Laboratory Start-Up Procedure

Laboratory Start-Up Procedure 1. Purpose and Scope 1.1. The purpose of this procedure is to help faculty establish a safe and compliant laboratory environment. 2. Responsibilities 2.1. Department Head 2.1.1. Ensures that all new faculty in the department receive communication of this procedure. 2.1.2. Notifies EHS when a new faculty member is hired who will establish a research laboratory. 2.1.3. Provides the Laboratory Registration Form (Appendix A) and the TAMUG and Hazard/Risk Control Plan Template (Appendix B) to incoming faculty who will be setting up a research laboratory. 2.2. Laboratory Directors or new faculty. 2.2.1. Complete the Laboratory Registration Form (Appendix A) and forward the hazardous materials inventory to TAMUG EHS Lab Safety Coordinator. 2.2.2. Complete the TAMUG Hazard Control Plan Template and submit to TAMUG EHS Lab Safety Coordinator (Appendix B) 2.3. Environmental Health and Safety (EHS): 2.3.1. Will act as an information resource for new faculty establishing new laboratories. 2.3.2. Conduct initial joint assessment before work in laboratory begins?. This may include a Biosafety level 2 and/or Radioisotope use laboratory approval inspection with TAMU. 3. New Laboratory Start-Up Procedures 3.1. Department shall notify EHS when new faculty have been hired and will require laboratory space. 3.2. Departments shall provide the Laboratory Registration Form (Appendix A) and the TAMUG Hazard/Risk Control Plan Template (Appendix B) to incoming faculty. 3.3. New faculty researcher shall provide EHS an inventory of all hazardous materials that will come to campus. **PI seems to be used interchangeably with faculty. 3.4. New faculty researcher shall provide their department a list of equipment and, where applicable, decontamination certificate for used equipment that will come to campus. Revised 5 - Oct- 15 Page 1 of 17

3.5. Lab Space Acceptance 3.5.1. New faculty researcher shall walk through the lab to accept or reject any remaining chemicals and/or equipment. 3.5.2. If there are unwanted legacy chemicals and equipment the new faculty researcher shall request the department remove prior to moving into the lab. 3.5.3. All accepted legacy chemicals and equipment become the sole responsibility of the new faculty researcher. 3.6. The new faculty researcher shall submit Required Protocols appropriate oversight bodies with a copy to TAMUG EHS 3.6.1. Institutional Biosafety Work with Biohazards (blood, other bloodborne pathogens, cell/tissue cultures, parasites, bacteria, fungi, viruses, etc.) 3.6.2. Recombinant DNA 3.6.3. Animal Use Protocol 3.6.4. Human subject work 3.6.5. Hazardous Risk Controls 3.7. The new faculty researcher shall schedule laboratory certification inspections as necessary with EHS. 3.7.1. Department head shall forward a copy of signed Laboratory Registration Form (Appendix A) and the TAMUG Hazard/Risk Control Plan Template (Appendix B) to Environmental Health and Safety. Please email to ehs@tamug.edu Revised 5 - Oct- 15 Page 2 of 17

Appendix A Laboratory Registration Form All Principal Investigators (PIs) should complete the following laboratory registration form upon assignment of lab space and prior to conducting research at Texas A&M University at Galveston. Once the form and other related documents are completed and have been reviewed by EHS, the PI will be contacted if necessary to discuss university policies, lab safety guidelines, and training requirements relating to the type of research involved. LABORATORY INFORMATION Faculty/PI Name: Department: Bldg. # and Name: Room(s): Office Phone: Lab(s) Phone: Other Phone: Email: Move-In Date: Alternate Contact s Name: Alternate Contact s Office Phone: Alternate Contact s Other Phone: Alternate Contact s Email: Revised 5 - Oct- 15 Page 3 of 17

Please answer the following questions as YES or NO and list materials that will be used. Attach an inventory report if necessary. LABORATORY HAZARDS Chemical Will you be using / storing hazardous chemicals (e.g. flammables, combustibles, corrosives, oxidizers, carcinogens, toxins, etc.)? Will you be bringing chemicals with you? If so, please attach a chemical inventory. If help is needed to ship items, contact EHS Hazardous Material Shipping at (409)741-4055. Do you have MSDS sheets for all chemicals in the laboratory? Will you have more than 10 gallons of flammable liquids in the laboratory? Will you be using / storing peroxide forming chemicals (e.g. cyclohexane, ethyl ether, tetraydrofuran, perchloric acid)? Will you be working with any chemical that might pose an extraordinary threat to one s physical health or university property (e.g. hydrofluoric acid, picric acid)? Will you be generating hazardous chemical waste? Do you have a chemical spill kit in the laboratory? Will gas cylinders be used in the laboratory? Do you plan to use hazardous / toxic gases that require ventilated storage (e.g. hydrogen sulfide, carbon monoxide, ammonia)? Will you be using cryogenic liquids such as liquid nitrogen or liquid helium? Will you be using or synthesizing nanoparticles? If you answer YES to the above questions, please contact the TAMUG EHS at 409-741-4055 Revised 5 - Oct- 15 Page 4 of 17

