LABORATORY
SAFETY
MANUAL
ii
FOREWORD
Texas Tech University is dedicated to excellence in the scientific laboratory. It is the
desire of Texas Tech that all campus laboratory activities are conducted safely to protect
the health of employees, students, and the community. To support this mission, the
Laboratory Safety Program directed by the Department of Environmental Health and
Safety strives to provide adequate laboratory safety resources to the University
community.
The Laboratory Safety Plan is a compilation of Texas Tech University safety policies and
procedures across scientific disciplines. Its purpose is to serve as a singular laboratory
safety resource for faculty, staff and students.
For added document navigation, links (indicated in blue) are provided on the cover page
of each section and in the table of contents.
iii
TABLE OF CONTENTS
CHEMICAL HYGIENE PLAN ........................................................................................ A
Helpful Links and Documents ................................................................................................................ A-v
Changes from the Previous CHP Edition ............................................................................................... A-vi
Purpose of this Plan ............................................................................................................................... A-1
EMERGENCY ASSISTANCE INFORMATION ............................................................................................. A-2
Useful Acronyms and Definitions ........................................................................................................... A-2
Useful Acronyms ................................................................................................................................ A-2
Useful Definitions............................................................................................................................... A-4
Policies ................................................................................................................................................... A-8
Proper Laboratory Attire .................................................................................................................... A-9
General Laboratory Practices ........................................................................................................... A-12
Buddy System .................................................................................................................................. A-13
Work Area Investigation .................................................................................................................. A-14
Request Clarification or Deviation ................................................................................................... A-15
Responsibilities .................................................................................................................................... A-17
General Responsibility for Safety ..................................................................................................... A-17
Department of Environmental Health and Safety ........................................................................... A-17
Chemical Hygiene Officer ................................................................................................................. A-18
Departmental Safety Officer ............................................................................................................ A-20
Principal Investigator / Supervisor ................................................................................................... A-20
Laboratory Safety Captain ............................................................................................................... A-24
Laboratory Personnel ....................................................................................................................... A-24
Institutional Compliance Committees ............................................................................................. A-24
Non-Laboratory Personnel ................................................................................................................... A-25
Maintenance Workers in Laboratories ................................................................................................ A-26
Minors in Laboratories ......................................................................................................................... A-27
Minors Age 13 Years and Younger ................................................................................................... A-27
Minors Age 14 and 15 Years ............................................................................................................ A-27
Minors Age 16 and 17 Years ............................................................................................................ A-29
Supervision of Minors ......................................................................................................................
A-29
Authorization of a Minor ................................................................................................................. A-31
Facilities ................................................................................................................................................ A-31
iv
Access Control .................................................................................................................................. A-32
Required Signage ............................................................................................................................. A-32
Hygiene ............................................................................................................................................ A-33
Housekeeping .................................................................................................................................. A-33
Furniture ......................................................................................................................................... A-34
Equipment ....................................................................................................................................... A-35
Electrical ........................................................................................................................................... A-36
Physical Hazards ................................................................................................................................... A-37
Sharps .............................................................................................................................................. A-37
Required Precautions ....................................................................................................................... A-39
Soldering .......................................................................................................................................... A-39
Work Area Safety Plan ......................................................................................................................... A-40
Standard Operating Procedures .......................................................................................................... A-42
Employee Exposure Assessment and Monitoring ................................................................................ A-44
Training Requirements ......................................................................................................................... A-45
Training Timeline ............................................................................................................................. A-45
Required EHS Safety Training .......................................................................................................... A-46
Research Group / Departmental Training........................................................................................ A-47
Occupational Health Program .............................................................................................................. A-49
Conditions for Enrollment ................................................................................................................ A-49
Program Steps .................................................................................................................................. A-50
Chemical Identification Requirements ................................................................................................. A-50
Labeling on Incoming Chemical Containers ..................................................................................... A-50
Labeling on Secondary Chemical Containers ................................................................................... A-51
Chemical Substances Developed in a Laboratory ............................................................................ A-51
Safety Data Sheets ........................................................................................................................... A-52
Chemical Handling ............................................................................................................................... A-53
Chemical Containers ........................................................................................................................ A-53
Chemical Storage ............................................................................................................................. A-53
Flammable Storage .......................................................................................................................... A-54
Chemicals of Special Concern .......................................................................................................... A-55
Spill Prevention Measures ............................................................................................................... A-60
Chemical Spill Response................................................................................................................... A-60
Chemical Review ............................................................................................................................. A-62
v
Respiratory Protection Program .......................................................................................................... A-63
Waste Management and Disposal ....................................................................................................... A-64
Waste Segregation and Labeling ..................................................................................................... A-64
Waste Containers ............................................................................................................................. A-65
Satellite Accumulation Areas ........................................................................................................... A-67
Glass Waste ...................................................................................................................................... A-68
Transport and Shipment of Hazardous Materials ................................................................................ A-69
Transport of Chemicals on or to TTU Property ................................................................................ A-69
Shipment of Hazardous Materials ................................................................................................... A-70
Chemical Gateway................................................................................................................................ A-71
Procurement of Chemicals for Laboratories .................................................................................... A-71
Chemical Inventory for Laboratories ............................................................................................... A-72
Chemical Fume Hoods ......................................................................................................................... A-74
Chemical Fume Hood Operating Procedures................................................................................... A-74
Chemical Fume Hood Surveillance Program .................................................................................... A-75
Non-Compliance................................................................................................................................... A-76
Laboratory or Studio Space Closure ..................................................................................................... A-77
Conditions for Closure ..................................................................................................................... A-77
Procedures for Closure .................................................................................................................... A-78
Supervisor Actions ........................................................................................................................... A-79
Conditions for Resumption .............................................................................................................. A-79
Decommissioning a Work Area ............................................................................................................ A-80
Allowable Material Transfers ........................................................................................................... A-81
Reviews and Updates ........................................................................................................................... A-82
BIOSAFETY MANUAL .................................................................................................. B
Recent Changes ..................................................................................................................................... B-iv
Purpose and Policy Statement .............................................................................................................. B-1
Purpose .............................................................................................................................................. B-1
Policy ................................
.................................................................................................................. B-2
Important Contact information ............................................................................................................. B-3
Emergency Assistance Information ................................................................................................... B-3
University Emergency Assistance Numbers ....................................................................................... B-3
vi
Safety and Compliance Committee Information .............................................................................. B-4
Useful Acronyms and Definitions ........................................................................................................... B-5
Acronyms .......................................................................................................................................... B-5
Definitions .......................................................................................................................................... B-8
Responsibilities .................................................................................................................................... B-13
Department of Environmental Health and Safety .......................................................................... B-13
Principal Investigators ..................................................................................................................... B-14
Institutional Biosafety Committee .................................................................................................. B-16
Biocontainment ................................................................................................................................... B-17
Biosafety Levels (BSL) ...................................................................................................................... B-17
Table 1. Summary of Recommended Biosafety Levels .................................................................. B-19
Animal Containment ....................................................................................................................... B-19
Arthropod Containment ................................................................................................................. B-20
Plant Containment .......................................................................................................................... B-20
Classification of Biological Materials ................................................................................................... B-20
Introduction .................................................................................................................................... B-20
Risk Groups ..................................................................................................................................... B-21
Genetically Engineered Microorganisms and Organisms ............................................................... B-22
Human and Non-Human Primate Materials ................................................................................... B-25
Biologically Derived Toxins ............................................................................................................. B-26
Prions and Prion-like Proteins ......................................................................................................... B-26
Respiratory Viruses ......................................................................................................................... B-27
Emergency Procedures ....................................................................................................................... B-28
Biological Spills ................................................................................................................................ B-28
BioSpill Kit Contents ................................................................................................................... B-28
General Spill Clean Up Guidelines ................................................................................................... B-29
With broken glass ....................................................................................................................... B-31
Human Fluids ................................
............................................................................................. B-31
In a Biosafety Cabinet ................................................................................................................. B-31
In a Centrifuge ............................................................................................................................. B-32
Illness or Injury Involving Biological Materials ................................................................................. B-32
Fires Involving Biological Materials .................................................................................................. B-33
Decontamination and Disposal ............................................................................................................ B-34
Factors Contributing to Destruction/Inactivation of Biological Materials ....................................... B-34
vii
Properties of Chemical Disinfectants .............................................................................................. B-35
Management of Biologically Contaminated Materials and Waste .................................................. B-39
Collection and Disposal Containers ............................................................................................ B-40
Treatment of Biologically Contaminated Materials and Waste ...................................................... B-41
Regulations Pertaining to Chemical Disinfection of Biological Wastes .......................................... B-42
Steam Disinfection (Autoclaving) ..................................................................................................... B-44
Preparing and Loading the Autoclave ........................................................................................ B-48
Summary of Biological Waste Treatment and Disposal by Generators .......................................... B-50
Biowaste Pick-up by EHS ................................................................................................................. B-52
Disposal of Animal Tissues, Carcasses, & Bedding .......................................................................... B-54
Plant & Seed Devitalization .............................................................................................................. B-54
Other Common Waste Issues in Biological Research ..................................................................... B-54
Biological Laboratory Operation ......................................................................................................... B-56
Risk Management ........................................................................................................................... B-56
Risk Assessment ......................................................................................................................... B-56
Risk Control ................................................................................................................................ B-59
Biological Work Area Safety Plan (BioWASP / WASP) ................................................................ B-60
Personal Protective Equipment (PPE) ......................................................................................... B-61
Working with Biological Materials .................................................................................................. B-63
The IBC Protocol Application ..................................................................................................... B-64
BSL1 Requirements .................................................................................................................... B-67
BSL2 Requirements .................................................................................................................... B-69
ABSL1 Requirements .................................................................................................................. B-70
ABSL2 Requirements .................................................................................................................. B-71
ACL 1 Requirements ................................................................................................................... B-72
ACL 2 Requirements ................................................................................................................... B-73
PCL 1 Requirements ................................................................................................................... B-75
PCL 2 Requirements ................................................................................................................... B-75
Collection and Manipulation of Human Materials ..................................................................... B-76
Basics to Aseptic Technique ....................................................................................................... B-76
Sharps M
anagement ................................................................................................................... B-77
Entry of non-Lab Personnel into BSL2 Spaces ............................................................................ B-78
Common Laboratory Equipment Usage ............................................................................................... B-80
Biological Safety Cabinet.................................................................................................................. B-80
Laminar Flow Hood .......................................................................................................................... B-85
viii
Centrifuge ........................................................................................................................................ B-85
Vacuum Lines and Pumps ................................................................................................................ B-85
Decontamination and Decommissioning of Laboratory Equipment ................................................... B-86
General Information ........................................................................................................................ B-86
Hazard Assessment .......................................................................................................................... B-87
EHS Clearance of Decommissioned Laboratory Spaces ................................................................... B-87
Considerations for Common Equipment ......................................................................................... B-87
Decommissioning of a Laboratory Space ............................................................................................ B-90
General Information ........................................................................................................................ B-90
Decontamination ............................................................................................................................. B-90
Packing and Moving ......................................................................................................................... B-90
Waste Disposal ................................................................................................................................. B-91
Transport and Shipment of Biological Materials ................................................................................. B-91
Transport of Biological Materials on Campus .................................................................................. B-91
General Shipping Information ......................................................................................................... B-93
Permits and Documentation ............................................................................................................ B-93
Packaging ......................................................................................................................................... B-96
RADIATION SAFETY MANUAL ..................................................................................... C
Section I – Management of Broad License........................................................................................... C-I-1
Definitions ....................................................................................................................................... C-I-1
Radiation Protection Program ........................................................................................................ C-I-1
ALARA Program ............................................................................................................................... C-I-3
Radiation Safety Management ....................................................................................................... C-I-4
Radiation Safety Committee ........................................................................................................... C-I-4
Radiation Safety Officer .................................................................................................................. C-I-7
Radiation Safety Office ................................................................................................................... C-I-9
Personnel Monitoring Procedures ................................................................................................ C-I-11
Bioassay Procedures ..................................................................................................................... C-I-13
Section II – S
ublicense Program Safety .............................................................................................. C-II-1
Definitions ...................................................................................................................................... C-II-1
Sublicense Application Procedures ................................................................................................ C-II-1
Absence of Sublicensee from Campus ........................................................................................... C-II-3
Procedure for Termination of a Sublicense ................................................................................... C-II-4
ix
Sublicensee Inspection/Monitoring Program ................................................................................ C-II-5
Sublicense Programs and Procedures ............................................................................................ C-II-7
Maximum Permissible Doses, Dose Limits .................................................................................... C-II-8
Policies and Procedures for Radioactive Material Use .................................................................. C-II-9
Safety Procedures for Individuals Using Radiation Sources Under Sub-licenses ........................ C-II-33
General Laboratory Radiation Safety Rules ................................................................................. C-II-36
Section III – Radiation Producing Machine Safety Program ............................................................. C-III-1
Radiation Producing Machines (X-ray) ......................................................................................... C-III-1
Radiofrequency and Microwave Devices ...................................................................................... C-III-5
Section IV – Emergency Procedures ................................................................................................ C-IV-1
General Information ..................................................................................................................... C-IV-1
Fires, Explosions, or Major Emergencies ...................................................................................... C-IV-2
Accidents Involving Possible Radiation Overexposure ................................................................. C-IV-2
Accidents Involving Significant Releases of Radioactive Material ................................................ C-IV-3
Personnel Injuries ......................................................................................................................... C-IV-3
Policies for Radioactive Spills ........................................................................................................ C-IV-3
Loss or Theft of Radiation Equipment .......................................................................................... C-IV-4
Malfunction of Radiation Producing Equipment .......................................................................... C-IV-4
Vehicle Accident During PMDG or RAM Transportation .............................................................. C-IV-4
Reporting of Radiation Incident .................................................................................................... C-IV-5
Decontamination Procedures ....................................................................................................... C-IV-5
EMERGENCY PHONE NUMBERS .................................................................................................... C-IV-7
Section V –Radiation Surveys ............................................................................................................ C-V-1
Guidelines for Surveys of Radiation Levels ................................................................................... C-V-1
Surface Contamination Surveys .................................................................................................... C-V-2
Section VI – F
orms and Records (Contact RSO) ............................................................................... C-VI-1
Section VII – Appendices: Radiation Safety Information and Resources ...................................... C-VII-1
Appendix A: Reference Information .......................................................................................... C-VII-1
Appendix B: Texas Regulations for Control of Radiation References ........................................ C-VII-8
Appendix C: Radiation Survey Instrument Calibration Procedures ........................................... C-VII-9
LASER SAFETY MANUAL ............................................................................................ D
Section I – Management of Laser License ............................................................................................. D-1
Laser Safety Program ........................................................................................................................ D-1
x
Radiation and Laser Safety Committee ............................................................................................ D-2
Laser Safety Officer ........................................................................................................................... D-4
Inspections ........................................................................................................................................ D-6
Section II – Sublicense Program ............................................................................................................ D-9
Definitions ......................................................................................................................................... D-9
Sublicense Application Procedures ................................................................................................. D-10
Absence of Sublicensee from Campus ............................................................................................ D-12
Termination of a Sublicense ........................................................................................................... D-12
Deactivation/Reactivation of a Sublicense ..................................................................................... D-13
Deactivation/Reactivation of Equipment ....................................................................................... D-15
Responsibilities of Sublicensees ..................................................................................................... D-16
Responsibilities of Users and Operators ......................................................................................... D-18
Program Requirements ................................................................................................................... D-18
Lab Personnel .................................................................................................................................. D-26
Section III - Lasers ................................................................................................................................ D-27
Basic Laser Characteristics .............................................................................................................. D-27
Specific Laser Requirements ........................................................................................................... D-32
Section IV – Emergency Procedures ................................................................................................... D-34
General Information ....................................................................................................................... D-34
Organization and Authority ............................................................................................................ D-34
Fires, Explosions or Major Emergencies ......................................................................................... D-35
Incidents: Possible Exposure or Injury ........................................................................................... D-35
Loss or Theft .................................................................................................................................... D-36
Emergency Phone Numbers ........................................................................................................... D-36
FIELD SAFETY MANUAL .............................................................................................. E
Foreword and Title IX Information .......................................................................................................... E-i
Helpful Telephone Numbers and Links ................................................................................................. E-iii
Purpose .................................................................................................................................................. E-1
Acronyms and Definitions ...................................................................................................................... E-1
Pre-Planning ........................................................................................................................................... E-3
Risk and Hazard Assessment ................................
