Chemical and Biological Compliance

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[The following was approved by the Chancellor of Southern Illinois University on May 5, 2010.]

Southern Illinois University Carbondale (SIUC), the Chemical Oversight Advisory Committee and the Center for Environmental Health and Safety (CEHS) intend to work cooperatively with faculty, staff and students to provide guidance for safe chemical and biological handling, in order to achieve compliance with SIUC safety policies, the Chemical Hygiene Plan, and government regulations. These regulations serve to protect the health and safety of faculty, staff and students, and to protect the environment.

If cooperation fails, sanctions may be necessary to achieve compliance. This policy is designed to ensure compliance through a system of phases that applies increasing pressure on a chemical or biological user to make the appropriate corrective actions. The policy applies to all facilities that SIUC owns or controls and that purchase, store or utilize chemicals or biologic agents, or generate chemical or biological waste.

In the case of immediate or imminent danger to life, health, or the environment, the Director of CEHS is authorized to immediately order the cessation of the hazardous activity and/or close the laboratory or facility until such activity has ceased and the responsible individual(s) have taken adequate measures to correct the situation and prevent recurrence of the noncompliance.

Category 1 Deficiencies – Immediate or Imminent Hazards

Category 1 includes issues that represent an immediate or imminent hazard to SIUC personnel, risk to the environment, or potential to cause damage to SIUC facilities. Laboratory personnel and other users should contact CEHS for guidance should they discover an immediate or imminent chemical or biological hazard.

The following actions are to be taken if the deficiency represents an immediate or imminent hazard:

  1. CEHS will inform the user and/or Principal Investigator (hereafter referred to as the PI) about what safety policy, rule or best management practice has been violated. CEHS will provide information about why the issue is a violation, and recommend a course of action to correct the deficiency. This information will be provided in writing to the PI and will constitute a Notice of Violation (NOV).
  2. An attempt shall be made by the PI to correct the deficiency immediately.
  3. If the issue is not immediately corrected, or arrangements to rectify the issue are not immediately made, the Department Chair or unit supervisor (hereafter referred to as the Chair) and PI will be notified of the deficiency and the required corrective actions. This notification will occur within two weeks of the reported violation. The PI must immediately correct or make arrangements to correct the deficiency.
  4. If immediate actions are not taken, the Director of CEHS will meet with the Chair of the Department, Dean or Director (hereafter referred to as the Dean) and/or Chancellor and consider the next course of action. Steps taken can include mandatory re-training of all personnel who handle chemicals or biologic agents, temporary loss of laboratory or workplace privileges or loss of the ability to order or use chemicals or biologic agents. This meeting will take place within 30 days of the reported violation, or as soon thereafter as practical.
  5. The PI will be informed of any restrictions in person, by phone and/or by email. A letter signed by the Director of CEHS will be sent to the PI explaining any restrictions. A copy of the letter will also be sent to the Chair and the Dean.
  6. Authorization to reinstate privileges will occur only after the PI has appeared in person before the Director of CEHS, the Chair and/or the Dean or Provost, at a meeting called specifically for that purpose, and satisfactorily explained the measures taken to avoid future deficiencies.
  7. Once the PI is re-authorized, CEHS will audit the laboratory or workplace of the PI once a calendar quarter for a year, unless otherwise instructed by the Director of CEHS.

Examples of Category 1 deficiencies include, but are not limited, to:

  1. Working with highly toxic chemicals, reactive material, hydrofluoric acid or other extremely dangerous materials without proper training and/or specialized personal protective equipment
  2. Improper storage and use of reactive or highly toxic chemicals
  3. Improper storage of flammable chemicals or reactive chemicals in refrigerators
  4. Evidence of improper waste disposal
  5. Chemicals, chemical waste and/or gas cylinders stored and used in a manner that represents a hazard to personnel or the environment
  6. Unlabeled chemical containers, gas cylinders, and/or chemical waste containers
  7. Unsafe, unguarded equipment or electric wires.
  8. Unsafe housekeeping or blocked egresses
  9. Improper use of fume hoods or other laboratory ventilation equipment
  10. No immediate access to safety showers or eyewashes
  11. Evidence of eating, drinking or smoking occurring in a laboratory space
  12. Laboratory personnel not wearing proper laboratory attire (lab coat, closed toe shoes, long pants or skirts below the knees), safety glasses and other required personal protective equipment based on work being performed
  13. An incident that results in an injury or damage to SIUC property
  14. Failure to post emergency contingency plan or emergency phone numbers
  15. Unsafe work practices such as mouth pipetting or failure to use appropriate ventilation devices when working with chemicals
  16. Failure to report an incident that involves chemical or biological agent exposure or bodily harm

Category 2 Deficiencies

Category 2 deficiencies include items that are violations of applicable rules, regulations or laws, but which do not present an immediate or imminent hazard. 
The following process shall be followed, should a deficiency be identified in a laboratory.

