Facilities and Estates Natural Gas: Standard Operating Procedure Document Control Summary Status: Version: Author/Title: Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures New v1.0 Date: January 2016 John Biggs - Estates Officer Robert Graves - Director of Facilities and Estates Policy and Procedures Committee Date: 21.04.2016 Policy and Procedures Committee Date: 21.04.2016 To Meet Statutory Compliance and Health and Safety Requirements February 2106 January 2018 Gas safety Health and Safety Policy for Facilities and Estates Contents 1.0 Introduction... 3 2.0 Purpose... 3 3.0 Scope... 3 4.0 Procedures for Working / Inspection & Testing of Natural Gas Systems... 4 4.1 Compliance... 4 4.2 Responsibilities for Compliance with the Procedure... 5 4.3 Duty Holder... 5 4.4 Responsible for gas safety... 5 4.5 Responsible Person... 5 4.6 Competent Person ( In house Staff)... 6 4.7 Approved and Nominated Gas safe Contractors... 7 4.8 Landlords... 7
4.9 Gas Emergency Actions and Procedures... 7 4.10 Reporting Faults and Gas Leaks... 7 4.11 Training... 8 4.12 Lone working... 8 4.13 PPE Equipment... 8 4.14 Asbestos... 8 4.15 Control of Contractors Policy... 8 4.16 Associated Policies / Standard Operating Procedures (SOP) -... 8 4.17 O & M Manuals / Mimic Diagrams & Drawings Line diagrams... 8 4.18 Method Statements and Risk Assessments... 9 4.19 Model forms... 9 4.20 Permit to Work System... 9 4.21 Isolation of supplies... 9 4.22 Drop Tests of Pipe work Distribution... 9 4.23 Acquisition of new and replacement Gas Equipment... 10 4.24 Installation, Maintenance and Repairs... 10 4.25 Installation, Servicing and Repair Documentation... 11 5.0 Process for Monitoring Compliance and Effectiveness... 12 6.0 References... 12 Appendix 1 - Management Structure... 13 Appendix 2 - Emergency Procedure if gas or fumes are suspected... 14 Appendix 3 - Emergency Procedure reporting information... 15 Change Control Amendment History Version Dates Amendments Page 2 of 15
1.0 Introduction Trust premises have a range of gas fired equipment and the Trust recognises the inherent danger of gas escapes and the need for the safe and effective operation of gas fired systems and will take all reasonably practical steps to ensure the safe installation, operations and maintenance of all gas services included within the scope of this procedure. Gas can be inherently dangerous if the distribution pipe system and gas fired equipment is not installed and maintained correctly. Hazards normally associated with gas include the risk of explosion and fire resulting in an escape of gas and asphyxiation by carbon monoxide gas, a colourless and odourless gas that is the by-product of combustion. This may be a danger due to inappropriate ventilation of the combustion flue gases from gas fired equipment. Due to legislation which requires proven competence to work on gas appliances (to be Gas Safe registered) and therefore all installations and gas maintenance is undertaken by contractors and their employees all whom are Gas Safe Registered to assure competence. The current authorising body is the Gas Safe Register (Gas Safe) it is acknowledged that the authorised body may be subject to change in which case all reference to gas safe in the policy should be read as the new authorising body. 2.0 Purpose The purpose of this document is to identify how the Trust shall manage the ongoing risks to persons from dangers relating to gas and applies to all premises occupied by the Trust. It will comply with all relevant Health and Safety legislation regarding gas safety, including The Gas Safety (Installation and Use) Regulations 1998 (GSIUR), Approved Code of Practice and Guidance: Safety in the installation and use of gas systems and appliances Gas Safety (Installation and Use) Regulations 1998 published by the Gas Safe and associated Building Regulations. This document details what steps will be undertaken by the Trust to ensure that the risk associated with gas is adequately managed. It also details the responsibilities of the Trust s employees and contractors, and requires the cooperation of all employees, contractors and building users to ensure a safe and healthy working environment is maintained at all times. 3.0 Scope This Procedure covers the safe installation and use of all fixed gas distribution systems and gas fired equipment on Trust premises i.e. all permanently installed distribution pipe work and equipment. This will include gas service mains and equipment under the control of the Trust on Trust premises and all permanently installed gas served equipment e.g. gas fired boilers, catering equipment, gas etc. Included in this Procedure is equipment served by Page 3 of 15