.............................................................................. E-3
Field Safety Plan ................................................................................................................................. E-3
Equipment .......................................................................................................................................... E-4
xi
Field Safety Briefing ........................................................................................................................... E-6
Medical Treatment and/or Evaluation .............................................................................................. E-7
Field Hazards ........................................................................................................................................... E-7
Vehicles .............................................................................................................................................. E-8
Vehicle Maintenance ......................................................................................................................... E-8
ATVs and Related Vehicles ................................................................................................................. E-9
Machinery and Equipment .............................................................................................................. E-10
Boats and Other Watercraft ............................................................................................................ E-11
Terrain .............................................................................................................................................. E-12
Weather and Climate ....................................................................................................................... E-14
Severe Weather ............................................................................................................................... E-15
Fauna and Flora ............................................................................................................................... E-16
Disease and Pathogens .................................................................................................................... E-17
Remote / Overseas Locations .......................................................................................................... E-18
Chemicals and Biological Materials ................................................................................................. E-19
The Public ......................................................................................................................................... E-20
Personal Safety..................................................................................................................................... E-22
Establishing Campsites ......................................................................................................................... E-23
APPENDICES ........................................................................................................ AA-ED
AA Chemical Segregation ................................................................................................................... AA-1
AB Chemical Hygiene Checklist .......................................................................................................... AB-1
AC Chemical Spill Response ................................................................................................................AC-1
AD Handling and Operating Gas Cylinders ......................................................................................... AD-1
AE Traps for Vacuum Lines .................................................................................................................. AE-1
AF Hazardous Waste Disposal ............................................................................................................. AF-1
AG Carcinogen, Mutagen and Teratogen Procedures ....................................................................... AG-1
AH Peroxide Forming Compounds ...................................................................................................... AH-1
AI Exposure Assessment Worksheet .................................................................................................... AI-1
AJ Equipment Decontamination Form ................................................................................................ AJ-1
AK
Laboratory Decommissioning Checklist ......................................................................................... AK-1
AL Forms .............................................................................................................................................. AL-1
Incident Report Form ....................................................................................................................... AL-2
xii
Initial Investigation of Overexposure Form ..................................................................................... AL-3
BA Biosafety Level 1 Practices and Facilities ...................................................................................... BA-1
BB Biosafety Level 2 Practices and Facilities ...................................................................................... BB-1
BC Biosafety Level 3 Practices and Facilities ...................................................................................... BC-1
BD Animal Biosafety Level 1 Practices and Facilities ......................................................................... BD-1
BE Animal Biosafety Level 2 Practices and Facilities .......................................................................... BE-1
BF Characteristics of Common Disinfectants ...................................................................................... BF-1
BG CDC List of Select Agents .............................................................................................................. BG-1
BH Department of Commerce List of Select Microorganisms and Biological Toxins ......................... BH-1
BI Forms ............................................................................................................................................... BI-1
Biosafety Protocol Application ......................................................................................................... BI-1
BJ Biological Safety Cabinets ............................................................................................................... BJ-1
Class I ............................................................................................................................................... BJ-1
Class II .............................................................................................................................................. BJ-2
Class III ............................................................................................................................................. BJ-4
BK Autoclave Testing Documents ....................................................................................................... BK-1
Procedure ......................................................................................................................................... BK-1
Record Log ....................................................................................................................................... BK-5
Report Form ..................................................................................................................................... BK-6
CA Radiation Reference Information ..................................................................................................CA-1
Glossary of Terms ............................................................................................................................CA-1
Index of Abbreviations and Acronyms .............................................................................................CA-8
List of Symbols for Units and Terms ................................................................................................CA-9
CB Texas Radiation Regulations .......................................................................................................... CB-1
CC Instrument Calibration ................................................................................................................... CC-1
Procedures ....................................................................................................................................... CC-1
Sample Survey Meter Calibration Label ........................................................................................... CC-5
Sample Certificate of Calibration ..................................................................................................... CC-6
DA Laser Forms .................................................................................................................................. DA-1
Laser Application (LS-1)................................................................................................................... DA-1
Application Amendment (LS-2) ....................................................................................................... DA-7
Amendment Attachment (LS-2A) .................................................................................................... DA-8
xiii
Laser SOP Outline (LS-7) ................................................................................................................. DA-9
SOP Training Acknowledgement Form (LS-8) ............................................................................... DA-10
Laser Usage Log (LS-11) ................................................................................................................ DA-11
Short-Term Laser Application (LS-17) ........................................................................................... DA-12
DB Laser Reference Information ........................................................................................................ DB-1
Glossary of Terms ........................................................................................................................... DB-1
Index of Abbreviations and Acronyms ............................................................................................ DB-8
Texas Laser Regulations .................................................................................................................. DB-9
References .................................................................................................................................... DB-10
EA Field Activity Planning Checklist and Risk Assessment .................................................................. EA-1
EB Field Site Kit Checklist .................................................................................................................... EB-1
EC First Aid for Heat Illness ................................................................................................................. EC-1
ED First Aid for Cold Illness .................................................................................................................ED-1
xiv
RECENT CHANGES
Chemical Hygiene Plan
Section A4 Policies
• Addition of Section A4.7 on requests for clarification and deviation
Section A5 Responsibilities
• DSO responsibilities now references TTU Operating Policy 60.29
A16 Chemical Identification
• Revision to allow SDSs databases for work areas to be kept in paper copy, electronic copy or via
access to the internet
A17 Chemical Handling
• Pyrophoric chemicals shall be handled according to their respective SDS
A19 Waste
• Chemical waste must be stored in the designated Satellite Accumulation Area (SAA)
• Tubs and SAA signage are provided by EHS. Additional secondary containers shall be supplied by
the PI.
• Hazardous Waste stored in the SAA shall not exceed 55 gallons of hazardous waste, 1 qt of
acutely hazardous waste, or 1 Kg of solid acutely hazardous waste.
• Incompatible waste streams shall be segregated into separate secondary containment within
the SAA.
• Only appropriately labeled, sealed containers with a corresponding EHS Transaction Number will
be collected during routine collection.
• Biological waste container description only in Biosafety Manual
A21 Chemical Storage
• Pyrophoric chemicals shall be stored according to their respective SDS
A23 Non-Compliance
• Procedures for addressing non-compliant individuals in a work area have been added
Biosafety Manual
xv
We would like to reiterate that checklists for basic biosafety at BSL1 and BSL2 containment were
amended to reflect the requirements in the 6
th
edition of the BMBL in November of 2021. Certain
requirements for all laboratories from the CHP have been reiterated in the BSL1 checklist. These are not
new requirements.
Verbiage has been clarified regarding sinks and sharps containers at BSL1. A plumbed sink and eyewash
are both required in the immediate (vs adjacent) work area at BSL1. There is no delineation of BSL1 vs
other biocontainment in the regulations for the management of sharps. The use of FDA-approved
containers (i.e., puncture-proof and securable) is required for the disposal of sharps in all biological
laboratories.
Guidelines for double gloving have been added.
Policy changes
Special criteria have been added for animal (ABSL), plant (PCL), and arthropod (ACL) containment. These
sections will continue to be expanded and updated as program needs are assessed. The checklists are
located in section B9.2.3 Special Considerations for Certain Research Foci. References to biosafety level
have been changed to containment level given the formalization of these new types of biocontainment
areas.
B9.2.1 Regarding IBC protocol registration has been amended to address the transition to the online
cloud-based Cayuse application. As announced in January 2023, all new protocols, protocol renewals,
and protocol amendments will be completed within the Cayuse system. To get started in Cayuse,
researchers and laboratory personnel will need to complete the personnel form to be added to the
system. More information is provided on the IBC registration page:
https://www.depts.ttu.edu/ehs/academicsafety/Biosafety/protocolregistration-bio.php
B6.5 Biologically Derived Toxins section was added. These materials are subject to IBC oversight.
Responsibilities to the PI and IBC in section B4 were also added to reflect this change.
B6.6 Prions and Prion-like Proteins was added. These materials are subject to IBC oversight.
Responsibilities to the PI and IBC in section B4 were also added to reflect this change.
B6.7 Respiratory Viruses was added. These materials are subject to work using BSL2 Enhanced
requirements.
B9.2.2.1(a) Cleaning equipment (i.e., brooms, mops, buckets, etc.) is dedicated to the work area for all
containment levels.
B10.1.4.4 was amended to state that the PI is responsible for coordination and completion of annual BSC
certification. This change was made so that our policies are not misinterpreted to imply that PIs are
financially liable for certification. The financially responsible party (or parties) for BSC certification is
determined by the department/college/school.
