, State, and local regulations, in accordance with References

(e) and (f).

2. APPLICABILITY. This DHA-PM applies to the DHA, MTFs, and DTFs located within the continental United States, Alaska, Hawaii, and U.S. territories.

3. POLICY IMPLEMENTATION. It is DHA’s instruction, pursuant to References (a) through (ae), that Medical Logistics (MEDLOG) Medical Gas Services will include the procurement, handling, transport, storage, and disposition of medical gas within MTFs and DTFs.

4. RESPONSIBILITIES. See Enclosure 2.

5. PROCEDURES. See Enclosure 3.

6. PROPONENT AND WAIVERS. The proponent of this publication is the Deputy Assistant Director (DAD), MEDLOG. When Activities are unable to comply with this publication the activity may request a waiver that must include a justification, to include an analysis of the risk

DHA-PM 6040.06

associated with not granting the waiver. The activity director or senior leader will submit the waiver request through their supervisory chain to the DAD, MEDLOG to determine if the waiver may be granted by the Director, DHA or their designee.

7. RELEASABILITY. Cleared for public release. This DHA-PM is available on the Internet from the Health.mil site at: https://health.mil/Reference-Center/Policies and is also available to authorized users from the DHA SharePoint site at:

https://info.health.mil/cos/admin/pubs/SitePages/Home.aspx.

8. EFFECTIVE DATE. This DHA-PM:

a. Is effective upon signature.

b. Will expire 10 years from the date of signature if it has not been reissued or cancelled before this date in accordance with Reference (c).

9. FORMS

a. The following stocked forms can be ordered from the Defense Logistics Agency (DLA) at:

https://forms.documentservices.dla.mil/order/.

(1) DD Form 1191, Medical Oxygen Equipment, Warning Tag for Medical Equipment

(2) DD Form 1574, Serviceable Tag–Materiel

b. DD Form 1225, Storage Quality Control Report is available on the internet at:

https://www.esd.whs.mil/Directives/forms/dd1000_1499/.

/S/

RONALD J. PLACE

LTG, MC, USA

Director

Enclosures

1. References

2. Responsibilities

3. Procedures Glossary https://health.mil/Reference-Center/Policies https://info.health.mil/cos/admin/pubs/SitePages/Home.aspx https://forms.documentservices.dla.mil/order/ https://www.esd.whs.mil/Directives/forms/dd1000_1499/

3 TABLE OF CONTENTS

TABLE OF CONTENTS

ENCLOSURE 1: REFERENCES

ENCLOSURE 2: RESPONSIBILITIES

DIRECTOR, DEFENSE HEALTH AGENCY

DEPUTY ASSISTANT DIRECTOR, MEDICAL LOGISTICS DIRECTORATE

DIVISION CHIEF, DEFENSE HEALTH AGENCY ENVIRONMENTAL SERVICES

BRANCH CHIEF, DEFENSE HEALTH AGENCY MEDICAL GAS SERVICES

DIRECTORS, MEDICAL TREATMENT FACILITY AND DENTAL TREATMENT

FACILITY

MEDICAL TREATMENT FACILITY CHIEF MEDICAL LOGISTICS OFFICER

MEDICAL TREATMENT FACILITY MEDICAL/DENTAL TREATMENT

FACILITY GAS CONTROL OFFICER

ENCLOSURE 3: PROCEDURES

GENERAL

STORAGE

TRANSPORTING COMPRESSED GAS CYLINDERS

TESTING OXYGEN DURING DELIVERIES

DISPOSAL AND SHIPPING

APPENDICES

1. CHARACTERISTICS OF GASES

2. CHARACTERISTICS OF CYLINDERS

GLOSSARY

PART I: ABBREVIATIONS AND ACRONYMS

PART II: DEFINITIONS

TABLES

1. COLOR CODING FOR CYLINDERS

2. MEDICAL GAS TYPES AND PURITIES

3. DEPARTMENT OF TRANSPORTATION CYLINDER RETEST PERIODS

4. HAZARD WARNING COLORS FOR COMPRESSED GAS CYLINDERS

4 ENCLOSURE 1

ENCLOSURE 1

REFERENCES

(a) DoD Directive 5136.01, “Assistant Secretary of Defense for Health Affairs (ASD(HA)),” September 30, 2013, as amended

(b) DoD Directive 5136.13, “Defense Health Agency (DHA),” September 30, 2013

(c) DHA-Procedural Instruction 5025.01, “Publication System,” August 24, 2018

(d) United States Code, Title 10, Section 1073c, "Administration of Defense Health Agency and Military Medical Treatment Facilities"

(e) DoD Directive 4715.1E, “Environment, Safety, and Occupational Health (ESOH),”

March 19, 2005, as amended.

(f) DoD Instruction 6055.01, “DoD Safety and Occupational Health (SOH)”, October 14, 2014, as amended.

(g) National Defense Authorization Act for Fiscal Year 2017, Section 702

(h) DHA-Procedural Instruction 6430.02, “Defense Medical Logistics (MEDLOG) Enterprise

Activity (EA),” September 27, 2018

(i) National Fire Protection Agency 55, Compressed Gases and Cryogenic Fluids Code

(j) National Fire Protection Agency 99, Health Care Facilities Code

(k) National Fire Protection Agency 101, Life Safety Code

(l) Code of Federal Regulations, Title 29

(m) Military Standard MIL-STD-1411B, “Department of Defense Standard Practice:

Inspection and Maintenance of Compressed Gas Cylinders,” June 8, 20101

(n) Military Standard MIL-STD-101C, “Department of Defense Standard Practice: Color Code for Pipelines and Compressed Gas Cylinders,” August 26, 20142

(o) Code of Federal Regulations, Title 49

(p) DoD Manual 4160.21, Volume 4, “Defense Materiel Disposition: Instructions for

Hazardous Property and Other Special Processing Materiel,” October 22, 2015, as amended

(q) Defense Logistics Agency Instruction (DLAI) 4145.3, “Preparing Hazardous Materials for

