SOP 138-53 Lockout-Tagout Program 2024 Update.pdf

April 8, 2024 SOP 138-53

LOCKOUT/TAGOUT PROGRAM

Sheridan VA Health Care System

SOP 138-53

Service Line(s):

Sheridan, WY 82801

Signatory Authority:

Chief, Facilities Management Service

Responsible Owner:

Chief, Facilities Management Service

1. PURPOSE AND AUTHORITY

Facilities Management Service (FMS)

Effective Date:

April 8, 2024

Recertification Date:

April 8, 2029

a. The purpose of this standard operating procedure (SOP) is to establish procedures for an effective program for the safe management and control of hazardous energy. Control of hazardous energy is needed to prevent unexpected start-up or release of stored energy that could result in employee injuries. This SOP establishes the requirements for isolation of energy sources: kinetic, electrical, chemical, thermal, hydraulic, pneumatic, and gravitational prior to equipment repair, adjustment, replacement, installation, or removal in accordance with related Occupational Safety and Health Administration (OSHA) Standards. All contractors must comply with the lockout/tagout procedures in accordance with this policy.

b. This SOP applies to job tasks that require:

1) Servicing and/or maintenance of machines and equipment.

2) Removing or bypassing a guard or other safety devices.

3) Work on or near electrical equipment /performing procedures near exposed energized and/or de-energized parts.

4) Placing any body parts in an area on a machine or piece of equipment where work is actually performed upon the material being processed (point of operation) or where an associated danger zone exists during a machine operating cycle.

c. This SOP does not apply to job tasks that require:

1) Minor tool changes, adjustments, and other minor servicing activities, which take place during normal production operations and are routine, repetitive, and integral to the use of the equipment for production. In such cases specific procedures must be in place to ensure employees are protected from potential injury. These tasks will be evaluated on a case-by-case basis.

2) Work on cord and plug connected electric equipment if, and only if, the plug is in exclusive control of the employee performing the servicing or maintenance.

If the employee cannot maintain visual contact with the plug, it must be locked and tagged out.

d. There is no governing document.

2. PROCEDURES

a. Only Authorized employees will conduct Lockout/Tagout (LOTO) procedures.

b. Locks and Energy Isolating Devices.

1) Locks and energy isolating devices will be used for isolating potential energy sources and for securing de-energizing power sources.

2) Lockout devices will be singularly identified; will be the only devices used for controlling energy; will not be used for other purposes. All locks will be numbered and colored red or clearly identified by red markings. Lockout devices, lock boxes, hasps, etc., should also be red and/or clearly identified.

3) Authorized employees will each be issued one keyed lock with the key and a personal identification tag to identify they are the lock owner. No combination type locks are allowed. The only key that will be available for the issued lock will be in control of the authorized employee the entire time the employee is issued and using the lock. Each member of a multiple group lockout will be issued and utilize a personal lock and tag. Multi lock devices will be provided and used.

4) Copying of any LOTO keys by unauthorized persons is not permitted.

5) Lockout devices will be readily available and provided to trained and authorized employees conducting Lockout/Tagout procedures.

6) Lockout/Tagout devices will be controlled and issued by the designated Supervisor of the section required to conduct LOTO procedures.

7) Each lock will be numbered and tracked per #3 above. Locks will only be issued to authorized employee and tracked by employee name, lock number, location where lock is being used, date of issuance and date of lock and key return, using the Lock Log (Appendix 3). If an employee needs additional locks or to keep a lock on overnight, off shift, they shall get with their supervisor and obtain the necessary locks.

8) Lockout devices in combination with a lock must be substantial enough to prevent removal without excessive force or unusual techniques (i.e., lock cutters).

9) Examples of lockout devices are:

Ball Valves Lockout Devices

Circuit Breakers Lockout Devices

Flow Port Valve Lockout Device

Fuse Lockout Device and Fuse Pullers

Gate Valve

Hasp

Lock Boxes

Plug Lockout Devices

Pneumatic Lockout Devices

c. Lockout Tags:

1) Tags will be used to identify the person(s) performing the LOTO procedure.

2) Tags will be readily available and provided to trained and authorized employees conducting Lockout/Tagout procedures.

3) Tags will be used in conjunction with locks and contain the printed name of the authorized employee and the date the lock was applied.

4) Tags are essentially warning devices and do not provide the physical restraint a lock does.

5) Tags will not be used alone as a lockout means to control energy. They will not be used without a lock or as a substitute for a lock.

a) Exceptions:

(1) Fleet/Vehicle (paragraph g.)

(2) Electrical (paragraph h.) - If a lock cannot be applied, or if the employer can demonstrate that tagging procedures will provide a level of safety equivalent to that obtained by the use of a lock, a tag may be used without a lock. A tag used without a lock, will be supplemented by at least one additional safety measure that provides a level of safety equivalent to that obtained by use of a lock. Examples of additional safety measures include the removal of an isolating circuit element, blocking of a controlling switch, or opening of an extra disconnecting device.

(3) Exceptions must be approved by a supervisor and be documented in writing, to include the what, where and why it is being authorized.

6) Tags must be removed only by the authorized employee who applied the tag.