mains gas provided by the national network supply and locally stored liquefied petroleum gas (Calor gas) serving permanently fixed equipment. Excluded from this procedure are any piped medical gases or gases stored in cylinders for portable equipment e.g. blow torches, barbecue grilles or portable medical gas cylinders. All of which can be easily transported from one location to another. This Procedure is managed and administered by the Estates and Facilities Department 4.0 Procedures for Working / Inspection & Testing of Natural Gas Systems 4.1 Compliance The basis for compliance of this Procedure is that all installations, operations and maintenance of gas services and equipment shall be undertaken in accordance with the 1998 Gas Safety (Installation and Use) Regulations. This requires installations and maintenance of gas services to be undertaken by competent persons in a safe manner. Competence will be deemed to have been achieved by employing individuals holding a current Gas Safe Registered Certificate for the appropriate class of gas installation. Gas Safe is a national body that sets training criteria and assesses and monitors the competence of companies and individuals that work on gas installations who will issue a Certificate of Competence. The Certificate of Competence will indicate proven competence to work on either domestic gas installations, non-domestic gas installations or both. Following registration individuals are subject to regular but random audits by Gas Safe Inspectors to confirm compliance of their work. All documentation relating to gas maintenance will be held by the Trust in chronological order for each property for a minimum of two years. For gas installations in residential premises, the gas safety inspection shall be recorded on a CP12 Landlords Certificate. South Staffordshire and Shropshire Healthcare NHS Foundation Trust is committed to the protection of the health and safety of all its employees, Service Users, visitors and contractors, and to the safe use of natural gas. The Trust recognises its responsibilities as duty holder and will ensure that: As a central point of contact, the Estates and Facilities Department will ensure that responsibilities of the duty holder are undertaken on behalf of the Trust and will appoint a Nominated Responsible Person/Company to undertake the specific duties as required by Statute and health and safety guidance notes In as much as is reasonably practicable, that the Trust complies with all Statutory Regulations and other guidance relating to gas safety The Trust will ensure that all parties working with natural gas are Gas Safe Registered The accountability for the management of gas systems is devolved to the organisation with overall control of the building. These can be categorised as follows: Properties managed by other organisations Page 4 of 15
Other NHS organisations, Local Authorities, private landlords 4.2 Responsibilities for Compliance with the Procedure Control Natural Gas Systems The Trust's Estates Department shall implement a management regime to control and Operate the Safe gas Systems across the Trusts properties / Estate and any other properties they may be responsible for. The Estates Department shall appoint and or nominate the following 4.3 Duty Holder The Chief Executive As the Duty Holder, ensures that the Trust has an effective Gas Safety Policy 4.4 Responsible for gas safety The Director Estates Ensures appropriate funds are available to resource managing gas safety effectively 4.5 Responsible Person The Director of Estates and Facilities shall appoint a Responsible Person in writing. The Responsible Person (as appointed by the Trust in respect of gas safety) shall have sufficient competence to assess the risk associated with maintaining gas safety and implement procedures and control measures to maintain and confirm compliance with the Gas Safety Regulations in those buildings that the Trust retains the responsibility of managing the gas systems, and their responsibilities will include: Maintaining a current record of the location and route of all gas mains and service pipes on Trust operated property including locations of all isolation valves, primary meters and check meters Ensure gas service pipes above ground level are appropriately identified appropriate British Standard markings or banding Maintaining a current asset register of all gas equipment to include the type of equipment, age and estimated remaining life Maintain a library of health and safety maintenance manuals and operating instructions provided for each item of equipment and to ensure users receive adequate instruction on the routine operation of individual items of equipment. This will normally be in the form of a users manual supplied with the equipment Ensure adequate maintenance programmes are initiated for all gas fired equipment and work is undertaken at appropriate frequencies by competent persons in accordance with the Gas Safety Regulations Page 5 of 15
Ensure all gas detection systems and automatic gas isolation systems are routinely physically tested and work efficiently Maintain all records of installations, maintenance and repairs undertaken on gas equipment in such a form to allow easy retrieval and inspection Liaise with all premises to ensure planned maintenance work on gas equipment is undertaken at times to cause minimum disruption Ensure individuals working on gas equipment are competent for the tasks undertaken Ensure a Permit to Work System for any isolation of the gas systems are in place For properties managed by other organisations the Nominated Person will review the arrangements in place relating to the management of the gas systems, to ensure there suitability. Ensures compliance with statutory legislation, approved Codes of Practice and the Health and Safety Executive requirements regarding gas safety Ensures there are robust systems in place for monitoring incidents associated with gas Provides a link with