Military Air Shipments,” April 21, 2015

(r) Defense Logistics Agency Instruction (DLAI) 4145.25, “Storage and Handling of Liquefied and Gaseous Compressed Gasses and Their Full and Empty Cylinders,” June 16, 2000

(s) American Society for Testing and Materials (ASTM) D-323-15a, “Standard Test Method for Vapor Pressure of Petroleum Products (Reid Method)”3

(t) Code of Federal Regulations, Title 40

(u) Military Specification MIL-O-27210, “Oxygen, Aviator’s Breathing, Liquid and Gas,”

August 1, 1990, as amended4

(v) Defense Logistics Manual 4000.25-2, “Military Standard Transaction Reporting and Accounting Procedures (MILSTRAP),” June 13, 2012, as amended

1 This reference can be found at: http://everyspec.com/MIL-STD/MIL-STD-1400-1499/MIL-STD-1411B_23144/ 2 This reference can be found at: http://everyspec.com/MIL-STD/MIL-STD-0100-0299/MIL-STD-101B_21221/ 3 This reference can be found at: https://www.astm.org/Standards/D323.htm 4 This reference can be found at: http://everyspec.com/MIL-SPECS/MIL-SPECS-MIL-O/MIL-O-27210F_32997/ https://www.astm.org/Standards/D323.htm https://www.astm.org/Standards/D323.htm http://everyspec.com/MIL-STD/MIL-STD-1400-1499/MIL-STD-1411B_23144/ http://everyspec.com/MIL-STD/MIL-STD-0100-0299/MIL-STD-101B_21221/ https://www.astm.org/Standards/D323.htm http://everyspec.com/MIL-SPECS/MIL-SPECS-MIL-O/MIL-O-27210F_32997/

5 ENCLOSURE 1

(w) Detail Specification MIL-DTL-2 Series, “Valves, Cylinder, Gas (For Compressed or Liquefied Gases), General Specifications”5

(x) Federal Standard (FED STD) H28, “Screw-Thread Standards for Federal Services”6

(y) Federal Standard (FED STD) H28/9, “Gas Cylinder Valve Outlet and Inlet Threads”7

(z) Military Specification MIL-V-17360, “Valves, Cylinder, Gas, Carbon Dioxide Fire

Extinguisher”

(aa) Military Specification MIL-E-24572, “Extinguisher, Fire, Bromotrifluoromethane (Halon

1301) System Components (Fixed Pipe, Pneumatically Actuated, Naval Shipboard Use)”

(ab) Military Specification MIL-E-24572, “Extinguisher, Fire, Bromotrifluoromethane (Halon

1301) System Components (Fixed Pipe, Pneumatically Actuated, Naval Shipboard Use)”

(ac) DoD Instruction 6055.05, Occupational and Environmental Health (OEH) November 11, 2008, as amended

(ad) DoD Instruction 6055.07, “Mishap Notification, Investigation, Reporting and Record

Keeping,” August 31, 2018

(ae) Compressed Gas Association C-7, Guide to Classification and Labeling of Compressed Gases

5 This reference can be found at: https://www.dla.mil/TroopSupport/Subsistence/OperationalRations/mildtl/ 6 This reference can be found at: http://everyspec.com/FED-STD/download.php?spec=FED-STD- H28_9.024788.pdf 7 This reference can be found at: http://everyspec.com/FED-STD/download.php?spec=FED-STD- H28_9.024788.pdf https://www.dla.mil/TroopSupport/Subsistence/OperationalRations/mildtl/ http://everyspec.com/FED-STD/download.php?spec=FED-STD-H28_9.024788.pdf http://everyspec.com/FED-STD/download.php?spec=FED-STD-H28_9.024788.pdf http://everyspec.com/FED-STD/download.php?spec=FED-STD-H28_9.024788.pdf http://everyspec.com/FED-STD/download.php?spec=FED-STD-H28_9.024788.pdf

6 ENCLOSURE 2

ENCLOSURE 2

RESPONSIBILITIES

1. DIRECTOR, DHA. The Director, DHA will assign the DAD-MEDLOG to implement this DHA-PM in accordance with Reference (b) and Reference (d).

2. DAD-MEDLOG. The DAD-MEDLOG will support oversight of the delivery of all MEDLOG services at MTFs and DTFs in accordance with Reference (f) and must:

a. Establish an Environmental Services Division to manage Medical Gas.

b. Appoint, Chief, Environmental Services Division, as appropriate, for day-to-day management of division operations.

3. DIVISION CHIEF, DHA ENVIRONMENTAL SERVICES. The Chief, DHA Environmental Services must provide the guidance, policy, and oversight for MTF environmental service operations.

4. BRANCH CHIEF, DHA MEDICAL GAS SERVICES. The Chief, DHA Medical Gas Services will provide guidance and direction for managing all medical gas regulatory requirements to include the procurement, handling, transport, storage, and disposition of medical gas.

5. DIRECTORS, MTF/DTF. The Directors, MTF/DTF will:

a. Have overall responsibility for the management of medical gas within the MTF.

b. Ensure medical gas is managed in accordance with the appropriate Federal, State, and local regulations.

c. Appoint the Chief, MEDLOG Officer to manage the MTF/DTF Medical Gas Services.

d. Ensure that all personnel handling medical gases in cylinders are properly trained on transporting, handling, storing, and the hazardous of working with medical gases.

6. MTF CHIEF, MEDLOG OFFICER. The MTF Chief, MEDLOG Officer must:

a. Designate the MTF Medical Gas Control Officer.

7 ENCLOSURE 2

b. Contact the Contracting Officer’s Representative and MTF Chief, DHA Medical Gas Services Program Manager if there are substantial discrepancies or changes required in the Medical Gas Services contract.

c. Arrange for and supervise the procurement, handling, transport, storage, and disposition of medical gas.

