SOP For Refrigeration Plant

Standard Operating Procedure for Mechanical Engineering System
FEMS SOP(M)-001
FEMS SOP(M)-002
FEMS SOP(M)-003
FEMS SOP(M)-004
FEMS SOP(M)-005
FEMS SOP(M)-006
FEMS SOP(M)-007
FEMS SOP(M)-008
FEMS SOP(M)-009
FEMS SOP(M)-010
FEMS SOP(M)-011
FEMS SOP(M)-012
Air Conditioning and Mechanical Ventilation (ACMV) System

Fire Protection System
Medical Gas Pipeline System
Pneumatic Tube System
Building Management System
Steam and Hot Water System
Vertical Transportation System
Liquefied Petroleum Gas (LPG) and Laboratory Gases
Fleet Management
Autoclave And Sterilization System
Cold Room and Mortuary Freezer
Nuclear Waste Decontamination System
FEMS SOP (M)-001AIR CONDITIONING AND MECHANICAL VENTILATION (ACMV)

SYSTEM
1.0
INTENTION
1.1 To establish procedures for the operation and maintenance of installed
ACMV system.
1.2 To deliver services as required for the operation and standard.
2.0
SCOPE
2.1 ACMV system under the Facility Engineering Maintenance Services not
limited to Clean Room Facilities and Local Exhaust Ventilation (LEV) system.
3.0
DEFINITION
Air Conditioning and Mechanical Ventilation (ACMV) system is a system that
provide fresh air, controlling temperature and humidity, filter air coming into the
building, control air flow by creating pressure differential (positive / negative),
alignment of supply and exhaust / return and to quickly relocate, dilute, remove
airborne contaminants.
4.0
REFERENCES
4.1
Manufacturer Operation and Maintenance Manual.
4.2
Hospital Engineering Planned Preventive Maintenance (HEPPM).
4.3
Related guidelines and standards :

4.3.1 ASHRAE.
4.3.2 Guidelines on Occupational Safety and Health of Design,
Inspection, Testing and Examination of Local Exhaust Ventilation
System.
4.3.3 Guides to The Development of Sterile Pharmaceutical Preparation
Facilities.
4.3.4 National Air Duct Cleaners Association (NADCA).
4.3.5 Air Duct Cleaners Association.
5.0
RESPONSIBILITIES
5.1
Government
5.1.1 To report malfunction of equipment/system operated by user.
5.1.2 To update the registration and maintenance records of assets based
on latest Treasury Circular and Instructions.
5.1.3 To manage the calibration process if necessary for equipment that
comes without involving certification of calibration measurements by
authorized bodies.
5.2
Company
5.2.1 The Company shall schedule and implement maintenance works as
per manufacturer checklist or Hospital Engineering Planned
Preventive Maintenance (HEPPM).
5.2.2 To report malfunction of system, plant or equipment without any
delay.
5.2.3 To carry out maintenance and repairs by trained/competent person
either in house or specialised sub-contractor except for chiller.
5.2.4 Maintenance and repairs for chiller shall be carried out by a
nominated sub-contractors/suppliers/vendors.
5.2.5 To perform the operation of the ACMV Services.
5.2.6 To conduct the functionality test in order to meet the design
specification where applicable (i.e.: room pressure, temperature, air
circulation, etc.)
5.2.7 All air conditioning ducts shall be inspected twice a year as
recommended by Air Duct Cleaners Association, USA for critical
areas or as and when required. For other areas it shall be once a
year or as required. The report for duct inspection shall be
submitted to the hospital. Duct cleaning shall be carried out once a
year or as required and to conduct particle count and swab test

after duct cleaning work.
5.2.8 All HEPA filters shall be replace once a year or as required (an
event of outbreaks or pressure differential as per table below). The
result of pressure differential shall be proof in HEPPM if the HEPA
filters still in limits.
Typical Initial Pressure Drops for Air Filters (at 500 fpm [2.5 m/s])
Filter MERV Rating
Initial P,
Application
in. of water [Pa]

7-8
Prefilters
0.20 to 0.30
[50 to 75]
13 to 14
Final filters
0.40 to 0.50
[100 to 124]
16 (95% for 0.3 m
HEPA filters
particles)
0.50 to 0.60
[124 to 149]
16 (99% for 0.3 m
HEPA filters
1.00
particles)
[249]
*Source : ASHRAE Second Edition 2013
5.2.9 The company shall responsible to manage the calibration process

for
equipment
that
comes
with
certification
of
calibration
measurements by authorized bodies.
6.0
PROCEDURES
6.1
The Company shall prepare and submit the ACMV systems operations
document to Contract Hospital / Institution.
6.2
The Government has to verify and approve the ACMV systems operations
document.
6.3
Comprehensive Maintenance as per Hospital Engineering Planned