7) Tags must meet the following requirements:

a) Be legible and understandable by all employees in the area.

b) Be able to withstand their environment.

c) Be securely attached to the designated lock attached in such a way that it cannot be inadvertently or accidentally detached during use.

d) Electrical - Each tag shall contain a statement prohibiting unauthorized operation of the disconnecting means and removal of the tag.

d. General Requirements

1) All machines/equipment will have a specific Lockout/Tagout procedure as required by the OSHA Lockout/Tagout (LOTO) standard.

2) All machines and equipment will be evaluated for LOTO requirements utilizing the process outlined in Appendix 5. Requirements and procedures will be documented. Assessment and documentation can be done using an equivalent process. For example: If a third party is used to help identify and develop procedures, their forms can be used provided the process and forms meet requirements outlined in this SOP.

3) Machine specific Lockout/Tagout procedures will be written prior to machine use and maintenance. An evaluation will be made to determined machine Lockout/Tagout requirements. Machine specific Lockout/Tagout procedures will be available in the immediate vicinity of each device. A mechanical room may have a conspicuous safety station that contains the procedures for equipment located within that mechanical room. If the procedures are not at a device or safety station, no actions will be performed until a copy of the procedures is obtained and is physically present at the device.

4) New and unfamiliar equipment: When new equipment is procured or unfamiliar equipment is found, it should be identified to the station LOTO Champions, who will assign and track actions for LOTO procedure development. LOTO procedure will be developed by a competent person using information available from applicable equipment manufacturer and instruction manuals. When available training should be provided by equipment manufacturer. The process for adding new equipment LOTO procedures is detailed in Appendix 5.

Warning: Return the Operating Controls to the “Neutral” or “Off” position after completing the test.

NOTE: All new equipment/machinery should be accompanied by an operator’s manual upon its arrival at the facility.

5) Equipment will not be procured that cannot meet LOTO requirements. LOTO will be considered, and equipment will be installed in such a way as to facilitate appropriate LOTO procedures. Work order will be submitted, and equipment installation modified as needed to ensure LOTO requirements are met.

6) When LOTO requirements apply; the equipment will be brought to a zero-energy level. If multiple sources of energy are identified, all such sources must be brought to a zero-energy level.

7) If it is concluded a lockout cannot be done on a piece of equipment/machinery, the Safety Manager will be notified. The Safety Manager will work with the service department to develop an effective procedure to control hazardous energy for that piece of equipment/machinery.

8) Lockout/Tagout procedures will contain the following steps:

a) Notification. Affected employees will be notified when a machine or piece of equipment is being locked out and taken out of services. Notification will be given before the controls are applied to the machine or equipment.

b) Prepare for Shutdown. Identify all energy sources and isolation points.

More than one source of energy, i.e., electrical, hydraulic or pneumatic, may be involved. Reference the machine/equipment specific procedures.

Obtain the necessary LOTO equipment for the job (i.e., generic locks, lock box, tags, hasps, etc.).

c) Shutdown. If the machine or equipment is operating, shut it down by the normal stopping procedures (depress stop button, open toggle switch, etc.).

d) Isolate. Operate the switch, valve or other energy isolating devices so that the equipment is isolated from its energy source.

e) Apply Lockout Devices, Locks, and Tags. Lock out the energy isolating devices with the appropriate locks/devices and apply tags. All energy sources for the applicable machine or equipment must be locked out.

f) Release/Restrain. Stored energy (such as that in springs, elevated arms, rotating flywheels, hydraulic or air systems or air, gas, steam or water pressure, etc.), which presents a potential hazard to employees working on the machine or equipment, must be dissipated or restrained by methods, such as repositioning, blocking, bleeding down, etc. Bring all other energy sources down to zero energy level.

g) Re-Check. Make sure the equipment does not operate. After assuring no personnel are exposed, check that energy sources have been effectively disconnected, by operating the normal controls.

h) Document. LOTO tracking to be accomplished by documenting any overnight LOTO in an Annual Index, then creation of individual LOTO tracking sheets that document the reason for the LOTO, all affected system(s), isolation points, lock systems utilized, personnel applying the LOTO, method of energy release, and all person(s) that lock on/off with dates and times for each activity.

e. Restoring Machinery/Equipment to Normal Operations

1) After the servicing and/or maintenance are complete and the equipment is ready for normal operation, check the area around the machine or equipment to ensure no one is exposed.

2) Remove all tools from the machine or equipment and install all guards.

3) Check for and notify all affected employees in the immediate area that the lockout is being removed.

4) Ensure all employees are clear.

5) Remove the lockout devices and any safety blocks.

6) Affected employees will be notified when the machine or equipment is being brought back into service. Notification shall be given after controls are removed from the machine or equipment and prior to machine/equipment startup and use.

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

f. Removal of Locks and Lockout Devices

1) Lock owners must remove their own locks. No one else is permitted to remove them unless the requirements described below are met.

