II. Common Elements of the UMass Boston Integrated Chemical Hygiene & Environmental Management Plan
A. ROLES AND RESPONSIBILITIES
The primary element in this section is the Designation of Authority and Responsibility for implementation of the CH/EM Plan. The activities of the university research community are varied, complex and constantly changing. For maximum effectiveness, as well as end-user acceptance, most decisions regarding appropriate work practices for a particular procedure will have to be made by the individual laboratory worker developing or carrying out that procedure. Our goal then is to create an organizational structure which ensures an adequate flow of pertinent, site-specific information to the individual laboratory worker, together with the training needed to utilize this information in the selection and design of work practices for any specific task. To this end. the following entities are responsible for implementing the requirements of the Integrated CH/EM Plan:
Chemical Hygiene Committee
Environmental Health & Safety Office
Chemical Hygiene Officer
Laboratory Workers
The role of each group is:
A1. University Senior Management
University Senior Management as defined by this plan consists of the University Deans, the Provost, and the Vice Chancellor of Administration and Finance. Senior management is bestowed with the ultimate authority to ensure proper and timely implementation of this plan. Senior management also has the authority to order cessation of hazardous activity within laboratories if danger or threat of release to the environment is present.
A2. Chemical Hygiene Committee
A standing committee appointed by the Deans of Arts and Sciences, and consisting of a representative from each laboratory-based Department of the University including Biology, Chemistry, Environmental Coastal and Ocean Sciences, Psychology, and Anthropology, and one or more representatives from Environmental Health & Safety. Its duties include:
- Reporting to the Deans, Provost and Vice-Chancellor of Administration & Finance.
- Annual review of the CHP/EMP.
- Monitoring status and implementation of the Integrated CH/EM Plan.
- Issuing reports on implementation status
- Maintaining records of project review
- Review of written guidelines and training programs.
- Exercise of disciplinary or corrective action in cases of noncompliance.
A3. UMass Boston Environmental Health & Safety Office
Reports to the Vice Chancellor of Administration and Finance.
- Tracks legal requirements by utilizing current regulations, the internet, journals and memberships in relevant professional organizations
- Updates CHOs as necessary on regulatory changes or other legal requirements via the EHS web page, e-mail,direct mail, newsletter, etc.
- Designs training programs.
- Conducts training programs which are not laboratory-specific.
- Conducts site-specific training upon request.
- Conducts annual comprehensive laboratory inspections.
- Conducts annual and requested inspection of engineering controls.
- Notifies and advises Facilities Administration of necessary repairs.
- Carries out or assists with corrective actions in cases of noncompliance.
- Maintains the Institutional Hazardous Chemicals Inventory.
- Conducts annual review of Hazardous Chemicals of Concern (HCOC) from the annual Institutional Hazardous Chemicals Inventory.
- Indexes the Laboratory Chemical List by Hazard Category.
- Aids in Hazard Assessment and Standard Operating Procedure design.
- Investigates cases of suspected exposure, or exposure due to accident.
- Provides Chemical Spill Control services.
- Provides small spill control materials to laboratories.
- Provides Laboratory Waste Removal or Detoxification services.
- Evaluates materials and makes hazardous waste determinations.
- Ensures institutional compliance with RCRA regulations.
- Maintains comprehensive compliance records.
A4. Chemical Hygiene Officer (CHO)
The Chemical Hygiene Officer (CHO) is the administrator of the Integrated CH/EM Plan for his or her laboratory and must have the knowledge, background, and authority to ensure compliance with its requirements. The Chemical Hygiene Officer of each laboratory shall also be the Principal Investigator (PI) of that laboratory or his or her qualified designee. Both the Lab Standard and the Environmental Management Standard address the potential hazard posed by chemicals to individuals, which is determined in large part by the specific conditions of use. Each Chemical Hygiene Officer will ensure an adequate transfer of information regarding hazards and physical properties of chemicals present at the worksite from the Environmental Health & Safety Office to each laboratory workerin order to aid them in design of safe work practices. In addition, the CHO insures compliance with the requirements of the CH/EM Plan. The CHO, appointed by the Dean of Sciences, has the following duties: Provides Laboratory Workers with specific training, instruction and information on the details of the Integrated CH/EM Plan as it applies to his/her duties, including:
- Procedures for Spill Control.
- Procedures for emergency notification.
- Procedures for Evacuation.
- Procedures for First Aid/Emergency Response.
- Procedures for Obtaining Medical Consultation.
