Environmental Health and Safety Office
Health and Safety Procedure
Decommissioning of Laboratories or Equipment used with Chemical Biological or Radioactive Material
Date revised: / June 26, 2007Original version developed / January 14, 2004
Originating Department: / Environmental Health and Safety Office (EHSO)
Effected Departments: / Physical Plant
All Academic Departments using Controlled Products
Background:
At the University, Researchers within Academic Departments commonly use potentially hazardous materials in research areas and with equipment. These potential hazards specific to the research activities must be identified to all persons with access to these areas. Researchers must realize that Physical Plant staff (caretakers and trades), Contractors and Security Services staff may enter areas during the normal course of their work, including times when Researchers are not present. Researchers are obligated to protect the health and safety of these workers by using hazards signage, engineering or administrative controls.
When possible, researchers who use the potentially hazardous materials (chemicals, biologicals or radioactive material) are obligated to remove these materials and any related contamination before the public, or service personal (University staff or contractor) have access to these areas or equipment. This process is known as decommissioning and the process is defined herein.
Potential Hazards Present: Contamination may occur by touching surfaces or being exposed to airborne contamination or liquids in the lab. Contamination may also occur by walking through a spill, breathing in vapours or by producing contaminated dust, mists or aerosols. Contamination may result from the research activities or from the servicing.
Additional precautions are required if asbestos or mould is present or suspected to be present. Refer to the Asbestos or Mould Management Program.
CONTENTS
1. Purpose: Page 2
2. Policy: Page 2
3. Definitions: Page 2
4. Responsibilities Page 3
5. Decommissioning Procedure for Rooms, Areas or Equipment used to store or manipulate chemical, biological or radioactive materials: Page 3
6. Procedure for disposal of Equipment Page 4
7. PPE for Contamination Control: Page 5
8. WORKERS DUTIES with Job Hazard Analysis Page 6
Appendix A: Decommissioning/Decontamination Form for Equipment Page 7
Appendix B: Decommissioning/Decontamination Form for Laboratories or Rooms Page 8
1. Purpose:
To define the decommissioning process to:
1.1 To reduce or eliminate exposure to potentially harmful chemical, biological or radioactive material to service (Physical Plant), contractors and research (Academic Department) staff.
1.2 Update the EHSO inventory of lab equipment and advise on appropriate disposal of related equipment.
2. Policy:
Prior to servicing or renovation, all laboratories, work areas or equipment used to store or manipulate Controlled Products (chemical, biological or radioactive material) shall be decommissioned by the Responsible User.
2.1 If the Responsible User is not available, the appropriate Department Head shall be responsible for ensuring that the appropriate resources are available to accomplish the decommissioning.
2.2 At the University, decommissioning of areas (rooms) or equipment used to manipulate or store chemical, biological and radioactive materials shall be recorded by completing a decommissioning form as prescribed by the Environmental Health and Safety Office.
2.3 Contractors and Physical Plant staff shall never be allowed to dispose or work with equipment or in areas where potentially harmful chemicals, biological or radioactive material has been used or stored without a documented decommissioning, unless they have documented training to ensure they understand the risks and can identify and mitigate the hazards.
2.4 Since decommissioning can only remove the apparent and accessible hazards, this limitation must be clearly communicated to all Physical Plant or contracted service personnel prior to servicing through training related to this procedure.
2.5 Decommissioned equipment shall be appropriately labeled to limit inappropriate re-use.
3. Definitions:
3.1 Decommissioning: Decommissioning is the process of removing all the accessible chemical, biological and radioactive materials and any related contamination from accessible surfaces.
3.2 Responsible User: Principal Investigator or PI/departmental designate that has authority for the equipment or area and understand the hazards associated with the related chemical, biological or radioactive materials.
3.3 Contractors: Non-Physical Plant staff that provide service or construction work as authorized by Physical Plant, EHSO or Academic Departments.