2) Forcible Lock/Tag Removal: When it becomes necessary to remove an employee’s lock and/or lockout device during the employee’s absence the following steps will be followed and documented to ensure employee safety:

a) Removal procedures will be documented on the Forcible Lock/Tag

Removal Form (Appendix 2).

b) The Chief Engineer/FMS Chief, Supervisor, or Safety Manager may approve lock removal after verification the authorized person who applied the lockout device is not “on premises”.

c) Verification will be accomplished by an active search using radio, pagers, and phone as applicable.

d) If the employee is verified as not “on premises,” a reasonable attempt will be made to reach the employee at home. If the employee does not answer a message will be left (if possible). If employee could not be contacted or a message could not be left the Chief Engineer/FMS Chief, Supervisor, or Safety Manager may then approve removal of the lock. Attempts to locate the employee should be documented on the Forcible Lock/Tag Removal Form (Appendix 2).

e) The person approving removal will complete the Forcible Lock/Tag Removal Form (Appendix 2) and ensure the authorized person who applied the lock is aware it has been forcibly removed before they resume work.

f) The lock owner will sign the Forcible Lock/Tag Removal Form immediately upon returning to work to acknowledge his/her lock was removed.

g) The lock owner will be issued a new lock.

h) The Forcible Lock/Tag Removal Form will be maintained by the Service Chief/Supervisor for tracking and documentation purposes.

g. Vehicle and Mobile Equipment Lockout Requirements:

1) Fleet equipment is not required to have a machine specific LOTO procedure;

however, before work begins the vehicle and related equipment will be evaluated for potential energy hazards.

2) Energized equipment will be powered down while work is physically being done and only powered for testing or evaluating and/or upon completion of work. A “Danger - Do Not Operate” tag should be placed on the steering wheel. (This is the only tag exception to previously stated rules.)

3) Potential energy sources, such as an extended hydraulics, gravity, wheel movement, etc., will be controlled (i.e., retract hydraulics or secure them, chocking wheels).

h. Electrical Requirements

1) In addition to other procedures outlined in this SOP the following considerations apply to electrical work:

a) Electrical parts and current to which an employee may be exposed will be de-energized, locked and tagged before employees work on or near them, unless it can be demonstrate that de-energizing introduces additional or increased hazards or is infeasible due to equipment design or operational limitations.

b) Verification of de-energized condition.

(1) A qualified person will verify that the equipment cannot be restarted.

(2) A qualified person will use test equipment to test the circuit elements and electrical parts of equipment to which employees will be exposed and will verify that the circuit elements and equipment parts are de-energized.

(3) Prior to reenergizing, a qualified person will conduct tests and visual inspections, as necessary, to verify that all tools, electrical jumpers, shorts, grounds, and other such devices have been removed, so that the circuits and equipment can be safely energized.

(4) Employees exposed to the hazards associated with reenergizing the circuit or equipment will be warned to stay clear of circuits and equipment (see requirements for affected employee).

(5) See Electrical Safety SOP 138-16 for “Live Work” and other related safety requirements.

i. Special Requirements

1) Procedures with Multiple Lockout/Tagout Points (more than one energy source):

a) LOTO procedures that require more than one energy source may require the use of generic locks and a lock box. Keys for the generic locks will be placed in the lock box and a designated (red) lock will be used to control the generic locks.

b) A LOTO tag will be placed on the box.

2) Lockouts Involving More Than One Person:

a) For procedures that have one lockout point, a hasp will be used where all involved authorized employees will place their personal locks.

b) For procedures that have more than one lockout point (more than one energy source), the requirements in paragraph I 1a) must be met. A hasp will be attached to the lock box where all will place their personal locks.

3) When it is necessary to temporarily remove lockout devices and re-energize machines or equipment for testing or adjustment, the following sequence of actions must be followed:

a) Clear the machine or equipment of all tools and materials.

b) Ensure all employees are out of the machine or equipment area and are in the clear.

c) Remove the lockout devices and any safety blocks.

d) Energize and continue with testing or adjustment.

e) De-energize all systems and re-apply energy control systems as stated above to bring the equipment back to a zero-energy level.

4) Shift Change:

a) If the work is not complete at the end of the shift and work will not continue with the next shift crew, the employees will leave their personal locks on the lockout for the next day.

b) If the work is not complete at the end of the shift and work will continue with the next shift crew, the next shift crew will place their locks on the hasp/lockout point BEFORE the current shift takes theirs off.

Communication of job status will be done at the time of this job transfer.

Departments that have a gap between shifts (i.e., 3rd shift ends at 1:00 a.m. and 1st shift starts at 5:00 a.m.) will place a department generic lock, remove their personal lock, and leave the generic lock’s key in a secure place with written communication for the next shift’s area manager/supervisor or group leader.

j. Contractors

1) Contractors hired to install, repair or perform servicing activities for machinery and equipment shall comply with OSHA Lockout/Tagout procedures.

2) Contractors must have and use an OSHA compliant LOTO program and procedures.

3) LOTO affecting an area outside of the contractor’s project area will also have a VA Lock in addition to the contractor’s lock.

k. Training and Competency

1) Training shall be provided to ensure the purpose and function of the energy control program are understood by employees and that the knowledge and skills required for the safe application, usage, and removal of the energy controls are acquired by employees. The training shall include the following:

2) Authorized Employees

a) Will receive training in the recognition of applicable hazardous energy sources, the type and magnitude of the energy available in the workplace, and the methods and means necessary for energy isolation and control.

b) Will be trained on Lockout/Tagout procedures for specific equipment they are required to maintain/work on that is capable of movement, is required to be de-energized or disengaged and locked out during cleaning, servicing, maintenance, adjusting or setting up operations, or whenever required.

c) Once an employee completes training and demonstrates competency, the employee will be authorized to Lockout/Tagout equipment, using equipment/machine specific Lockout/Tagout procedures.