- Procedures for Reporting Suspected Exposure.
- Ensures that laboratory workers are in possession of, and are familiar with, all relevant Operational MSDS sheets.
- Be responsible for and maintain the Chemical Inventory.
- Be responsible for the UMB Monthly Laboratory Self Inspection
- Carries out corrective actions in cases of non-compliance.
- Maintains adequate supplies of Personal Protective Equipment.
- Personally supervises the activities of non-laboratory personnel while they are in the laboratory.
- Follows posted emergency notification procedures in the event of an emergency (reportable or non-reportable).
- Maintains records as necessary.
A5. Laboratory Workers
Individuals who work in laboratories are responsible for performing their work in accordance with the Integrated CH/EMPlan and complying with the Minimum Performance Criteria (MPC) for the laboratory in which he or she works, including designing or obtaining aid in the design of Standard Operating Procedures applicable to those hazardous chemicals. Laboratory workers are also responsible for bringing to the attention of their Chemical Hygiene Officer, the UMB Environmental Health & Safety Office and/or the Chemical Hygiene Committee any problems with safety and concerns with respect to potential environmental impacts. Laboratory workers are responsible for informing the CHO of the introduction of new chemicals to the worksite. Laboratory workers have the following responsibilities:
- Choosing appropriate containers for laboratory waste.
- Inspecting waste containers upon each use.
- Ensuring that waste containers have secondary containment if necessary.
- Ensuring that waste containers are closed unless waste is being added or removed.
- Consulting Operational MSDS sheets when working with chemicals in the laboratory.
A6. Visitors
All laboratory visitors (i.e., on-site contractors, vendors, visiting scientists/students, other university personnel, etc.) will be informed of the existence of an integrated CH/EM plan. For those who must conduct work in a laboratory, specific training will be provided by EH&S as needed. Access to laboratory materials will not be permitted unless proper training has occurred. Copies of the University's CH/EM Plan are available for review in the EH&S Office (150/UL/034) and from Principal Investigators. A copy of the plan may also be found at the website listed on the cover page of this document.
A7. Facilities Administration
Works in conjunction with the EH&S Office to repair and maintain engineering control systems and/or other mechanical issues in laboratories.
A8. Laboratories Covered Under the UMass Boston Integrated CH/EM Plan
All laboratories that contain chemicals in the following departments are covered by the CH/EM Plan:
| Department | Locations | #Labs | #Labs with Chemicals | #PIs |
|---|---|---|---|---|
| Anthropology | Science, McCormack | 6 | 3 | 2 |
| Biology | Wheatley, McCormack | 59 | 53 | 25 |
| Chemistry | Science | 36 | 42 | 14 |
| Earth & Geological Sciences | Science | 5 | 1 | 1 |
| Environmental, Coastal & Ocean Sciences | Science, Wheatley | 11 | 9 | 7 |
| Physics | Science | 23 | 7 | 7 |
| Psychology | Science | 7 | 7 | 2 |
A detailed list of all laboratories can be found in Appendix I.
B. OPERATIONAL ELEMENTS
B1. Medical Services
Medical services for UMB employees are obtained from Boston City Hospital. The Laboratory Standard does not mandate medical surveillance for all laboratory workers. There are, however, certain circumstances where employers must provide any employee who works with hazardous chemicals an opportunity for medical attention. Specifically, medical attention, including any follow-up examination and treatment recommended by the examining physician, must be offered in the following circumstances:
- A medical consultation conducted to determine the need for a medical examination must be offered to any employee who is present in the work area when a spill, leak, explosion or other accident occurs that results in a potential significant exposure to a hazardous chemical.
- A medical examination must be provided to any employee who exhibits signs or experiences symptoms associated with exposure to a hazardous chemical used in the laboratory.
- Medical surveillance, as defined by the particular Standard for that substance must be provided to any employee who is exposed routinely above the action level or, in the absence of an action level, above the PEL to an OSHA regulated substance for which there are exposure monitoring or medical surveillance requirements.
The 'Special Substances' (29 CFR 1910.1001-1048) most commonly encountered in the laboratory are Formaldehyde, Methylene Chloride, Benzene, Glycol Ethers (Cellosolve), and to a lesser extent Benzidine, Ethylene Oxide, Cadmium, Lead and ß-Naphthylamine.
