S02 - 3. SOP 578-21-21-677 Confined Space Program.pdf

CONFINED SPACE PROGRAM

STANDARD OPERATING PROCEDURE

SOP-578-21-21-677

Edward Hines Jr VA Hospital Hines, IL 60141 Signatory Authority:

Chief of Occupational Safety & Health Service Responsible Owner:

Safety Service

Service Line(s):

Occupational Safety & Health Service

Effective Date:

March 8, 2021

Recertification Date:

March 31, 2026

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to protect Hines VA Hospital staff from the hazards associated with confined spaces.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with Occupational Safety and Health Administration (OSHA) standard 29 CFR 1926 Subpart AA - Confined Spaces in Construction (consisting of 29 CFR 1926.1200 to 1926.1213).

2. PROCEDURES

a. Hazard Identification

(1) Engineering Service will conduct a survey of the property and all other worksites

Hines employees are working at and identify confined spaces. The surveys will be completed from site observations, building blueprints and job hazard analyses, and will include air monitoring to determine the air quality in the confined spaces and identification of hazards.

(2) An inventory of confined spaces shall be maintained by Engineering Service and a copy provided to Safety Service. this will include any potential for engulfment, entrapment, hazardous energy, atmospheres with flammable or explosive potential, oxygen deficiency, and/or the presence of toxic and corrosive material and all other hazards. This information will also be communicated to all personnel, and appropriate confined space procedures will be developed and followed prior to entry. Based on the identified hazards, determinations of which confined spaces will be entered and require a permit prior to entry and which confined spaces will not be entered. Both determinations will be documented on the inventory.

(3) Hazard re-evaluation shall be conducted at least annually.

(4) Hines will use hierarchy of hazard control techniques to first eliminate and then, if they cannot be eliminated, reduce hazards of confined spaces. The following order of precedence will be followed when eliminating or reducing confined space hazards:

Engineering Controls, Administrative Controls, and Personal Protective Equipment (PPE).

(5) All confined spaces with identified hazards will have a written plan for mitigation of those hazards.

(6) Work practices must also conform to Hines policies and procedures regarding Cutting, Welding, and Other Hot Work; Personal Protective Equipment; Respiratory Protection Program; and Fire Safety.

b. Training

(1) Training shall conform to the requirements of OSHA 29 CFR 1926.1207. The training

March 8, 2021 SOP-578-21-21-677 will provide the understanding, knowledge and skills necessary to safely perform required work in confined spaces.

(2) Training will be conducted:

(a) Before the employee is first assigned duties involving confined spaces.

(b) Before there is a change in an affected employee’s assigned duties.

(c) When there is a change in a permit-required confined space operation that presents new hazards not previously covered in training.

(d) When Hines has reason to believe that there are deviations from the permit-required confined space entry procedures, or that there are inadequacies in the employee's knowledge or use of these procedures.

(e) Annually thereafter.

c. Confined Space Entry - Routine

(1) All confined space entry shall be performed in accordance with OSHA 29 CFR 1926 Subpart AA - Confined Spaces in Construction.

(2) From the confined space survey and inventory data, the confined space can be properly prepared for entry and necessary precautions identified. The following hazards are typical of confined spaces and should be encountered with suitable personal protective equipment, special tools, ventilation, proper appliances, and rescue apparatus:

(a) Toxic vapors

(b) Flammable vapors, gases, or ducts.

(c) Oxygen deficiency

(d) Gases from fermentation of organic matter.

(e) Electric shock.

(f) Spark producing tools.

(g) Injury from mechanical equipment.

(h) Bodily injury from direct contact with corrosives or irritating chemicals.

(i) Physical hazards.

(j) Burn hazards.

(3) Pre-Planning: Each operating department or group shall have comprehensive written procedures covering confined space entries for its area of responsibility. This Site- Specific Confined Space Entry Plan should follow a standardized format approved by Engineering Service and are adequately communicated to the affected personnel. The individual(s) writing these procedures should be thoroughly knowledgeable in potential hazards that may be present, and operations covered by the procedures. Safety Service should review local procedures to assure that safety/health concerns have been sufficiently addressed.

As a minimum, written procedures must be specific and include the following:

(a) Responsibilities of all personnel involved in confined space entry;

(b) discussion of potential hazards that are present;

(c) vessel preparation requirements:

i. isolation (piping),

ii. ventilation,

iii. lockout (mechanical, electrical, utilities),

iv. environmental testing,

v. and, illumination;

(d) issuance and use of the entry permit system;

(e) precautions and equipment usage:

i. physical dimensions of confined space,

ii. personal protective equipment,

iii. safety equipment,

iv. tools,

v. and, emergencies.

d. Permit-Required Confined Space (PRCS) Entry must comply with requirements outlined for Routine Confined Space Entry above, applicable parts of OSHA 29 CFR 1910.146, Permit-required confined spaces and OSHA 29CFR 1926 Subpart AA, especially 1926.1204 Permit-required confined space program, 1926.1205 Permitting process, and 1926.1206 Entry permit.