3) Affected Employees - All affected employees will receive awareness training upon hire. Employees will be instructed in the purpose and use of the energy control procedure.

4) All other employees whose work operations are or may be in an area where energy control procedures may be utilized, shall be instructed about the procedure, and about the prohibition relating to attempts to restart or reenergize machines or equipment which are locked out or tagged out.

5) Periodic inspections of energy control procedures will be conducted at least annually to ensure procedures and requirements set forth by the OSHA Standard - Control of Hazardous Energy (Lockout/Tagout) are being followed.

a) The inspector will observe the implementation of the energy control procedure and conduct a review of sufficient breadth to enable him/her to detect, and to correct, any deviations from, or inadequacies in, the energy control procedure. The inspector may comply with this requirement by observing a representative number of authorized employees as they implement the energy control procedure.

b) In addition, where lockout is used for energy control, the inspector will review with every authorized employee, that employee's responsibilities under the energy control procedure being inspected. Where tagout is used for energy control, an inspector must review with every authorized employee and with every affected employee that employee's responsibilities under the energy control procedure being inspected and must also review the elements set forth in 29 CFR §1910.147(c)(7)(ii). The review must include all authorized employees (and affected employees when tagout is used), regardless of whether they were observed during the inspection process. Group meeting(s) between the authorized employee who is performing the inspection and all authorized employees (as well as affected employees when tagout is used) who implement the procedure would constitute compliance with these 29 CFR §1910.147(c)(6)(i)(C) and (D) requirements.

6) Refresher Training for all authorized and affected employees: Refresher training and re-evaluation will be provided when:

a) Whenever there is a change in their job assignments, a change in machines, equipment or processes that present a new hazard, or when there is a change in the energy control procedures or policy.

b) Additional retraining will be conducted whenever a periodic inspection reveals, or whenever there is reason to believe, that there are deviations from or inadequacies in the employee's knowledge or use of the energy control procedures.

c) Requirements of this SOP will be reviewed during refresher training.

d) The retraining shall reestablish employee proficiency and introduce new or revised control methods and procedures, as necessary.

7) Training will be documented to certify that employee training has been accomplished and is being kept up to date. The certification shall contain each employee's name and dates of training.

l. Recordkeeping

1) Training records will be maintained for the duration of employment of each employee:

a) Awareness training given to employees upon hire.

b) Authorized employee training and initial competency completed upon hire or upon assignment of LOTO duties.

2) Documentation of annual competency evaluations and refresher training/re-evaluation will be maintained by the Service Chief/Supervisor for 3 years.

3) Forcible Lock Removal Forms will be maintained on file for three years.

Forced Lock Removal Forms will be saved electronically in the following directory: S:\FMS\8 LOCK OUT TAG OUT PROGRAM\Forced Lock Removals.

m. Chief of FMS.

1) Develop written Stand Operating Procedures for isolating energy sources for all machines or equipment on which their employees would be working, performing service or maintenance. Specific procedures need not be documented (i.e., in writing) if the machine or piece of equipment meets all eight elements listed under the exception in Section 1910.147 (c)(4)(i) of the OSHA Lockout/Tagout Standard. Contact the Safety Office with any questions.

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

3) Ensure that all supervisors have received instructions sufficient to allow them to carry out their duties and responsibilities under the lockout/tagout program.

4) Provide training as outlined in this policy to all authorized employees.

Training shall be documented (and maintained) to include date of training and names of employees. Supervisors will work with other services and the Safety Office to assure that affected employees are included in this training.

5) Ensure 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. Ensure that the LOTO Champion completes the LOTO Written Program Review annually (See Appendix 6). Supervisors will work with other services and the Safety Office to assure that all affected employees are included in the annual review.

6) May approve energized electrical work plan for Branch Circuits, from the final over current protecting devices to the outlasts, that do not sever the critical patient care areas, such as Critical/Urgent Care, Isolation Rooms, or Supply, Processing, and Distribution (SPD) rooms.

n. Authorized employees.

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

o. All Supervisors.

1) All supervisors are responsible for implementing these procedures in accordance with this policy, for isolating energy sources for machines or equipment prior to any service or maintenance. They are also responsible for ensuring that all contractors under their control comply with this medical center’s policy and procedures for lockout/tagout.

p. Lockout.

1) It shall be the policy that a lockout procedure will be followed in combination with a tag to identify who has applied the lock. A tagout procedure will be used “alone” only when specifically approved by the Chief, Facilities Management Service for that single task.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Safety Manager:

1) Assist Engineering, Service Chiefs, and Supervisors as requested or needed with inspections, training, and guidance related to lockout/tagout program requirements.

2) Will identify a LOTO Champion from within the Safety staff to work with the FMS LOTO Champion.

b. Chief Engineer/FMS Chief and Supervisors (Others as applicable):

1) Develop and publish the lockout/tagout program.