7. MTF/DTF MEDICAL GAS CONTROL OFFICER. The MTF/DTF Medical Gas Control Officer must:

a. Be functionally responsible for the daily management of medical gas in accordance with References (n) through (p).

b. Supervise Medical Gas Services personnel and supplier operations while suppliers and other operations personnel are within the MTF/DTF.

c. Maintain accurate records and account for all Medical Gas Services.

d. Develop local medical gas management implementing policies and guidance.

e. Submit funding requirements for medical gas management.

f. Provide technical expertise on medical gas management.

g. Inspect MTF/DTF medical gas management, collection, disposition, and contingency plans.

h. Report any mismanagement to the Contracting Officer’s Representative.

i. Assess Medical Gas Services at least annually to identify and document processes.

j. Work with department supervisors to:

(1) Establish and use management controls and conduct periodic inspections to ensure compliance with policies and procedures. All empty cylinders will be inspected every 6 months to determine their serviceability status with respect to the requalification date and physical condition. See Reference (w) for more information on inspection criteria.

(2) Plan, conduct, and document training of personnel to ensure medical gas management is conducted safely and in compliance with established policies and procedures.

Initial training must be completed within 90 days of employment or change of station for military members and refresher training completed every 3 years.

8 ENCLOSURE 2

j. Coordinate with the MTF/DTF ground safety manager and MTF/DTF facility manager to establish designated routes and times that medical gas will be moved within the facility to minimize patient exposure and ensure patient and employee safety, safe handling, transport, and storage of pressurized medical gas cylinders.

k. Ensure contracts specify the appropriate type of gas desired, (i.e., medical oxygen United States Pharmacopeia (USP), nitrous oxide USP, carbon dioxide USP, helium-oxygen, nitrogen USP, helium USP, nitrogen). The supplier is required to provide a Certificate of Purity documenting the concentration for each container.

l. Ensure storage sites for medical gases in bulk liquefied form are installed, repaired, and maintained in accordance with all applicable codes, standards, and regulations.

m. Maintain the supplier’s Certificate of Purity for bulk liquid oxygen on file for 3 years from date of receipt. A certificate of analysis is not required prior to accepting delivery of medical gases in cylinder form. The vendor is required to maintain all documentation certifying the purity of the compressed gas being supplied to the MTF/DTF.

n. Program, requisition, and maintain sufficient stocks of medical gases to satisfy requirements of the using activity.

o. Establish contingencies for emergency resupply of medical gases and ensure gas levels in reservoirs are monitored in accordance with the local emergency preparedness plan, in the event of a natural disaster or disruption of medical gases.

p. Establish cylinder exchange program for using activities to include after hours and emergency procedures.

q. Report maintenance problems on liquid oxygen reservoir to Chief, MEDLOG Officer.

r. Ensure all gas cylinders are correctly marked and colored in accordance with Reference (s).

s. Oversee the Medical Gas program and:

(1) Maintain maintenance records based on MEDLOG Standard Support.

(2) Monitor the oxygen purity monitor daily.

t. Ensure procurement of medical gas replenishment requirements. Monitor medical gas levels and order oxygen (liquid) whenever the level reaches 50 inches.

u. Ensure all cylinders have been hydrostatically tested within the past 5 years.

v. Ensure all Oxygen Cylinders contain “Do Not Oil” tags and Green Full/In-Use Tags.

9 ENCLOSURE 3

ENCLOSURE 3

PROCEDURES

1. GENERAL

a. DHA MTFs/DTFs will not maintain medical gases in operating inventories and instead will immediately issue the total quantity received to the requesting activity.

b. All workers who store, handle, or use compressed gas cylinders will be thoroughly familiar with procedures, safety requirements and potential mishap hazards associated with their use. Information pertaining to each specific gas is contained within its product labeling and Safety Data Sheet. Compliance with precautions provided on product labels and Safety Data Sheets is mandatory. Mishaps will be handled in accordance with Reference (ae).

c. All workplaces in the MTF/DTF that use compressed gas cylinders must be included in the MTF/DTF safety and occupational health program, consistent with Reference (ac).

Workplaces where compressed gases are used, including compressed gases used in delivery of inhalant anesthetics, will be monitored and, when indicated, workers will be monitored, in accordance with Reference (ad).

d. Supervisors will ensure workers are trained and familiar with the properties and hazards of the products they use, and the handling, usage, and storage requirements of compressed gas cylinders. The characteristics of gases and cylinders are outlined in Appendices 1 and 2 of this enclosure in accordance with Reference (x). Supervisors will ensure valves, hoses, pipes, etc., are compatible with the compressed gases being used and non-compatible with breathing air.

Warning: Valves, hoses, pipes, etc., used with breathing air will not be interchanged with other compressed gases under any circumstances, even though the parts may be physically compatible.

e. The worker will ensure the cylinder and attached equipment are in proper working condition and any discrepancies are fixed or reported to the supervisor.

f. All cylinders will be inspected for damage (e.g., dents, gouges, evidence of leakage, or cracks) daily before use to include:

(1) Inspection of Oxygen Cylinders to ensure “Do Not Oil” warning tag is in place and that the tag is annotated with a test date and purity indicating it is safe for use.

(2) Inspection of all cylinders to ensure “Green” In-Use/Empty tag is affixed and used in such a manner to accurately display the current condition/contents of the cylinder.

(3) Inspection of all cylinders to ensure there is adequate remaining pressure before beginning daily clinical use.

10 ENCLOSURE 3

(4) Inspection of all cylinders to ensure they are properly stored. Empties must be segregated from full cylinders and well-marked to avoid mistakenly being used in an emergency.

g. Damaged cylinders will be tagged, “Out of Service,” and returned to the manufacturer or distributor. Check the cylinder upon arrival for the test date, usually stamped on the neck of the cylinder. Workers may store the cylinder with the newest delivery behind older deliveries to ensure cylinders are used in the sequence received. Requalification of cylinders, including Department of Transportation (DOT)-8 cylinders will be in accordance with Subpart 180.209 of Reference (u).

