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OEH&S Chemical Safety Manual Chapter 1
OVERVIEW OF REGULATIONS AND RESPONSIBILITIES
This manual provides a description of the policies and procedures that
are expected of UCSF hospitals, Principal Investigators (PIs) and laboratory
workers in managing their chemical laboratories and inventories,
and in
satisfying legislative and regulatory requirements of outside
agencies. Our campus program has been developed to promote safe use of
chemicals
without limiting academic freedom. The descriptions of the
Hazard Communication Program, Chemical Hygiene Program, general laboratory
procedures, and other
information given in this manual are designed to minimize laboratory
accidents and health problems through safe work practices and education,
and to implement
requirements as they have been interpreted by the University
of California, San Francisco (UCSF) Chemical Safety Committee.
This manual is derived from the applicable sections of the California
Occupational Safety and Health Act (Cal-OSHA), California Environmental
Protection Agency (Cal-EPA) California Education Code, state
and local
Fire Codes, and state
and local Health Code regulations. Accreditation standards
with which UCSF must comply, such as those of the Joint Commission
on Accreditation of
Healthcare Organizations are addressed as well as other requirements
imposed by the City and County of San Francisco, Cal-OSHA,
Cal-EPA, and other agencies.
Our campus program incorporates elements that attempt to satisfy
all requirements.
This manual therefore constitutes the campus and departmental Chemical
Hygiene Plan and Hazard Communication Program.
A. RESPONSIBILITIES:
THE ROLES OF INVOLVED PERSONS
The rules and procedures set forth in the Handbook have one single, straightforward
purpose - to protect UCSF patients, students, visitors, and
employees against unnecessary and potentially harmful chemical
exposure. For these rules
and procedures to be effective, it is important to have a structured
administrative format in place which defines the roles and
responsibilities of each person,
or administrative office.
High standards of laboratory practice are an essential element of excellence
in the research, instructional and clinical settings. Clearly,
the quality of both research and clinical data, and of the
training of students and
laboratory workers, depends upon observation of such high standards.
Of primary importance are the health and safety of members
of the UCSF community
who are directly affected by laboratory practices. Some of
these may be the prerogatives of individual laboratory directors,
but statutory and
regulatory mandates, University policies, and institutional
responsibility necessitate that some laboratory practices be
determined at the campuswide
level. Moreover, even while some practices remain largely discretionary
within each laboratory, the institution has the responsibility
and liability of providing guidance, advice and appropriate
informational resources in
support of the highest standards of laboratory practice.
The responsibility of UCSF is to take every reasonable precaution to
provide a workplace that is free from hazards. More specifically, UCSF’s responsibility is to
make certain that all work practices, procedures, and policies necessary to protect employees working in laboratories, with consideration given to the chemical hazards present, are in place.
This responsibility is shared among the members of the University community:
the Chancellor, the Chemical Safety Committee, Deans and Department Heads,
Principal Investigators, laboratory personnel, and the Office of Environmental
Health and Safety.
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1. CHANCELLOR RESPONSIBILITIES
The Chancellor has the ultimate responsibility for the safe handling
of chemicals on the UCSF campus, for approval of all UCSF
policies dealing with hazardous chemical operations, and for directing
implementation of
those policies. Acting for the Chancellor, the Director
of the Office of Environmental Health and Safety (OEH&S) administers
the UCSF Chemical Safety Program.
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2. CHEMICAL AND ENVIRONMENTAL SAFETY COMMITTEE
Duties and Responsibilities of the Chemical and Environmental Safety
Committee are as follows:
- provide expert advice to the Chancellor on issues related
to chemical and environmental safety, and implementation
of the UCSF Integrated Safety and Environmental Management
System (ISEMS);
- review technical, environmental and safety-related aspects
of laboratory research and the use of hazardous and
toxic substances;
- continuously review and update UCSF's ISEMS and the laboratory
safety manual;
- certify that facilities, procedures and practices have
been reviewed and approved;
- promulgate a chemical and environmental safety program
in conjunction with OEH&S that encourages best
laboratory practices and satisfies federal, state and
local laws and
regulations;
- arbitrate campus disagreements regarding laboratory practices
and limit or revoke, as authorized by the Chancellor,
and investigator's authority to use hazardous or toxic materials
if such use presents a hazard to individuals or violates
health and safety codes.