2) Ensure compliance with procedures and requirements of this SOP by:

a) Ensuring employees under their supervision follow Lockout/Tagout procedures.

b) Ensuring written procedures are developed for all pieces of equipment as required by OSHA standards.

c) Scheduling and conducting required Lockout/Tagout training for employees under their direction.

d) Issuing locks and tags to employees under their direction.

e) Ensuring only employees trained as "Authorized" are permitted to perform repairs requiring LOTO on equipment.

f) Ensuring the procedure for shift change under LOTO is followed.

g) Maintaining an adequate supply of required locks, locking devices, and tags for use by employees.

h) Conducting and updating training as required by this SOP.

i) Maintaining written records as indicated in this SOP

j) Conduct periodic inspections of the lockout/tagout procedures to ensure authorized employees follow the written instructions.

3) Will identify a LOTO Champion from within the FMS supervisory staff to work with the Safety LOTO Champion.

c. Nutrition and Food Service (NFS) Chief:

1) Implement this SOP for NFS employees needing to LOTO kitchen equipment.

d. Project Engineer/Contract Officer Representative (COR):

1) Coordinating LOTO program requirements between Sheridan VA Health Care System and contracted employees on their respective projects.

2) Ensuring contracted personnel are properly trained in the use of our machine-specific procedures prior to allowing servicing and/or maintenance on any equipment.

3) Participating in any periodic inspections performed within their projects.

e. Authorized Employee:

1) Attending required training sessions.

2) Understanding and using the content of Lockout/Tagout procedures.

3) Locking, tagging, and de-energizing equipment before performing servicing and/or maintenance.

4) Performing servicing and/or maintenance only on equipment for which they’re trained as an “authorized” person.

5) Informing Affected employees in the project area whenever lockout is to take place, including the pieces of equipment to be serviced, when they will be Locked/Tagged out, and when it is safe to resume operation.

f. Affected and Other Employees:

1) Adhering to the policies set forth in this SOP.

2) Ensuring no employees in the area attempts to operate any locked out or tagged out equipment.

4. DEFINITIONS

a. Affected Employee. Employee that cannot perform a Lockout/Tagout but is exposed to Lockout/Tagout when the employee’s or surrounding machinery/equipment is under Lockout/Tagout.

b. Authorized Employee. A properly trained employee and determined competent to effectively de-energize and implement the lockout or tagout procedures on a machine or piece of equipment to perform service or maintenance.

c. Capable of Being Locked out. Ability to bring machinery/equipment to zero energy and secure it at zero energy without the need to dismantle, rebuild or replace the energy isolating device or permanently alter its energy control capability.

d. De-energized Parts. Live parts, greater than 50 volts to which an employee may be exposed that are de-energized before the employee works on or near them.

e. Energized Parts. Exposed live parts greater than 50 volts that are not de-energized.

f. Energy isolating Device. A mechanical device that physically prevents the relapse 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 a push button, selector switch or other circuit type devices.

g. Energy Source. The origin of any type of energy to include electrical, mechanical, hydraulic, pneumatic, chemical, thermal, etc.

h. Hazardous Energy. Any energy source associated with a machine or piece of equipment whose unexpected re-energizing or start up could cause injury to employees.

i. 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.

j. Lockout Device. A device that utilizes 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.

k. Normal Production Operations. The utilization of a machine or equipment to perform its intended production function.

l. Service and/or Maintenance. Workplace activities on a 5 machine or equipment where an employee may be exposed to the unexpected re-energizing or startup of the equipment or machine or may be exposed to the release of hazardous energy. These activities include lubrication, cleaning, unjamming of machines, adjusting, and performing tool changes.

m. Tagout. The placement of a tagout device on an energy-isolation device, in accordance with established procedure, to indicate that the energy-isolating device and the equipment being controlled may not be operated until the tag is removed.

n. Tagout Device. A prominent warning device, such as a tag and a means of attachment, which can be securely fastened to an energy-isolating device to indicate that the energy-isolating device to indicate that the energy-isolating device and the equipment being controlled may not be operated until the tagout device is removed.

o. Zero Energy Level. All energy sources to include stored energy are absolutely eliminated.

5. REFERENCES

a. NFPA 70, National Electrical Code,

b. NFPA 70B, Recommended Practice for Electrical Equipment Maintenance,

c. NFPA 70E, Standards for Electrical Safety in the Workplace,

d. NFPA 99, Health Care Facilities Code,

e. NFPA 101, Life Safety Code

f. NFPA 110, Standard for Emergency and Standby Power Systems

g. The Joint Commission Accreditation Manual for Hospitals

h. OSHA – Occupational Safety and Health Requirements part 1910 Subpart J. – The control of hazardous energy (lockout/tagout) (1910.399)

i. OSHA – Occupation Safety and Health Requirements Part 1910 Subpart S – Electrical (1910.301 – 1910.399)

6. REVIEW

Frequency of required review: At minimum at the 5-year recertification, or when there are changes to the governing document, 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 April 2029.