Additionally, the provisions of the UMB Respiratory Protection Program require that any employee required to wear a negative-pressure respirator in performance of his or her duties must first, and annually, undergo medical screening by completion of the appropriate questionnaire which will be evaluated by Student Health Services, be trained in the care, use and limitations of the apparatus, and be provided with a fit-test. A full text of the program is located in the EHS Manual, section 1.3.
B2. Engineering Controls: Monitoring and Maintenance
The chemical fume hood is the primary mechanical mechanism preventing individual exposure to vapor emissions by hazardous chemicals during experimental processes. It is essential that the fume hood always be operating properly. Any observed malfunction should be reported immediately to Environmental Health & Safety (7-5445) who will act as liaison between Facilities personnel and the lab.
The Environmental Health & Safety Office will monitor the function of all fume hoods, and any other local exhaust ventilation devices annually in April, and date and post the results on each hood. If at any time the performance level of a hood comes into question, the Environmental Health & Safety Office will respond immediately. On a daily basis, a 'flag' such as a kimwipe should be taped to the sash edge to act as a 'no-flow' indicator. All requests for hood maintenance must be forwarded through the Environmental Health & Safety Office, and not reported directly to Facilities Administration.
Initial certification of Biological Hoods should be carried out by an outside agency; obtaining the services will be the responsibility of the Chemical Hygiene Officer. Contact the Environmental Health & Safety Office for recommended contract services. If the hood is used for the containment of agents infectious to humans, or for recombinant DNA experimentation, the hood must be fully certified to NSF specification on installation or after being moved. Following this, a more limited certification, carried out by the EH&S Office must be carried out annually, and the hood signed and posted.
SPECIAL NOTICE: It is forbidden to use fume hoods as a means to evaporate laboratory chemicals for the purpose of disposal. Close all caps tightly and seal containers to minimize escape of vapors. Chemicals should not be stored in fume hoods long term. Excess storage not only clutters the workspace, but can inhibit air flow needed for proper fume hood operation.
B3. Emergency Response for Laboratories
For all emergency situations such as as any fire or non-incidental release, the appropriate response for the CHO is to:
- Ensure that all individuals in the affected area evacuate immediately.
- Notify Public Safety (911) of the location and situation.
- Tend to any injured personnel.
- Ensure that no one enters the area until it can be isolated by Security personnel.
If the CHO is not available, anyone else in that lab may proceed with the aforementioned steps. The EHS office provides emergency notification procedures and signage for emergency response equipment in the laboratories and elevators. The CHO must ensure that this equipment, including fire extinguishers and spill-control materials, are properly maintained in the laboratory. Keep in mind that emergency situations are usually ill-defined and subject to rapidly changing conditions. When any doubt exists, report the situation immediately by calling 911. Additional information may be found in the UMB Emergency Response Policy (see EHS Manual, section 1.2).
B4. Standard Operating Procedures (SOPs)
The Laboratory Standard and the Environmental Management Standard require that Standard Operating Procedures (SOPs) be established for the use of any hazardous chemical or laboratory waste, respectively. UMB has developed a program which provides laboratory staff with a set of rules comprising a 'Basic SOP' (see Appendix A) which is applicable to every chemical procedure in the laboratory. In many circumstances however, it will be necessary to take additional measures to protect yourself and others in your laboratory. It is not a requirement to formally document these additional steps.
EH&S had taken each chemical inventory and developed a Primary Index which identifies potential hazards beyond those controlled by the Basic SOP and Secondary Indices which rank the relative degree of hazard. The Primary and Secondary Indices are presented as Operational Material Safety Data Sheets. An explanation of how to read these sheets is included in Section IV. Operational MSDS's should be reviewed before beginning each new procedure. Section V. provides additional information for developing chemical specific SOPs. Finally, Appendix B contains information on chemical classification that may be used to compare with materials in your laboratory.
B5. Training
All individuals working with chemicals in laboratories in a generally unsupervised capacity, including, but not limited to faculty, staff, post-doctorates, graduate students, and some undergraduate students, are required to be trained in the application of the Integrated CH/EM Plan. This training must be done once, and need not be repeated, unless a significant new hazard is introduced into the laboratory. Training will be conducted by Environmental Health & Safety at the beginning of each semester, and whenever required by the addition of new staff/students. The EH&S Office is notified when Orientation sessions will take place for new faculty/staff members and a representative always attends. In addition, each laboratory department is contacted at the beginning of each semester and asked to identify new students, staff and faculty. EH&S then schedules times for training sessions. Sessions are either large groups or small groups depending on the number of new people each semester. Principal Investigators also can request individual visits to their laboratories. Follow-up training will also be provided if laboratory workers work with new hazards for which they have not been previously trained. Sign up sheets for each training session will be filled out before each session. Documentation of training records will be maintained in a training database in the EH&S office.