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3. DEANS AND DEPARTMENT CHAIRPERSONS
Deans and Department Chairpersons are responsible for ensuring that individuals
working with chemicals are adequately trained to understand the hazards
associated with the chemicals and to understand procedures and policies
used within the department. Deans and Department Chairpersons are responsible
for assuring that adequate resources exist to comply with the UCSF safety
policies and standards. They must also ensure that proper project/experiment
designs and monitoring methods are in place to guarantee safe laboratory
operations. They have the responsibility for correcting work practice errors
and unsafe conditions that may lead to personal injury. These responsibilities
may be delegated to a department safety representative.
4. PRINCIPAL INVESTIGATORS
Principal Investigators (PIs) are responsible for the safety of all employees
reporting to them. PIs are responsible for ensuring that the laboratory
environment of each individual user is kept safe. Other responsibilities
include adequate planning prior to the conduct of an experiment protocol
to determine the safety measures which will be required for that protocol,
and to make certain that those safety measures are implemented. PIs must
instruct or provide instruction to their employees in the safe use of the
chemicals used in their procedures, and provide access to all manuals,
procedures, flyers, and newsletters provided by the Office of Environmental
Health and Safety. They must also ensure that the proper personal protective
equipment (PPE) is available and used by employees.
To facilitate implementation of these requirements, each PI must designate
an experienced staff member to serve as Chemical Safety Officer for his/her
laboratory.
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5. LABORATORY CHEMICAL SAFETY OFFICER OR LABORATORY
MANAGER
The PI may delegate day-to-day safety program implementation and oversight
to the Laboratory Chemical Safety Officer (CSO). This designee then becomes
the primary contact for the Office of Environmental Health and Safety,
and the Chemical Safety Committee.
6. INDIVIDUAL EMPLOYEES AND STUDENTS
Although students are not explicitly covered by Cal-OSHA regulations,
UCSF policy requires all students to comply with UCSF safety policies and
regulations. Students shall also be provided information and equipment
to protect themselves from laboratory hazards. Individual employees are
responsible for their own safety. All employees whose work involves the
use of hazardous chemicals must accept the responsibility for operating
in a safe manner, making certain they are informed of the hazards in their
workplace, and following training and safe operating procedures for their
tasks. Employees are also responsible for notifying their supervisors of
accidents, incidents, and any unsafe working conditions they encounter.
7. OFFICE OF ENVIRONMENTAL HEALTH AND SAFETY
The Office of Environmental Health and Safety (OEH&S) is responsible
for implementation and oversight of the UCSF Chemical Safety
Program. The Director of the Office of Environmental Health and Safety
acts for the
Chancellor in this role.
The responsibility of OEH&S is to maintain communications with
regulatory agencies which includes preparation of reports, and correspondence,
maintaining
records, and obtaining permits.
Top of page B. THE ROLE OF THE OFFICE OF ENVIRONMENTAL HEALTH AND SAFETY (OEH&S)
The Office of Environmental Health and Safety (OEH&S) is organized into four Programs. Although interdependent, they have been designed to individually address specific functional areas and campus needs. The four Programs are:
- Administration
- Clinical
- Campus (non-clinical)
- Hazardous Materials Management
Each Program is staffed with specialists in all areas of need for that
particular Program. In addition, each Program draws upon expertise or services
offered by other OEH&S Programs (e.g. waste disposal, monitoring, etc.) rather than duplicating roles.
Each Program is fully responsible for all aspects of its services including,
but not limited to, obtaining regulatory permits from outside agencies,
issuing internal permits, conducting chemical / radiation / biological
safety training and inspections, and developing policy and procedural manuals.