the Operational Risk Governance Committee to ensure that all identified risks are included in the Trust s Risk Register Reports to the Trust Board the details of any major accident/incident relating to the management of gas safety Ensures that the management of gas safety is co-ordinated effectively and that a Nominated Person/Company is appointed on behalf of the Trust Provide all resources deemed necessary to manage the risk posed by natural gas Ensures that the Policy is reviewed and updated regularly in accordance with current legislation and best practice and is fully implemented Ensure all Trust employees or those working on behalf of the Trust, are given adequate gas safety awareness/training and/or site induction, including sites where the Trust is not the primary duty holder Following any survey work or work with gas appliances, will ensure that all appropriate certification is in place i.e. Test Certificate. The Trusts Responsible Person shall appoint the following Persons / Contractors 4.6 Competent Person (In house Staff) The Trust will train and nominate competent persons to enable - Safe Isolation of gas supplies in the event of an emergency or gas smell / leak. Disconnection / Reconnection of gas equipment that is connected via a hose Page 6 of 15
4.7 Approved and Nominated Gas safe Contractors Nominated Person (Contractors) - management / supervision of works/ inspection & testing Competent Persons (Contractors) - carrying out the works / inspection & testing For properties managed by other organisations the Responsible Person will review the arrangements in place relating to the management of the gas systems, to ensure there suitability. 4.8 Landlords Where the Trust occupies premises owned and managed by other parties, gas services may be maintained by third party organisations on behalf of the Trust by means of a Service Level Agreement or a Lease. Where this occurs it is expected that the operation and maintenance of gas services by the third party, will be undertaken in line with this policy. 4.9 Gas Emergency Actions and Procedures It is the responsibility of the person who manages the premises or the most senior person on site to take immediate reasonable steps whenever they suspect that gas or fumes are escaping into the premises including shutting off the gas supply at the meter/emergency control valve and to ventilate the property. Only a competent person (Gas Safe) is allowed to reinstate the supply and re-commission the installation. A full list of emergency procedures is detailed within Appendix 2 along with a full list of emergency reporting information within Appendix 3. 4.10 Reporting Faults and Gas Leaks Faults on gas fired equipment where there is no gas escape evident should be reported to the estates department in the normal manner. Where a gas leak is evident or suspected the user should report the leak to Transco by dialling 0800 111 999. Report the leak to the Estates Helpdesk on 7128450 (internal) or 01785 783050(externally) For premises maintained by other Heath Trust Estates Departments (normally where premises are embedded into other Trust premises) reports of faults and leaks should be made to that local estate service in line with normal procedures. Turn off the gas supply if possible at the meter or to the affected equipment. Open doors and windows to ventilate the area affected. Prevent any smoking. Prevent turning on or off light switches. Prevent the use of naked flames. If in doubt, evacuate the area. Page 7 of 15
4.11 Training In House estates staff shall be trained as competent persons for the means of isolation purposes General staff shall receive gas awareness training perhaps by e learning modules, fire lectures and /or induction training. 4.12 Lone working Reference should be made to the Trust's lone working arrangements SOP when appropriate 4.13 PPE Equipment All staff shall use the appropriate PPE equipment and should also follow the Estates guidance procedures and the Trust's COSSH policy. 4.14 Asbestos Before any work commences clearance must be given by the estates department to confirm that there is no risk from Asbestos to the persons carrying out the work or to any other people that could be affected. The Asbestos register held in the estates department must be consulted. 4.15 Control of Contractors Policy Where contractors are used they shall operate under the Trust's control of contractor s policy and all the appropriate Permit to work systems which are in place and may be applicable. 4.16 Associated Policies / Standard Operating Procedures (SOP) - Permit to Work SOP Control of Contractors Policy Safe Working with Asbestos Policy COSSH Health and Safety Policy for Facilities and Estates Community and/or Lone Working SOP Working in Confined Spaces SOP 4.17 O & M Manuals / Mimic Diagrams & Drawings Line diagrams O&M manuals, schematic and line diagrams shall be available for the gas systems and will form part of the safe working procedures. Detailed records and inspection and test results shall be generated and maintained up to date for the gas installations and equipment. Page 8 of 15