A-i
TABLE OF CONTENTS
Helpful Links and Documents .......................................................................................A-v
Recent Changes .......................................................................................................... A-vi
A1 PURPOSE OF THIS PLAN ............................................................................ A-1
A2 EMERGENCY ASSISTANCE INFORMATION .............................................. A-2
A3 USEFUL ACRONYMS and DEFINITIONS .................................................... A-2
Useful Acronyms ........................................................................................................ A-2
Useful Definitions ......................................................................................................... A-4
A4 POLICIES ...................................................................................................... A-8
Proper Laboratory Attire .............................................................................................. A-9
General Laboratory Practices .................................................................................... A-12
Buddy System ........................................................................................................... A-13
Work Area Investigation ............................................................................................ A-14
Request Clarification or Deviation ............................................................................ A-15
A5 RESPONSIBILITIES .................................................................................... A-17
General Responsibility for Safety .............................................................................. A-17
Department of Environmental Health and Safety ....................................................... A-17
Chemical Hygiene Officer .......................................................................................... A-18
Departmental Safety Officer ...................................................................................... A-20
Principal Investigator / Supervisor ............................................................................. A-20
Laboratory Safety Captain ......................................................................................... A-24
Laboratory Personnel ................................................................................................ A-24
Institutional Compliance Committees ........................................................................ A-24
A6 NON-LABORATORY PERSONNEL............................................................ A-25
A7 MAINTENANCE WORKERS IN LABORATORIES ..................................... A-26
A8 MINORS IN LABORATORIES ..................................................................... A-27
Minors Age 13 Years and Younger ............................................................................ A-27
Minors Age 14 and 15 Years .................................................................................... A-27
A-ii
Minors Age 16 and 17 Years ..................................................................................... A-29
Supervision of Minors ................................................................................................ A-29
Authorization of a Minor ............................................................................................. A-31
A9 FACILITIES .................................................................................................. A-31
Access Control .......................................................................................................... A-32
Required Signage ...................................................................................................... A-32
Hygiene ..................................................................................................................... A-33
Housekeeping ............................................................................................................ A-33
Furniture .................................................................................................................... A-34
Equipment ................................................................................................................. A-35
Electrical .................................................................................................................... A-36
A10 PHYSICAL HAZARDS ................................................................................. A-37
Sharps ....................................................................................................................... A-37
Required Precautions ................................................................................................ A-39
Soldering ................................................................................................................... A-39
A11 WORK AREA SAFETY PLAN ..................................................................... A-40
A12 STANDARD OPERATING PROCEDURES ................................................. A-42
A13 EMPLOYEE EXPOSURE ASSESSMENT AND MONITORING .................. A-44
A14 TRAINING REQUIREMENTS ...................................................................... A-45
Training Timeline ....................................................................................................... A-45
Required EHS Safety Training ................................................................................... A-46
Research Group / Departmental Training .................................................................. A-47
A15 OCCUPATIONAL HEALTH PROGRAM ..................................................... A-49
Conditions for Enrollment .......................................................................................... A-49
Program Steps ........................................................................................................... A-50
A16 CHEMICAL IDENTIFICATION REQUIREMENTS ....................................... A-50
Labeling on Incoming Chemical Containers .............................................................. A-50
Labeling on Secondary Chemical Containers ............................................................ A-51
A-iii
Chemical Substances Developed in a Laboratory ..................................................... A-51
Safety Data Sheets .................................................................................................... A-52
A17 CHEMICAL HANDLING .............................................................................. A-53
Chemical Containers ................................................................................................. A-53
Chemical Storage ...................................................................................................... A-53
Flammable Storage ................................................................................................... A-54
Chemicals of Special Concern ................................................................................... A-55
Hydrofluoric Acid (HF) ..................................................................................... A-56
Perchloric Acid ................................................................................................ A-56
Poisonous Gases ............................................................................................ A-56
Energetic Materials ......................................................................................... A-57
Volatilizing Chemicals ..................................................................................... A-57
Pyrophoric Materials ....................................................................................... A-58
Mercury ........................................................................................................... A-58
Toxin Handling ................................................................................................ A-58
Nanoparticles .................................................................................................. A-59
Picric Acid ....................................................................................................... A-60
Spill Prevention Measures ......................................................................................... A-60
Chemical Spill Response ........................................................................................... A-60
Chemical Review ....................................................................................................... A-62
A18 RESPIRATORY PROTECTION PROGRAM ............................................... A-63
A19 WASTE MANAGEMENT AND DISPOSAL ................................................. A-64
Waste Segregation and Labeling ............................................................................... A-64
Waste Containers ...................................................................................................... A-65
Glass Waste .............................................................................................................. A-66
Satellite Accumulation Areas ..................................................................................... A-66
A20 TRANSPORT AND SHIPMENT OF CHEMICALS ...................................... A-68
Transport of Chemicals on or to TTU Property .......................................................... A-68
A-iv
Shipment of Hazardous Materials .............................................................................. A-69
A21 CHEMICAL GATEWAY ............................................................................... A-71
Procurement of Chemicals for Laboratories .............................................................. A-71
Chemical Inventory for Laboratories .......................................................................... A-72
A22 CHEMICAL FUME HOODS ......................................................................... A-73
Chemical Fume Hood Operating Procedures ............................................................ A-73
Chemical Fume Hood Surveillance Program ............................................................. A-74
A23 NON-COMPLIANCE .................................................................................... A-76
A24 LABORATORY OR STUDIO SPACE CLOSURE ....................................... A-78
Conditions for Closure ............................................................................................... A-78
Procedures for Closure .............................................................................................. A-79
Supervisor Actions ..................................................................................................... A-79
Conditions for Resumption ........................................................................................ A-80
A25 DECOMMISSIONING A WORK AREA ....................................................... A-80
Allowable Material Transfers ..................................................................................... A-81
A26 REVIEWS AND UPDATES .......................................................................... A-82
A-v
HELPFUL LINKS AND DOCUMENTS
29 CFR 1910.1450 (Occupational exposure to hazardous chemicals in laboratories)
29 CFR 1910, subpart Z (Toxic and Hazardous Substances)
40 CFR 262 (Standards Applicable to Generators of Hazardous Waste)
49 CFR 100-185 (DOT Hazardous Materials Regulations)
Carcinogen List
NIOSH Pocket Guide to Chemical Hazards
Prudent Practices in the Laboratory
EHS Home Page
Barcode Request Form (The fillable form cannot be opened in a web browser. Download the
form to your computer and open using Adobe Acrobat Pro to complete and save).
Barcode Return Form
Chemical Inventory (SafetyStratus)
Chemical Transfer Form (The fillable form cannot be opened in a web browser. Download the
form to your computer and open using Adobe Acrobat Pro to complete and save).
ChemWatch – SDS database, label printing
Equipment Decontamination Form
Occupational Health Program
A-vi
RECENT CHANGES
Section A4 Policies
• Addition of Section A4.7 on requests for clarification and deviation
Section A5 Responsibilities
• DSO responsibilities now references TTU Operating Policy 60.29
A16 Chemical Identification
• Revision to allow SDSs databases for work areas to be kept in paper copy, electronic copy
or via access to the internet
A17 Chemical Handling
• Pyrophoric chemicals shall be handled according to their respective SDS
A19 Waste
• Chemical waste must be stored in the designated Satellite Accumulation Area (SAA)
• Tubs and SAA signage are provided by EHS. Additional secondary containers shall be
supplied by the PI.
• Hazardous Waste stored in the SAA shall not exceed 55 gallons of hazardous waste, 1 qt
of acutely hazardous waste, or 1 Kg of solid acutely hazardous waste.
• Incompatible waste streams shall be segregated into separate secondary containment
within the SAA.
• Only appropriately labeled, sealed containers with a corresponding EHS Transaction
Number will be collected during routine collection.
• Biological waste container description only in Biosafety Manual
A21Chemical Storage
• Pyrophoric chemicals shall be stored according to their respective SDS
A23 Non-Compliance
• Procedures for addressing non-compliant individuals in a work area have been added
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A1 PURPOSE OF THIS PLAN
It is the desire of Texas Tech University to set forth policies, procedures, and work practices
capable of informing employees of physical and chemical health hazards associated with
chemicals in "work and storage spaces" as defined by 29 CFR 1910.1450 - Occupational
Exposures to Hazardous Chemicals in Laboratories, and to train employees to maintain
exposures below the limits prescribed in 29 CFR 1910, subpart Z. This document is designed
to comply with the requirements and intent of 29 CFR 1910.1450 and employee "right-to-know"
legislation.
TEXAS TECH UNIVERSITY HEALTH AND SAFETY POLICY
It is the policy of Texas Tech University to conduct all educational, research, and campus
activities safely and in a manner that protects the health of employees, students, and the public.
Each administrator must be committed to the enforcement of the health and safety policies of
the University and to implement appropriate safety practices within his or her area of
responsibility.
All faculty members and others involved in instructional and/or research programs are
responsible for seeing that the students in their courses and laboratories
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are properly trained
and educated about applicable safety and health safety policies and practices prior to exposure
to instructional or research hazards.
Each employee and student is entitled to have access to information about the University’s
health and safety policies and practices and is responsible for knowing and adhering to health
and safety policies and practices as they are applicable to the instruction, research, and work
settings in which he or she participates.
Each employee is responsible for maintaining a safe work place. Employees have a continuing
responsibility to develop and follow practices that achieve these goals.
Each employee who manages or supervises the work of others is additionally responsible for
ensuring that employees and students for whom they are responsible are properly trained and
educated about safety and health practices.
Every guest, vendor, media personnel or contractor present on the University is expected to
adhere to the health and safety policies of the University while on campus. TTU personnel who
contract with invited individual(s) or oversee a work area are responsible for informing outside
vendors of policies.
All University-related facilities, activities and programs shall be designed, conducted, and
operated in a manner which reasonably protects human health and safety. Adherence to these
principles is necessary in order for the University to achieve its mission of providing quality
instruction, research and services.
The University strives to provide training and education conducive to the establishment and
maintenance of safe educational, research and work environments.
Where there is conflict or overlap between state or federal regulations and TTU policies, the
most protective provisions shall be used.
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A2 EMERGENCY ASSISTANCE INFORMATION
TTU Environmental Health and Safety
Daytime Emergencies (M-F, 8:00am – 5:00pm) – 806-742-3876
TTU Emergency Maintenance
Operations Call Center – 806-742-4677
After hours and weekend emergencies (24 hrs/day, 7 days/week) – 806-742-4OPS (4677)
TTU Police (TTUPD)
Emergency – 911
Non-Emergency – 742-3931
A3 USEFUL ACRONYMS AND DEFINITIONS
A3.1
Useful Acronyms
AAALAC – Association for Assessment and Accreditation of Laboratory Animal Care
ACGIH – American Conference of Governmental Industrial Hygienists
ANSI – American National Standards Institute
BSL1 – Biosafety Level 1
BSL2 – Biosafety Level 2
BSL3 – Biosafety Level 3
BSL4 – Biosafety Level 4
C – Ceiling
CAS – Chemical Abstracts Service
CDC – Center for Disease Control
CFR – Code of Federal Regulations
CHO – Chemical Hygiene Officer
CHP – Chemical Hygiene Plan
CSA – Container Storage Area
DOT – Department of Transportation
DSO – Departmental Safety Officer
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EHS – Environmental Health and Safety
EPA – Environmental Protection Agency
ERP – Emergency Response Plan
FAA – Federal Aviation Administration
GFCI – Ground-Fault Circuit Interrupter
GHS – Globally Harmonized System
HVAC – Heating, ventiliation and air conditioning
HAZCOM – Hazardous Communications
HAZWOPER – Hazardous Waste Operations and Emergency Response
HEPA – High Efficiency Particulate Air
IACUC – Institutional Animal Care and Use Committee
IBC – Institutional Biosafety Committee
IDLH – Immediately Dangerous to Life or Health
IFC – International Fire Code
ILSC – Institutional Laboratory Safety Committee
IRB – Internal Review Board
ISO – International Organization for Standardization
LASER – Light Amplification by Stimulated Emission of Radiation
LC50 – Air concentration lethal to 50% of the test population
LD50 – Dose lethal to 50% of the test population
LEL – Lower Explosive Limit or Lower Exposure Limit
LOAEL – Lowest Observed Adverse Effect Level
LOEL – Lowest Observed Effect Level
NFPA – National Fire Protection Agency
NIOSH – National Institute for Occupational Safety and Health
NOAEL – No Observed Adverse Effect Level
NOEL – No Observed Effect Level
OHP – Occupational Health Program
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OEL – Occupation Exposure Limit
OSHA – Occupational Safety and Health Administration
PEL – Permissible Exposure Limit
PI – Principal Investigator
PPE – Personal Protective Equipment
REL – Recommended Exposure Limit
RQ – Reportable Quantity
RSO – Radiation Safety Officer
SAA – Satellite Accumulation Area
SCAN – Safety Concern and Near-Miss
SDS – Safety Data Sheet
SOP – Standard Operating Procedure
STEL – Short Term Exposure Limit
TCEQ – Texas Commission on Environmental Quality
TLV – Threshold Limit Value
TWA – Time Weighted Average
UEL – Upper Explosive Limit and Upper Exposure Limit
USDA – United States Department of Agriculture
VOC – Volatile Organic Compounds
WASP – Work Area Safety Plan
A3.2
Useful Definitions
Action Level – a concentration designated in 29 CFR 1910 for a specific substance, calculated
as an 8-hour time weighted average, which initiates certain required activities such as exposure
monitoring and medical surveillance.
Administrative Controls – (or work practice controls) are changes in work procedures such as
written safety policies, rules, supervision, schedules, and training with the goal of reducing the
duration, frequency, and severity of exposure to hazardous chemicals or situations.
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Chemical Gateway – an area at TTU Central Receiving under EHS control where chemical
packages are received, opened, inspected, barcoded and inventoried before delivery to the
responsible party.
ChemWatch – an online Safety Data Sheet (SDS) library that includes vendor SDSs and
printable GHS labels for most chemicals. Available through the Safety Data Sheets Quick Link
on the EHS website.
Combustible Liquid – A liquid that has a closed-cup flash point at or above 100°F (37.8°C).
Container Storage Area – a completely enclosed, self-supported structure under EHS control
where hazardous waste is accumulated and stored before transport to a designated waste
treatment facility.
Correction Period – the time period allotted for personnel to correct compliance issues identified
during an inspection or in a written memorandum for potential work area closure.
Critical Finding - a safety departure that can result in personnel injury or exposure and/or
environmental contamination. Non-critical findings that continue unaddressed or are found to
be excessive within a work area and thus present more than a moderate hazard will be elevated
to a critical finding. Critical findings must be corrected by lab personnel within 24 hours following
the inspection that identified the finding(s).
Dangerous – a non-routine procedure that poses significant threat to life or health.
Departmental Representative – any TTU personnel who acts as a liaison between their
department and EHS during any correspondence (e.g., incident report, facility planning,
hazardous material shipping, etc.)
Dignitary – any representative from federal or state regulatory agencies, industry, law
enforcement officials, investors, etc.
Engineering Controls – includes designs or modifications to plants, equipment, ventilation
systems, and processes that reduce the source of exposure.
Energetic Materials – can be classified into three categories: explosives, propellants, and
pyrotechnics. Explosives detonate not combust and contain oxygen as part of their mixture.
Propellants combust and contain oxygen; however, the burn rate depends upon pressure.
Pyrotechnics may contain propellant ingredients and tend to be made of metal salts and are
intended to produce light, smoke, gas, sound and heat.
Finding – used synonymously with safety departure; describes behavior, practices or facility
features that deviate from the University Laboratory Safety Manual or other regulatory
guidelines.
Flammable Liquid – A liquid that has a closed-cup flash point at or below 100°F (37.8°C) and a
maximum vapor pressure of 2068 mm Hg (40 psia) at 100°F.
Horseplay – rough or boisterous play.
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Incident – an event or occurrence that results in damage to property and / or damage /
exposure to person(s) that requires medical attention, including the use of available safety
equipment and/or first aid.
Institutional compliance committee – a committee established by the University and/or required
by federal/state law to maintain compliance with regulatory agencies and oversee and
authorize certain activities. The ILSC, IBC, IRB, IACUC and IRLSC are the institutional
compliance committees at Texas Tech University.
Laboratory – a facility equipped for experimental or observational study in a science or for testing
and analysis and that contains chemical, biological, mechanical, radiological and / or LASER
materials / equipment for these purposes.
Laboratory Personnel – anyone working in a TTU laboratory including principal investigators,
staff, students, visiting researchers, volunteers, etc.
Localized Exhaust – an exhaust system designed to remove contaminants at the point of origin.
Minor – individual under the age of 18 years old.
Mixed Waste – waste generated in which at least two of the following are present: chemical,
biological and / or radiological hazards.
Municipal Solid Waste – defined in Texas Administrative Code 30 TAC 330.3.
Nanoparticles – (also known as nanomaterials) defined as particles intentionally engineered
and created that range from a size of 1 nm to 100 nm in size.
Non-critical finding – a safety departure that presents a moderate hazard and are generally
indicative of inadequate safe work practice(s). Non-critical findings must be corrected by lab
personnel within 30 days following the inspection that identified the finding(s).