(1) Cylinders will be hydrostatically tested in accordance with reference (s), which also contains additional guidance on inspection and requalification criteria for cylinders.

(2) Each time a cylinder is requalified, the date of the test or inspection indicating the month and year must be stamped into the shoulder, collar, or foot ring of the cylinder with a steel stamp. This date is used to determine the next scheduled re-qualification date. The service period for each type of cylinder is considered expired if the latest marked re-qualification date precedes the current date by more than the period indicated. Cylinders will not be accepted or used if the requalification date does not meet specifications.

h. Workers must know cylinder contents. Do not use a cylinder if you cannot quickly determine its contents either by wording on the cylinder or a tag securely attached to the cylinder. If the tag has become detached or the label defaced, do not use the cylinder. Do not rely on color coding of the cylinder. Different manufacturers use different color codes.

(1) DHA-owned cylinders will be color coded, and contents stenciled on the cylinder in accordance with Reference (t) and Reference (ae). Color codes for commonly used gases will be posted in the cylinder storage area, as indicated by Table 1.

Type Cylinder Top A Band B Band C Body Oxygen White Green Green Green Nitrogen Black Black Black Black Nitrous Oxide Blue Blue Blue Blue Carbon Dioxide Gray Gray Gray Gray Compressed Air Yellow Yellow Yellow Yellow Helium Brown Brown Brown Brown

Table 1. Color Coding for Cylinders

(2) Two DD Form 1574, Serviceable Tag-Materiel, will be placed on all cylinders. The first tag is used to identify the contents of the cylinder and the second tag will identify the cylinder. Additionally, the cylinder will carry a DOT identification label and a hazard class

11 ENCLOSURE 3

label. For commercially filled cylinders, the user is responsible for affixing a three-part cylinder status tag (Full, In-use, Empty), which is useful for identifying content status and cylinder inventory.

i. For commercially filled cylinders, the user is responsible for affixing a three-part cylinder status tag (Full, In-use, Empty), which is useful for identifying content status and cylinder inventory.

j. Workers will be aware of the flammability, corrosiveness, or oxidation potential as well as the physiological properties (e.g., toxic, anesthetic, or irritating, of compressed gases they use or handle).

k. Handle all cylinders carefully. Careless handling may damage cylinders and valves.

Install valve and dust covers when cylinders are not in use. Use cylinders for no purpose other than containing compressed gases; handle them with the same care whether full or empty.

l. Secure all cylinders by using a chain or other fastening device to a solid fixture (wall, stanchion, etc.), to prevent cylinders from falling over, whether in use or in storage, full or empty. Non-metallic or synthetic straps may be used to secure non-flammable gases, except oxygen.

m. Move cylinders safely. Appropriate dollies or hand trucks must be used to move cylinders weighing more than 50 pounds. The cylinder must be secured to the hand-truck prior to and during movement. Movement by spinning, sliding, rolling, etc., is prohibited. Cylinders less than 50 pounds may be moved without using a dolly or hand-truck. Proper lifting techniques must be used when lifting cylinders.

(1) Electromagnets or slings must not be used to move cylinders.

(2) Cylinders cannot be moved unless the regulator is removed, and the protective cap is in place and securely fastened to the cylinder. Note: cylinders secured to a hand truck are exempt from this requirement if regulators and hoses are connected to the cylinders.

n. Some gases/cylinders pose problems if placed in a horizontal position. Keep all cylinders in a vertical position at all times, unless the cylinders are designed to work in a horizontal position.

o. Do not tamper, or allow others to tamper, with cylinder valves or any part of a valve, such as a safety nut or stem packing nut.

p. Use cylinders only with the appropriate equipment. Do not force connections or use unauthorized adapters. Never use a cylinder without a regulator.

q. Always close the cylinder valve when the cylinder is not in use or when it is empty.

Replace safety covers and dust caps.

12 ENCLOSURE 3

r. Oxygen will support the rapid combustion of most materials. Flammable materials, such as oil, paint, or grease, may ignite if exposed to pressurized oxygen gas.

(1) Most compressed oxygen is not intended for breathing and must not be substituted for air used in ventilation systems. Oxygen will not be used as a substitute for compressed air.

(2) Never oil or grease an oxygen regulator. If oil or grease is found on an oxygen cylinder or regulator, it must be taken out of service immediately and the cylinder returned to the supplier.

s. Before attempting to place regulators or other fittings on a cylinder, ensure the threads on the cylinder match those on the fittings. The type of thread, number of threads per inch and the hand of the thread must match to ensure a satisfactory seal. If the fittings are hard to turn, do not force them; instead, check the threads.

t. Open cylinder valves slowly (cracking) so the gas is not released suddenly into the regulators. Operate valve hand-wheels only by hand. Do not use cheaters or pipes. Cylinders without fixed hand-wheels will be equipped with keys, handles or nonadjustable wrenches on the valve stems during the time they are in service.

u. Before removing a regulator from a cylinder, close the control valves and allow the gas to escape from the regulator.

v. On oxygen cylinders, do not use a regulator previously used for oil-pumped gases or any combustible gases. Gauges on oxygen regulators will be marked, “USE NO OIL.”

w. Only cylinders that are in use should be in the laboratory or work area. Cylinders will be secured by a chain or other effective fastening device to a solid fixture (wall, stanchion, etc.) to prevent cylinders from falling over. Spare or empty cylinders will only be stored in a designated storage area.

x. Compressed gas cylinders represent a hazard because the gases may be:

(1) Flammable. These gases can burn or explode if ignited.

(2) Asphyxiants (Inert). Gases that are chemically inactive but may displace oxygen and cause death.

(3) Oxidizers. Oxidizing gases such as compressed oxygen and nitrous oxide do not burn, but support combustion of flammable materials by releasing oxygen or other oxidizing substances. Increasing the concentration of an oxidizer can stimulate and accelerate combustion.

Materials that are nonflammable under normal conditions may burn in oxygen-enriched atmospheres.