In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

STEPHEN

PETZOLD

Digitally signed by STEPHEN

PETZOLD

Date: 2024.04.08 16:33:32 -06'00'

Stephen C. Petzold Chief, Facilities Management Service Date Approved: April 8, 2024

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

DISTRIBUTION: SOP’s are available at: SVAHCS SharePoint https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=70 https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=70B https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=70E https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=99 https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=101 https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=101 https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=110 https://www.jointcommission.org/standards/ https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910SubpartJ https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910SubpartJ https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910SubpartS https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910SubpartS https://dvagov.sharepoint.com/sites/VHASHE/Service%20Policies/Forms/AllItems.aspx?viewpath=%2Fsites%2FVHASHE%2FService%20Policies%2FForms%2FAllItems%2Easpx&viewid=88d0c42e%2Dc0b1%2D43fe%2D898f%2Dd384b9790cd1

Appendix 1 Annual Assessment Form

Appendix 2 Forcible Lock/Tag Removal Form

Appendix 3 Lock Issue Log

Appendix 4 Lockout/Tagout Steps

Appendix 5 Determination For Lockout/Tagout Procedures

Appendix 6 Control of Hazardous Energy Lockout/Tagout Written Program, 29

CFR 1910 Program Review https://dvagov.sharepoint.com/sites/VHASHE/Service%20Policies/Forms/AllItems.aspx?viewpath=%2Fsites%2FVHASHE%2FService%20Policies%2FForms%2FAllItems%2Easpx&id=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments%2FAppendix%201%20%2D%20SOP%20138%2D53%20Lockout%2DTagout%20Program%20Annual%20Assessment%20Form%2Epdf&viewid=88d0c42e%2Dc0b1%2D43fe%2D898f%2Dd384b9790cd1&parent=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments https://dvagov.sharepoint.com/sites/VHASHE/Service%20Policies/Forms/AllItems.aspx?viewpath=%2Fsites%2FVHASHE%2FService%20Policies%2FForms%2FAllItems%2Easpx&id=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments%2FAppendix%202%20%2D%20SOP%20138%2D53%20Lockout%2DTagout%20Program%20Forciable%20Lock%2DTag%20Removal%20Form%2Epdf&viewid=88d0c42e%2Dc0b1%2D43fe%2D898f%2Dd384b9790cd1&parent=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments https://dvagov.sharepoint.com/sites/VHASHE/Service%20Policies/Forms/AllItems.aspx?viewpath=%2Fsites%2FVHASHE%2FService%20Policies%2FForms%2FAllItems%2Easpx&id=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments%2FAppendix%203%20%2DSOP%20138%2D53%20Lockout%2DTagout%20Program%20Lock%20Issue%20Log%2Epdf&viewid=88d0c42e%2Dc0b1%2D43fe%2D898f%2Dd384b9790cd1&parent=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments https://dvagov.sharepoint.com/sites/VHASHE/Service%20Policies/Forms/AllItems.aspx?viewpath=%2Fsites%2FVHASHE%2FService%20Policies%2FForms%2FAllItems%2Easpx&id=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments%2FAppendix%204%20%2D%20SOP%20138%2D53%20Lockout%2DTagout%20Program%20Lockout%2DTagout%20Steps%2Epdf&viewid=88d0c42e%2Dc0b1%2D43fe%2D898f%2Dd384b9790cd1&parent=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments https://dvagov.sharepoint.com/sites/VHASHE/Service%20Policies/Forms/AllItems.aspx?viewpath=%2Fsites%2FVHASHE%2FService%20Policies%2FForms%2FAllItems%2Easpx&id=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments%2FAppendix%205%20%2D%20SOP%20138%2D53%20Lockout%2DTagout%20Program%20%2DDetermination%20for%20Lockout%2DTagout%20Porcedures%2Epdf&viewid=88d0c42e%2Dc0b1%2D43fe%2D898f%2Dd384b9790cd1&parent=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments https://dvagov.sharepoint.com/sites/VHASHE/Service%20Policies/Forms/AllItems.aspx?viewpath=%2Fsites%2FVHASHE%2FService%20Policies%2FForms%2FAllItems%2Easpx&id=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments%2FAppendix%206%20%2D%20SOP%20138%2D53%20Lockout%2DTagout%20Program%20%2DControl%20of%20Hazardous%20Energy%20Lockout%2DTagout%20Written%20Program%2Epdf&viewid=88d0c42e%2Dc0b1%2D43fe%2D898f%2Dd384b9790cd1&parent=%2Fsites%2FVHASHE%2FService%20Policies%2FFacilities%20Management%20%28138%29%2FAttachments

April 8, 2024 Appendix 1 SOP 138-53

ANNUAL LOCKOUT/TAGOUT ASSESSEMENT

Date of Inspection: Equipment

Inspectors, including at least one Authorized Employee:

Authorized Employee(s) performing servicing, repair, or maintenance:

If necessary, specific procedure used by the Authorized Employee(s):

Yes No

1. Were the affected employees notified prior to the project start?

2. Are the appropriate locks, tags, and attachment devices available?

3. Are machine-specific procedures available at the work site?

4. Are all sources of energy de-energized, locked, and tagged out?

5. Have all exposed employees used locks/tags on all disconnects?

6. Was the on/off switch returned to "off" position following try out?

7. Has the inspector reviewed and corrected any deficiencies?

Comments:

We certify that any problems discovered during this inspection were reviewed with the authorized employees on this job during the inspection process:

Authorized Employee Authorized Employee Inspector

April 8, 2024 Appendix 2 SOP 138-53

FORCIBLE LOCK/TAG REMOVAL FORM

Date / /

Name of lock owner:

Name of supervisor/group leader removing lock:

Name of affected employee:

Machine/Equipment lock being removed from:

Locate lock owner (document all attempts to find individual) if not on the facility attempt to contact at their home. Use additional sheets if necessary to properly document.