The following is a brief description of each Group.
1.
ADMINISTRATION PROGRAM
This Program is responsible for general administrative support to and
for the OEH&S office. There are a wide range of campus needs which
cross the boundaries of all Administrative, Medical Center and Academic
Groups of the Campus. This Program is organized to provide the needed OEH&S
Administrative services for these activities.
2. CLINICAL PROGRAM
The “Clinical Program” is responsible for providing services in areas
reflecting the needs of the Clinics and Medical Center.
This Program adopts and implements health and safety policies for the
Clinics and Medical Centers as well as developing programs to meet the
unique needs and requirements of Joint Commission on Accreditation of Healthcare
Organizations (JCAHO).
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3. CAMPUS PROGRAM
This Program has similar goals, duties and responsibilities as the Clinical
Program but provides services to all non-clinical areas of UCSF. In order
to ease the burden on the users, this Program has adopted a Department
Safety Advisor approach which is unique to UCSF. (To find your DSA, Click Here)
a. Department Safety Advisor
To assist the Campus in achieving its health and safety goals, OEH&S
has assigned a professional staff member to each Department
/ Unit to act as its Department Safety Advisor (DSA). This individual
is responsible
for all safety needs of that Department / Unit. This DSA
is the primary contact for all OEH&S
activities and is supported by the assistance or services of other OEH&S
staff. This concept provides basic advantages including:
- The DSA’s ability to develop a working relationship with
individual departments and personnel and thus be able
to provide service on a more personal level.
- Departments have to contact only one (and always the same)
person for all their OEH&S needs.
- One OEH&S staff member, the DSA, has the responsibility
of ensuring that requested information or services
have been provided to the requester.
- The DSA concept has assured that OEH&S operations become
much more efficient than they have been in the past.
4. HAZARDOUS MATERIALS MANAGEMENT PROGRAM
This Program manages hazardous materials at UCSF. These include chemical
materials, asbestos, medical waste, and radioisotopes.
This Program provides services for all of UCSF and collaborates with
other OEH&S Programs
in the development of its procedures.
C. THE FUNCTION OF THE OFFICE OF ENVIRONMENTAL HEALTH & SAFETY (OEH&S)
- General surveillance of all chemicals in use, including both personnel
and environmental monitoring.
- Furnish consulting services to personnel at all levels of responsibility
on all aspects of chemical safety.
- Distribute and process personnel chemical monitoring devices when necessary.
Keep records of any personnel exposure. Notify individuals and their
supervisors of exposures approaching or exceeding the maximum permissible
levels and recommending appropriate remedial action.
- Instruct personnel in proper procedures for the use, storage, and disposal
of chemicals.
- Supervise and coordinate the chemical waste disposal program.
- Maintain inventories of all chemicals at UCSF in accordance with local
government agency requirements.
- Supervise chemical decontamination when necessary.
- Investigate accidents.
- Maintain correspondence, permits and communications with regulatory
agencies.
- Maintain Material Safety Data Sheets.
Top of page D. AGENCIES, LAWS, AND REGULATIONS
PERTAINING TO CHEMICAL SAFETY AT THE UNIVERSITY OF CALIFORNIA,
SAN FRANCISCO (UCSF)
Over the past two decades there has been
a proliferation of laws and regulations
governing every aspect of chemical
purchasing,
use, storage, and disposal. Regulations have been enacted
at the federal, state, city / county level and
are implemented by agencies at these
levels. It is unreasonable to expect researchers to be thoroughly
familiar with the myriad of implementing agencies and their
regulations. However, all workers must
be aware of and have a basic understanding of agencies
and the regulations which directly affect their work environment.
The major programs are listed below.
1. CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
(CAL-OSHA)
In 1974, the U. S. Congress passed the Occupational Health and Safety
Act, which was intended to provide workers with protection from the hazards
in their workplaces. This Act was to be implemented by the concurrently
created Occupational Health and Safety Administration (OSHA). OSHA was
empowered to initiate regulations and create enforcement capability to
protect workers from workplace accidents. An element of the legislation
allows states to administer the OSHA requirements, and levy additional
requirements of their own. In California, this role was filled by the already
existing Cal-OSHA.