Preventive Maintenance, Predictive Maintenance and Parts Life Cycle
Assessment and operating all installed ACMV System equipment.
7.0
RECORDS
7.1
7.2
Log Sheet.
7.3
Log Book.
7.4
Hospital Specific Implementation Planned (HSIP).
FEMS SOP (M)-002 FIRE PROTECTION SYSTEM
1.0
INTENTION
1.1
To establish procedures for the operation and maintenance of installed

Fire Protection System.
1.2
2.0
To deliver services as required for the operation and standard.
SCOPE
2.1
All fire protection system and installations under the Facility Engineering
Maintenance Services.
3.0
DEFINITION
Fire protection system comes into specific form which is active and passive
systems. Passive fire protection system are always present and rely on the
operation any form of mechanical device. Passive fire protection system may
include fire rated door, barrier, ceilings and structural fire protection.
Active fire protection system depend on operation of a mechanical device in the

form of suppression, detection, alarm and smoke control.
4.0
REFERENCES
4.1
Uniform Building By-Laws (UBBL).
4.2
Fire Services Act 1988.
4.3
Malaysian Standard (MS).
4.4
4.5
5.0
RESPONSIBILITIES
5.1
Government
5.1.1 To establish Fire Safety Committee in Contract Hospital / Institution.
5.1.2 To report malfunction of equipment / system operated by user.
5.1.4 To apply and renew annually Fire Certificate (FC) for the building of
the Contract Hospital / Institution.
5.1.5 To recharge the fire suppression agent due to actual fire event.
5.1.6 To
replace
any
fire
suppression
system
due
to
BOMBA
requirements.
5.1.7 To
comply
with
any
latest
BOMBA
correspondence
and
requirement.
5.1.8 To participate in fire drill and safety activities conducted by the
Company.
5.2
Company
5.2.1 To participate in Fire Safety Committee established by Contract
Hospital / Institution.
5.2.2 To schedule and implement maintenance works as per Hospital
Engineering Planned Preventive Maintenance ((HEPPM).
delay.
5.2.4 To carry out maintenance and repairs either in house or by
approved sub-contractor by Jabatan Bomba dan Penyelamat
Malaysia (JBPM) or other equivalent authority.
5.2.5 To perform the operation and safety testing.
5.2.6 To ensure compliance to statutory requirement.
5.2.7 To assist the Government to obtain Fire Certificate (FC).
5.2.8 To conduct fire drill activities and demonstration of fire safety at
least once a year.
5.2.9 To conduct audit in fire safety once a year.
6.0
PROCEDURES
6.1

Assessment and operating all installed automatic, manual, active and
passive fire detection and suppression equipment / system.
6.2
7.0
The Company shall take appropriate action in event of fire or evacuation.
RECORDS
7.1
7.2
Fire Certificate by JBPM.
7.3
Log book.
7.4
Log sheet.
FEMS SOP(M)-003 MEDICAL GAS PIPELINE SYSTEM (MGPS)
1.0
INTENTION
1.1

Medical Gas Pipeline System.
1.2
2.0
To deliver services as required for the operations and standards.
SCOPE
All Medical Gas Pipeline System under the Facility Engineering Maintenance
Services.
3.0
DEFINITION
MGPS is designed to provide a safe and effective method of delivering medical
gases, medical air and surgical air from the source of supply to the appropriate
terminal unit by means of a pipeline distribution system. Medical vacuum is also
provided by means of a pipeline system. Anaesthetic gas scavenging disposal
systems are provided to control occupational exposure to waste anaesthetic
gases and agents.
4.0
REFERENCES
4.1
Akta Kilang Dan Jentera 1967
4.2
Medical Device Act 2012
4.3
Department of Occupational Safety and Health (DOSH)
4.4
4.5
HTM 2022 / HTM 02-01.
4.6
5.0
RESPONSIBILITIES
5.1
Government
5.1.2 To update the registration and maintenance records of assets
based on latest Treasury Circular and Instructions.
5.1.3 To procure medical gases and carry out quality test by Pharmacy
Department.
5.1.4 To ensure all gas cylinder / VIE rental tank are refilled / maintained
by the appointed contractor and shall be borne by the Government.
5.1.5 The Government shall liase with appointed contractor to make the
necessary arrangement for inspection by the authorities and ensure
valid certificates of fitness at all times for the rental VIE tank.
5.1.6 To verify Permit-To-Work (PTW) for all work involving alterations,
extensions or maintenance work on the system shall be subject to
the permit-to-work procedure which shall under the control of the
Authorised Person (MGPS).
5.2
Company
5.2.1 Company
shall
advice
the
Contract
Hospitals
Pharmacy
Department on the amount and frequency for each consignment of