Non-laboratory Personnel – any TTU personnel whose primary work area is not a laboratory.
Personal Protective Equipment (PPE) – Personal protective equipment includes all clothing
and work accessories designed to serve as a barrier against laboratory hazards. Basic PPE
requirements for most campus laboratories include, solid shoes, a lab coat and safety glasses;
however other PPE may be required. Examples include gloves, face shields, surgical masks,
respirators, head/shoe covers, splash goggles, impermeable lab coats or suits, fire retardant
coats/suits, steel-toed shoes, full-face respirator, scrubs, solid-front gowns, aprons, etc.
Physical Barrier – an environmental control that serves as a means of containment in the event
primary containment fails. Hazardous materials stored inside a closed cabinet, closed
refrigerator, closed drawer, closed incubator, etc. are considered behind a physical barrier.
Primary Explosive – explosive initiated by simple ignition such as spark, flame or impact.
Portable Sink – a sink designed to be mobile and contains a reservoir for containing gray water.
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Public Area – any are where non-laboratory personnel may be present such as common
corridors, stairways, elevators, office spaces, etc.
Pyrophoric Materials – chemical in which oxidation by oxygen or moisture proceeds so rapidly
that ignition occurs. Common examples of pyrophoric materials include, but are not limited to,
finely divided metals (whose degree of reactivity depends on particle size), metal hydrides, alloys
of reactive metals, low-valent metal salts and iron sulfides.
Quarterly – every 90 days.
Risk Assessment - continuous and evolving analysis of hazards associated with work
procedures or operations, assessment of the risks of the identified hazards, identification of
actions or equipment to manage and/or mitigate the risks and creation of an emergency plan.
Responder – any person designated by the employer, including employees from within the
immediate release area, to respond to an incidental release of hazardous material.
Safety Concerns and Near Misses (SCAN) – an event or occurrence that was caught before
an incident occurred, did not result in an incident but could have or unsafe practice(s),
condition(s), environment that could result in an incident.
Safety Data Sheet – (SDS) OSHA Hazard Communication Standard (HCS) (29 CFR
1910.1200(g)) requires that chemical manufacturers, distributors, or importers provide a safety
document, written in English, for each hazardous chemical to communicate information such as:
the properties of each chemical; the physical, health, and environmental health hazards;
protective measures; and safety precautions for handling, storing and transporting the chemical.
See Section A16.4 for SDS requirements for laboratories.
Safety survey / survey – an inspection of a work area where there are physical, chemical,
and/or biological hazards to evaluate and access the presence of safety departures as
described in appendix AB.
Satellite Accumulation Area – (SAA) designated hazardous waste storage area at or near any
point of generation where wastes initially accumulate inside of a work area (definition adapted
from 40 CFR 262.15).
Secondary Containment – (for chemical storage or transport) must be: 1) sturdy, 2) leak-proof,
3) capable of holding ten (10) percent of the volume of the containers or 100 percent of the
volume of the largest container, whichever is greater, 4) able to be appropriately
decontaminated, and 5) compatible with the chemicals it contains (i.e. no reaction should a spill
occur).
Secondary Explosive – explosive initiated by shock created by primary explosives.
Select Carcinogens – substances that are classified as carcinogens or potential carcinogens in
OSHA standard 29 CFR 1910, subpart Z.
Sharps – any metal object / device used to puncture or cut. Examples include any type of
injection device and whatever is attached to it, razors, X-Acto knives, pointed scissors, scalpels,
etc.
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Shipper – individual who signs declaration and or shipping documents for hazardous materials
shipping.
Spill Kit – a compilation of appropriate absorbent materials, cleaners, disinfectants, chemical
neutralizers, personal protective equipment and other equipment (e.g., container for clean-up
materials, scoop, broom, disposal bags, waste labels, etc.) used to contain and clean up spills.
See Appendix AC for spill response and kit guidance.
TechBuy – (also known as SciQuest) a procurement website for TTU personnel to make
University purchases from approved vendors. For more information visit
https://www.depts.ttu.edu/procurement/purchasing/ or contact techbuy.purchasing@ttu.edu.
Toxin – any substance poisonous to an organism; toxins may be synthetic or produced and
released from the metabolic activities of a living organism (i.e. biological toxin). These
substances can cause harmful effects when they are injected, inhaled, eaten or absorbed
through the skin. Use of toxins listed as Select Agents by the CDC requires approval by the
Institutional Biosafety Committee and is subject to regulations as described in 7 CFR 331, 9 CFR
121 and 42 CFR 73.
Vacuum Line Trap – equipment that protects a vacuum system from separated solvents and
prevents vapors from being emitted back into the system or work area; in biological systems, the
trap prevents contamination of the vacuum system with potentially biohazardous materials (see
Appendix AE for guidance on vacuum line trapping).
Volunteer – individual who is assigned to perform duties for a department or area of TTU without
compensation or the expectation of compensation, beyond reimbursement for pre-approved
specified expenses. Potential volunteer workers may be members of the public, TTU alumni,
students, faculty, staff or retired TTU faculty or staff (definition from TTU OP 70.21).
A4 POLICIES
A4.1
All policies included in this Chemical Hygiene Plan apply to all areas of TTU activity.
A4.1.1
The terms laboratory
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and work area are used interchangeably to refer to the areas on-campus
and off-campus in which TTU faculty, students, or staff work with chemical, biological or physical
hazards. These areas include, but are not limited to, laboratories
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, studios, shops, field sites and
classrooms.
A4.2
Occupational Safety and Health Administration (OSHA) Regulated Substances
A4.2.1
Employee exposures to chemical substances will be kept below the OSHA exposure limits
established in 29 CFR 1910, subpart Z and as low as reasonably achievable through the use of
administrative controls
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, engineering controls
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and personal protective equipment (PPE).
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A4.2.2
The exposure limits include Permissible Exposure Limits (OSHA), Threshold Limit Values
(ACGIH), Recommended Exposure Limits (NIOSH), Time Weighted Averages, Short Term
Exposure Limits, and Ceiling Values. The most restrictive value is to be used.
A4.2.3
Substances regulated in 29 CFR 1910, subpart Z will be identified within each work area. EHS
will keep and maintain a chemical inventory for each lab
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in the EHS Assistant inventory system
by barcoding all incoming chemicals.
A4.3
Proper Laboratory
d
Attire
A4.3.1
Proper lab attire must be worn at all times in the laboratory
d
.
A4.3.1.1
Proper footware is required.
A4.3.1.1(a)
Footware must be liquid-repellant. Canvas shoes, such as Toms, Converse and most tennis
shoes are not liquid-repellant.
A4.3.1.1(b)
Footware must cover the entire foot. Shoes such as ballet flats and sandals are not appropriate.
A4.3.1.2
Shorts or other garments which expose the skin of legs or feet shall not be worn in the
laboratory
d
. Clothing that allows any skin below the waist to be seen is not allowed.
A4.3.1.3
Secure long hair away from the face.
A4.3.2
Selection of Personel Protective Equipment (PPE)
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(e.g., lab coats, gloves, eye protection, etc.)
must be appropriate for the work being done and agents being worked with.
A4.3.2.1
Lab coats and eye protection must be worn in the work area while chemical and/or biological
agents are not behind a physical barrier
d
.
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A4.3.2.2
In teaching laboratories
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, the minimum PPE
d
required while working with chemical or biological
agents include all of the following: laboratory coats, safety glasses and gloves appropriate to the
agents being used.
A4.3.2.3
Splash goggles are required when working with chemical / biological agents that present a
splash hazard.
A4.3.2.4
Eye protection must be ANSI certified for the hazards present.
A4.3.2.5
Appropriate gloves must be worn while working with chemical / biological agents. Glove selection
must be appropriate for the work being done or agent(s) being handled. The following provisions
apply to glove usage:
A4.3.2.5(a)
Avoid touching your face, eyewear, personal items, or other environmental surfaces with your
gloves.
A4.3.2.5(b)
Gloves should be removed in such a way as to not contaminate the wearer or aerosolize material
on the gloves.
A4.3.2.5(c)
Used disposable gloves shall be discarded immediately after removal and not reused.
A4.3.2.5(d)
Gloves should be changed frequently. Gloves shall be changed when they are visibly
contaminated, between procedures or when integrity has been compromised.
A4.3.2.5(e)
Wash hands prior to donning gloves to remove lotions which may compromise glove integrity.
A4.3.2.5(f)
Wash hands any time gloves are removed. Hands must be washed before leaving the
laboratory
d
.
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A4.3.2.6
If a different type of PPE
d
is required or the use of PPE
d
could result in injury (e.g. loose clothing
around moving machinery), the SOP (see Section A12) for these activities must state the PPE
d
that must or must not be used while performing the required operation.
A4.3.3
Visitors are required to wear the PPE
d
determined for the work area while hazardous operations
are being conducted and / or chemical / biological agents are not behind a physical barrier
d
. If
visitors refuse to don PPE
d
, or if PPE
d
is not available, entry will be refused.
A4.3.4
Individuals at a desk or computer work station inside of the work area are required to wear the
same PPE
d
required to enter the lab
d
while hazardous operations are being conducted and / or
chemical / biological agents are not behind a physical barrier
d
.
A4.3.4.1
If (and only if) no hazardous operations are being conducted and all chemical / biological agents
are stored behind a physical barrier
d
, PPE
d
can be removed.
A4.3.4.2
All individuals in the work area must always put their PPE
d
back on any time that hazardous
operations are being conducted and / or chemical / biological agents are not behind a physical
barrier
d
.
A4.3.5
PPE
d
should be dedicated to the work area and shall not to be worn in public areas
d
.
A4.3.5.1
Laboratory coats must be stored in the work area and not in offices or public areas
d
.
A4.3.5.1(a)
The coat must be stored in such a way that the inner surfaces that contact the user are not at
risk of becoming contaminated.
A4.3.5.2
In instances where laboratory coats are transported outside a work area, such as in transit
between work areas, the coat must be folded is such a way that the outside of the garment 1) is
not exposed, and 2) does not touch the inner parts of the garment that directly contact the
wearer.
A4.3.6
Defective, soiled and/or damaged PPE
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shall not be used.
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A4.3.6.1
Defective and/or damaged PPE
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must be replaced by the supervisor (see A5.5.13).
A4.3.6.2
Soiled, reusable PPE
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must be decontaminated; regular laundering of PPE
d
is encouraged.
A4.3.6.2(a)
A commercial laundry service shall be used for laundering laboratory coats or other washable,
protective apparel where dedicated laundry units are not available. PPE
d
shall not be laundered
at home or at a public laundry mat.
A4.4
General Laboratory
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Practices
A4.4.1
Eating, drinking, chewing gum or tobacco, smoking, vaping, taking medications, applying
cosmetics or lotions, etc. are strictly prohibited in laboratories
d
.
A4.4.2
Storage of items identified in A4.4.1 and other personal hygiene products is not permitted in the
laboratory
d
.
A4.4.2.1
Items of this nature for research / experimental purposes shall be labeled “for research use only”
or an equivalent phrase.
A4.4.2.2
First aid kits should be clearly labeled as such.
A4.4.3
Hand washing must occur before leaving the work area and when there is potential for
contamination on hands such as after a spill.
A4.4.4
Mouth pipetting is prohibited.
A4.4.5
Appropriate disinfectants / neutralizers must be available before work begins.
A4.4.6
Mercury thermometers should be replaced with alcohol or digital thermometers. If assistance is
needed to replace mercury thermometers, contact EHS at 742-3876.
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A4.4.6.1
Contact EHS at 742-3876 to clean up broken mercury thermometers.
A4.4.7
Empty chemical containers not repurposed for waste collection must be disposed of in a proper
container disposal area, if provided, or a dumpster.
A4.4.7.1
Containers for P-listed chemicals must be triple-rinsed with an appropriate solvent for removal
of the material before diposal into a proper container disposal area, if provided, or a dumpster.
A4.4.8
Ignition sources must be kept away from where flammable materials are stored or used.
A4.5
Buddy System
A4.5.1
It is always best practice in to have a partner in the work area with you (i.e., buddy system).
A4.5.2
In lieu of a physically present partner, supervisors/PIs should have a check in, check on, and
check out policy for working outside of standard business hours (8:00am-5:00pm, Monday-
Friday and University closures) or when the supervisor/PI is physically away from campus, which
follows the following general guidelines.
A4.5.2.1
Upon entering a lab
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, the lab personnel
d
should contact a designated contact person. The lab
personnel
d
should inform the designated contact of their entrance to the work area, the general
nature of their activities, and their planned exit time.
A4.5.2.1(a)
The designated contact should be someone who understands the risk of the work and proper
emergency response procedures related to the work. This can include supervisor/PI, lab
manager, lab safety captain, or another designated lab personnel
d
.
A4.5.2.1(b)
Contact includes email, phone calls, text messages, or other direct forms of communication as
outlined in the work area safety plan (WASP).
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A4.5.2.1(c)
If the total time in the work area is predicted to be less than three hours, the designated contact
should be contacted again when lab personnel
d
exits the work area.
A4.5.2.1(d)
If the total time is greater than three hours, the designated contact should be contacted at least
once every three hours by the lab personnel
d
to confirm safety and upon final exit of the work
area.
A4.5.3
The responsibilities of the designated contact person include the following:
A4.5.3.1
Responding to receipt of all communications to acknowledge contact (i.e. lab entrance, 3-hour
check-ons, and exit).
A4.5.3.2
If after three hours a check-on or exit time is not reported, the designated contact should attempt
to contact the lab personnel
d
.
A4.5.3.3
If attempts to contact the lab personnel
d
fail, the designated contact must notify the PI/supervisor.
Then either the contact person or the PI/supervisor should physically visit the work area and
check for the lab personnel
d
.
A4.5.4
It is recommended that experiments be planned to avoid conducting any high-risk procedure
after hours (5 pm – 8 am), on weekends or holidays. Should this work be conduction outside
regular business hours, Section A9.2.3 applies.
A4.6
Work Area Investigation
A4.6.1
Work areas may be investigated when 1) an incident
d
has occurred in the work area, 2) a work
area is found to have excessive non-compliance (see Section A23) to safety policy, and/or 3)
there is an open investigation by a regulatory agency involving the work area / project.