3.4 Supervisors: Anyone who directs the work of another person.
3.5 PPE or Personal Protective Equipment: Safety devices or safeguards worn by workers to protect against environmental hazards. PPE includes helmets, safety goggles, hearing protectors, face shields, respirators, arm guards, smocks, gloves, protective clothing and safety boots.
4. Responsibilities:
4.1 The Academic Department is responsible to ensure that all academic and support staff working with chemical, biological or radioactive materials are aware of the requirement for decommissioning prior to renovation or servicing by Physical Plant staff or Contractors as set out in this procedure.
4.2 Physical Plant Department is responsible to ensure that all Physical Plant staff who may work with equipment or in areas where chemical, biological or radioactive materials have been used or stored, or who may direct the work of others are aware of the requirement for decommissioning prior to renovation or servicing by Physical Plant staff or Contractors as set out in this procedure.
4.3 The Environmental Health and Safety Office is responsible to communicate to Physical Plant and Academic Department Heads the requirement for decommissioning and to advise on appropriate procedures prior to renovation or servicing by Physical Plant staff or Contractors as set out in this procedure.
4.4 Supervisors are responsible to:
a) Identify the hazards and communicate the requirement for decommissioning to staff and contractors,
b) Verify that their staff is appropriately trained to recognise potential chemical, biological or radioactive hazards, understand the risks and be able to control the hazards.
c) Supervise their staff to ensure that safe procedures are followed, prescribed personal protective is worn and the existing potential hazards as known are communicated on the decommissioning form.
SAFETY ALERT Laboratories have many hazards (chemical, biological, and physical hazards such as radioactivity and sharps such as needles and scalpels). Check for signs and hazard labels. Even when chemical, biological and radioactive hazards are removed from the accessible areas of the lab, BE AWARE that hidden areas such as fume hood ducts and sink drains may still be contaminated!
5. Decommissioning Procedure for Rooms, Areas or Equipment used to store or manipulate chemical, biological or radioactive materials:
5.1 The Responsible Users shall decommission rooms, areas or equipment by removing all the accessible chemical, biological and radioactive materials and any related contamination from accessible surfaces. They shall record this decommissioning and actions taken on a DECOMMISSIONING form provided by EHSO. Consult Section & for advise on appropriate PPE and Section 8 for a detailed set up procedure with Job Hazards analysis.
5.1.1 Remove chemicals from the equipment and work area.
5.1.1.1 Chemicals, biological or radioactive materials need to be disposed via EHSO or stored in a manner that does not:
a) Impede access to the equipment or area to be serviced.
b) Create a hazard to others.
c) Allow unauthorized access by persons that are not trained to identify, understand or mitigate the hazard.
5.1.1.2 Chemical, biological or radioactive contamination must be removed by staff that:
a) Are trained to use approved decontamination methods.
b) Wear appropriate personal protective equipment (minimum lab coat, disposable chemically resistant gloves and eye/face protection such as goggles or face shield) in a manner to contain contamination.
c) Dispose of related chemical wastes via approved methods.
d) Biological contamination shall be decontaminated via methods that are effective.
e) Radioactive contamination shall be repeated until contamination monitoring documents that the remaining removable contamination is below the limit prescribed by the internal radioisotope permit.
5.1.1.3 Method of decontamination:
a) Surface and accessible interior shall be totally empty; all chemicals and samples, stray vials, debris or loose items must be removed. Any PCBs, Mercury, Lead, oil or water must be drained and disposed of separately.
b) Surface cleaning is required before items from research areas are moved to or transported through publicly accessible areas:
a) Except where water-reactive chemicals may be present, the exterior and interior surfaces shall be wiped with a detergent solution.
b) If biological contamination is a possibility, 1/5 bleach solution or 70% ethanol solution, should be applied and let to soak for 30 minutes before being wiped dry.
c) If bleach is contraindicated due to the presence of stainless steel or the possible presence of chemicals that may react, an alternate disinfectant should be researched and used.
d) Before cleaning equipment containing spoiled biological material or mould, EHSO should be consulted.
c) Loose or sharp parts, including doors and cords should be secured prior to transport.