Cal-OSHA has been at the forefront of assuring worker safety, and often
implements regulations prior to Fed-OSHA; many times the regulations are
more demanding than their federal counterparts. Recent state legislation
has shifted implementation and enforcement of OSHA regulations from the
state agency to local agencies, i.e., the City and County of San Francisco.
Cal-OSHA and/or Fed-OSHA Regulations which significantly impact the UCSF
research environments are identified below.
a. Occupational Exposure to Hazardous
Chemicals in Laboratories (the Laboratory Standard)
This regulation is tailored to the safety of workers in
the laboratory environment. For laboratory workers,
it generally supersedes the Hazard Communication Standard, discussed
below.
One requirement of this regulation is that employers
(i.e., UCSF) prepare and implement a Chemical Hygiene Plan for the
laboratories; this document is intended to satisfy
that requirement. This Standard requires employers to designate a Chemical
Hygiene Officer; at UCSF, this person is a member of
the
Office of Environmental Health and Safety. The Laboratory
Standard requires Material Safety Data Sheets (MSDSs)
for all chemicals in the workplace be available to employees.
It also requires that employees be trained to recognize
and control hazards in the laboratory; to detect the presence
of or release of a chemical in the workplace, and to
follow appropriate work practices for the chemicals and processes
used. Additional requirements include a requirement
to develop and follow Standard Operating Procedures for the laboratory,
provision and use of personal protective equipment
and engineering
controls, medical surveillance when appropriate, proper
labeling, and emergency planning. UCSF’s implementation of each of
the requirements is described in later sections of
this Plan.
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b. Hazard Communication Standard
This Federal and California regulation, commonly called
the worker’s “right-to-know” standard, applies to all UCSF
employees not covered by the Laboratory Standard such as
custodial, material delivery and maintenance staff who service
the laboratory. All non-laboratory operations “where chemicals
are either used, distributed or are produced for distribution” are
covered. It requires manufacturers and distributors of hazardous
chemicals to provide certain information on the hazards associated
with that chemical. (Specific requirements are addressed
in sections on “MSDSs” and “labeling”. Employers are required
to provide information of hazards associated with chemicals
in the workplace to all employees and must develop and implement
a “written hazard communications program”. This document
is intended to satisfy these requirements. Training of
all employees to recognize the hazards in their workplace
is
required. The HazCom standard requirements are, in some
respects, more demanding than those of the Laboratory
Standard. For
example, the HazCom standard requires that each container
of chemicals be labeled, for the protection of uninformed
or untrained personnel.
c. Registered Carcinogens
Cal-OSHA may require users of listed carcinogens to register.
At UCSF, Department Safety Advisors obtain the necessary
information from Principal Investigators. OEH&S
obtains and maintains one institutional registration,
and provides
necessary monitoring of personnel and areas, as needed.
d. Injury and Illness Prevention Program The California
General
Industry Safety Orders mandate that each employer doing
business in the State of California must have an Injury
and Illness
Prevention Program (IIPP). This program must include
several elements not addressed in the above regulations.
Each employer
must identify the person or persons with the authority
and responsibility to implement the IIPP. At UCSF,
this person
is the Chancellor; the Office of Environmental Health
and Safety is charged with implementation and oversight
of the
program. A system for ensuring that all employees comply
with safe and healthful work practices is required;
this is met through training, inspections, and disciplinary
actions
for noncompliance. There are strong requirements for
communications with employees about safety matters.
One means of meeting
these requirements at UCSF is the use of Department
Safety Committees.