medical gas to be purchased.
5.2.2 To develop procedure for dedicated plant room and to be displayed
in the plant room for the safety of handling and operation.
5.2.3 The Company shall schedule and implement maintenance as per
delay.
5.2.5 To carry out maintenance and repairs by trained/competent person
either in house or specialised sub-contractor.
5.2.6 To perform the operation and safety testing.
5.2.7 Ensure compliance to statutory requirements.
5.2.8 To arrange and manage annual inspection by Department of

Occupational Safety and Health (DOSH) and to obtain certificate of
fitness for system, equipment and plant according to Akta Kilang
Dan Jentera 1967.
5.2.9 To manage Permit-To-Work (PTW) for all work involving alterations,
extensions or maintenance work on the MGPS system shall be
subject to the permit-to-work procedure which shall under the
control of the Authorised Person (MGPS).
6.0
PROCEDURES
6.1
The Company shall provide adequate competence technical and

supervisor of the appropriate class to operate and monitor the relevant
operation and maintenance.
6.2
The Company shall also provide adequate and appropriate tools for
maintenance.
6.3

Assessment and operating all installed Medical Gas Pipeline System.
7.0
RECORDS
7.1
Log Sheet.
7.2
Logbook.
7.3
Permit-to-work.
7.4
Certificates of Fitness.
7.5
FEMS SOP(M)-004 PNEUMATIC TUBE SYSTEM (PTS)
1.0
INTENTION
1.1
To establish procedures for the operation and maintenance of the installed

Pneumatic Tube System (PTS).
1.2
2.0
To deliver services as required for the operations and standards.
SCOPE
All Pneumatic Tube System and installations
under the Facility Engineering
3.0
DEFINITION
Pneumatic Tube System (PTS) provide an efficient, rapid and secure means of
transporting various items such as blood and tissue samples, drugs, X-ray films
and documents from one department to another.
4.0
REFERENCES
4.1 Manufacturer Operation and Maintenance Manual.
4.2 Hospital Engineering Planned Preventive Maintenance (HEPPM).
4.3 HTM 2009 : Pneumatic Air Tube Transport Systems Management Policy or
any latest version.
4.4 Infection Control Guideline
5.0
RESPONSIBILITIES
5.1
Government
5.1.2 To
ensure
the
hygiene
and
physical
canister/container/capsule/carrier of the tube.

5.1.3 To avoid misuse of PTS.
condition
of
5.2
Company
delay.
5.2.3 To carry out maintenance and repairs of Vertical Transportation
system by a nominated sub-contractors/suppliers/vendors .
5.2.4 To conduct user training on handling and operational.
6.0
PROCEDURES
6.1

Assessment and operating all installed Pneumatic Tube System
equipment.
6.2
The Company shall produce and submit monthly report on the PTS system
transaction.
7.0
RECORDS
7.1
7.2
Logbook
FEMS SOP(M) 005 BUILDING MANAGEMENT SYSTEM (BMS)
1.0
INTENTION
1.1 To establish procedures for the operation and maintenance of the installed
Building Management System (BMS).
1.2 To deliver services as required for the operations and standards.
2.0
SCOPE
All BMS and installations under the Facility Engineering Maintenance Services.
3.0
DEFINITION
A Building Management System is a computer base centralised procedure that
help to manage, control and monitor certain engineering services within a
building or a group of building. Such a system ensures efficiency and costeffectiveness in terms of labour and energy costs, and provides a safe and more
comfortable environment for building occupants. This system also known as
Building Automation System (BAS), Building Control System (BCS) and Building
Supervisory System (BSS).
4.0
REFERENCES
4.2 HTM 2005 Building Management System Validation and Verification or
any latest version.
5.0
RESPONSIBILITIES
5.3
Government
5.3.1 To report malfunction of equipment / system operated by user.
5.3.2 To handover the control room to the Company for the purpose of
managing the engineering system.
5.3.3 To ensure that only respective person / team appointed have an