The syllabus of the training program shall include the following:
a. Contents of the Laboratory Standard and the Environmental Management Standard and its Appendices
i. Emergency Response / Spill Control
ii. Medical Consultation
iii. Labeling and Signage: Physical and Health Hazard Categories
iv. Special Considerations for Highly Hazardous Substances
v. Chemical/Physical Hazards of Laboratory Waste
vi. Minimum Performance Criteria
b. Location of the Integrated CH/EM Plan(s)
c. Location of Indexed Lists, SOP's, MSDS's, Reference Material
d. Detection of Exposure:
i. Exposure Routes
ii. Employer: Methods, how to access.
iii. Employee/Laboratory Worker:
1. Warning Properties
2. Signs and Symptoms of Exposure/Release
vi. Release Prevention
e. Standard Operating Procedures:
i. Defined as Basic SOP plus Site-Specific variations
ii. Use of Lists, SOP's, MSDS's, addt'l reference
iii. Use and Limitations of Engineering Controls
1. Eye Wash and Drench Showers
2. Fume Hoods
3. BioCabinets
iv. Use and Limitations of Personal Protective Equipment
1. Eye Protection
2. Skin Protection: Gloves
3. Skin Protection: Aprons, Coats, Jumpsuits
4. Respiratory Protection (Program)
a. Conditions warranting protection
b. Medical Surveillance
c. Selection and Fit Test
v. On-Site Work practices and Procedures
f. Pollution Prevention
The Standard Operating Procedures and the Operational Material Safety Data Sheets are designed to provide the specific information required by the Training component of the Lab Standard and the Environmental Management Standard. It is the responsibility of the Chemical Hygiene Officer to ensure that each affected employee:
- Has attended a training session.
- Has read those documents which pertain to his\her potential exposure.
- Has been given a copy of the Basic Standard Operating Procedure.
- Knows the location of Personal Protective Equipment and Engineering Controls.
- Knows where to find additional information (EH&S Internet Homepage, CD-ROM set, RTECS, etc.).
- Is aware of any local variance from the UMB Integrated CH/EMPlan.
B6. Laboratory Inspections
The Principal Instigator, or the PI designated laboratory respresentative (a graduate student in most cases) shall conduct monthly self inspections, with an emphasis on chemical container checks. Monthly Laboratory Self-Inspection forms (EHS Manual, section 1.10) will be maintained in individual laboratories and the EH&S Office. Individual laboratories will maintain records for one year. The EH&S Office will review monthly inspections for compliance. Annually, EH&S will present a summary of inspection findings and assessing the success of the program on a lab-by-lab basis to the CHP Committee
Annual comprehensive laboratory inspections will be performed by the EH&S Office. The focus of the inspections will be conformance with the Integrated CH/EM Plan. The format of the inspections will be reviewed annually by the CHP Committee. A sample inspection form containing the basic inspection items is located in the EHS Manual, section 1.9.
Inspections may be unannounced. However, EH&S will always attempt to include responsible personnel in the inspection. All departments and laboratory workers will continue to maintain Monthly Laboratory Inspection sheets to ensure compliance with the Integrated CH/EM Plan.
Compliance with the Plan will also be reviewed by EH&S during routine laboratory waste pick-ups. Documentation of annual inspections will be maintained in the EH&S Office
B7. Corrective Action
During annual inspections, if non-conformance is noted, items that can be taken care of during the inspection will be addressed immediately. All actions taken will be noted.
In cases of repeated non-compliance, notice will be given to the department Chairperson of the Principal Investigator. The PI will have one week to perform necessary corrective actions. If action is not taken within the one week time period, a directive from the CHP Committee will be issued to the PI and notification to the appropriate Dean and Provost will be made. Both the Dean and the Provost have the authority to cease laboratory operations until corrective actions are completed.
In cases of potential imminent danger to life, health or the environment, the EH&S Office and/or University Senior Management is authorized to order cessation of hazardous activity until the danger from such a condition is abated or adequate measures have been taken to eliminate the danger.
B8. Movement and transfer of chemical containers
Whenever chemicals are transported outside the laboratory, the primary container should be placed in a secondary, non-breakable carrier container.
When transporting more than one container of hazardous waste, use of a cart is mandatory.