(4) Corrosive. A gas that causes destruction of living tissue by chemical action.

13 ENCLOSURE 3

(5) Toxic. A gas that may cause illness or death if inhaled, ingested or from skin contact. Refer to Subpart 1910.1200 of Reference (l) for additional information.

(6) Extremely Cold (Cryogenic). A cryogenic liquid has a boiling point below minus 130º F (minus 90º) at 14.7 pounds per square inch absolute.

y. Do not attempt to repair a cylinder or cylinder valve. All malfunctioning cylinders should be marked and returned to the vendor for repairs.

z. Cleaning, internal and external, is performed by the commercial supplier and/or vendor at the time of retesting and reconditioning or at the time the cylinder is filled. Should external cleaning become necessary during storage, materials used to clean the cylinders must be compatible with the gas or liquid to be put into the cylinders, or the gas previously in the empty cylinders. For instance, 1, trichloroethylene can explode.

aa. Verification of the quality of the purchased or manufactured product is conducted at the site of manufacturer or at the product distributor’s warehouse. Necessary testing is performed by the supplier's personnel under the surveillance of a Government representative, or records of the examination and tests are maintained by the supplier and made available to the Government upon request. The quality of the gas product contained under pressure in a compressed gas cylinder will not change under normal storage and handling conditions; however, the condition of the cylinder may deteriorate and render the cylinder unsafe for further use.

2. STORAGE

a. While in storage, cylinder valve protection caps must be firmly in place. All cylinders will be secured by a metal chain, straps, braces, or other restraining devices to a solid fixture (wall, stanchion, etc.), to prevent cylinders from falling over. Synthetic straps will not be used to secure cylinders of flammable gases or oxygen. While in storage, cylinder valve protection caps must be firmly in place.

(1) Doors or gates for gas cylinder supply areas must be locked.

(2) Enclosures for gas supply systems must not be used for storage purposes other than for cylinders.

(3) Cylinders attached to a manifold must also be secured to solid fixtures to prevent the cylinder from falling over.

(4) The enclosure must be posted as a “No Smoking Area.”

(5) The storage area is to be dry, cool, and well ventilated. The storage area is to be kept clean, neat, and free of debris at all times.

14 ENCLOSURE 3

b. While in storage, do not store cylinders in locations where temperatures may exceed 125 deg F (51.7 deg C) or near other sources of heat to prevent excessive pressures in the cylinders.

Many cylinders have fusible safety plugs that will release the contents when high temperatures or pressures exist in the cylinder.

(1) Do not store cylinders where there is danger of accidental damage or in areas where they will be subject to corrosive chemicals. Do not store flammable gases near electrical wires, batteries or other conductors or sources of electricity.

(2) Empty cylinders must be plainly marked “EMPTY” and stored in a separate area, segregated, if possible, from full cylinders. When stored together, full, and empty cylinders must be stored so that the older cylinders (old stock) can be removed first with minimum handling of other cylinders (newer stock).

(3) The preferred method of securing compressed gas cylinders is by enclosure within a length of chain firmly anchored at both ends to a solid fixture (wall, stanchion, etc.). An alternative method of securing is with a canvas tank strap securely clamped to an immovable table or bench top. In either case, the anchor points of the chain or strap must be about 2/3 the way up the tank. Metallic or synthetic nylon straps must not be used to secure cylinders of flammable gases or oxygen.

(4) Cylinders stored in the open must be adequately protected from extreme heat and cold. Cold weather usually increases the brittleness of the cylinder metal, and if brittle cylinders are handled roughly, they can rupture. Remove accumulated ice or snow to prevent cylinders from rusting.

(5) When gas cylinders are stored indoors, ventilate the area to prevent accumulation of flammable or asphyxiating gases in the atmosphere. Cylinders must not be kept in unventilated enclosures.

c. Cryogenic cylinders must be fitted with stainless steel or other suitable plumbing only.

d. Stored cylinders (either inside or outside) must not obstruct exit routes or other traffic areas.

e. All stored cylinders must have their valves closed. Valve protection caps must always be in place and hand tight except when cylinders are in use or connected for use. All cylinders must be stored valve end up.

f. Oxygen cylinders must not be stored within twenty feet of combustible material (especially oil and grease), other fuel gas cylinders or near any other substance likely to cause or accelerate fire.

15 ENCLOSURE 3

g. Storage facilities must be prominently labeled/posted with the types of gases being stored.

Where gases of different types are stored at the same location, cylinders must be grouped by type of gas and the groups arranged to consider the gases contained. Cylinders must be prominently labeled in accordance with Part 172, Subparts D through F of Reference (o).

3. TRANSPORTING COMPRESSED GAS CYLINDERS

a. As a minimum, cylinders must be transported on an appropriate cart secured by a chain or strap. Cylinders must not be dropped, dragged, slid, or allowed to strike each other violently.

Protective valve caps should be utilized whenever cylinders are in transport.

b. Consult the safety officer prior to establishing or relocating storage areas for compressed gas cylinders.

4. TESTING OXYGEN DURING DELIVERIES. The purity of oxygen will be tested when received from the vendor and for monitoring oxygen provided to using activities. Table 2 contains the medical gas types and purities.

Medical Gas USP Grade Purity

Liquid Oxygen 99%

Gaseous Oxygen 99%

Liquid Nitrogen 99%

Compressed Nitrogen 99%

Carbon Dioxide 99%

Nitrous Oxide 97%

Compressed Air N/A

Table 2. Medical Gas Types and Purities

a. Oxygen is replenished via contract. Oxygen (liquid and compressed) delivered by commercial vendors must be at least 99% pure.

b. During delivery, the following actions are to be performed:

(1) The vendor is to verify purity of the oxygen and provide a statement certifying the purity of the oxygen on the delivery ticket.

(2) Utilizing calibrated oxygen analyzers, the Medical Gas Control Officer must test all delivered oxygen.