access to control room.
5.4
Company
5.4.2 To ensure only trained staff shall be appointed by management to
operate and maintain the BMS room.
5.4.3 To ensure the system is supervise twenty four (24) hours.
5.4.4 To monitor of data from BMS enable fault to be rectify at an early
date.
delay.
system by a nominated sub-contractors/suppliers/vendors.
5.4.7 To schedule of routine maintenance activities, such as third spares
list and operational information shall be prepared and notify to the
Government.
6.0
PROCEDURES
6.1
The Company shall maintaining and operating all installed BAS system
equipment.
6.2
The Company shall provide adequate competence technical and

supervisor of the appropriate class to operate and monitor the relevant
operation and maintenance.
6.4
The Company shall also provide adequate and appropriate tools for
maintenance.
6.5

Assessment and operating all installed BAS system.
RECORDS
7.1
7.2
Logbook.
FEMS SOP(M)-006
1.0
STEAM AND HOT WATER SYSTEM
INTENTION
1.1
To establish procedures for the operation and maintenance of Steam and

Hot Water System.
1.2
2.0
To deliver service of required operations and standards.
SCOPE
All Steam and Hot Water System under the Facility Engineering Maintenance
Services.
3.0
DEFINITION
Boiler is a closed vessel intended to heat water and produce hot water or steam
through combustion of a fuel or through action of electric resistant element.
4.0
REFERENCES
4.1 Akta Kilang Dan Jentera 1967
4.2 Akta Keselamatan dan Kesihatan Pekerja 1994
4.3 Department of Occupational Safety and Health (DOSH)
4.4 ASME Boiler and Pressure Vessel Code
4.6 Any other related guideline and standard
5.0
RESPONSIBILITIES
5.1
Government
5.1.1 Report malfunction and noncompliance to statutory requirement of
the system operated by the Company.
5.1.2 The user department shall identify person in charge through whom
the Company shall communicate, request and co-ordinate for
access at user location.
5.2
Company
5.2.1
The company shall comply with the number and grade of Boilerman
for boiler system according to Akta Kilang Dan Jentera 1967 .
5.2.2
To ensure the equipment, plant and system is in safe condition for

operation
5.2.3
To develop procedure for dedicated plant room and to be displayed

in the plant room for the safety of handling and operation.
5.2.4
To report malfunction or abnormality of system, plant or equipment

without any delay.
5.2.5
Carry out maintenance and repairs by competent or specialised

sub-contractor and registered under Department of Occupational
Safety and Health (DOSH).
5.2.6
To perform the operation and safety testing of the Steam and Hot
Water Boiler Services.
5.2.7
The Company shall comply with all statutory requirement.
5.2.8
To manage Permit-To-Work (PTW) for all work involving alterations,

extensions or maintenance work on the Boiler System shall be
subject to the permit-to-work procedure which shall under the
control of the Department of Occupational Safety and Health
(DOSH).
5.2.9
The company shall ensure the system is well-supervised by

competent person as stated in Akta Kilang Dan Jentera 1967 during
operation.
5.2.10 The company shall ensure the water treatment inspection is carried
out periodically by competent chemical treatment company.
5.2.11 To arrange and manage annual inspection by Department of
Dan Jentera 1967.
5.2.12 To perform any test instructed by Department of Occupational

Safety and Health (DOSH) in order to obtain certificate of fitness for
system, equipment and plant.
5.2.13 To maintain quality of water supply to boiler system and to ensure
quality of hot water/steam supplied to equipment/area.
6.0
PROCEDURES
6.1 Comprehensive Maintenance as per Hospital Engineering Planned
Assessment and operating all installed Steam and Hot Water Boiler System
equipment.
7.0
RECORDS
7.1
Certificates of Fitness (Boiler, Softener, Steam Header, Calorifier,