A4.6.1.1
The WASP (see Section A11) in work areas under investigation will be reviewed during the
investigation.
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d
Word is listed in Useful Definitions
A4.6.1.2
Work areas under investigation will be surveyed quarterly
d
. Safety surveysd will continue on a
quarterly
d
basis until two consecutive surveys
d
are without critical findings
d
and all findings
d
(critical
d
and non-critical
d
) are addressed.
A4.6.1.2(a)
A seven business day grace period will be granted to correct findings
d
not corrected on site or
were unable to be corrected on site. Documentation of the corrective actions must be submitted
to EHS by email at ehs.lab.safety@ttu.edu. By submitting corrective actions within the grace
period, the survey will be counted towards the two consecutive survey criteria defined in
A4.6.1.2.
A4.6.1.3
The PI and all lab personnel for the work area will repeat EHS-required safety training(s) for the
work area prior to the first quarterly
d
inspection. Trainings may be in-person or online as dictated
by the relevant institutional compliance committee(s)
d
.
A4.6.1.3(a)
If retraining is not completed prior to the first quarterly
d
inspection, work area operations will
cease until all lab personnel and the PI for the area have completed training.
A4.6.2
Work areas with an open investigation will not be allowed to host non-TTU personnel (including
visiting minors, students and researchers), visiting scholars, dignitaries, media, volunteers
d
, or
other visitors in any capacity.
A4.6.3
If the work area is closed, the work area will remain closed to lab personnel until EHS completes
a root-cause analysis and corrective actions related to the cause are taken.
A4.7
Request for Clarification or Deviation
A4.7.1
Request for Clarification
A4.7.1.1
If a principal investigator would like clarification regarding a Texas Tech University
policy/procedure in the University Laboratory Safety Manual (LSM) - Chemical Hygiene Plan,
they will need to submit the request in writing to the Institutional Laboratory Safety Committee
(ILSC).
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d
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A4.7.1.2
The ILSC’s evaluation and response to the Request for Clarification will be communicated in
writing to the PI in the form of a memorandum from the ILSC chair.
A4.7.1.3
The written Request for Clarification will need to address the following:
A4.7.1.3(a)
The policy(s) or procedure(s) for which clarification is needed as written in the LSM.
A4.7.1.3(b)
Why clarification is necessary, citing reputable references or peer-review literature as needed.
A4.7.1.3(c)
Whether they wish to address the committee in-person regarding this matter so the coordinator
can inform the ILSC chair.
A4.7.1.4
The Request for Clarification is to be emailed to the ILSC at the institutional email address
(ilsc.ehs@ttu.edu) no less than 5 business days before a scheduled meeting to be placed on
the upcoming meeting’s agenda. If the request is not received 5 business days prior to the
meeting, the request may not be considered until the following meeting if the agenda is already
full.
A4.7.2
Request for Deviation
A4.7.2.1
If a PI desires to deviate from Texas Tech University policy(s)/procedure(s) outlined in the
University Laboratory Safety Manual - Chemical Hygiene Plan, they will need to submit the
justification in writing to the Institutional Laboratory Safety Committee (ILSC).
A4.7.2.2
The ILSC’s evaluation and response to the Request for Deviation will be communicated in writing
to the PI in the form of a memorandum from the ILSC chair. Deviations may not be implemented
unless approved by the ILSC.
A4.7.2.3
The written Request for Deviation will need to address the following:
A4.7.2.3(a)
The agents and/or hazards in use and/or impacted by the proposed changes.
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d
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A4.7.2.3(b)
How the PI wishes to modify the approved-SOP(s) or policy.
A4.7.2.3(c)
A final copy of their proposed SOP(s) or policy.
A4.7.2.3(d)
A written justification as to why the approved-SOP or policy is not appropriate which sites the
specific deviations from the approved-SOP or policy citing reputable references and/or peer-
review literature to support their position for the needed change; and
A4.7.2.3(e)
Whether they wish to address the committee in-person regarding this matter so the coordinator
can inform the ILSC chair.
A4.7.2.4
The Request for Deviation is to be emailed to the ILSC at the institutional email address
(ilsc.ehs@ttu.edu) no less than 5 business days before a scheduled meeting to be placed on
the upcoming meeting’s agenda. If the request is not received 5 business days prior to the
meeting, the request may not be considered until the following meeting if the agenda is already
full.
A5 RESPONSIBILITIES
A5.1
The implementation of University health and safety policies and procedures is the responsibility
of management, faculty and staff of each department. All individuals in the laboratory
d
(including
faculty, employees, visiting researchers, students and volunteers
d
) are expected to participate
actively in the program to ensure its success.
A5.2
Environmental Health and Safety (EHS)
A5.2.1
Maintain a list of laboratories
d
affected by the Chemical Hygiene Plan (CHP) that is provided to
EHS annually by the individual departments;
A5.2.2
Maintain a chemical inventory for each laboratory
d
;
A5.2.3
Maintain a Safety Data Sheet (SDS)
d
library;
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d
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A5.2.4
Supply Occupational Health Program (OHP) information and training as required;
A5.2.5
Train laboratory personnel
d
on the principles of the CHP;
A5.2.6
Provide chemical spill kits
d
to TTU facilities upon request;
A5.2.7
Respond to emergencies in the event of a spill or release;
A5.2.8
Collect wastes and maintain waste records;
A5.2.9
Conduct weekly inspections of the Container Storage Area
d
(CSA);
A5.2.10
Maintain a list of all Satellite Accumulation Areas
d
(SAAs).
A5.3
Chemical Hygiene Officer (CHO)
A5.3.1
The University CHO is appointed by the Vice President of Environmental Health and Safety and
is responsible for the oversight of all aspects of the CHP.
A5.3.1.1
The CHO may delegate certain aspects of the program to others. Senior safety officers may act
as a proxy for the CHO as delegated by the CHO.
A5.3.2
Work with administrators and other employees to develop and implement appropriate chemical
hygiene policies and practices;
A5.3.3
Monitor procurement, use and disposal of chemicals used on the TTU campus;
A5.3.4
Help departmental representatives
d
develop precautions and adequate facilities;
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d
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A5.3.5
Conduct personnel exposure monitoring as necessary;
A5.3.6
Develop and implement the chemical fume hood surveillance program to include an inventory of
chemical fume hoods, criteria for evaluating hood performance, and recommended corrective
actions for deficiencies in hood performance (See Section A22);
A5.3.7
Investigate SCAN
d
or Incident
d
Reports, provide root-cause determinations and corrective
actions, and take appropriate action(s) as necessary;
A5.3.8
Maintain accurate records of the following:
A5.3.8.1
Any measurements taken to monitor employee exposures;
A5.3.8.2
Any medical consultation and examinations including tests or written opinions required by this
Manual;
A5.3.8.3
Laboratory safety surveys
d
conducted with responses for each laboratory
d
; and
A5.3.8.4
Measurements of equipment performance.
A5.3.8.5
Records are kept, transferred, and made available in accordance with 29 CFR 1910.120.
A5.3.9
Assist in performing physical and health hazard determinations for chemicals generated within
the lab
d
;
A5.3.10
Know the current legal requirements concerning regulated substances;
A5.3.11
Seek ways to improve the Chemical Hygiene Program;
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d
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A5.3.12
Assist in implementing related training;
A5.3.13
Provide announced and / or unannounced chemical hygiene and housekeeping surveys
d
;
A5.3.13.1
Deficiencies discovered upon survey
d
will be given 30 days for correction. Notification of findings
will be sent to the PI / supervisor, DSO and Department Chair.
A5.3.13.2
A follow-up survey
d
will be conducted after the correction period
d
. Notification of findings will be
sent to the PI / supervisor, DSO, Department Chair and Dean of the College.
A5.3.14
The CHO has the authority to remove any individual from a work area that is not following the
practices outlined in the CHP or the Work Area Safety Plan (WASP) for the work area in
question.
A5.4
Departmental Safety Officer (DSO)
A5.4.1
This individual is appointed by the department chair.
A5.4.1.1
The appointment of a DSO must be relayed to EHS.
A5.4.1.2
The DSO will be the contact between the department and CHO.
A5.4.2
DSO responsibilities are outlined in TTU OP 60.29.
A5.4.3
The DSO has the authority to remove any individual from a laboratory
d
and / or take pictures of
any individual or area in the laboratory
d
that are not compliant with or following the practices
outlined in the University CHP or the WASP for the work area in question;
A5.5
Principal Investigator / Supervisor
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A5.5.1
Each work area shall have a Principal Investigator (PI) or supervisor assigned to it who is
responsible for implementing all aspects of the University Laboratory Safety Manual;
A5.5.2
Prepare and implement a Work Area Safety Plan (WASP) (see Section A11 for requirements of
a WASP);
A5.5.3
Ensure chemical containers are labeled with required information, barcoded, segregated by their
hazard class (see Appendix AA) and stored in an appropriate manner;
A5.5.4
Perform a hazard determination of chemicals generated within the laboratory
d
;
A5.5.5
Ensure all individuals who enter their work area(s) know and follow the University Laboratory
Safety Manual;
A5.5.6
Prepare written standard operating procedures (SOPs) for all operations conducted and all
equipment used in the work area (see Section A12);
A5.5.7
Date receipt and track the age of peroxide forming compounds;
A5.5.7.1
Test peroxide formers for peroxide formation at a minimum every six months after opening (see
Appendix AH);
A5.5.7.2
Contact EHS for disposal of any peroxide former if the peroxide test yields 30 ppm or more or if
there is visible crystallization, discoloration, or stratification.
A5.5.8
Provide regular chemical hygiene and housekeeping surveys
d
, including routine inspections of
emergency equipment using Appendix AB;
A5.5.8.1
The PI is responsible for ensuring chemical hygiene and housekeeping issues are corrected, or
for completing a Work Order for issues that the PI needs assistance in fixing.
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d
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A5.5.9
Determine required PPE
d
and administrative
d
and engineering controls
d
and document this
information in written procedures;
A5.5.10
Ensure that facilities and training for any material being ordered or used are adequate;
A5.5.11
Notify the DSO and CHO of the need for medical monitoring, consultation and / or examinations;
A5.5.12
In the event of injury or damage to property an incident report is to be filled out and submitted to
the DSO or CHO within 24 hours after incident
d
;
A5.5.12.1
Injuries that require or result in medical attention must be reported to EHS immediately.
A5.5.13
Supply all appropriate PPE
d
to all individuals entering the work area(s) and ensure that the PPE
d
is used and in good working order;
A5.5.14
Ensure that all personnel with access to work area(s) have taken and passed the required EHS
safety training(s) outlined in Section A14.2 prior to being given permission to enter the work
area. Registration for safety trainings is done through EHS;
A5.5.15
Check eyewashes weekly to make sure they are running properly. If they need maintenance,
contact TTU Building Maintenance and Construction at 742-2102 for repair;
A5.5.16
Check fire extinguishers to make sure they are charged and in date. If they have not been
inspected within the last year or they are not charged, contact Physical Plant at 742-4677 to
have them serviced;
A5.5.17
Appoint a member of the laboratory
d
as the Laboratory Safety Captain;
A5.5.18
Ensure that equipment being removed from the work area for disposal, Surplus, or transfer is
appropriately decontaminated and cleared by EHS;
A-23 CHP Table of Contents
d
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A5.5.19
Submit protocols meeting any of the following criteria to the relevant institutional safety
committee(s)
d
for review and approval prior to work commencing:
A5.5.19.1
Protocols involving 1) organisms potentially pathogenic to plants, animals or humans, 2)
biological toxins listed as Select Agents, 3) recombinant or synthetic DNA / RNA, and / or 4)
human materials must be submitted to the Institutional Biosafety Committee (IBC) regardless of
sponsorship;
A5.5.19.2
Protocols involving the use of energetic materials
d
must be submitted to the Institutional
Laboratory Safety Committee (ILSC) regardless of sponsorship;
A5.5.19.3
Protocols involving any live vertebrate animals for research, instruction, demonstration,
production, or maintenance purposes, whether the animals are located in facilities at TTU or
elsewhere, must be submitted to the Institutional Animal Care and Use Committee (IACUC)
regardless of sponsorship;
A5.5.19.4
Protocols involving human subjects require proposal submission and review by the Instituional
Review Board (IRB) regardless of sponsorship;
A5.5.19.5
Protocols involving the use of radioactive materials, radiation producing equipment and lasers
require proposal submission and review by the Radiation and LASER Safety Committee (RLSC)
regardless of sponsorship.
A5.5.20
EHS must be informed by email to ehs.lab.safet[email protected]du of any non-TTU inspectors (e.g.,
USDA, CDC, FAA, etc.) planning to enter research work areas as soon as a tentative or
definite date and time is known.
A5.5.20.1
If non-TTU inspectors show up for an unannounced inspection, EHS shall be notified
immediately by phone.
A5.5.20.2
Exclusions to A5.5.20.1 include: scheduled USDA and AAALAC inspections for animal facilities,
TCEQ site visits, state fire marshal inspections, and inspections related to insurance policies.
A-24 CHP Table of Contents
d
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A5.6
Laboratory Safety Captain
A5.6.1
The Laboratory Safety Captain will serve as the liaison between the PI, laboratory
d
group
members, DSO, CHO, and other offices. The responsibilities of the Laboratory Safety Captain
will be outlined by the respective departments and PIs.
A5.7
Laboratory Personnel
d
A5.7.1
Follow all procedures outlined in the University Laboratory Safety Manual and WASP;
A5.7.2
Adhere to recommendations made by the Laboratory Safety Captain, PI, DSO and CHO;
A5.7.3
Receive biennial Laboratory Safety Training supplied by EHS online or by seminar and following
any updates to this program;
A5.7.4
Receive any additional training required by the WASP (see Section A11 for WASP details and
Section A14 for training requirements);
A5.7.5
Report safety concerns and near-misses through the SCAN system and report incidents
d
that
result in personnel injury or property damage immediately to their supervisor; and
A5.7.6
Report chemical fume hoods and / or other protective equipment that is damaged or not working
properly to their supervisor;
A5.7.7
Volunteers
d
that work in areas where chemical, biological and/or radiation hazards are present
must provide the proper authorizations in writing from their sponsoring department, EHS, and
Human Resources, as well as the Adult Volunteer Worker Application, Volunteer Release Form,
and Volunteer Worker Authorization Sheet as described in TTU OP 70.21.
