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1 Maricopa Integrated Health System Administrative Policy & Procedure Effective Date: 08/01 Reviewed Dates: 09/04, 06/08, 05/10, 04/16 Revision Dates: 11/06, 06/08, 05/10, 12/12, 04/13 Policy #: T Policy Title: Compliance/Environmental Safety: Confined Space Program Scope: [ ] District Governance (G) [X] System-Wide (S) [ ] Division (D) [ ] Multi-Division (MD) [ ] Department (T) [ ] Multi-Department (MT) Purpose: The purpose of this program is to provide specific procedures/safe work practices for employees and contractors required to enter confined spaces. These procedures/practices will be implemented in compliance with all applicable state and federal regulations pertaining to confined space entry. Definitions: Confined Space: 1. Is large enough and so configured that an employee can physically enter and perform assigned work; 2. Has limited or restricted means for entry or exit (for example, tanks, vessels, silos, storage bins, hoppers, vaults, and pits are spaces that may have limited means of entry); and 3. Is not designed for continuous employee occupancy. Permit Required Confined Space: A confined space that has one or more of the following characteristics: 1. Contains or has a potential to contain a hazardous atmospheres 2. Contains a material that has the potential for engulfing an entrant 3. Has an internal configuration such that an entrant could be trapped or asphyxiated by inwardly converging walls or by a floor, which slopes downward and tapers to a smaller cross section 4. Contains any other recognized serious safety or health hazard Permit required confined spaces will not be entered by MIHS personnel. These spaces will only be entered by authorized contractors and vendors. MIHS requires these authorized contractors and vendors to adhere to all the stipulations of this program while entering permit required confined spaces at MIHS. Required Confined Space Permit: The written or printed document that is provided by the contractor/vendor to allow and control entry into a permit confined space and that contains the information specified. See Appendix 2 Entry Permit. Policy # T Title Confined Space Program Page 1 of 8

2 Entry Supervisor: The person (such as foreman, or crew chief) responsible for determining if acceptable entry conditions are present at a permit space where entry is planned, for authorizing entry and overseeing entry operations, and for terminating entry as required. Attendant: An individual stationed outside one or more permit spaces who monitors the authorized entrants and who performs all attendant's duties assigned in the employer's permit space program. See Appendix 1 Standby Observers Checklist. Hazardous Atmosphere: An atmosphere that may expose employees to the risk of death, incapacitation, impairment of ability to self-rescue (that is, escape unaided from a permit space), injury, or acute illness from one or more of the following causes: 1. Flammable gas, vapor, or mist in excess of 10% of its lower flammable limit (LFL). 2. Airborne combustible dust at a concentration that meets or exceeds its LFL. NOTE: This concentration may be approximated as a condition in which the dust obscures vision at a distance of 5 feet (1.52 m) or less. 3. Atmospheric oxygen concentration below 19.5% or above 23.5%. 4. Atmospheric concentration of any substance for which a dose or a permissible exposure limit is published in Subpart G, Occupational Health and Environmental Control, or in Subpart Z, Toxic and Hazardous Substances, of this part and which could result in employee exposure in excess of its dose or permissible exposure limit. Immediately Dangerous to Life or Health (IDLH): Any condition that poses an immediate or delayed threat to life or that would cause irreversible adverse health effects or that would interfere with an individual's ability to escape unaided from a permit space. Non-permit confined space: A confined space that does not contain or, with respect to atmospheric hazards, have the potential to contain any hazard capable of causing death or serious physical harm. Oxygen deficient atmosphere: An atmosphere containing less than 19.5% oxygen by volume. Oxygen enriched atmosphere: An atmosphere containing more than 23.5% oxygen by volume. Policy: A. MIHS Safety Director: The Safety Director is responsible for establishing a written Confined Space Program that includes evaluating all confined spaces entered by the employee/contractor. The Safety Director shall review the Confined Space Program. B. Entry Supervisor: (Non-MIHS Staff) Entry Supervisors are the persons responsible for determining if acceptable entry conditions are present at the confined space where entry is planned, authorizing entry, supervising entry operations, and terminating entry when required. Entry supervisors shall be trained on necessary skills and responsibilities and ensuring that Policy # T Title Confined Space Program Page 2 of 8