Dearator).
7.2
Log book.
7.3
Log sheet.
7.4
Water Treatment Report.
7.5
Certificate of Competency.
7.6
FEMS SOP(M)-007 VERTICAL TRANSPORTATION SYSTEM
1.0
INTENTION
1.1
To establish procedures for the operation and maintenance of vertical

transportation system.
1.2
2.0
SCOPE
All vertical transportation system under the Facility Engineering Maintenance
Services.
3.0
DEFINITION
Vertical Transportation is a type of vertical transport equipment (lift, escalator,
dumbwaiter, goods lift) that efficiently moves people or goods between floors of a
building or other structures.
4.0
REFERENCES
4.1 Akta Kilang Dan Jentera 1967
4.2 Department of Occupational Safety and Health (DOSH)
4.2 Garis Panduan Kerja-kerja Menyelamat Bagi Insiden Mantrap untuk Lif di
Fasiliti KKM
4.3 Any other related guideline and standard.
5.0
RESPONSIBILITIES
5.1
Government
5.1.1 The user department shall identify their staffs through which the
Company shall communicate, request and co-ordinate for access.
5.1.2 Report malfunction of equipment operated by user.
5.1.3 Hospital shall apply for approval from State Department of
Occupational Safety and Health (DOSH) to keep Key Landing Door
for each lift in hospital on behalf of Company. However, approval to
keep Key Landing Door is subject to State Department of

Occupational Safety and Health (DOSH) discretion.
5.2
Company
5.2.1 The Company shall schedule and implement Hospital Engineering
Planned Preventive Maintenance (HEPPM).
delay.
5.2.4 Perform the operation of the vertical transportation system.
5.2.6 The Company shall have On Site Competent Person to safely
secure elevator landing door keys (subject to State Department of
Occupational Safety and Health (DOSH) approval) to be use in the
event of mantrap.
5.2.7 Ensure all vertical transportation license renewed annually and
make available in HSIP and ASIS and assist hospital/institution to
obtain license if originally the vertical transportation come without
license.
5.2.8 In case of mantrap, the Company shall attend as soon as possible
and not more than 15 minutes to control the situation and start the
rescue if the Company acquire elevator key landing door .
5.2.9 In case of total system breakdown (i.e: all elevator in the building
breakdown) The Company shall provide adequate man power even
for standby purpose, to help the user transporting goods,
equipment, patients etc. from floor to floor.
6.0
PROCEDURES
6.1

Preventive Maintenance, Predictive Maintenance and Parts Life
Cycle
Assessment
and
operating
all
installed
Transportation System equipment.
7.0
RECORDS
7.1
7.2
7.3
Logbook.
Vertical
FEMS SOP(M)-008 LIQUEFIED PETROLEUM GAS (LPG) AND LABORATORY GAS

SYSTEM
1.0
INTENTION
1.1
To establish procedures for the operation and maintenance of the installed

LPG and Laboratory Gas.
1.2
2.0
SCOPE
All LPG and Laboratory Gas system under the Facility Engineering Maintenance
Services.
3.0
DEFINITION
LPG is a mixture of light gaseous hydrocarbons (ethane, propane, butane, etc)
made liquid pressure and used as fuel. LPG facilities include plants, pipeline
system and fittings. Laboratory gas include:
(a)
Acetylene
(b)
Argon
(c)
Nitrogen
(d)
Helium
(e)
Hydrogen
(f)
Nitrous oxide
(g)
Compress Air
(h)
Carbon Dioxide
(i)
Oxygen
4.0
5.0
REFERENCES
4.1
4.2
Akta Bekalan Gas 1993
4.3
Suruhanjaya Tenaga
4.4
Hospital Engineering Planned Preventive Maintenance (HEPPM)
4.5
Any other related guideline and standard.
RESPONSIBILITIES
5.1
Government
5.2.1 The user department shall identify their staff through whom the
Company shall communicate, request and coordinate for access.
5.2.3 To ensure all gas cylinder / bulk tank are refilled by the appointed
contractor and shall be borne by the Government.
5.2
Company
5.2.1 The
Company
shall
schedule
and
implement
as
per

delay.
5.2.3 Carry out repairs either in house or by competent / specialised subcontractor listed under Suruhanjaya Tenaga (ST).
5.2.4 Perform the operation and safety testing.
5.2.6 The Company shall liaise with appointed contractor to make the
necessary arrangement for inspection by the authorities and ensure
valid certificates of fitness at all times for the bulk tank.
6.0
PROCEDURES
The Company shall provide adequate competence technical and supervisor of
the appropriate class to operate and monitor the relevant installations. The
Company shall also provide adequate and appropriate tools for maintenance.
Comprehensive Maintenance as per Hospital Engineering Planned Preventive
Maintenance, Predictive Maintenance and Parts Life Cycle Assessment and
operating all installed LPG and Laboratory Gas.
7.0
RECORDS
7.1 Log Sheet.
7.2
Log book.
7.3
7.4
FEMS SOP(M)-009 FLEET MANAGEMENT
1.0
INTENTION
1.1
To establish procedures for the operation and maintenance of fleet