5.1.1.4 The method and related confirmation of decontamination shall be documented on the Decommissioning form.
6. Procedure for disposal of Equipment that has previously been used to store or manipulate chemical, biological or radioactive materials: After appropriate decommissioning, the following label must be attached to the equipment prior to disposal:
7.
PPE for Contamination Control:
Supervisors may stipulate additional PPE be worn by their staff.
Type of PPE minimally required:
Lab coat, apron or coveralls (disposable or washable) must be worn if there is any possibility of contamination of the workers body.Gloves: If there is any possibility of contamination of the hands, wear re-useable chemically resistant gloves (wash and dry after use) or disposable gloves.
Use thicker gloves when physical hazard is also present.
Disposable gloves are required if radioactive contamination is a possibility.
Eye protection (Safety glasses, goggles or face shield) required if procedure has any chance or producing projectiles, dust, aerosols or splashes.
Respiratory protection required if procedure has any risk of producing dusts, hazardous vapors or aerosols. Respiratory protection is required whenever the worker may be exposed to vented air from fume hoods or other local ventilation. For exposure to hazardous particulates, dusts, aerosols, the minimum is N-95. For exposure to hazardous volatile chemicals, a multi-contaminant respirator for organic vapors is required. Respiratory train and fit testing are mandatory.
Hygiene: Wash hands, clean and disinfect tools at the end of the job and whenever chemical, biological or radioactive contamination is a possibility.
If no sink is readily available, take along hand wipes to use until you can wash your hands in a sink.
Disinfectant wipes are recommended if biological contamination on tools is a possibility.
Waste containers for any wastes generated - All wastes generated shall be disposed in accordance with Controlled Product Standard, Part B.
Footwear: Feet should be completely covered and provide necessary grip for working conditions.
8.
WORKERS DUTIES with Job Hazard Analysis
Be cautions about hidden Chemical, Biological and Radiological Hazards. Stop and ask your supervisor if you are not sure. Additional precautions are required if asbestos or mould is present or suspected to be present. Refer to the Asbestos or Mould Management Program.
1. BASIC JOB STEPS / 2. HAZARDS & POTENTIAL ACCIDENTS / 3. HAZARD CONTROLS & SAFE WORK METHODSPREPARATION OF WORK AREA or EQUIPMENT
1. Assemble PPE as indicated above. Additional PPE may be required by your supervisor. / Not using prescribed PPE or using it incorrectly may create a personal contamination or injury such as an acid burn. / Wear PPE. Wear PPE correctly. Be fit tested for respirators. Be trained how to use PPE.
2. Be prepared to reduce/ eliminate the possibility of becoming contaminated or spreading contamination. / Contamination must be contained on disposable or washable surfaces. Care must be taken to not spread contamination other areas to reduce the risk of personal contamination. / Drape splash or spill areas area with plastic (6mil poly) or plastic backed absorbent (if radioactive contamination is possible). Secure drape with tape. A kiddie pool may be needed to contain over spray or drips.
Pre-plan how to wash up self and decontaminate supplies or tools that you plan to re-use another time.
3. Visually inspect and remove hazards (chemical, biological and radioactive). / Chemical, biological and radioactive materials may create hazard. / Dispose of hazardous materials according to University procedures. Consult EHSO as appropriate. Hazardous material must be stored safe from unauthorized access.
4. Security / Unauthorized people may remove hazardous material. Untrained people may not recognize hazards. / Ensure unauthorized staff do not have access to hazardous materials or enter the area. Possibly post signage stating “Restricted area. Authorized personnel only.”
Lock door when unattended. Do not place equipment that may be contain or be contaminated with hazardous materials in areas that the public may access.
5.Personal hygiene / Personal contamination is possible from improper hygiene. / Avoid touching your face during work. Do not eat or drink during procedure. Do not bring food or beverages into work area.
6. Follow lab defined Safe Work Procedure; consult equipment manual or other defined equipment related procedures. / Be cautious of variations. / Consult supervisor or manufacturer for clarifications.