3 these workers receive required training before entering the spaces, and ensuring that their subordinates follow established entry procedures. C. Authorized Attendants and Entrants (Non-MIHS Staff) Trained and authorized attendants and entrants are responsible for working in and around confined spaces according to guidelines and work practices established by Maricopa Integrated Health System. Authorized entrants are also responsible for refusing to work in confined spaces until an entry supervisor has deemed entry to be safe and has given approval for entry, or if a hazard is identified while working in the confined space. The authorized attendants shall attend only one confined space entry at any one time, and shall not perform any other duties. Confined Space Training: MIHS staff required to enter confined spaces will be trained by their manager/supervisor on this Confined Space Program. Contractors/Vendors will be required to comply with all elements of this confined space program. Additional confined space training for MIHS staff will occur; when there is a change in assigned duties; or operations create a new hazard; whenever an employee deviates from established procedure and when inadequacies in an employee's knowledge is identified. Confined space training will establish employee proficiency in the duties required by the confined space standard. Confined Space Locations: A. Maricopa Integrated Health System (MIHS) Safety Director will routinely evaluate the work site for any confined space areas B. MIHS Safety Department has designated the following areas as "Confined Spaces": Power Plant Cooling Tower Pits Power Plant Cooling Tower Interior Elevator Shaft Pits Air Handler Units Dock Trash and Cardboard Compactors C. MIHS Safety Department has designated the following areas as "Permit Required Confined Spaces": Power Plant Diesel Fuel Vault Power Plan Water Softeners and Brine Tower Power Plant Boilers Power Plant De-aerator Tanks Hogan Building Crawl Space Sewage Ejector Tanks Service Tunnel 2619 Building Service Tunnel 2611 Building Utility Manholes Entry Permits: (Non-MIHS Staff) Permit Required Confined Spaces Some confined spaces located at Maricopa Integrated Health System meet the definition of a Permit Required Confined Space and The Entry Supervisor shall prepare an MIHS Confined Space Permit See Appendix 2 MIHS Confined Space Entry permit. Policy # T Title Confined Space Program Page 3 of 8

4 The permit shall be made available to all supervisors, entrants, attendants, authorized employee representatives, and rescue personnel. The permit must remain posted outside of the permit space entry portal, and remain there for the duration of the authorized entry. Any changes of personnel (supervisors, attendants, entrants), or testing and monitoring data shall be added to the permit. At the end of the authorized entry or after entry operations have been completed, the entry supervisor shall cancel the permit and maintain all cancelled permits for at least one year. A new and updated permit shall be developed, implemented, and maintained for each permit space entry. Prevention of Unauthorized Entry: Posting of Confined Spaces All Permit Required Confined Spaces that can be readily labeled are posted in a manner designed to inform employees of the existence/location of the dangerous space. The signs read as follows: PERMIT-REQUIRED CONFINED SPACE, DO NOT ENTER! If posting danger signs cannot be used to inform the exposed employees, use any other effective means to warn of the existence, location, and the danger posed by the permit spaces. Procedure: The MIHS Safety Director will review entry operations, procedures, and cancelled entry permits at least annually. Additionally, a review shall be conducted if there is reason to believe that the measures taken under the MIHS Confined Space Program may not provide affected employees with the necessary protection. The review and revisions shall correct any deficiencies found to exist under the prior entry operations and procedures. Circumstances that require the review of the permit space program are listed below: Unauthorized entry of a permit space; A detection of a permit space hazard not covered by the permit; The detection of a condition prohibited by the permit; The occurrence of an injury, or a near-miss during entry operations; The change in the use or configuration of a permit space; and Employee complaints about the ineffectiveness of the permit space program. Confined Space Equipment: The MIHS Facilities Director and/or Safety Director will ensure that authorized contractors/vendors working in or around permit required confined spaces will properly use the following equipment: Testing and monitoring equipment; Ventilation equipment; Communication equipment; Personal protective equipment; Lighting equipment; Barriers and shields; Equipment necessary for safe ingress and egress; Rescue and emergency equipment; and Any other equipment necessary for safe entry into and rescue from permit spaces Evaluation of Permit Space Conditions: Policy # T Title Confined Space Program Page 4 of 8