A5.8
Institutional Compliance Committees
d
A-25 CHP Table of Contents
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A5.8.1
Institutional Biosafety Committee (IBC)
A5.8.1.1
See TTU OP 74.05 for the policies and procedures of the IBC.
A5.8.2
Institutional Laboratory Safety Committee (ILSC)
A5.8.2.1
See TTU OP 74.18 for the policies and procedures of the ILSC.
A5.8.3
Institutional Animal Care and Use Committee (IACUC)
A5.8.3.1
See TTU OP 74.11 for the policies and procedures of the IACUC.
A5.8.4
Institutional Review Board (IRB)
A5.8.4.1
See TTU OP 74.09 for the policies and procedures of the IRB.
A5.8.5
Radiation and Laser Safety Committee (RLSC)
A5.8.5.1
See TTU OP 60.11 for policies and procedures of the RLSC.
A6 NON-LABORATORY PERSONNEL
d
A6.1
Individuals seeking prolonged access (greater than 24 hours) to hazardous work area(s) on
campus to perform work or experiments shall receive the permission of the Principal Investigator
/ supervisor in writing before entering the work area.
A6.2
Non-laboratory personnel
d
entering a work area must wear the appropriate PPE designated for
that work area unless hazardous operations are not being conducted and chemical / biological
agents are behind a physical barrier
d
.
A-26 CHP Table of Contents
d
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A6.3
Dignitaries
d
and media visiting a laboratory
d
must wear the appropriate PPE for entrance to the
laboratory
d
and must be escorted by a senior member of the laboratory
d
. Research operations
shall be reduced to a level of demonstration.
A6.4
For minors
d
that are going to be in the laboratory
d
for a tour, the following guidelines shall be
followed:
A6.4.1
The Department Chair must give written permission to the PI;
A6.4.2
Groups will be no larger than ten (10) minors
d
per senior laboratory member at a time;
A6.4.3
The PI / supervisor must be in direct supervision while the tour group is in the work area;
A6.4.4
Appropriate PPE
d
must be worn by all individuals while in the laboratory
d
when chemical,
physical or biological hazards are not behind a physical barrier;
d
A6.4.5
Research operations must be suspended while the tour group is in the laboratory
d
;
demonstration activities are allowed;
A6.4.6
If an active experiment is to be observed, Section A8 must be followed.
A7 MAINTENANCE WORKERS IN LABORATORIES
d
A7.1
Maintenance workers shall complete annual Hazard Communication Training through TTU EHS
(online).
A7.2
Maintenance workers must check in with the responsible party of a building before entering the
work area(s).
A7.3
Maintenance workers must also notify the PI / supervisor, if present, before entering the work
area(s).
A-27 CHP Table of Contents
d
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A7.4
Maintenance workers must wear the required PPE while in the work area(s) if hazards are
present as stated in Section A4.3.3.
A8 MINORS
d
IN LABORATORIES
d
A8.1
Minors
d
Age 13 Years and Younger
A8.1.1
Minors
d
age 13 and younger are not eligible for laboratory
d
study or work experiences, or allowed
to be present in laboratories or other hazardous work areas at TTU, with the following exceptions
and guidelines:
A8.1.1.1
Special observation-only experiences may be arranged for minors
d
(including those age of 13
years and younger) through the sponsoring department, the Associate Vice President for
Research (Research Integrity) and EHS;
A8.1.1.2
Special participatory / educational laboratory
d
experiences involving minors
d
age 13 years and
younger may be considered on a case-by-case basis by the sponsoring department, if
authorized in accordance with Section A8.5 below, provided that the minor
d
is:
A8.1.1.2(a)
Under the direct supervision of the sponsoring investigator or senior laboratory personnel
d
, and
A8.1.1.2(b)
Not involved and / or exposed in any activities that could be considered “particularly hazardous”
as defined in 29 CFR 570, “Child Labor Regulations, Orders and Statements of Interpretation,”
or that may be considered to be detrimental to their health or well-being.
A8.1.1.3
For purposes of (A8.1.1.1) or (A8.1.1.2) above, all minors
d
under the age of 14 must be properly
supervised and accompanied by an adult while on TTU grounds and within TTU facilities where
hazards are present.
A8.2
Minors
d
Age 14 and 15 Years
A8.2.1
Minors
d
of age 14 and 15 years may participate, if authorized in accordance with Section A8.5
below, in laboratory
d
study or work experiences that do not include work in areas or occupations
A-28 CHP Table of Contents
d
Word is listed in Useful Definitions
considered to be “particularly hazardous” as defined in 29 CFR 570, “Child Labor Regulations,
Orders and Statements of Interpretation,” or that may be considered to be detrimental to their
health or well being, including, but not limited to, the following:
A8.2.1.1
Any work in a workroom where ionizing radioactive materials or ionizing radiation-producing
devices are present or used; and / or
A8.2.1.2
Any work in any workroom in which the following conditions may exist:
A8.2.1.2(a)
Potential presence or use of “highly hazardous” biological or chemical materials as defined by
the TTU IBC and ILSC;
A8.2.1.2(b)
Potential presence of infectious diseases transmitted by an aerosol route;
A8.2.1.2(c)
Potential exposures to animals with infections potentially transmissible to humans, human blood,
body fluids, or tissues;
A8.2.1.2(d)
Potential exposures to Level 3 or 4 biological agents (as defined by the CDC);
A8.2.1.2(e)
Potential exposures to Level 3 or 4 chemicals (as defined by the Hazardous Material
Identification System (HMIS) or National Fire Protection Association (NFPA) System);
A8.2.1.2(f)
When Class IIIb or IV laser devices are in operation; use of Class I-IIIa devices is allowed if all
personnel, including all minors
d
, are wearing appropriate PPE
d
for laser exposure.
A8.2.1.2(g)
Hazards requiring special protective wear (not including latex, vinyl or nitrile gloves, goggles,
face shields or dosimeter badges);
A8.2.1.2(h)
Potential presence or use of controlled substances;
A8.2.1.2(i)
Potential presence or use of select agents (as defined by the CDC); or
A-29 CHP Table of Contents
d
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A8.2.1.2(j)
Work in an area where there is a known risk of exposure to infectious diseases of human or
animal origin.
A8.3
Minors
d
Age 16 and 17 Years
A8.3.1
Minors
d
age 16 and 17 years may participate, if authorized in accordance with Section A8.5, in
laboratory
d
study or work experiences that include work in non-hazardous jobs or activities.
Minors
d
of age 16 and 17 years:
A8.3.1.1
Are prohibited from handling radioactive material source vials and must have prior written
permission from the Radiation Safety Officer (RSO) at 742-3876 to use other radioactive
materials, including performing contamination surveys; and / or
A8.3.1.2
Are prohibited from working directly with highly hazardous materials, including, but not limited to
the following:
A8.3.1.2(a)
Select agents (as defined by the CDC);
A8.3.1.2(b)
Controlled substances;
A8.3.1.2(c)
Highly hazardous biological or chemical agents (as defined by the TTU IBC and ILSC); or
A8.3.1.2(d)
Potentially infectious animals or agents.
A8.4
Supervision of Minors
d
A8.4.1
Minors
d
shall be closely and directly supervised by the sponsoring investigator or senior member
of the laboratory
d
.
A-30 CHP Table of Contents
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A8.4.1.1
Sponsoring investigators hosting minors must be able to be directly and immediately contacted
by phone or in person by minor and others while the minor is present in the laboratory or under
the direction of the sponsoring investigator.
A8.4.2
All use of radioactive material by the RSO-approved minor
d
must be directly supervised by a
trained adult TTU staff member at all times, including performing contamination surveys;
A8.4.2.1
Failure to supervise the minor
d
while using radioactive material will result in immediate
suspension of the Authorized User’s Radioactive Material Sublicense.
A8.4.3
Failure to supervise the minor
d
while using chemical hazards will result in the immediate
suspension of the laboratory’s activities until the EHS investigation is complete.
A8.4.4
Failure to supervise the minor
d
while using biological agents will result in the immediate
suspension of the PI’s IBC protocols.
A8.4.5
Failure to supervise the minor
d
while working with animals will result in the immediate suspension
of the PI’s IACUC protocols.
A8.4.6
Failure to supervise the minor
d
while working with human subjects will result in the immediate
suspension of the PI’s IRB protocols.
A8.4.7
Minors
d
shall be provided with adequate and appropriate personal protective equipment,
including dosimeter badges when required.
A8.4.8
Minors
d
shall successfully complete all required laboratory
d
and radiation safety training, as
appropriate, and any site-specific training required by the sponsoring laboratory
d
prior to
commencing work activities.
A8.4.9
Under no circumstances will minors
d
be allowed to work or study with or around radiation
sources, biological agents, hazardous chemicals, equipment, or animals that pose a risk to their
health or well-being.
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A8.4.10
Supervisors overseeing hazardous work areas or laboratories are specifically responsible for the
safety and compliance of all minors who are approved under institutional guidelines as
employees, students, or visitors in their areas.
A8.5
Authorization of a Minor
d
A8.5.1
A parent or guardian must give written consent for minors
d
to participate in laboratory
d
study or
work experiences, unless the minor is emancipated;
A8.5.2
The sponsoring department, EHS and Human Resources must also authorize the participation
in writing. Authorization will be granted only for recognized TTU or other recognized sponsored
educational programs;
A8.5.3
The Minor
d
Volunteer Worker Application, Volunteer Worker Authorization Sheet and Volunteer
Release Form shall be completed and submitted as described in TTU OP 70.21.
A8.6
Minors
d
may work in office space (not located in a laboratory
d
) under the supervision of a PI /
supervisor, faculty, staff or their personnel. Conditions presented in Section A8 apply.
A9 FACILITIES
A9.1
Access Control
A9.1.1
Work areas shall have doors for access control.
A9.1.1.1
Doors shall have a locking mechanism and be secured when there are no laboratory personnel
d
present;
A9.1.1.2
Laboratory
d
doors shall remain shut at all times with the exception of rooms acting as distribution
points for refilling of chemicals / supplies for laboratories
d
. In such cases, the area shall have a
split door; the bottom half is to remain shut and the top half may remain open while distribution
and refilling of chemicals / supplies is actively taking place.
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A9.2
Required Signage
A9.2.1
Door signs for laboratories
d
will be produced, modified and supplied by EHS.
A9.2.2
Special hazard signs (e.g., biohazard, LASER, radiation, etc.) must be clearly posted on all doors
entering the work area so that any reasonable person can see the sign prior to opening the door.
A9.2.3
If dangerous
d
activities are being conducted in the laboratory
d
that require restricted access, a
temporary sign must be posted on the door stating what activity is being conducted. The sign
must clearly state:
A9.2.3.1
Name of personnel conducting the experiment and provide contact information. Contact
information must be good for date(s) and time(s) specified in A9.2.2.2;
A9.2.3.2
The start date / time and expected stop date / time of the experiment;
A9.2.3.3
Specifically who is to have access to the laboratory
d
; and
A9.2.3.4
Additional PPE
d
, engineering controls
d
and precautions must be used when entering the
laboratory
d
while the experiment is in progress.
A9.2.3.5
The CHO, DSO, and Department Chair must be notified of what activities require restricted
access.
A9.2.4
Emergency contact information shall be posted in a highly visible location in the laboratory
d
in
close proximity to the entrance.
A9.2.4.1
The minimum contact information shall include the 1) PI and / or supervisor after hours contact
information, 2) EHS contact information, 3) University Police contact information, and 4)
Emergency Medical contact information.
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A9.3
Hygiene
A9.3.1
Laboratories
d
must have a sink for hand washing.
A9.3.1.1
Plumbed sinks are preferred, but if circumstances warrant, a portable sink
d
may be used.
Contact the DSO and CHO if a portable sink
d
might be used.
A9.3.1.2
It is permissible to have a sink in an adjacent room such that the path of travel does not use a
public area
d
. BSL2 and BSL3 laboratories must have a sink in the immediate work area.
A9.3.1.3
Soap and paper towels must be available at sinks used for handwashing.
A9.3.2
The laboratory
d
shall be designed so that it can be easily cleaned. Carpets and rugs shall not be
placed in laboratories.
A9.3.3
Spaces between benches, cabinets and equipment shall be accessible for cleaning.
A9.3.4
Vertical surfaces and floors shall be regularly decontaminated.
A9.3.5
First aid kits or supplies are recommended but not required for laboratory
d
work areas.
A9.4
Housekeeping
A9.4.1
Aisles must be free of slip, trip and fall hazards.
A9.4.2
Bench tops must be free of excess storage and clutter.
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A9.4.3
Trash must be disposed of properly with glass and sharps
d
waste segregated from other trash.
Trash must not be left on bench tops.
A9.4.3.1
Broken glass to be repaired must be secured in a labeled drawer or container.
A9.4.4
Counters and liners that become contaminated must be cleaned or replaced immediately after
contamination. Lab paper is not recommended as a permenant bench top covering.
Appropriately-sized paper may be used for procedures and discarded after use.
A9.4.5
Any equipment that becomes contaminated must be cleaned immediately after contamination.
A9.4.6
Fire extinguishers, fire blankets, safety showers, eyewashes and electrical panels shall be kept
clearly visible and free of obstruction.
A9.4.6.1
Eye wash covers shall be in place to prevent contamination.
A9.4.7
There must be no obstruction within 18” of the center of the spray from the safety shower.
A9.4.8
If first aid kits are made available, the kits must be checked regularly. Any expired items shall be
removed and may be replaced with unexpired items.
A9.4.9
There must be a minimum 32” clearance at the exit(s) from the laboratory
d
.
A9.4.10
Overhead storage must be at least 18” lower than the fire sprinkler head.
A9.5
Furniture
A9.5.1
Furniture must be capable of supporting anticipated loads and uses.