management.
1.2
2.0
SCOPE
All vehicle transportation under the Facility Engineering Maintenance Services.
3.0
DEFINITION
Fleet management is the management of a transportation fleet may include
motor vehicles such as ambulance, cars, vans, trucks, buses etc. Fleet
management can include arrange of function such as vehicle maintenance, driver
management, fuel management, and health and safety management.
4.0
REFERENCES
4.1 Akta Pengangkutan Jalan 1987
4.2 Suruhanjaya Pengangkutan Awam Darat.
4.3 Garis Panduan Penyelenggaraan Ambulans Di Hospital Dan Klinik Kesihatan
4.4 Any other related guidelines and standards.
5.0
RESPONSIBILITIES
5.1
Government
5.1.1 The user department shall identify their staffs through which the
5.1.2
Perform the operation of the vehicle transportation.
5.1.3
The user (driver) shall carry out daily routine inspection.
5.1.4
Report malfunction of equipment operated by user.
5.1.5 The user (Pegawai Kenderaan) shall arrange an appointment and

sent the vehicle to Government Workshop for yearly inspection.
5.1.6 During warranty period, the user shall ensure to send the vehicle to
authorised service centre on routine basis recommended by
manufacturer/supplier.
5.1.7 The user shall clean all spillage and trash in the vehicles.
5.1.8 The user responsible to monitor mileage of vehicle and inform the
Company when the vehicle due to servicing.
5.2
Company
5.2.1 The Company shall schedule and implement Hospital Engineering
Planned Preventive Maintenance (HEPPM).
5.2.2 To report malfunction of the vehicle without any delay.
5.2.3 Submit list of in-house workshops for KKM approval.
5.2.4 Carry out maintenance and repairs either in-house or by authorised
service centre.
5.2.5 The Company shall provide loaner unit including driver (available in
hospital 24 hours) and full tank of fuel (for first time delivery only; if
the company decided to withdraw the loaner unit while the vehicle
breakdown has not been fully rectified, and the Company decided to
provide back the loaner again, it will be considered as first time
delivery) for breakdown vehicle. For ambulance, the loaner unit
shall be as per one (1) to one (1) basis and other vehicle the
Company shall provide loaner unit to make sure services not
interrupted.
5.2.6 The Company shall provide towing service for breakdown vehicles
due to maintenance failure. If the vehicles breakdown due to
accident, the Company shall assist the Government to tow the
vehicle under Reimbursable Work.
6.0
PROCEDURES
6.1

Assessment and operating all vehicle transportation.
7.0
RECORDS
7.1
Registration Card.
7.2
KEW.PA-2.
7.3
7.4
Vehicles Log book.
FEMS SOP(M)-010 AUTOCLAVE AND STERILIZATION
1.0
INTENTION
1.1
To establish procedures for the operation and maintenance of autoclave

and sterilization.
1.2
To deliver service of required operation and standard.
2.0 SCOPE
All autoclave and sterilization under the Facility Engineering Maintenance
Services.
3.0 DEFINITION
A device that use to sterilize medical equipment and other objects by means all
bacteria, viruses, fungi, spores are inactivated.
4.0 REFERENCES
4.1
4.2
Akta Keselamatan dan Kesihatan Pekerja 1994
4.3
4.4
Health Building Note 13 (HBN 13)
4.5
Malaysian Standard of Sterilization Process, Second Edition
4.6
Any other related guideline and standard
5.0 RESPONSIBILITIES
5.1
Government
5.1.1 The user department shall identify person in charge through whom
the Company shall communicate, request and co-ordinate for
access at user location.
5.1.2
Perform the operation of the autoclave and sterilization according

to Akta Kilang dan Jentera 1967.
5.1.3
The user shall carry out Bowie Dick Test and Leak test on daily
basis, and Biological Test by weekly.
5.1.4 Person in charge shall report malfunction of equipment operated by

user department.
5.2
Company
5.2.1 The Company shall schedule and implement as per Hospital
Engineering Planned Preventive Maintenance (HEPPM).
delay.
5.2.3 Carry out maintenance and repairs by competent and specialised
sub-contractor.
5.2.4 To carry out Bowie Dick Test and Leak Test once completed
periodic maintenance, minor and major repair.
5.2.5 The Company shall comply with all statutory requirement.
5.2.6 To arrange, manage annual inspection by
Department of