16 ENCLOSURE 3

(3) Testing the Bulk Oxygen System each time a delivery is made. This will consist of testing the oxygen in the delivery truck prior to discharge into our storage tank using an oxygen analyzer for oxygen percentage. Individual conducting test will notify Chief, Anesthesia or Senior Clinical Director when oxygen concentration is less than 99%. When concentration is less than 99%, supplier will not be allowed to connect to the bulk tank until approved by the Chief, Anesthesia or Senior Clinical Director.

(a) Compressed oxygen cylinders less than 99% pure will be returned to the vendor and a discrepancy report submitted to Chief, MEDLOG Officer. Inspect each cylinder for a Green In-Use/Empty Tag, Test results for compressed oxygen cylinders are to be recorded on DD Form 1191, Medical Oxygen Equipment, Warning Tag for Medical Equipment and the form attached to the cylinders. Annotations to the DD 1191 will include Julian Date of quality check;

quality of oxygen (in percentage); and initials of individual accomplishing check.

(b) For bulk liquid oxygen, readings are to be taken from the vendor’s truck reservoir, not the MTF/DTF bulk liquid oxygen system reservoir. This action prevents any possibility of impure oxygen entering the main oxygen system.

c. The MTF/DTF Medical Gas Control Officer will complete a Report of Discrepancies whenever the vendor delivers empty tanks or impure oxygen. These reports are to be provided to the Chief, MEDLOG Officer, on the same day, for appropriate action.

d. The MTF/DTF Medical Gas Control Officer will immediately notify the Chief, Anesthesia or Senior Clinical Director if readings taken on the bulk liquid oxygen reservoir become less than 96% pure.

e. Records of receipt must be maintained for 3 years.

5. DISPOSAL AND SHIPPING

a. Disposal of Compressed Gas Cylinders. Disposal of compressed gas cylinders will be accomplished in accordance with References (k) and (m).

(1) Non-government owned cylinders will be returned to the owner. Language requiring takeback of non-government owned cylinders must be included in all contracts. If the owner cannot be determined, cylinders must be processed in accordance with Reference (k).

(2) Cylinders rejected for failure to pass hydrostatic testing or any other reason must be disposed of as condemned property after the identification numbers, symbols and cylinder contents have been destroyed according to procedures outlined within the governing medical gas contracts.

b. Prior to shipment, empty cylinders must be inspected for dents, bulges, oxidation pits or other damage. Faulty cylinders must be disposed of in accordance with local policy and/or

17 ENCLOSURE 3

procedures outlined within the governing medical gas contract. Additional information regarding the procedures for faulty cylinder disposal can be found at:

https://www.dla.mil/DispositionServices. Cylinders must be shipped in accordance with instructions outlined in Reference (l). Ensure cylinders (especially oxygen) will not be contaminated with oil, grease, paint, etc., by the shipper while en route to or from the filling agency.

http://www.dla.mil/DispositionServices http://www.dla.mil/DispositionServices

18 APPENDIX 1

APPENDIX 1

CHARACTERISTICS OF GASES

1. GENERAL. Personnel having the responsibility of storing, handling, and/or using compressed gases and gas cylinders must have a working knowledge of the characteristics and hazards associated with each individual gas. Specific and detailed information on the properties and/or hazards of any gas is best obtained from the manufacturer or supplier of the product through Safety Data Sheets (SDS) or brochures. Additional information related to this Appendix is available from commercial sources and is referred to below; however, references to commercial manufacturers or service providers does not constitute an overt or implied federal endorsement and is provided only to promote the education of and technical expertise of DHA personnel. The following commercial publications are sources for additional information pertaining to technical data and to first aid and medical treatment for exposure to gases:

a. Effects of Exposure to Toxic Gases/First Aid and Medical Treatment, available from Matheson Gas Products.

b. Gas Data Book, available from Matheson Gas Products. This document contains technical information about the various compressed gases and provides such information as the chemical characteristics, how a gas is manufactured, how it is used, how it is transported, safety and health information and how to dispose of it.

c. Methods for Hydrostatic Testing of Compressed Gas Cylinders, Compressed Gas Association (CGA) Pamphlet C-1, available from the CGA. This pamphlet provides the detailed information on the retesting (requalification) of compressed gas cylinders.

d. Handbook of Compressed Gases, available from the CGA. This document is a compilation of technical information like that of the Matheson Gas Data Book but also contains much of the specific information found in the individual CGA pamphlets.

e. Chlorine Manual, available from The Chlorine Institute. This document provides detailed information on the manufacture, transporting, safety, and health and other critical information on the chlorine industry.

f. Cylinder Service Life Seamless, High-Pressure Cylinder Specification Interstate Commerce Commission (ICC)/DOT-3, ICC/DOT-3A, ICC/DOT-3AA, CGA Pamphlet C-5, available from the CGA. This document provides detailed information on the manufacture of cylinders and, when used with the results of the hydrostatic test outlined in Pamphlet C-1, a person can determine the expected life of a high pressure steel cylinder.

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g. Standards for Visual Inspection of Compressed Gas Cylinders, CGA Pamphlets C-6, C-6.1, C-6.2 and C-6.3 available from the CGA. These documents provide direction and guidance in performing a visual inspection of a compressed gas cylinder to visually determine the integrity of the structure of the cylinder.

2. GASES AND THEIR CHARACTERISTICS. The gases most likely to be found in DoD storage and support facilities inventories are listed below. The label requirements for each gas are indicated. For special handling and transportation, refer to the specific label requirements found in Part 82 of Reference (j) and of Reference (o).

a. Air, Compressed (Hazard Class 2.2, I.D. NO. UN1002, Nonflammable Gas Label); Air, Refrigerated liquid (Cryogenic Liquid) (Hazard Class 2.2, I.D. No. UN1003, Nonflammable Gas (primary) and Oxidizer (subsidiary) Labels). Air is the natural atmosphere of the earth – a nonflammable, colorless, odorless gas that consists of a mixture of gaseous elements (with water vapor, a small amount of carbon dioxide, and traces of many other constituents). Synthesized air is produced by combining pure oxygen and nitrogen and contains between 19.5 and 23.5 percent oxygen, with the balance nitrogen and with a major portion of the other components eliminated.