ehs@tamug.edu Radiation / Laser Will you be working with radioactive materials? Have you previously worked with radioactive materials? If so, what licenses or authorizations have you held? Will you be using radiation generating equipment (e.g. X-ray machines)? Will you be generating radioactive waste? Do you plan to work with Class IIIb or Class IV lasers? Do you have any sealed sources of radiation? If you answer yes to any of the above please contact the TAMU Office of Radiation Safety at 979-862-6497 Ltha@tamu.edu. Upon completion of the radiation safety program please attach to this form the safety training completion certificates for all persons working in the lab, the registration receipt for laser or radiation producing device. Biological Will you be working with recombinant materials, animals/animal parts, human/primate blood, cells, or tissue? Will you be working with Biosafety Level 1, 2, or 3 agents? Will you be autoclaving biohazard waste (e.g. rdna, culture plates, and vials)? Will you have biological waste that can t be autoclaved? Will you be using sharps (e.g. needles, scalpels, razor blades)? If you answer YES to the above questions, please contact the Office of Biosafety at 979-458- 1467 outreachrcb@tamu.edu. Please attach the requisite approvals and or control numbers from the; Animal Welfare Assurance Program, Biosafety Program, Biosafety Occupational Health Program, and or Human Subjects Protection Program Revised 5 - Oct- 15 Page 5 of 17

General Lab Safety Does the lab(s) have a biological safety cabinet? Does the lab(s) have an emergency eyewash and safety shower? Does the lab(s) have a flammable storage cabinet? Does the lab(s) have a corrosive storage cabinet? Does the lab(s) have an explosion proof / flammable safe refrigerator or freezer? Does the lab(s) have an autoclave? Does the lab(s) contain any equipment that generates noise over 85 decibels? Has all necessary Personal Protective Equipment (PPE) been provided for laboratory personnel (e.g. chemical safety goggles, gloves, lab coats, hearing protection, respirators, etc.)? List any additional safety concerns here: After completing this checklist, please return to Environmental Health & Safety. Email: ehs@tamug.edu Page 6 of 17

Introduction Hazard identification and the steps taken to minimize the risks associated with identified hazards are a critical component of working safely. A hazard/risk assessment and control plan will provide the basis for the requirements needed to work safely. These plans require continuous evaluation to ensure risk assessments do not change and that new hazards created by process changes are identified. Responsibilities 1. Associate Vice-President (Research) will: 1.1 ensure that adequate resources are available to implement appropriate measures. 1.2 ensure that the program is communicated to employees. 1.3 require compliance with the procedures. 2. Directors, Department and Unit Heads will: 2.1 ensure that the program is communicated to employees. 2.2 require compliance with the procedures. 2.3 participate in hazard identification and take action to correct unsafe conditions. 3. Principal Investigator will: 3.1 inform employees when processes may lead to hazardous exposure. 3.2 require compliance with the procedures. 3.3 formulate and document a hazard/risk assessment for the areas under their supervision and control. 3.4 participate in hazard identification and take action to correct unsafe conditions. 4. Lab Employees will: 4.1 comply with the procedure. 4.2 where required, attend training sessions. 4.3 report any conditions that could lead to unsafe conditions to their supervisor. 5. University Health and Safety Committee will: 5.1 support and promote implementation of the procedure and related education and training. 5.2 monitor the adequacy and effectiveness of the procedures. 6. Environmental Health and Safety (EHS) will: 6.1 provide expertise and advice to all levels of management, employees and students on matters pertaining to hazard identification and control. 6.2 ensure the procedure is kept current. Procedures A Hazard/Risk Identification and Control Plan (the Plan) must be completed by the Laboratory Principal Investigator (PI) before any new or modified equipment, machinery or work process is used Page 7 of 17