Phase 1

When a deficiency is identified in any area using chemicals on campus, the following steps will be taken:

  1. CEHS will inform the PI about which safety policy, rule or best management practice has been violated. CEHS will provide information about why the issue is a violation, and recommend a course of action to correct the deficiency. This information will be provided to the PI electronically, in the form of an Inspection Report.
  2. The PI shall make an attempt to correct the deficiency immediately.
  3. The PI will be informed on the Inspection Report that a follow-up audit will be conducted, and that a repeat of the deficiency will result in a Notice of Violation.
  4. Within 45 days, or as soon thereafter as practical, a follow-up audit by CEHS will be conducted to determine if the PI’s corrective actions were successful at eliminating the deficiency.

Phase 2

When a follow-up audit identifies the same, or a similar deficiency, the following steps will be taken:

  1. CEHS will inform the PI of the repeat deficiency electronically.
  2. A Notice of Violation, signed by the Director of CEHS, will be sent to the user or PI with a copy sent to the Chair, requiring that the PI send a written response to CEHS explaining the corrective measures that will be employed to prevent future deficiencies. The PI must respond within 14 days.
  3. CEHS will review the PI’s response. If unsatisfactory, the Director of CEHS will exercise his judgment to either require more information from the user or PI, or move directly to Phase 3. If satisfactory, the Director of CEHS will respond to the PI in writing. The PI will be informed that another violation of the same requirement any time in the next 12 months will initiate Phase 3 actions.
  4. The work area or laboratory of the PI will be audited more frequently by CEHS for the next 12 month period.

Phase 3

The following actions will be taken if any of the following occur-- 1) The PI does not respond to a Notice of Violation (NOV) within 45 days, 2) The PI’s response to the NOV is deemed unsatisfactory by the Director of CEHS or 3) The same or similar deficiency is noted within 12 months of the Director of CEHS’ acceptance of the PI’s NOV response.

  1. The Chair and PI will be notified of the deficiency and the required corrective actions. The PI must immediately correct or make arrangements to correct the deficiency.
  2. If immediate actions are not taken, the Director of CEHS will meet with the Chair and the Dean and consider the next course of action. Steps taken can include mandatory re-training of all location personnel, temporary loss of laboratory or workplace privileges or loss of the ability to order and use chemicals or biologic agents.
  3. The PI will be informed of these restrictions in person, by phone and/or by email. A letter signed by the Director of CEHS will also be sent to the PI explaining any restrictions. A copy of the letter will be sent to the Chair.
  4. Authorization to reinstate privileges will occur only after the PI has appeared in person before the Director of CEHS, the Chair, and/or the Dean, at a meeting called specifically for that purpose, and satisfactorily explained the measures taken to avoid future deficiencies.
  5. Once the PI is re-authorized, CEHS will audit the laboratory or work area of the PI at an increased frequency, and at least quarterly, for the next 12 months.

Phase 4

If deficiencies continue past the Phase 3 stage, the Director of CEHS, in consultation with the Chair, the Dean and/or the Provost, will determine the next course of action on a case-by-case basis. This may include temporary or permanent loss of laboratory privileges.

Examples of Category 2 deficiencies include, but are not limited, to:

  1. Lack of Standard Operating Procedures for highly hazardous materials and carcinogens
  2. Lack of required records of training (i.e. Chemical Safety Training or Bloodborne Pathogens Training)
  3. Lack of monthly waste inspection records
  4. Poor housekeeping and hygiene (laboratory and fume hoods)
  5. Slipping or tripping hazards
  6. Improper shipment of chemical materials off campus
  7. Chemical waste stored outside of a satellite waste accumulation area
  8. Chemical waste containers that are open (except when actively adding) or that lack a proper label indicating the chemical name
  9. Improper storage of chemicals that does not represent an immediate hazard
  10. Chemicals or waste products stored in improper containers; this may include storage in food or beverage containers, or storage in containers utilizing ground glass stoppers, neoprene stoppers, parafilm or duct tape.

For the purposes of this policy, a chemical is defined as any organic or inorganic substance of a particular molecular identity, including any combination of such substances occurring in whole or in part as a result of a chemical reaction or occurring in nature. For the purposes of this policy, a biological material is defined as any naturally occurring substance derived from organisms, including but not limited to microorganisms, cells and subcellular components, cultures, specimens, toxins, blood, vaccine and prions.

This policy is based on a similar policy developed by the University of Delaware.