Dry air is noncorrosive. Liquefied air is transparent with a bluish cast and has a milky color when it contains carbon dioxide. Because air is a mixture, not a compound, it can be separated into its components. The most common method is the liquefaction of air by reducing its temperature to approximately -320 deg F (-195.6 Deg C), then fractionally distilling to remove each of the constituents as fractions. Compressed air is nontoxic. It may act as an oxidizing material. Direct contact with the releasing high pressure gas or the cryogenic liquid may cause frostbite.

b. Argon, Compressed (Hazard Class 2.2, I.D. NO. UN1006, Nonflammable Gas Label);

Argon, Refrigerated Liquid (Cryogenic Liquid) (Hazard Class 2.2, I.D. NO. UN1951, Nonflammable Gas Label). Argon is nonflammable and nontoxic and will not support combustion. It is manufactured as a cryogenic liquid with a normal boiling point of -302.6 deg F. As a cryogenic fluid, it is stored and transported in special insulated and vacuum-jacketed cylinders (DOT 4L) with a water capacity of not over 1000 pounds (454.6 liters or 120 gallons) or in insulated tanks and cargo tank trucks. It is also vaporized into its gaseous state and charged into high-pressure cylinders (DOT 3A or 3AA) of 1800 pounds per square inch gauge (psig) or greater. Argon, in its cryogenic liquid state, is normally stored in large, insulated storage tanks at the manufacturing facility and is delivered in small quantities directly to the point of use or to a special storage facility designed for cryogenic liquids. Argon, as a cryogenic liquid, cannot be stored in a closed container because the liquid is continuously boiling (vaporizing) and building up pressure; therefore, it is stored in a container with an open vent or a vent that incorporates a controlled pressure relief device. The storage and handling of argon, as addressed in this regulation, will be in its vapor or gaseous state in high-pressure DOT 3A, 3AA, or 3AL cylinders. Due to its ability to displace air, argon is a simple asphyxiant. Contact with the cryogenic liquid or its cold vapors and the escaping high pressure from a cylinder may cause frostbite and serious eye damage.

20 APPENDIX 1

c. Carbon Dioxide (Hazard Class 2.2, I.D. NO. UN1013, Nonflammable Gas Label).

Carbon dioxide in cylinders is in the form of a gas over liquid and at 70 deg F exerts a pressure of 838 psig. Humans cannot breathe air containing more than 10 percent carbon dioxide (by volume) without losing consciousness. The gas is about 1.5 times heavier than air and is nontoxic, nonreactive, slightly acidic, and will not burn or support combustion or human life.

Carbon dioxide gas interferes with proper mentation at 1.9 percent and is not tolerable at 3.5 percent-5.0 percent. Carbon dioxide cylinders become extremely dangerous when heated to a temperature approximating 125 deg F and should never be placed near furnaces, radiators, or any other source of heat. Contact with the liquid or high-pressure gas may cause frostbite and serious eye damage.

d. Ethylene Oxide, Pure or with nitrogen (Hazard Class 2.3, I.D. NO. UN1040, Poison Gas and Flammable Gas Labels). Ethylene oxide is a highly reactive colorless gas that condenses to a colorless liquid boiling at 50.7 deg F (10.4 deg Celsius) and 14.7 psia. It is miscible in all proportions with water, alcohol, ether, and most organic solvents. The vapors of ethylene oxide are flammable and explosive. It is generally noncorrosive to metals and leaves no residual odor or taste. The major use of ethylene oxide is as a chemical intermediate for the manufacture of ethylene glycol and higher glycols. These glycols are used as drying agents, antifreezes, and raw materials for the manufacture of other chemical derivatives. Ethylene oxide, both pure and mixed with carbon dioxide or halocarbons, is also used as a sterilant and fumigant for heat-sensitive materials. Ethylene oxide is a toxic liquid and gas. The vapors from Ethylene oxide form flammable mixtures with air over a wide range (lower flammable limit (LFL) 3 percent and upper flammable limit (UFL) 100 percent). The vapor is heavier than air (vapor density 1.5 times heavier) and may travel a considerable distance to a source of ignition and flash back.

Ethylene oxide is dangerously reactive; it may rearrange chemically and/or polymerize violently with evolution of heat when in contact with highly active Catalytic surfaces such as anhydrous chlorides of iron, tin, aluminum, and pure oxides of iron and aluminum, and alkali metal hydroxides. Although soluble in water, solutions will continue to burn until diluted to approximately 22 volumes of water to one volume of ethylene oxide. Ethylene oxide is moderately toxic by inhalation and breathing and high concentrations may cause pulmonary edema. It is a severe, eye, skin, and respiratory irritant, and effects may be delayed. For specific health hazards refer to the SDS, the DoD Hazardous Materials Information System, or the manufacturer, supplier, or vendor for information.

e. Ethylene Oxide and Nonflammable Gas Mixtures (Labeled According to Mixture). Due to the high flammability and explosive hazards of pure ethylene oxide and the need for its use as a sterilizer for medical equipment and material, a mixture of nonflammable gases is added to the material to reduce its hazard. The mixtures are usually 20 to 90 percent carbon dioxide or dichlorodifluoromethane by volume. The mixtures are less toxic than pure ethylene oxide but do pose a health threat when inhaled or when in direct contact with skin or eyes. For specific health hazards refer to the SDS, the DoD Hazardous Materials Information System, or the manufacturer, supplier, or vendor for information.

f. Helium, Compressed (Hazard Class 2.2, I.D. NO. UN1046, Nonflammable Gas); Helium, Refrigerated Liquid (Cryogenic Liquid) (Hazard Class 2.2, I.D. NO. UN1963, Nonflammable Gas Label). Helium is a colorless, odorless, and tasteless gas at room temperature and

21 APPENDIX 1

atmospheric pressure. Its principal source in the United States is from certain natural gas wells in which the natural gas may contain up to 9 percent helium. It is normally supplied as a nonliquefied compressed gas in high-pressure DOT 3A or 3AA cylinders at or above a pressure of 1800 psig at 70 deg F. Helium can be condensed into a cryogenic liquid when refrigerated to below its normal boiling point of -452.1 deg F, the lowest boiling point of any substance known.