4.18 Method Statements and Risk Assessments All Gas works, maintenance and the inspection and testing of the gas systems shall be covered by the appropriate method statements and risk assessments. The Competent Person carrying out the work must be familiar and fully understand the method statement and risk assessment for the task or works to be undertaken. 4.19 Model forms The Following forms or equivalent shall be used Permit to work form Service Check lists Test result sheets 4.20 Permit to Work System There shall be a Gas Safety Permit to Work system in place for working on the Gas systems and equipment of the Trust. Work and / or the Inspection and testing of the Gas Systems may require where appropriate to be covered with additional Permit to work systems which are in use such as - Confined spaces Asbestos Lone working Issue of a permit to a contractor A contractor s employee may be issued with a permit-to-work, providing the Responsible Person (gas) is satisfied of the capability and competence of the individual. The manager who approved the issue of the contract to the contractor s company clearly also has a duty to ensure the capability and competence of the company and its employees. The Responsible Person (gas) should be given confirmation that checks have been made. 4.21 Isolation of supplies Before any work starts notification and agreement shall be obtained with all users departments. 4.22 Drop Tests of Pipe work Distribution The gas pipe work distribution shall have drop tests applied to check and record the soundness of the systems. The tests may need to be done in two parts depending on the situation and or results obtained these are as follows Underground gas distribution pipe work Page 9 of 15
Above ground gas distribution pipe work 4.23 Acquisition of new and replacement Gas Equipment The Estates Engineering Manager will coordinate any decision to purchase and install any new or replacement gas fired equipment and will confirm suitability of the equipment for its particular location. All new equipment shall be commissioned by the competent installer prior to use. Maintenance Manuals and User Instructions and Commissioning Certificates will be received by the Estates Engineering Manager and copies of User Manuals will be provided to users at the location of the equipment. 4.24 Installation, Maintenance and Repairs All installation work, inspections maintenance and repairs on gas fired equipment under the control of the Trust that involves the disconnection of equipment and or breaking into gas ways shall be undertaken by competent GAS SAFE registered individuals. This in practice requires GAS SAFE registration for all work on gas services and equipment with the following exceptions. Other competent individuals (Estates trade staff who are not GAS SAFE registered) may repair gas fired equipment or equipment associated with gas fired equipment where the work does not interfere with or interrupt any gas way e.g. repairing boiler controls, timers, catering equipment doors, shelves and the like, all of which do not interfere with or interrupt the integrity of the gas supply. Undertake a simple disconnection and reconnection of equipment on a temporary measure (for the purposes of cleaning or similar operation) when the appliance is connected to the gas supply with a bayonet fitting connector only. Maintenance comprises both ad hoc running repairs that may occur during regular servicing schedules and an annual service. Annual servicing of equipment will be undertaken by companies employing GAS SAFE registered operatives. Annual servicing of equipment will be let on a maintenance contract basis, to include all gas fired equipment under the Trusts control and will comprise in addition to that recommended by the manufacturers maintenance instructions an annual safety inspection of the appliance, its flue and installation pipe work back to the meter and a test for leaks. Prior to commencing the annual service of equipment the Estates Engineering Manager will obtain from the contractor for operatives nominated to work on Trust premises copies of their registration card and GAS SAFE Registration Certificate to confirm they are competent to work on the range of equipment. The Estates Engineering Manager will undertake random checks with GAS SAFE web site for at least two operatives to confirm the validity and currency registration documentation. Should the registration documentation prove to be false the Estates Engineering Manager will: Report the incident to GAS SAFE via their web site www.gassaferegister.co.uk Report the incident to the Health and Safety Executive Page 10 of 15
Report the incident to the Contractor employing the individual Undertake further validation checks with GAS SAFE for the remainder of all operatives nominated to work on site prior to commencing any work. Report the incident on a Trust untoward incident report. Annual servicing and safety inspections will be scheduled to be completed during the summer months when the requirements for gas supplies are at their lowest. The Estates Engineering Manager will arrange for premises to be advised in advance of the service visit to enable them to prepare for any temporary shut down of gas services. In addition to annual frequency for domestic accommodation (single tenant occupied premises) a gas safety inspection will be undertaken between any change in tenancy where this occurs between scheduled annual service inspections. This ensures the gas equipment is fit for use for the ingoing tenant. 