CLEAN UP
7. Clean items that will be reused with a moistened cloth as appropriate. / Cross contamination to self or other areas. Be cautious of wetting electrical hazards. / Clean and monitor re-useable items prior to reuse.
8. Wipe works surfaces with a damp cloth and remove drape. / Cross contamination to self or other areas. / Bag all wastes including damp cloth and dispose of appropriately.
9. Remove PPE as trained / Cross contamination of self or other areas. / Be careful no to spread contamination. Wash hands.
Appendix A
U of M Decommissioning/Decontamination Form for Laboratory Equipment
(ONE Form per Item please)
1. This Form must be completed prior to commencing service, maintenance, renovation or disposal.
2. EHSO signature is optional.
3. Up to 2 weeks may be required for EHSO signature in Section D.
4. If ASBESTOS or MOULD is present or suspected, refer to the Asbestos or Mould Management Program (474-6633)
5. Fax completed form to Physical Plant at 474-7547 Fort Garry or 789-3933 Bannatyne
Section A: Requestor: / Section B: Equipment Description:Reason: ð Disposal ð Servicing ð Maintenance
Name (Please Print):
Department: / Location:
Room Building
Tel: / Type of Equipment:
Responsible user Name: / Make and Model:
Date requested: / Serial Number
Date Required: / U of M Property # OR other ID (specify):
If the equipment has a U of M property #, then the Asset Disposal Form been completed and approved? ð
Is this part of a project or renovation? ð Y ð N
Physical Plant Coordinator OR Contractor Contact:
Name Tel:
Section C: To be completed by Senior Lab Staff
C1. How many years of history do you have on this item? ______
C2. For the item above indicate the related hazardous materials usage:
Hazardous Material / If never used / If applicable, record related information here / C3. Decontamination
Information
Radioactive material / ð / Specify isotope(s) and when: / What was done (check all that apply):
ð All needles, razor blades, broken glass removed and disposed according U of M Protocol
ð Minimum requirement is that all equipment from labs is surface wiped with water & mild detergent to remove surface dust, debris.
ð interior only ð exterior only
ð both interior and exterior
ð monitored for radioactive contamination
(attach results)
Date______
ð 1/5 bleach with 30 min soaking
ð 70% ethanol with 30 min soaking
ð other - specify type and concentration:
Date Completed:
Done by:
Name (Please Print) Tel:
Biological material or blood and body fluids / ð / Specify type and when:
Has BSC been surface disinfected-inside and out- if it is to remain in the renovation area? ð
Hazardous chemicals or gas/vapour in equipment / ð / Consider: Highly toxic material, perchloric acid, hydrofluoric acid, corrosives, mercury. Specify type and when:
Collect in sealed containers and label as hazardous waste.
Oil, vacuum pump oil, PCB’s in equipment / ð / Drain vacuum pumps of oil into containers and label and dispose with hazardous waste program (PCBs?)
Lead or other leachable metals present, including in any internal components of equipment / ð / Removed ð or
List on green Equipment Disposal sticker ð
Other hazards or pertinent information / ð
C4. All hazard labels removed once equipment is decontaminated? ðY ðN
C5. If this is an equipment decontamination/disposal have you checked with the manufacturer regarding any specific instructions or hazardous internal components? If yes, please append information (check here if information is appended) ð Y ð N
C6. Do you have any specific recommendations for PPE or disposal? If yes, please list on back ð Y ð N
DECLARATION OF COMPLIANCE: Signature confirms information is Section C is accurate.
Signature of Responsible User Print Name and Phone # of Responsible User
Section D1: / Section D2: To be completed by EHSO upon request of physical plant
Any special instructions (itemize and initial) use extra page
as required: Check here if information is appended ð
For Personnel carrying out disposal minimum PPE are:
ð Coveralls
ð Eye and Face Protection
Additional workplace protection required by units:
ð Gloves, specify type ______
ð Respiratory Protection- specify ______
ð Other – describe______/ Bio/Chem Decommissioning:
(initials, phone & date) / Rad Decommissioning verified:
(RSO initials, phone & date)
Appendix B