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2. UNITED STATED ENVIRONMENTAL PROTECTION AGENCY
(EPA) AND CALIFORNIA ENVIRONMENTAL PROTECTION AGENCY (CAL-EPA)
These agencies seek to protect the quality of air, water, land and other
natural resources. Numerous environmental laws impact our laboratory operations
at UCSF. There are three major areas of operation at UCSF which are directly
impacted by the EPA regulations: hazardous waste disposal, major chemicals
spills that release hazardous materials into any portion of the environment,
and maintenance of a detailed inventory of all hazardous chemicals present
on campus.
a. Resource Conservation and Recovery
Act (RCRA)
This law was passed by Congress to regulate the recycling
and disposal of hazardous waste. The Resource Conservation
and Recovery Act (RCRA) regulates the activities of all
parties involved from generation, transport, storage, and disposal
of hazardous wastes; thus the law is often referred to
as “cradle
to grave”. This law impacts laboratories in accumulation
and storage of waste; the 90-day storage limit and labeling
requirements originate here. RCRA requires extensive record-keeping
to track waste from its generation site (the laboratory)
to its ultimate end. Recycling and reuse are strongly encouraged;
it is the responsibility of the OEH&S Hazardous Materials
Management Group to make certain UCSF meets all RCRA
requirements.
b. Superfund Amendments and Reauthorization
Act of 1986 (SARA) Title III
Although Title III has little to do with the Superfund
program, it exists as an addition to Superfund Amendments
and Reauthorization Act of 1986 (SARA). The intent
of Title III is to help local and state agencies respond to hazardous
spills. This law requires that a comprehensive chemical
inventory
be maintained and that accidental releases of any hazardous
materials be reported to the implementing agency. In
San Francisco, the implementing agency is the San Francisco Department
of Public Health’s (SF DPH), Bureau of Environmental
Health Management, Hazardous Materials Unified Program
Agency (HMUPA).
The SFDPH is granted the right to conduct inspections
of the campus and to issue permits for the use and
storage of
hazardous chemicals.
c. Clean Air Act and Clean Water Act
These laws are intended to control emissions of hazardous
materials into the air or water; the impact at UCSF is to
limit materials that can be disposed of through the sewage
system and through evaporation into the air.
d. Uniform Building Code and Uniform
Fire Code
These codes affect the construction, renovation, and operations
of facilities. The Office of the State Fire Marshal (a division
of the California Forestry and Fire Protection Agency) is
responsible for oversight of all State-owned buildings and
facilities with regard to enforcement of these codes. One
area of jurisdiction is the types and quantities of chemicals
which can be kept in campus areas.
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e. Toxic Substances Control Act
In 1976, the U.S. Congress passed the Toxic Substances
Control Act (TSCA). The purpose of the act is to ensure that
adequate data exists regarding the effects of chemical substances
and mixtures on human health and the environment prior to
the sale or distribution of said chemical for common usage.
TSCA is administered by the U.S. Environmental Protection
Agency, and currently covers over 64,000 separate chemicals
manufactured and distributed within the United States. Data
required for each chemical includes its health effects, ecological
effects, physical and chemical properties, environmental
fate characteristics, human exposure data and environmental
release data.
At UCSF, TSCA ensures that all chemicals purchased for
use in laboratories have been evaluated for the above properties,
and that this data is available to the user. Material Safety
Data Sheets for each chemical are the most common source
for that information. TSCA provides that materials being
manufactured for research and development or being manufactured
in quantities less than 1000 kilograms may be exempted. It
is important to note that this may include experimental chemicals
used in research at UCSF; therefore users should exercise
caution when working with materials for which exposure data
does not exist.
TSCA is used by the EPA to control and regulate certain
specific chemicals, including lead, radon, asbestos, and
polychlorinated biphenyls.
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3. U.S. DEPARTMENT OF TRANSPORTATION
Transportation Uniform Safety Act The act gives the Department of Transportation
authority to regulate packaging and transport of hazardous
chemicals. Anyone transporting hazardous waste on public roads must comply
with the requirements
of the act. Provisions include the requirement for special
training of all individuals involved in the transport. At UCSF, this
process is handled
by OEH&S’s Hazardous Materials Management group.
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|| Chapter 2 ||
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