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A9.5.2
Bench tops must be impervious to water and resistant to heat, organic solvents, acids, alkalis
and other chemicals.
A9.5.3
Chairs used in laboratories must be covered in a non-porous material that can be easily cleaned
and decontaminated with an appropriate disinfectant.
A9.5.4
Flammable storage units must be properly installed and not left on the transport materials / pallet.
A9.6
Equipment
A9.6.1
Equipment in the laboratory
d
must be maintained, used appropriately, kept clean and in good
repair.
A9.6.1.1
Equipment accessories, such as tubing, rotors and other attachments, are considered part of
the equipment and must meet the requirements of A9.6.1.
A9.6.2
Freezers shall be defrosted periodically to prevent ice build-up.
A9.6.3
Common household appliances shall be labeled “Lab Use Only”.
A9.6.4
Vacuum lines must be equipped with traps
d
(see Appendix AE).
A9.6.5
Devices containing mercury shall be secured in secondary containment
d
so that if a spill occurs
the mercury is contained. Do not attempt to clean a mercury spill yourself. Contact EHS
immediately at 742-3876 if a mercury spill occurs.
A9.6.6
Equipment that is not working shall be labeled as out of service.
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A9.6.6.1
Equipment being offered to TTU Surplus must be appropriately decontaminated by lab
personnel, cleared by EHS and have a completed Equipment Decontamination Form (Appendix
AJ) attached.
A9.6.6.2
Equipment being shipped for repair must be appropriately decontaminated by lab personnel,
cleared by EHS and a completed Equipment Decontamination Form (Appendix AJ) must
accompany any documentation required by the servicing company.
A9.6.6.3
Equipment being disposed of must be appropriately decontaminated and cleared by EHS.
A9.6.6.4
Equipment containing refrigerants must have refrigerants collected before removal to Surplus or
disposal. Contact TTU Work Control at 806-742-4677 to submit a work order.
A9.6.6.5
Equipment leaking fluid(s) must be taken out of service (i.e., secured and labeled as “out of
service”) and repaired.
A9.6.7
Any biologically contaminated equipment should follow guidelines provided in Section B10.3 in
the Biosafety chapter of the University Laboratory Safety Manual.
A9.7
Electrical
A9.7.1
Electrical cords must be kept in good repair.
A9.7.2
Extension cords must only be used on a temporary basis and shall be plugged directly into an
outlet.
A9.7.3
Serial connections of electrical cords (i.e. daisy chaining) are not permitted; power strips and
extension cords may only be plugged into wall outlets, not into another power strip / extension
cord.
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A9.7.4
Electrical outlets within six (6) feet of a water source must have a ground-fault circuit interrupter
(GFCI).
A9.7.5
Only one item may be plugged into an individual receptable.
A9.7.5.1
Electrical devices with multiple receptacles must possess grounding and circuit-breaking
mechanisms.
A10 PHYSICAL HAZARDS
A10.1
Work Practices
A10.1.1
Large or heavy items are to be stored as close to ground level as possible.
A10.1.2
Horseplay
d
is not acceptable in the laboratory
d
.
A10.2
Trip Hazards
A10.2.1
Walkways are to be unobstructed and be 36” wide at minimum per NFPA 7.3.4.1(2).
A10.2.2
Trip hazards must be removed or mitigated.
A10.2.2.1
Electrical cords and hoses that have to run along the floor must be secured to prevent trip
hazards. The securing devices used for the securing electrical cords and hoses must not present
a trip hazard themselves.
A10.2.2.2
Equipment and containers that must be placed on the floor must be positioned so that they are
highly visible and out of the path of travel.
A10.3
Sharps
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A10.3.1
Avoid using sharps
d
whenever possible; use blunted needles and plastics when possible.
A10.3.2
Use disposable sharps
d
to avoid the hazards associated with decontaminating the items.
A10.3.2.1
Used sharps
d
must be discarded immediately after use into a puncture-resistant sharps
container.
A10.3.2.1(a)
Do not overfill sharps
d
containers. Remove from service when container is 3/4 full, close, and
dispose of in accordance with TTU OP 60.10.
A10.3.2.1(b)
Sharps
d
containers must be easily accessible.
A10.3.3
Be prepared to use the device the moment the sharp
d
is exposed and secure or discard
immediately after use.
A10.3.4
Do not bend, break or otherwise manipulate sharps
d
by hand.
A10.3.5
Needles must not be recapped.
A10.3.5.1
If there is a need to recap needles, a valid written reason and protocol must be submitted to and
approved by EHS.
A10.3.5.1(a)
Appropriate documented training in a one-handed recapping technique must be given to each
individual and documented demonstration of proficiency must be recorded.
A10.3.5.1(b)
If an EHS-approved recapping SOP is in place, it should be posted in the immediate work area
where sharps are recapped.
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A10.3.6
Reusable sharps
d
must be placed in a closeable, rigid container for transport or decontamination.
The sharp end must be secured in such a manner so as to prevent accidental injury.
A10.3.7
Sharps
d
that are to be stored must be secured in such a manner so as to prevent accidental
injury.
A10.3.8
Do not hand-pass exposed sharps
d
. Place sharps in a predetermined neutral zone to pass to
others.
A10.4
Required Precautions
A10.4.1
A blast shield must be in place when working with energetic or potentially energetic materials
d
.
A10.4.2
Closed systems under heat and / or pressure must be contained behind a blast shield or fume
hood with the sash closed.
A10.4.3
Proper gas cylinder handling and operation is required (see Appendix AD).
A10.4.4
Pulleys, belts, and other moving parts shall be properly guarded.
A10.4.5
Dewar flasks and cold traps
d
are wrapped with screens, friction tape or a metal jacket.
A10.4.6
Soldering
A10.4.6.1
Work areas with soldering stations must have a ten (10) foot zone of clearance between
soldering stations and desk or seating areas.
A10.4.6.2
If using solder containing lead, soldering stations must be located inside a fume hood or under
localized exhaust
d
or be equipped with a table top air scrubber.
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A11 WORK AREA SAFETY PLAN (WASP)
A11.1
The WASP is a research group-specific document that identifies potential hazards in the
laboratory
d
, outlines laboratory group-specific policies and procedures, and gives guidance to
laboratory personnel
d
in the event of an incident for all lab
d
locations. This document shall at
minimum contain:
A11.1.1
The laboratory
d
location(s) that are covered in the plan;
A11.1.2
Responsible party / parties for the laboratory
d
locations that are covered in the plan, including
designation of personnel responsible for WASP implementation;
A11.1.3
Emergency contact information for the responsible party for the laboratory
d
locations, including
the DSO’s contact information;
A11.1.4
Locations of SDSs
d
, University Chemical Hygiene Plan, and any other laboratory documents,
such as SOPs;
A11.1.5
Rules and policies of the laboratory
d
that are not less stringent than the University Laboratory
Safety Manual;
A11.1.6
Good laboratory
d
hygiene practices;
A11.1.7
Procedures to assess performance and operate chemical laboratory fume hoods and other
protective equipment;
A11.1.8
Identification of hazards and mitigation strategies in the laboratory
d
, including:
A11.1.8.1
Physical, electrical, chemical, biological and radiological hazards present;
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A11.1.8.1(a)
Employees must be informed of physical and health hazards associated with hazards present;
and
A11.1.8.1(b)
Employees must be informed of the Permissible Exposure Limits (PEL) for all hazards present.
A11.1.8.2
Control measures for reducing employee exposure to these hazards such as engineering
controls
d
, personal protective equipment (PPE)
d
, and hygiene practices;
A11.1.8.3
The instances under which a particular laboratory operation, procedure, or activity shall require
knowledge or presence of an appropriate responder
d
;
A11.1.8.4
Provisions for medical consultation and medical examinations;
A11.1.8.5
Provisions for additional employee protection for work with particularly hazardous substances
including but not limited to, "select carcinogens
d
”, reproductive toxins and substances which
have a high degree of acute toxicity. Alternatively, these provisions may be addressed in a
separate SOP (see Section A12). The provisions must cover:
A11.1.8.5(a)
Establishment of a designated area;
A11.1.8.5(b)
Use of containment devices such as laboratory hoods or glove boxes;
A11.1.8.5(c)
Procedures for safe removal of contaminated waste; and
A11.1.8.5(d)
Decontamination procedures.
A11.1.9
Waste disposal procedures for all waste streams;
A11.1.10
Clean-up procedures in case of a spill;
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A11.1.10.1
Procedures must be specified for all hazard classes present (e.g., acid, base, biological,
radiological, etc.).
A11.1.11
Guidance on what to do in case of emergency (e.g., fire, medical emergency, severe weather,
etc.);
A11.1.12
Acknowledgement sheet that all individuals working in the laboratory
d
are required to sign that
states they have read and understood the plan and will follow what is outlined in the plan; and
A11.1.12.1
Acknowledgement sheet should reflect active laboratory personnel
d
.
A11.1.12.2
Inactive laboratory personnel
d
should be indicated by a single strikethrough and PI / supervisor
initials.
A11.1.13
Current training records for all active laboratory personnel
d
, including the PI / supervisor.
A11.2
Plan Availability
A11.2.1
The WASP shall be readily available to employees, employee representatives and regulatory
agencies upon request.
A11.2.2
A hard copy of the most recent version of the WASP must be available in all laboratory
d
locations.
A11.3
The WASP shall be reviewed biennially and revised to address new hazards, operations,
equipment, etc. prior to introduction to the work area.
A12 STANDARD OPERATING PROCEDURES (SOPs)
A12.1
SOPs are written, step-by-step procedures that must be created for all laboratory
d
functions,
such that anyone with similar training would be able to use the procedure to complete the same
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task. The use of photographs, diagrams and flowcharts can be helpful in conveying information.
The following sections must be included:
A12.1.1
Appropriate title;
A12.1.2
Creator name, creation date, and PI approval;
A12.1.3
Training requirements for the SOP operator;
A12.1.4
Purpose that explains the objective and relays any other pertinent information to understand the
SOP;
A12.1.5
List of hazards and safety precautions;
A12.1.6
List of PPE
d
and / or other safety equipment needed for the task(s);
A12.1.7
List of materials and equipment needed to fully complete the task(s);
A12.1.8
Sequence of each task in detail;
A12.1.9
Information pertaining to interpretation of anticipated results, data collection and / or data
analysis;
A12.1.10
Shut-down procedures including decontamination and waste disposal. Procedures may
reference Work Area Safety Plan (WASP) (see Section A11);
A12.1.11
Emergency procedures such as spill response and response to personnel exposure which
include decontamination, waste disposal and OHP referrals. Procedures may reference the
WASP (see Section A11); and
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A12.1.12
List of references such as associated SOPs, cited literature and / or vendor documentation, if
available.
A12.2
All SOPs must be followed as written and approved by the PI or supervisor.
A13 EMPLOYEE EXPOSURE ASSESSMENT AND MONITORING
A13.1
An employee exposure assessment will be performed for hazardous chemicals regulated by
OSHA in 29 CFR 1910, subpart Z. This determination is based upon the nature of the material
and the conditions of use as described in Appendix AI.
A13.2
Exposure Determination for Substance-Specific Standards
A13.2.1
Initial monitoring - The CHO shall initiate monitoring of the employee's exposure to any
substance regulated by a standard which requires monitoring, if there is reason to believe that
exposure levels for that substance routinely exceed the action level
d
or Permissible Exposure
Limit (PEL). This may be done using the guidance in Appendix AI.
A13.2.2
Periodic monitoring - If the initial monitoring discloses employee exposure over the action level
d
or PEL, the CHO will comply with the exposure monitoring provisions of the relevant OSHA
standard.
A13.2.3
Termination of monitoring - Monitoring may be terminated in accordance with the relevant OSHA
standard.
A13.2.4
Employee notification of monitoring results - The CHO shall, within 15 days after the receipt of
any monitoring results, notify the employee of these results in writing either individually or by
posting results in an appropriate location that is accessible to employees.
A13.3
Routine Exposures Over PEL’s for Substance Specific Standards
A13.3.1
If air monitoring results indicate that employee exposures are above the limits prescribed in the
OSHA substance specific standards, medical monitoring is provided as required in the applicable
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standard for the regulated substance. The person responsible for establishing the need for
employee medical monitoring is the CHO.
A13.4
Exposure Evaluation Following an Incident
A13.4.1
The initial evaluation of an incident for possible overexposure shall be conducted by the DSO,
who will establish the need for a medical consultation / examination.
A13.4.2
The supervisor or DSO will fill out the Initial Investigation of Possible Overexposure found in
Appendix AL, and provide copies to the examining physician and the CHO.
A13.5
Responsibilities
A13.5.1
The person responsible for determining the need for monitoring employee exposure is the
supervisor or any departmental representative
d
.
A13.5.2
The person responsible for monitoring employee exposure is the CHO.
A14 TRAINING REQUIREMENTS
A14.1
Training Timeline
A14.1.1
All personnel who may be exposed to hazardous substances are to participate in the education
and training program established by the University.
A14.1.2
All TTU personnel will be informed about the hazards in their normal work area(s) as well as
hazards in other areas where they may be required to work.
A14.1.3
At the time of initial assignment, new employees shall receive the required training from the
department and complete TTU EHS safety training online.
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A14.1.3.1
New employees shall be informed about the University Laboratory Safety Manual and the SOPs
by their supervisor.
A14.1.4
Refreshers for TTU EHS safety trainings are required as detailed in Section A14.2.
A14.1.4.1
Refresher information for departmental training shall be provided at scheduled intervals as
determined by the supervisor but at least annually.
A14.1.5
When a new hazard is introduced into a work area, employees will be informed of the new hazard
and receive the appropriate training from their supervisor.
A14.1.6
All personnel must complete training prior to work commencing.
A14.2
Required EHS Safety Trainings Based on Activities
A14.2.1
Any university employee – Safety Awareness Training through Cornerstone (online). Refresher
training is required biennially for all personnel.
A14.2.2
Any non-laboratory personnel
d
occupationally exposed to chemicals – Hazard Communication
Training through TTU EHS (online). Refresher training required annually for all personnel.