4.25 Installation, Servicing and Repair Documentation For all new installations, a Maintenance Manuals including User Instructions and a Commissioning Certificate confirming the installation has been tested and is safe for use will be provided to the Mechanical Engineering Manager. These will be retained in the Health and Safety file for the relevant premise by the Estates Engineering Manager for future reference and a copy of the User Instructions will be provided to the user. For repairs and servicing of equipment a Gas Safety Record work sheet shall be provided to the Estates Engineering Manager identifying the equipment has been safely repaired/serviced or tested and is fit for use. Where faults are determined by the GAS SAFE engineer a Gas Safety Warning Notice will be provided to the Estates Engineering Manager identifying the particular item of equipment and detailing the fault. Depending on the severity of the fault the GAS SAFE engineer will indicate if the equipment has been left in service (for minor faults) or has been disconnected and warning notices attached to the equipment (for significant faults). On receipt of a Warning Notice the Estates Engineering Manager will investigate the reported fault and arrange for rectification. All documentation will be held by the Estates Engineering Manager in chronological order for each premise for a minimum of two years. For gas installations in residential premises (staff houses and staff residential accommodation) The gas safety inspection shall be recorded on a CP12 Landlords Certificate. In addition to retaining a copy on file the Estates Engineering Manager will provide a copy to the occupier within twenty eight days of receipt. In the case of residential accommodation with multiple occupancies the copy will be displayed in the entrance to the accommodation. Page 11 of 15
5.0 Process for Monitoring Compliance and Effectiveness Aspect of compliance or effectiveness being monitored Monitoring Method Individual Responsible for the Monitoring Frequency of the Monitoring Activity Reporting to the various Trusts/ Committees and Departments Only Gas Safe Registered Individuals to work/inspect or Test Gas Systems Equipment All Gas Fired equipment is safety checked by a competent individual at least annually Single occupant tenants are provided with a copy of a landlords certificate at least annually for their premise Audit Head of Estates Annually Designated Officer for the trust. H&S Risk Management Audit Head of Estates Annually Designated officer for the Trust H&S Risk Management Audit Head of Estates Annually Designated Officer for the Trust H&S Risk Management 6.0 References Gas Safety (installation and use) Gas Safety Regulations 1998 Approved code of practice and guidance: safety in the installation and use of gas systems and appliances Health and Safety at Work act 1974 HSE Approved Code of Practices Gas safe Registration / Register Page 12 of 15
Appendix 1 - Management Structure Chief Executive: Duty holder for gas safety Director of Estates: Management of Gas Safety Responsible Persons: Management and Control of gas systems across The Trust s Estate Competent Persons Nominated Persons / Trust in House Staff Competent Persons For Isolation of Gas Contractors supplies or Equipment Page 13 of 15
Appendix 2 - Emergency Procedure if gas or fumes are suspected The building manager of the premises or the most senior person in charge is required to: 1) Turn off the gas supply immediately at the meter / emergency control valve. 2) Extinguish all sources of ignition. 3) Ensure that nobody is smoking. 4) Ensure that nobody operates electrical or power switches (on or off). 5) Ventilate the building (s) by opening doors and windows. 6) Telephone the appropriate gas emergency service call centre call 0800 111 999 7) Telephone the Estates and Facilities Help Desk 7128450 (internally) or 01785 783050 8) Evacuate the premises if the most senior person in charge believes that there is a risk of health and safety of occupants. 9) Ensure that access to the premises can be made. N.B. Only a competent person (Gas Safe registered) can turn the gas back on and/or recommission appliances. Page 14 of 15
Appendix 3 - Emergency Procedure reporting information The building manager of the premises or the most senior person in charge is required to report the following information to the National Gas Emergency Call Centre on 0800 111 999 and will be required to relay the following information: 1) Address where the leak has been detected. 2) Name and telephone number of the gas user. 3) Name and telephone number of the person reporting the suspected escape. 4) Place where the smell is most noticeable. 5) Time when the smell was first noticed. 6) Whether the meter/emergency control is turned off. 7) If the meter/emergency control valve is turned off, whether there is still a smell of gas. 8) If it is not turned off, the reason why (emergency control not accessible or broken etc.). 9) Whether there is a smell of gas outside the property. 10) Any special circumstances (e.g. elderly or disabled residents, access problems, etc.). You should obtain the following information from the Gas Emergency Service Call Centre and keep a record of: The Job Number; The date and time of the report; and The person to whom you reported the incident. Page 15 of 15