Before moving containers, check and tighten caps or other enclosures.
Only EH&S personnel are authorized to transport laboratory waste to designated accumulation areas.
If you need assistance or additional information, please contact EH&S @ 7-5445.
B9. Chemical Inventories
UMass Boston is required by the Boston Fire Department to have complete chemical inventories for all locations on campus. Initial inventories were conducted in 1995.
Annually, in August, the EH&S Office generates a chemical inventory list from its database and sends them to all Principal Investigators. PI's generally update lists within one month, sign them, and return them to EH&S for input into a central database. Manual input into the EH&S central database is very time-consuming and can take several months to complete. EH&S utilizes the inventory to generate Operational Material Safety Data Sheets for each lab. Additionally, EH&S utilizes the data to sign doors for the Boston Fire Department according to the NFPA 704 standard. PI's are required to notify EH&S if the NFPA hazard rating must be changed due to the addition or subtraction of certain chemicals such as compressed gas cylinders, oxidizers or water-reactive materials. EH&S is piloting a bar-coding system to track chemicals on the in a small number of Chemistry laboratories. If the pilot is successful, EH&S will begin bar-coding all hazardous materials on campus during the FY2002. We estimate that all laboratories will be complete by Spring 2002. Once complete, full inventories will be complete very rapidly and manual entry of data will no longer be necessary.
B10. Hazardous Chemicals of Concern
As part of this plan, a separate list of extremely hazardous chemicals was generated by EH&S. This list of Hazardous Chemicals of Concern (HCOC) will be monitored annually by the EH&S Office and flagged on inventory sheets.
EH&S has designated the following materials to be HCOCs:
EPA P-listed wastes
OSHA Special carcinogens
OSHA Teratogens/Reproductive toxins
OSHA designated highly toxic substances
Explosive nitroarenes
Peroxide-forming chemicals
Pyrogens
Shock-Sensitive Explosives
For these materials, EH&S will generate a separate list for each PI (see example) to insure they are aware they should pay special attention.
B11. Recordkeeping
EH&S Office
The following records will be maintained in both paper and electronic format. Paper records will be maintained for 1 year, or in the case of annual items, for the current year. Electronic records, to the extent possible, will be maintained indefinitely.
- Training records
- Annual laboratory inspection reports
- Monthly laboratory self inspection reports
- Institutional hazardous chemical inventory (including HCOC)
The following records will be maintained indefinitely:
- Biennial Hazardous Waste Report
- Hazardous waste manifests/exception reports
- Land ban forms
Additional items to be maintained in the EH&S Office include:
- Records of non-conformance/corrective actions
- Regulations (local, state, federal)
- List of Principal Investigators and associated laboratories
- Incident reports
- CH/EM Plan
- EHS Manual
- SPCC Plan
- Contingency Plan
Departmental Offices/Individual Laboratories (will vary depending on individual Departmental policies)
- CH/EM Plan
- EHS Manual
- List of Principal Investigators and associated laboratories
- Monthly laboratory self-inspection reports will be submitted to EHS and maintained for one year following implementation
- Hazardous chemical inventories (including HCOC)
- Monthly container inspections (posted)
- Operational MSDS's
B12. CH/EM Plan Review
The EHS office is authorized to make minor changes in the CH/EM plan as deemed necessary. Requests, comments, etc., may be submitted for review and potential incorporation into the plan at any time. The plan will be reviewed on an annual basis by the CHP Committee, which will implement any necessary changes.
B13. Identification & Tracking of Legal Requirements
The Office of EH&S will actively identify and track legal requirements applicable to the management of laboratory waste through a variety of means, including:
- Journals (e.g. Chemical Health and Safety, published by the American Chemical Society)
- Internet and World Wide Web (may include EPA Web Site, DEP Web Site, mail lists)
- Professional organizations such as the Campus Safety Health and Environmental Management Association (CSHEMA) and the College and University Hazardous Waste Management Association (CUHWMA). EPA Compliance Assistance Program.
At least once a month the EH&S staff will perform a search of one or more of these resources in order to determine if there have been any changes in regulatory requirements. Any changes found that are applicable to the EMP will be taken into account for CH/EM Plan updates.
In addition, lab workers will be updated with new information via the following means:
- UMB EH&S website
- Memos periodically sent to faculty and staff in the science departments
- Meetings with affected departments, or other University meetings related to laboratory issues (such as the Chemical Hygiene Committee meetings)
- CH/EM Plan training.