Dan Jentera 1967.
5.2.8 To ensure the steam supply to equipment/department is in good
quality for operation.
6.0 PROCEDURES
6.1

Assessment and operating all installed autoclave and sterilization.
7.0 RECORDS
7.1
7.2
Log Book
7.3
FEMS SOP(M)-011 COLD ROOM AND MORTUARY FREEZER
1.0
INTENTION
1.1 To establish procedures for the operation and maintenance of installed cold
room and mortuary freezer.

1.2 To deliver service of required operations and standards.
2.0
SCOPE
All cold room and mortuary freezer under the Facility Engineering Maintenance
Services.
3.0
DEFINITION
A refrigerator, compartment, or room that can maintain freezing or subfreezing
temperatures, for freezing and storing.
4.0
REFERENCES
4.2 American
Society
Heating
and
Refrigerant
Association
Engineer
(ASHRAE).
4.3 Any other related guideline and standard.
5.0
RESPONSIBILITIES
5.1
Government
5.1.1 The user department shall identify their staffs through whom the
5.2
Company
delay.
5.2.3 Carry out maintenance and repairs either in house or by subcontractor.
5.2.4 Perform the operation of the cold room and mortuary freezer.
6.0
PROCEDURES
6.1

Assessment and operating all installed cold room and mortuary freezer.
7.0
RECORDS
7.1
7.2
Logbook.
FEMS SOP(M)-012 NUCLEAR WASTE DECONTAMINATION SYSTEM
1.0
INTENTION
1.1

nuclear waste decontamination system.
1.2
2.0
SCOPE
All nuclear waste decontamination system under the Facility Engineering
3.0
DEFINITION
A system to minimize water consumption which ultimately influences the size of
storage tank, to transfer the radioactive sewer from the patients toilet to the
receiving tank within the reasonable time and speed and to minimize the
occurrence of pockets of radioactive waste that could be formed due to the
distance and speed of travel of the waste.
4.0
5.0
REFERENCES
4.1
4.2
Akta Keselamatan dan Kesihatan Pekerja 1994
4.3
4.4
4.5
Any other related guideline and standard.
RESPONSIBILITIES
5.1
Government
5.1.1 The user department shall identify their staffs through whom the

5.1.4 In the event of one (1) isolation room toilet is not working, alarm
signal and warming light at nurse station will trigger if any Vacuum
Systems equipment trip/faulty or the system failure. The user shall
inform the RPO and the Company immediately. Only the authorized
personnel are allowed to reset the Push Reset Button at Nurse
Station as and when the Company/maintenance team advices to do
so. The user shall check with patient if his last visit to the toilet
ended with a successful flush and move the patient to unoccupied
room or share toilet of another isolation room.
5.1.5 In the event all isolation room toilet is not working, the user shall
inform RPO and temporarily cease administration of Radioiodine to
new patient until problem is resolved. The user shall designate one
(1) nearest emergency toilet for isolation patients with instructions
to double flush after every visit. The emergency toilet must be
restricted
to
these
patients
only
with
temporary
signage.
Decontamination of the emergency toilet is to be supervised by the

RPO after the emergency is lifted for the toilet to be put back to
normal use.
5.2
Company
delay.
5.2.3 Carry out maintenance and repairs nuclear waste decontamination
5.2.4 Perform the operation of the nuclear waste decontamination
system.
5.2.5 In the event of Discharge Pump / Vacuum Pump / Macerator alarm

is trigger at the Pilot Monitoring located outside the decay tank
room, a qualified electrical technician to be sent and troubleshoot
the problem at the Vacuum Tank Control Panel in the decay tank
control room. If the fault cant be resolved, immediately contact the
supplier.
5.2.6 In the event of Air/Liquid Separator / Macerator Feeder Pipe /
Solenoid Valve alarm is trigger at the Pilot Monitoring located
outside the decay tank room, a qualified mechanical technician to
be sent and troubleshoot the problem at the Vacuum Tank Control
Panel in the decay tank control room. If the fault cant be resolved,
immediately contact the supplier.
5.2.7 The Company shall comply with all statutory requirement.
5.2.8 To
arrange,
manage
annual inspection by
Department
of