or started. The Plan must be reviewed by the PI and Department Head at least annually and whenever there is a change in operations or procedures or there has been an incident. The PI is required to use Hazard Control Plan form or a similar form to complete the Plan. Prior to conducting the hazard assessment the PI and Lab Employees performing the work shall review the types of hazards and control measures available for the work being completed. The steps to completing a hazard/risk and control plan are: Step 1 Identify potential hazards Step 2 Assess the risk associated with each hazard Step 3 Select appropriate hazard controls Step 4 Implement the selected controls Step 5 Assess the effectiveness of the selected controls Step 1 Identify Potential Hazards Hazards can be identified by such means as review of the manufacturer s manuals, inspection, interviews with persons who perform similar work and review of incidents in this or similar work areas. Common hazards include exposure to chemicals, biological agents (bacteria, viruses, dust and mold), equipment in motion, electricity, sharps, extreme temperatures, noise, vibration, and violence. Other hazards may arise from work design (ergonomics), working alone, unattended processes, unplanned loss of air, power or water, animals, fire, unauthorized persons, spills and other emergencies. When hazardous materials will be used for the work, the following questions should be considered: What are the materials and in what quantities will they be purchased and used? Is the work to be conducted once, or will the hazardous materials be used repeatedly? Are any of the workers or people that may be affected by the work pregnant, likely to become pregnant, or sensitive to specific materials? Are any materials to be used toxic, corrosive, irritants or sensitizers? Will any carcinogens or potential carcinogens be used? Have flammability and environmental toxicity been considered? What are the potential routes of exposure (inhalation, absorption, ingestion, injection)? Page 8 of 17

Step 2 Assess the Risks Associated with each Hazard Risk assessment is important in the analysis and evaluation of risks associated with hazards. Risk assessment helps the persons involved determine appropriate ways to eliminate or control a hazard. Some risks associated with common hazards include: In the case of equipment: unintended contact with moving or dangerous parts; electrical shock; electrical fire; emission of harmful airborne material during use or maintenance; spills and leaks; sharps and burns. Animals pose a risk of physical injury and illness from improper restraint and hygiene controls. In the case of work design: most commonly musculoskeletal injury from such factors as lifting, awkward or repetitive movement and vibration. There may also be a risk of hearing damage. Risk is assessed by considering the probability of an event in combination with the severity of harm the event would cause to the University community, the public and the environment if it occurred. Probability factors are ranked in the following descending order of importance: Frequent Probable Occasional Remote Improbable Severity factors are ranked in the following descending order of importance: Catastrophic Critical Marginal Negligible Risk can be given a rating using the following matrix: Frequency Number of persons performing task Number of times task is performed by each person Few times per Many times per Less than daily day day Few 1 1 2 Moderate 1 2 3 Many 2 3 3 Severity 0 No injury or illness 2 Minor injury or illness without lost time 4 A lost time injury or illness without permanent disability 6 Permanent disability, loss of life or body part Probability -1 Low probability of loss 0 Moderate probability of loss +1 High probability of loss Page 9 of 17

Risk 10 to 7 = High 6 to 4 = Moderate 3 to 0 = Low Example: Working from height no fall protection provided Frequency Few people performing task, 6 times per day Rating = 2 Severity Fall can cause permanent disability or loss of life Rating = 6 Probability High probability of loss due to no fall protection available Rating = 1 Total Risk = 2 + 6 + 1 = 9 = HIGH RISK Working from height Fall protection provided and required Frequency Few people performing task, 6 times per day Rating = 2 Severity Fall restraint prevents fall from occurring, worker may be able to slip on same level Rating = 2 Probability Moderate probability of loss due to protective equipment Rating = 0 Total Risk = 2 + 2 + 0 = 4 = MODERATE RISK By implementing Fall Protection requirements into the job task, the risk of the task has been decreased by 50%. Assessing risks should be a team effort; these activities can be completed by the person performing the work and their direct supervisor or by members selected by the Faculty/Department performing the work. This Risk Matrix can be used to provide awareness, determine if control measures are adequate, and to prioritize hazards and control measures. Step 3 Select Appropriate Hazard Controls All hazards must be controlled either by removing the hazard or reducing its risk of harm to an acceptable safe level, both proactively (to prevent its occurrence) and reactively (to minimize its harmful affects in the event it does occur). Often more than one hazard control method must be implemented. For example, chemicals require a combination of proper storage, labeling, safe work practices, the use of PPE and emergency response equipment, procedures and training. In selecting appropriate hazard controls the following standards apply: The control must comply with legislated or regulatory requirements. Some of the legislation and regulations that specify standards for hazard control include: o The Occupational Health and Safety Act and Regulations both state and federal o Environmental Protection Act (TCEQ)both state and federal The control must comply with TAMU / TAMUS/TAMUG policies, procedures and rules. The priority for selection of controls is: Page 10 of 17