(1) Entry into a confined space is not permitted until a confined space entry permit is properly signed and completed and all provisions on the permit are satisfied. Prior to issuing and using the confined space entry permit, all parties involved in the entry shall meet and discuss entry procedures, responsibilities, and safety precautions\equipment needed to ensure correct entry.

(2) No Employee shall enter any confined space without reporting to and securing approval from his\her immediate supervisor. No permit should be valid except for the job, location, persons, and time specified.

(3) The confined space entry permit is authorized and approved in writing. It serves as a method of formalizing agreed upon procedures and also as a checklist to ensure that all existing hazards are considered, evaluated, and correct protective measures taken.

e. Emergency Rescue must comply with requirements applicable parts of OSHA 29CFR 1926 Subpart AA, especially 1926.1211 Rescue and emergency services.

(1) Emergency rescue is only conducted by local Fire Department personnel thoroughly-trained in confined space rescue.

(2) No Hines employee shall attempt Emergency Rescue entry. Hines staff can make emergency notification according to Site-Specific Confined Space Entry Plan.

(3) Pre-entry planning and training shall confirm rescue and emergency procedures.

(4) In the event of an emergency or rescue, the Site-Specific Confined Space Entry Plan shall be implemented, including emergency notification.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Engineering Service shall:

(1) Prepare written procedures covering specific confined space entries as described in

Procedures portion of this SOP;

(2) Review these procedures with all employees involved in confined space entry;

(3) Isolate if necessary and preclude entry of hazardous materials;

(4) De-energize and lockout movable parts;

(5) Assure adequate ventilation in confined space(s);

(6) Train employees in proper use of personal protective equipment, life lines, etc. And confined space entry procedures;

(7) Use appropriate monitoring, personal protective equipment, ventilation, and rescue equipment;

(8) Notify the Hines Police Service and the local Fire Department whenever a permit-required confined space is to be entered; and

(9) complete required entry permits.

b. Engineering Service Section Chiefs are responsible for

(5) verifying that the appropriate procedures required by the permit have been completed as specified, before endorsing the permit an allowing entry to proceed, per outlined in this SOP.

(6) Ensuring that acceptable entry conditions are maintained, and that entry operations are conducted consistently with permit operations.

(7) Removing unauthorized individuals who enter or attempt to enter Permit Required Confined Spaces (PRCS) during entry operations.

(8) Terminating the entry operations and cancelling _the entry permit as required, if entry conditions deteriorate into emergency conditions.

(9) Knowing and understanding the hazards associated with each entry.

c. Chief, Project/Planning Section or Designee is responsible for making contractors aware of the Hines SOP and procedures pertaining to confined space entry.

d. Chief, Maintenance/Operations Chief or Designee is responsible for informing the contractors of the following information and coordinates any confined space entry operations.

When contractors are involved in permit- space entry work, the Chief of Maintenance & Operations or his/her designee will inform the contractors of the following information and coordinate any entry operations:

(1) The location of the permit spaces at our facility, and notifying contractor that entry into these spaces is only allowed through a Permit-required confined space program, or alternate procedures or space reclassification.

(2) Noting any identified hazards and experience with the particular space.

(3) Precautions that the VA has implemented to protect the employees working in or near the space.

(4) The contractor will be debriefed at the completion of the entry operation, or during if any hazards were created during their work.

e. Occupational Safety & Health Service (Safety Section) is responsible for:

(1) Reviewing written procedures for Engineering Service groups;

(2) checking environmental levels when necessary;

(3) checking periodically for oxygen levels and conduct environmental testing, when necessary;

(4) checking noise levels where necessary;

(5) ensuring appropriate training is conducted on confined space entry;

(6) monitoring the Confined Space Program to ensure adherence to all requirements by all employees and revise the program as necessary to provide adequate protection.

f. Confined Space personnel are responsible for:

(1) Following policies and procedures.

(2) Knowing and complying with safety policies and regulations.

(3) Reporting unsafe conditions to immediate supervisor.

(4) Reporting all accidents to immediate supervisor or as stipulated in Confined Space

Entry Plan.

(5) Seeking medical treatment or first aid if necessary.

g. Radiation Safety Officer shall check levels of ionizing radiation, when necessary.

h. Police Service is responsible for contacting the local Fire Department upon notification by the attendant of the confined space to respond for an emergency rescue, as needed.

4. DEFINITIONS

NONE:

5. REFERENCES

NOTE: All references to VA, VHA, and Hines documents herein incorporate by reference subsequent VA, VHA, and Hines documents on the same or similar subject matter.

OSHA 29 CFR 1926 Subpart AA - Confined Spaces in Construction OSHA 29 CFR 1910.146, Permit-required confined spaces

6. REVIEW

Review will be conducted, at minimum at recertification. It may also be conducted when there are changes to any governing document (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 March 2026. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

Dr. Afif Marouf Chief of Occupational Safety & Health Service NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Hines Intranet Website and Service Chiefs/Service Line Managers via E-mail. SOPs are available at: http://vaww.hines.med.va.gov/hines/Policy/files.asp

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