Dan Jentera 1967.
5.2.10 To ensure the steam supply to equipment/department is in good
quality for operation.
6.0
PROCEDURES
6.1

Assessment and operating all installed nuclear waste decontamination
system.
6.2
The accurate activity in the Biological Radioactive Waste must be

determined before every tank is discharged into the sewer by taking a
sample from the relevant decay tank and measuring its concentration at
the well sampling point. The reading of the well sampling point can be
observed on the SCADA screen. This method of sampling is done
remotely via the SCADA system.
6.3
In this system, the daily discharged waste from the isolation wards is
collected in the receiving tank over a period of 30 days. At the end of that
period, the collected waste in the receiving tank is to be transferred to a
decay tank and to be stored for a further period of 90 days for it to achieve
a safe concentration level to allow it to be discharged into the
hospital/institution main sewers.
Note : In the event the collection in the receiving tank amounts to the
designed volume per month before the 30 days period, the system will
raise an alert for the transfer action.
7.0
RECORDS
7.1
7.2
Logbook.

SOP For Refrigeration Plant

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Standard Operating Procedure for Mechanical Engineering System

Air Conditioning and Mechanical Ventilation (ACMV) System

FEMS SOP (M)-001AIR CONDITIONING AND MECHANICAL VENTILATION (ACMV)

Manufacturer Operation and Maintenance Manual.

Hospital Engineering Planned Preventive Maintenance (HEPPM).

Related guidelines and standards :

year or as required and to conduct particle count and swab test

in. of water [Pa]

16 (95% for 0.3 m

16 (99% for 0.3 m

*Source : ASHRAE Second Edition 2013

5.2.9 The company shall responsible to manage the calibration process

measurements by authorized bodies.

Comprehensive Maintenance as per Hospital Engineering Planned

Hospital Engineering Planned Preventive Maintenance (HEPPM).

Hospital Specific Implementation Planned (HSIP).

FEMS SOP (M)-002 FIRE PROTECTION SYSTEM

To establish procedures for the operation and maintenance of installed

To deliver services as required for the operation and standard.

Active fire protection system depend on operation of a mechanical device in the

Uniform Building By-Laws (UBBL).

Fire Services Act 1988.

Malaysian Standard (MS).

Manufacturer Operation and Maintenance Manual.

Hospital Engineering Planned Preventive Maintenance (HEPPM).

5.2.9 To conduct audit in fire safety once a year.

Comprehensive Maintenance as per Hospital Engineering Planned

The Company shall take appropriate action in event of fire or evacuation.

Hospital Engineering Planned Preventive Maintenance (HEPPM).

Fire Certificate by JBPM.

FEMS SOP(M)-003 MEDICAL GAS PIPELINE SYSTEM (MGPS)

To establish procedures for the operation and maintenance of installed

To deliver services as required for the operations and standards.

Akta Kilang Dan Jentera 1967

Medical Device Act 2012

Department of Occupational Safety and Health (DOSH)

Manufacturer Operation and Maintenance Manual.

HTM 2022 / HTM 02-01.

Hospital Engineering Planned Preventive Maintenance (HEPPM).

Department on the amount and frequency for each consignment of

5.2.8 To arrange and manage annual inspection by Department of

The Company shall provide adequate competence technical and

Comprehensive Maintenance as per Hospital Engineering Planned

Hospital Engineering Planned Preventive Maintenance (HEPPM).

FEMS SOP(M)-004 PNEUMATIC TUBE SYSTEM (PTS)

To establish procedures for the operation and maintenance of the installed

To deliver services as required for the operations and standards.

under the Facility Engineering

canister/container/capsule/carrier of the tube.

Comprehensive Maintenance as per Hospital Engineering Planned

Hospital Engineering Planned Preventive Maintenance (HEPPM).

FEMS SOP(M) 005 BUILDING MANAGEMENT SYSTEM (BMS)

5.3.3 To ensure that only respective person / team appointed have an

The Company shall provide adequate competence technical and

Comprehensive Maintenance as per Hospital Engineering Planned

Hospital Engineering Planned Preventive Maintenance (HEPPM).

STEAM AND HOT WATER SYSTEM

To establish procedures for the operation and maintenance of Steam and

To deliver service of required operations and standards.

To ensure the equipment, plant and system is in safe condition for

To develop procedure for dedicated plant room and to be displayed

To report malfunction or abnormality of system, plant or equipment

Carry out maintenance and repairs by competent or specialised