5 When authorized contractors/vendors are conducting permit required confined space entry operations Maricopa Integrated Health System will ensure that all conditions stipulated on the MIHS Confined Space Entry Permit is conducted. See Appendix 2 MIHS Confined Space Entry permit. Multiple Employers/Contractors: Maricopa Integrated Health System shall inform all other affected outside employers and contractors of the permit space locations and permit space hazards at Maricopa Integrated Health System All affected outside employers and contractors will be educated on the confined space program and confined space requirements of Maricopa Integrated Health System Multiple permit space entries conducted by outside employers and contractors shall be reviewed and coordinated prior to authorized entry by any party. Maricopa Integrated Health System shall not enter into any binding business agreement with contractors or employers that do not meet the confined space program and training requirements of 29 CFR Rescue Procedures: As stipulated on the MIHS Confined Space Entry Permit, all authorized contractors/vendors will develop a rescue plan for each type of permit-required confined space at the facility. Whenever feasible, the rescue plan will specify methods that do not involve entry by rescuers into the confined space. The attendant and/or the Entry Supervisor are responsible for preventing unauthorized persons in attempting a rescue inside the confined space. Rescue Equipment: Permit required confined spaces will not be entered by MIHS personnel. These spaces will only be entered by authorized contractors and vendors. MIHS requires these authorized contractors and vendors to adhere to all the stipulations of this program while entering permit required confined spaces at MIHS. In the event that a confined space rescue is required, MIHS has made arrangements with the Phoenix Fire Department to be called for emergent assistance and entry into any of the permit required confined spaces. Verification is routinely conducted with the Phoenix Fire Department on the location and configuration of each physical permit required confined space at MIHS. References: Appendix 1 on page 6 Appendix 2 on page 7 Policy # T Title Confined Space Program Page 5 of 8

6 Appendix: 1 MIHS CONFINED SPACE STANDBY OBSERVER S CHECK LIST DATE OF ENTRY: LOCATION: NAME OF ATTENDANT: NAME(S) OF ENTRANTS: 1. Valid confined space entry permit posted......[ ] 2. Harness and life line present and in good condition......[ ] 3. Instructed in use of life line and harness......[ ] 4. Location of telephone or two-way radio known......[ ] 5. Knows location of work at the job site......[ ] 6. Knows how to report an emergency......[ ] 7. Knows not to leave site when employee(s) are inside, except to make emergency call... [ ] 8. The procedures to maintain communications between authorized entrants and attendants established...[ ] 9. Knows NOT TO ENTER CONFINED SPACE FOR ANY REASON other than rescue after informing others of intent......[ ] 10. Knows location of safety shower, eye wash......[ ] 11. Knows location of fire extinguisher and instructed in use...[ ] 12. Understands operation of air mover or other ventilating equipment...[ ] 13. Understands operation of supplied air respirators (air line and self contained)...[ ] 14. Informed of the potential hazards present and work to be performed...[ ] 15. Rescue plan developed and in place...[ ] 16. Has necessary safety equipment for rescue......[ ] Appendix: 2 MIHS CONFINED SPACE ENTRY PERMIT (All Sections of this Permit MUST be completed) Policy # T Title Confined Space Program Page 6 of 8

7 DATE: PROJECT NO. CONFINED SPACE ENTRY PERMIT NO. JOB LOCATION: WORK OBJECTIVE (S): CONFINED SPACE PREPARATION: CONFINED SPACE ISOLATION: ATMOSPHERE TESTING: Test Location Reading Time Initials Oxygen (%) Flammability (%LEL) Toxic Vapors (specify) Gases Dust Oxygen (%) Flammability (%LEL) Toxic Gases Vapors Dust (specify) RESPIRATORY PROTECTION REQUIRED: PROTECTIVE EQUIPMENT REQUIRED: RESCUE PLAN TO BE USED (ALL REQUIRED ELEMENTS IN PLACE): RESCUE EQUIPMENT: TYPE OF COMMUNICATION FOR ENTRANTS AND ATTENDANTS PERSONNEL ENTERING: (Print name) (Signature) STANDBY PERSON: ATMOSPHERE TESTER: PROJECT MANAGER: OPERATIONS MANAGER: EMERGENCY TELEPHONE Policy # T Title Confined Space Program Page 7 of 8

8 MIHS Policy & Procedure - Approval Sheet (Before submitting, fill out COMPLETELY.) POLICY RESPONSIBLE PARTY: Ken Bourdo DEVELOPMENT TEAM(S): Policy #: T Policy Title: Compliance/Environmental Safety: Confined Space Program e-signers: Sherry Stotler Place an X on the right side of applicable description: New - Retire - Reviewed -04/16 Revised with Minor Changes - Revised with Major Changes - Please list revisions made below: (Other than grammatical changes or name and date changes) Reviewed and Approved by in Addition to Responsible Party and E- Signer(s): Committee: Ken Bourdo 04/16 Committee: 00/00 Committee: 00/00 Reviewed for EPIC: 00/00 Other: 00/00 Other: 00/00 Other: 00/00 Other: 00/00 Policy # T Title Confined Space Program Page 8 of 8

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