Phone # called: ( ) -

Time Called Individual

Making Call Individual or Household member contacted (Y/N) Document Names

If no answer was a message left on an answering machine if available (Y/N)

Document dialogue of conversation or message

Call Maintenance Supervisor or Safety Manger if you cannot reach the owner for authorization to remove lock.

Signature of affected employee Date Time

Signature of lock owner Date Time

Signature of Supervisor Date Time

(Save electronic copy of completed form here: S:\FMS\8 LOCK OUT TAG OUT PROGRAM\Forced Lock Removals.)

April 8, 2024 Appendix 3 SOP 138-53

Lock Issue Log for Lockout/Tagout Program

Lock # Employee issued to Position Date issued Date returned

April 8, 2024 Appendix 4 SOP 138-53

Lockout/Tagout Steps:

Authorized Employee:

Process (Circle One): Lockout Tagout Both

Date: / /

Equipment Being Worked On:

Locking/Tagging Machine Out

1 Notification. The employee applying the lockout device notifies other affected employees in the immediate work area before applying the controls.

2 Prepare for Shutdown. Identify all energy sources and isolation points. More than one source of energy, i.e., electrical, hydraulic, or pneumatic, may be involved. Reference the machine/equipment specific procedures. Obtain the necessary LOTO equipment for the job (i.e., generic locks, lock box, tags, hasps, Nyties, etc.).

3 Shutdown. If the machine or equipment is operating, shut it down by the normal stopping procedures (depress stop button, open toggle switch, etc.).

4 Isolate. Operate the switch, valve, or other energy isolating devices so that the equipment is isolated from its energy source.

5 Apply Lockout Devices, Locks and Tags. Lock out the energy isolating devices with the appropriate locks and apply tags. All energy sources for the applicable machine or equipment must be locked out.

6 Release/Restrain. Stored energy (such as that in springs, elevated arms, rotating flywheels, hydraulic or air systems or air, gas, steam, or water pressure, etc.), which presents a potential hazard to employees working on the machine or equipment, must be dissipated, or restrained by methods, such as repositioning, blocking, bleeding down, etc. Bring all other energy sources down to zero energy level.

7 Re-Check. Make sure the equipment does not operate. After assuring no personnel are exposed, check that energy sources have been effectively disconnected, by operating the normal controls.

April 8, 2024 Appendix 4 SOP 138-53

Restoring Machinery/Equipment to Normal Operations

1 After the servicing and/or maintenance are complete and the equipment is ready for normal operation, check the area around the machine or equipment to ensure no one is exposed.

2 Remove all tools from the machine or equipment and install all guards.

3 Check for and notify all affected employees in the immediate area that the lockout is being removed.

4 Ensure all employees are clear.

5 Remove the lockout devices and any safety blocks.

6 Operate the energy isolating devices to restore energy to the machine or equipment.

7 Affected employees shall be notified by the employer or authorized employee of the application and removal of lockout devices or tagout devices. Notification shall be given before the controls are applied, and after they are removed from the machine or equipment.

Lock owners must remove their own locks. No one else is permitted to remove them unless Forcible Lock/Tag Removal procedures are followed in accordance with the

VAMTHCC LOTO SOP.

April 8, 2024 Appendix 5 SOP 138-53

DETERMINATION FOR LOCKOUT/TAGOUT PROCEDURES

Lockout/Tagout Procedures for

This is a preliminary survey form used to determine the need to document Lockout/Tagout procedures for a machine or piece of equipment.

Do the following conditions exist? YES NO

The machine or equipment has no potential for stored or residual energy or re-accumulation of stored energy after shut down which could endanger employees

The machine or equipment has a single energy source which can be readily identified and isolated

The isolation and locking out of that energy source will completely de-energize and deactivate the machine or equipment

The machine or equipment is isolated from that energy source and locked out during servicing and/or maintenance

A single lockout device will achieve a locked-out condition

The lockout device is under the exclusive control of the authorized employee performing the servicing or maintenance

The servicing or maintenance does not create hazards for other employees

No accidents involving the unexpected activation or re-energization of the machine or equipment during servicing and/or maintenance have occurred on this machine or equipment

If "YES" was indicated on ALL of the above points, the required procedure for the particular machine or equipment need not be documented. Otherwise, Lockout/Tagout Procedures should be included on the "Machine Specific" Location of Lockouts form.

Exception: The employer need not document the required procedure for a particular machine or equipment, when all of the following elements exist: (1) The machine or equipment has no potential for stored or residual energy or accumulation of stored energy after shut down which could endanger employees; (2) the machine or equipment has a single energy source which can be readily identified and isolated; (3) the isolation and locking out of that energy source will completely de-energize and deactivate the machine or equipment; (4) the machine or equipment is isolated from that energy source and locked out during servicing or maintenance; (5) a single lockout device will achieve a locker-out condition; (6) the lockout device is under the exclusive control of the authorized employee performing the servicing or maintenance; (7) the servicing or maintenance does not create hazards for other employees; and (8) the employer, in utilizing this exception, has had no accidents involving the unexpected activation or re-energization of the machine or equipment during servicing or maintenance.