o Eliminate hazards at their source (e.g. redesign the work process, substitute a safer chemical for a hazardous chemical, use different equipment). o If it is not practical to eliminate hazards; control the hazard to reduce the risk to workers by using engineering controls (e.g. machine guards, noise enclosures, ventilation to dilute the concentration of a hazardous substance). o If it is not practical to control the hazard, protect workers from the hazard by using tools such as administrative controls, safe work procedures, effective safety training, proper supervision, or personal protective equipment. Controls must be effective in reducing the risk of harm to staff, students, and the public, to an acceptable level. Step 4 Implement selected controls (Formal Safety Control Plans required) The person performing the work and their supervisor are responsible for ensuring that the hazard control measures selected to control the identified hazards are present, maintained and implemented. Implementation includes: the development of written safety control plans, and/or safe work procedures, the provision of information to personnel of the procedures, and a method of ensuring proper procedures are followed. Step 5 Assess effectiveness of selected controls It is also the responsibility of the person performing the work and their direct report to evaluate the effectiveness of the hazard control selected, and to make improvements where deficiencies are identified. The person performing the work and their direct report will assess effectiveness of controls through regular inspections, testing and monitoring, evaluations of complaints or concerns received and investigations into near misses or other incidents. Common symptoms of ineffective controls include: Repeated non-compliance. Non-compliance may be a consequence of lack of training or consequence, or other problems in the control that cause persons to be reluctant to implement them, such as the creation of another hazard. Failure to reduce risk. For example, testing may demonstrate that there has been no change in the measured risk after the control has been implemented. In other cases students/staff or others may have a continued complaint. Near Miss/Injury. A near miss, a risk, or incident causing harm is proof positive that the control measures are ineffective in some way. Page 11 of 17

Hazard/Risk Control Plan Template Location: Bldg: Room # Department: Lab Principal Investigator Supervisor: Person/Position Performing Task: Potential Hazardous Chemicals: List of Potential Hazardous Chemicals present or likely to be present: Item Quantity MSDS available ( ) MSDS reviewed ( ) Selected Control Measures: (Storage/ Labelling/Written procedures; PPE, emergency equipment) Number and Type of Chemical Storage Cabinets: Separation of Incompatible Chemicals: Hazardous Equipment: List of Hazardous Equipment: (e.g. flammable, high pressure, extreme temperature and high voltage equipment, ladders, mechanical equipment) Item Selected Control Measures: (e.g. Safeguards, Written safe operation and maintenance procedures, PPE, emergency equipment; training or restricted use) Other Potential Hazards: List of Other Potential Hazards: (e.g. noise sources above 85 dba Lex; musculoskeletal injury from lifting, awkward movement, repetitive motion, or vibration; working alone; unattended processes; unplanned loss of air, power or water; unplanned leaks) Item Selected Control Measures: (e.g. safeguards, written safe operation and maintenance procedures, PPE, emergency equipment, training) Page 12 of 17

Emergency Safet y Equipment Available: Location: Item Type: Location signage ( ) Eyewash Emergency Shower Spill Kit: First Aid Kit Fire Extinguisher Location: Location: Location: Type: Location: Type: Location: Type: Other: Personal Protective Equipment (PPE) Available Available Location and Type Item ( ) Eye Protection Foot Protection Hand Protection Skin protection Hearing Protection Respirator Other: Hazardous Waste Describe Type, Quantity and Disposal Methods Available: List of Safe work/operating/emergency procedures Describe Posted ( ) Describe training and/or implementation measures Safe work practices Page 13 of 17

Emergency Contact Describe Emergency Shut Down Equipment operation Equipment maintenance Spill Fire/evacuation Training requirements Posted ( ) Describe training and/or implementation measures Potential Accident and Responses (What If..) Utility Failures Electricity Gas Air Vacuum Hot Water Cold Water Ventilation Hood Room/Lab Vent Equipment Failure Leaks and Spills MSDS Available Spill Kit PPE Available Posted ( ) Posted ( ) Planned Response Response Page 14 of 17

Containment Procedures Disposal Procedures Training requirements Warning Placards and Signage: Necessary Signage Equipment Posted ( ) Instrumentation Utilities PPE Reagent Bottles Secondary Containers Chemical Storage Emergency Contact info Personnel Training Needs: Lab Safety Training HAZCOM Mandatory Mandatory Shop and Tool Fire Extinguisher SOP s Safe Work Practices Page 15 of 17

Other Comments: Attach Standard Operating Procedures (SOP) Identified: Safe Work Practices (SWP) Identified: Affected Personnel Trained on SOP s & SWP s: (Refer to training recordkeeping requirements) Yes / No Yes / No Yes / No This Hazard Control Plan has been submitted by: Signature Name/ Principle Investigator Date Subject Matter Expert (SME) Review (SME is approved by the Department Head) Signature Title Institution or Company Printed Name Date of Final (SME) Review This Hazard Control Plan has been reviewed and accepted by: Signature Name/ Department Head Date Signature Name / VP Research Date EHS Review and residual Risk Matrix Page 16 of 17

Description of Risk Impact HIGH MEDIU M LOW Likelihood HIGH MEDIUM LOW Mitigation and Control Mechanisms Monitoring Activities Residual Risk EHS Training to be provided 1. 2. TAMUG EHS affirms that containment facilities and control processes are in place and that the above residual risk remains if all procedures and controls are followed and maintained. Signature Name / Campus EHS Date Compliance Review Signature Name / Compliance Officer Date Page 17 of 17