As a cryogenic liquid, it is stored and transported in special insulated and vacuum-jacketed cylinders (DOT 4L) with a water capacity of not over 1,000 pounds (454.6 liters or 120 gallons) or in larger insulated and vacuum-jacketed tanks and cargo tank trucks. Helium, as a cryogenic liquid, is like argon and cannot be stored in a closed container because the liquid is continuously boiling (vaporizing) and building up pressure; therefore, it is stored in a container with an open vent or a vent that incorporates a controlled pressure relief device. The storage and handling of helium, as addressed in this regulation, will be in its vapor or gas state in high-pressure cylinders.

In high concentrations, helium acts as a simple asphyxiant, causing suffocation due to oxygen deficiency. Contact with the liquid or cold vapors may cause frostbite and serious eye damage.

g. Hydrogen (Hazard Class 2.1, I.D. NO. UN1049, Flammable Gas Label). Hydrogen is a colorless, odorless, flammable gas at room temperature and atmospheric pressure. It is the lightest gas known. It is usually shipped as a nonliquefied compressed gas in high-pressure DOT 3A or 3AA cylinders at a pressure greater than 1800 psig at 70 deg F. Hydrogen can be condensed into a cryogenic liquid when refrigerated below its normal boiling point of -423.0 deg F. As a cryogenic liquid, it is stored and transported in special insulated and vacuum-jacketed cylinders (DOT 4L) with a water capacity of not over 1000 pounds (454.6 liters or 120 gallons) or in larger insulated and vacuum-jacketed tanks and cargo tank trucks. Hydrogen, as a cryogenic liquid, is like argon and helium and cannot be stored in a closed container because the liquid is continuously boiling (vaporizing) and building up pressure; therefore, it is stored in a container with an open vent or a vent that incorporates a controlled pressure relief device. The storage and handling of hydrogen, as addressed in this regulation, will be in its vapor or gaseous state in high-pressure cylinders. Hydrogen burns in air with a pale blue, almost invisible, flame.

Hydrogen will form flammable and explosive mixtures over a wide range with air (LFL 4 percent, UFL 74 percent, lower explosive limit 4.1 percent, and upper explosive limit 74.2 percent) and oxygen (LFL 4 percent, UFL 95 percent, lower explosive limit 4.7 percent, and upper explosive limit 93.9 percent). Unlike hydrogen at normal ambient temperatures when it is lighter than air, the cold gas as it is vented or released from the container is slightly heavier than air and may remain near ground level until it warms up. Fog formed when the cold gas comes in contact with the moisture in the air will indicate where the gas is spreading; however, explosive mixtures can exist outside the visible fog. Hydrogen is nontoxic but can cause asphyxiation.

Contact with the cryogenic liquid or cold vapor can cause frostbite and serious eye damage.

h. Nitrogen, Compressed (Hazard Class 2.2, I.D. NO. UN1066, Nonflammable Gas Label) Nitrogen, Refrigerated Liquid (Cryogenic Liquid) (Hazard Class 2.2, I.D. No. UN1977, Nonflammable Gas Label). Nitrogen is an odorless, colorless, tasteless, nontoxic, and almost totally inert gas that makes up 78 percent of the earth's atmosphere. It is colorless as a cryogenic liquid. It is not flammable and will not support combustion or human life. It is manufactured as a cryogenic liquid with a normal boiling point of -320 deg F. As a cryogenic liquid, it is stored and transported in either special insulated and vacuum-jacketed cylinders (DOT 4L) with a water

22 APPENDIX 1

capacity of not over 1,000 pounds (454.6 liters or 120 gallons) or in insulated and vacuum-jacketed tanks or cargo tank trucks. It is also vaporized into the gaseous state and charged into high- pressure cylinders (DOT 3A, 3AA, or 3AL) 1800 psig or greater. Nitrogen in its cryogenic liquid state is normally stored in large storage tanks at the manufacturing facility and is delivered in small quantities directly to the point of use or to a special storage facility designed for cryogenic liquids. Nitrogen, as a cryogenic liquid like other cryogenic liquids, cannot be stored in a closed container because the liquid is continuously boiling (vaporizing) and building up pressure; therefore, it is stored in containers with an open vent or with a vent that incorporates a controlled pressure relief device. Alternate methods of producing nitrogen gas may be produced utilizing the pressure swing adsorption cycle or the use of membrane technology. The storage and handling of nitrogen as addressed in this regulation will be in its vapor or gas state in high-pressure DOT 3A, 3AA, or 3AL cylinders. Unlike nitrogen at normal ambient temperatures when it is lighter than air, the cold gas as it is vented or released from the cryogenic container is slightly heavier than air and may remain near ground level until it warms up. In this case, nitrogen can act as an asphyxiant, displacing air and causing suffocation due to oxygen deficiency. Fog formed when the cold gas comes in contact with the moisture in the air will indicate where the gas is spreading. Contact with the liquid or cold gas can cause frostbite and serious eye damage.

i. Nitrous Oxide, Compressed (Hazard Class 2.2, I.D. NO. 1070) and Nitrous Oxide, Refrigerated Liquid (Hazard Class 2.2, I.D. NO. 2201), Nonflammable Gas Label). Nitrous oxide at normal temperatures and pressures is a colorless, practically odorless, and tasteless, nontoxic gas. It is shipped as nitrous oxide, compressed, or nitrous oxide, refrigerated liquid.

Nitrous oxide is nonflammable, but, being a…