Evaluation must be made and documented to see if the exceptions apply.

Lockout/Tagout Procedure

Equipment Description

Machine ID

Department Supervisor

Authorized Employee(s)

Purpose:

Energy Sources:

Energy Sources Machine Specific

Electrical YES Steam YES Hydraulic NO

Pneumatic NO Natural Gas NO Other

Stored Energy Sources NONE

Identify Energy Sources

And Location

Lockable?

Yes or No

Type of Lock or Energy*

Control Device Needed

Steps necessary to shut down and de-energize

Procedure Lock Type and Location

De-Energized How Verified

YES NO

These procedures shall be utilized when performing maintenance or repairs on this machine.

This form must be completed for each machine or equipment for which Lockout/Tagout procedures are required to be documented

Example: Lockout/Tagout Procedure

#1 Tumbler Dryer

Machine ID: Model #DES170 / Serial # 80909797 / PMI# 17938

Department Supervisor:

Authorized Employee(s):

Purpose:

This procedure establishes the minimum requirements for the Lockout/Tagout of energy isolating devices. It shall be used to ensure the machine or equipment is isolated from all potentially hazardous energy and locked out or tagged out before employee(s) perform any servicing or activities where the unexpected energization, start-up or release of stored energy could cause injury.

Energy Sources:

Can the machine be locked out at the main power source? Some machine installations involve complex wiring schemes. A qualified electrician should evaluate machines where necessary to determine if all electrical circuits can be locked out.

Energy Sources Machine Specific

Electrical YES Steam YES Hydraulic NO

Pneumatic NO Natural Gas NO Other

Condensate Return

Stored Energy Sources NONE

Identify Energy Sources

And Location

Lockable?

Yes or No

Type of Lock or Energy*

Control Device Needed

1.

Electrical disconnect box labeled Dryer # 1 at rear of machine

Yes

Padlock with Tagout Tag

2.

Steam supply valve located at rear of machine labeled #1 dryer SS

Yes Valve locking device with a Tagout

Tag

3.

Condensate return valve

Behind #1 dryer labeled #1 dryer CD.

Yes Valve locking device with a Tagout

Tag

Steps necessary to shut down and de-energize the Flatwork Ironer.

Procedure Lock Type and Location

De-Energized How Verified

YES NO

On the electrical Padlock electrical The control panel disconnect box disconnect box should be blank, push labeled Dryer # 1 at F.I.C.F.S. on the the start button & the rear of machine backside of the pillar machinery should across from the start.

Men’s bathroom

Close main steam supply valve

Tagout Tag stating “do not open”

Open valve ahead of traps to release steam

Located at rear of machine

Open condensate low point drain

Tagout Tag stating “do not close”

Located at rear of machine

Open valve ahead of traps to release condensate pressure

These procedures shall be utilized when performing maintenance or repairs on this machine.

April 8, 2024 Appendix 6 SOP 138-53

Control of Hazardous Energy Lockout/Tagout Written Program, 29 CFR 1910 Program Review

This form is provided to ensure compliance with Lockout/Tagout Program requirements by providing a checklist to conduct an annual program self-evaluation. This is different and in addition the OSHA required periodic inspection conducted at least annually. This review shall be accomplished by the LOTO Champion within one year of the publishing of this SOP and annually thereafter.

Self-identify any deficiencies, document them, implement corrective actions and track those actions to completion.

FACILITY LOCKOUT TAGOUT EVALUATION

Facility: Date of Review:

Person conducting Review (Name, Title):

Annual Lockout Tagout Program Self-Evaluation Yes No

Have you established a written LOTO program consisting of energy control procedures, employee training and periodic inspections to ensure that before any employee performs any servicing or maintenance on a machine or equipment where the unexpected energizing, start up or release of stored energy could occur and may cause injury, that the machine or equipment is isolated from the energy source, and rendered inoperative?

Explain:

Do you have a documented inventory of equipment in each location that is capable of being locked out?

Do you have machine-specific Energy Control Procedures for all equipment on the inventory?

Have you established all Authorized employees?

Explain:

Are all of your lockout tagout procedures stored in a place that is accessible to authorized employees?

Do you have routine minor servicing procedures that include safety mechanisms (interlocks, light curtains, etc.) for operators to use?

When you upgrade equipment, do you also update your lockout procedures?

Explain:

Are labels or energy source ID tags clearly posted to mark energy isolation points?

Has annual training for Authorized, Affected and Other Employees been conducted and documented?

Are your employees trained on your facility-specific lockout devices?

Explain:

Do you maintain lockout tagout training records?

Explain:

Are padlocks durable and singularly identifiable? Example: standardized by color, shape, or size

Are appropriate employees provided with individually keyed personal safety locks?

Do you have appropriate lockout devices for each type of energy control point in your facility?

Are your lockout devices readily available near the machinery?

Are specific and comprehensive lockout/tagout procedures available and in use for each piece of equipment with…