A14.2.3
Any laboratory personnel
d
– Laboratory Safety Training through TTU EHS (seminar or online).
Refresher training is required biennially for all personnel.
A14.2.4
BSL2 laboratory personnel – Biological Safety Training through TTU EHS (seminar or online).
Refresher training is required biennially for all personnel.
A14.2.5
Personnel exposed to human materials – Bloodborne Pathogen Training through TTU EHS
(online). Refresher training is required annually for all personnel.
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A14.2.6
Personnel working with radioactive materials – Phase I Radiation Training through TTU EHS
(online) and Phase II Radiation Safety Training through TTU EHS (lecture). Online refresher
training is required biennially for all personnel.
A14.2.7
Personnel working with radiation producing equipment – Phase I Radiation Training through
TTU EHS (online) and generation of a safety SOP for the particular piece of equipment being
used to be reviewed by the TTU Radiation Safety Officer. Online refresher training is required
biennially for all personnel.
A14.2.8
Personnel working with lasers – Laser Safety Training through TTU EHS (online). Refresher
training is required biennially for all personnel.
A14.2.9
Additional training may be required based on agent or activities.
A14.3
Research Group / Departmental Training
A14.3.1
It is the supervisor’s responsibility to provide or ensure that everyone under their supervision
has completed the proper training for the operations they will be performing.
A14.3.1.1
Non-laboratory personnel
d
and visitors entering the laboratory
d
shall be notified of physical and
health hazards that are presented by chemical and biological material in the laboratory
d
(see
Section A6).
A14.3.2
TTU personnel and volunteers
d
shall be informed of the locations of the Work Area Safety Plan
(WASP), University Laboratory Safety Manual, SDSs
d
, chemical inventory and any other
relevant documents.
A14.3.3
Training shall include:
A14.3.3.1
Methods and observations that may be used to detect the presence or release of a hazardous
chemical (such as monitoring conducted by the department / EHS, continuous monitoring
devices, visual appearance or odor of hazardous chemicals when being released, etc.);
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A14.3.3.2
The physical and health hazards of chemicals in the work area;
A14.3.3.3
Physical hazards presented by chemicals (as distinguished from physical hazards (Section
A10)) can cause harm by triggering a secondary event not related to direct contact. These
include, but are not limited to, explosives, flammables chemicals, combustible chemicals,
oxidizing chemicals, gases under pressure, self-reactive substances, pyrophoric chemicals
d
,
self-heating substances, water reactive chemicals, organic peroxides, and chemicals corrosive
to metals. This training shall include:
A14.3.3.3(a)
Identification of the physical hazards;
A14.3.3.3(b)
Precautions used while handling these physical hazards such as the location where the agent
is to be handled and the proper PPE
d
required;
A14.3.3.3(c)
Proper storage of agents to minimize physical hazards; and
A14.3.3.3(d)
Procedures in case of uncontained release.
A14.3.3.4
Health hazards presented by chemicals include acute toxicity, skin corrosion, irritation, serious
eye damage or irritation, respiratory or skin sensitization, germ cell mutagenicity, carcinogenicity,
reproductive toxicology, target organ systemic toxicity from acute or chronic exposure and
aspiration hazard. This training shall include:
A14.3.3.4(a)
Identification of the health hazards;
A14.3.3.4(b)
Precautions used while handling this health hazards such as location where the agent is to be
handled and the proper PPE
d
required;
A14.3.3.4(c)
Proper storage of agents to minimize health hazards; and
A14.3.3.4(d)
Procedures in case of release.
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A14.3.3.5
The measures employees can take to protect themselves from these hazards, such as
appropriate work practices, emergency procedures and PPE
d
;
A14.3.3.6
The WASP (see Section A11) and SOPs (see Section A12);
A14.3.3.7
Detailed review of SDSs
d
for products which present physical and / or health hazards present in
the work area;
A14.3.3.8
Proper disposal of waste chemicals reiterating the fact that no chemical may be disposed of in
the sanitary sewer system; and
A14.3.3.9
Proper decontamination procedures for work area, equipment and person.
A15 OCCUPATIONAL HEALTH PROGRAM (OHP)
A15.1
The OHP at Texas Tech is designed to monitor, mitigate and treat health issues that can develop
due to occupational hazards. Employees may enroll in the Program under the following
circumstances:
A15.1.1
Whenever an employee develops signs or symptoms associated with a hazardous chemical to
which the employee may have been exposed in the work area;
A15.1.2
If an incident
d
occurs in the work area such as a spill, leak, explosion or other occurrence
resulting in the likelihood of a hazardous exposure, the affected employee can enroll in the OHP;
and /or
A15.1.3
Personnel may be assigned to the Program or enroll voluntarily due to occupational risks.
A15.1.3.1
Personnel meeting requirements outlined in the Respiratory Protection Program (TTU OP 60.05)
or Bloodborne Pathogen Protection Program (TTU OP 60.24) shall be enrolled in the OHP.
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A15.2
Program Steps
A15.2.1
An occupational risk assessment
d
should be performed by the workplace supervisor using the
Occupational Risk Assessment and details of workplace hazards should be described in the
position description of the employee.
A15.2.1.1
EHS should be consulted when encountering unknown or undefined hazards.
A15.2.2
The employee should complete the Assessment and Enrollment Form and submit the form to
ehs.ohp@ttu.edu to complete enrollment.
A15.2.3
EHS will submit the form to the Occupational Health Provider.
A15.2.4
The Occupational Health Provider will coordinate and perform appropriate medical care and
maintain all health records.
A15.2.5
The Occupational Health Provider will provide recommendations to EHS and the workplace
supervisor as to recommended work status and any restrictions for the employee.
A15.2.6
As necessary, EHS will provide exposure assessments, necessary training and
recommendations for engineering controls
d
, administrative controls
d
and PPE
d
to mitigate
workplace hazards.
A15.2.7
During an emergency response, medical care can be provided by any medical professional with
a follow-up Incident Form (Appendix AL) submitted to the OHP and coordinated follow-up
medical care through the Occupational Health Provider.
A16 CHEMICAL IDENTIFICATION REQUIREMENTS
A16.1
Labeling on Incoming Chemical Containers
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A16.1.1
Suppliers of chemical products must label their materials in accordance with the OSHA Hazard
Communication Standard (29 CFR 1910.1200) using the Globally Harmonized System (GHS).
A16.1.1.1
If containers are received at the Chemical Gateway
d
without the required information, the
container will be held until proper labeling is submitted by the responsible party. Container
labels may be obtained through ChemWatch
d
on the EHS website.
A16.1.2
The DSO and supervisor are responsible for ensuring that incoming containers are labeled with
the required information.
A16.1.3
Labels on chemical containers must not be removed or defaced while container holds the
indicated chemical.
A16.2
Labeling on Secondary Chemical Containers
A16.2.1
Secondary containers 15 mL or smaller may be labeled with an abbreviation if an abbreviation
chart written in English is posted where the containers are used and stored and can be easily
read.
A16.2.2
Containers larger than 15 mL must be labeled with the full English name according to the SDS
d
.
A16.2.3
Samples may be labeled to correspond with a lab notebook.
A16.3
Chemical Substances Developed in a Laboratory
d
A16.3.1
Chemical substances produced in a laboratory
d
must be labeled to correspond with a lab
notebook that is located in the laboratory
d
.
A16.3.2
If the composition of the chemical substance which is produced exclusively for the laboratory's
use is known, the supervisor shall determine if it is a hazardous chemical as defined by the
OSHA Hazard Communication Standard (29 CFR 1910.1200).
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A16.3.2.1
If the chemical is determined to be hazardous, the supervisor shall provide appropriate training
as required by this plan (see Section A14).
A16.3.3
If the chemical produced is a byproduct whose composition is not known, the supervisor shall
assume that the substance is hazardous and provide appropriate training as required by this
plan.
A16.3.4
If the chemical substance is produced for another user outside of the laboratory
d
, the supervisor
shall comply with the OSHA Hazard Communication Standard (29 CFR 1910.1200) including
the requirements for preparation of a SDS
d
and container labeling.
A16.4
Safety Data Sheets (SDSs)
d
A16.4.1
SDSs
d
shall be obtained for all chemicals obtained.
A16.4.2
The responsibility for obtaining, evaluating and maintaining SDSs
d
is assigned to each individual
laboratory
d
. Most SDSs
d
can be obtained through ChemWatch
d
or online chemical inventories.
A16.4.2.1
If a SDS
d
is not available through ChemWatch
d
, the laboratory group shall contact the
manufacturer(s) and / or distributor(s) for procurement of the SDS
d
. A copy of the SDS
d
must be
submitted to EHS.
A16.4.3
Access to SDSs should be maintained in the work area either in paper copy, electronic copy or
accessible via internet. Most SDSs
d
can be obtained through ChemWatch
d
or online chemical
inventories.
A16.4.3.1
SDSs
d
can be maintained in hard or electronic copy in a central location for work areas in the
same building. Signage in each work area shall identify this location.
A16.4.4
SDSs
d
for hazardous materials shall be readily accessible to employees during each work shift.
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A16.4.5
The location of these SDSs
d
, along with reference materials, will be addressed in the Work Area
Safety Plan (WASP).
A16.4.6
SDSs
d
shall be readily available for review upon request.
A17 CHEMICAL HANDLING
A17.1
Chemical Containers
A17.1.1
All chemical containers must be kept in a good condition.
A17.1.2
Chemical containers that are compromised shall not be used.
A17.1.2.1
Chemicals may be transferred to a different compatible container and labeled according to the
GHS labeling system.
A17.1.3
Parent (i.e., original) chemical containers shall be barcoded.
A17.2
Chemical Storage
A17.2.1
Chemicals shall be stored according to Appendix AA. Each storage group shall be stored in
secondary containment
d
if multiple groups are stored on the same shelf.
A17.2.1.1
There is a corresponding number on the EHS barcode for the chemical storage group as defined
by Appendix AA.
A17.2.1.1(a)
Chemicals with an NFPA health hazard rating of 3 or 4 will have a blue dot affixed to the EHS
barcode. Such chemicals should be treated with caution.
A17.2.1.1(b)
Chemicals in storage Group 9 (Compatible Pyrophoric and Water Reactive Materials) shall be
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stored according to their respective SDS.
A17.2.1.1(c)
When a chemical container is emptied, the yellow portion of the EHS barcode must be removed,
affixed to Barcode Return Form and returned to EHS at Campus Mail Stop 1090.
A17.2.2
If chemicals are stored in a non-visible area such as a drawer or cabinet, the drawer or cabinet
shall be marked as chemical storage.
A17.2.3
Chemical containers must be stored in an upright position to prevent accidental spills.
A17.2.4
Chemicals must be stored in a secured location when not in use.
A17.2.4.1
Secure locations are cabinets or shelving that should have a lip or restraining wire. Secondary
containment
d
is recommended if no lip or restraining wire is present.
A17.2.4.2
Cabinets must be appropriate for the type of chemical being stored.
A17.2.5
Chemicals collected to be recycled or reclaimed must be affixed with a label that states that
purpose (e.g., Xylene To Be Recycled or Xylene To Be Reclaimed).
A17.2.6
Chemical containers stored on the floor must be secured in secondary containment
d
to collect
spills.
A17.2.7
Chemicals must be stored away from intense light or heat sources.
A17.3
Flammable Storage
A17.3.1
Keep flammable liquids
d
used in the work area in original containers or safety cans.
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A17.3.2
In the event that such cans are not available, glass bottles no larger than four (4) liters may be
used with the proper precaution.
A17.3.3
Minimize the amount of flammable chemicals used and stored in the work area and do not
exceed the maximum allowable storage quantity as defined in Table A1.
A17.3.4
Flammables shall be stored in approved rated flammable storage cabinets at all times.
A17.3.5
A maximum of five (5) gallons of flammable liquids
d
may be in use at any one time in the work
area. All flammable liquids shall be put away when not in use.
A17.3.6
Flammables that require refrigeration shall be stored in a refrigerator that is designated and rated
for flammable or explosive storage.
A17.3.7
Flammable waste in a lab
d
shall be counted in the total allowable amount of flammable liquids
in the lab
d
.
A17.4
Chemicals of Special Concern
A17.4.1
Safety procedures for chemicals of special concern including carcinogens, teratogens and
other highly toxic chemicals must be posted in the immediate work area.
A17.4.2
Hydrofluoric Acid (HF)
A17.4.2.1
Work areas where HF is used or stored must have unexpired calcium gluconate gel available.
A17.4.1.1(a)
Gel should be in the immediate work area when actively working with HF.
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A17.4.2.2
Personnel working in areas where HF is used must be trained on SOPs and emergency
procedures for HF and be informed of the dangers of this chemical.
A17.4.2.2(a)
Never use HF when working alone or after hours.
A17.4.2.2(b)
HF may be used when working alone during regular working hours provided personnel
versed in first aid have been alerted and are in the general vicinity.
A17.4.2.3
Additional PPE
d
, including a face shield, chemically-resistant lab apron, and hand protection in
addition to basic nitrile or latex gloves, is required when working with HF.
A17.4.3
Perchloric Acid
A17.4.3.1
Heated perchloric acid operations must be performed inside a perchloric acid fume hood.
A17.4.4
Poisonous Gases
A17.4.4.1
Proper administrative
d
and engineering controls
d
for the storage and use of poisonous
gas(es), as defined 49 CFR 173.115(c), must be in place prior to acquisition of poisonous
gas(es).
A17.4.4.2
Work requiring the use of poisonous gas(es) must be submitted to and reviewed by EHS
before acquisition of poisonous gas(es).
A17.4.5
Energetic Materials
d
(i.e., explosives, propellants, pyrotechnics)
A17.4.5.1
Administrative
d
and engineering controls
d
for the storage, use and disposal of energetic
materials
d
must be outlined in the WASP (see Section A11).
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A17.4.5.2
WASP and SOPs (see Section A12) related to energetic materials
d
will be reviewed and
approved by the Institutional Laboratory Safety Committee prior to acquisition of energetic
materials
d
. The following points must be addressed:
A17.4.5.2(a)
Compatibility of laboratory instruments and appropriate safety barriers for laboratory
instruments;
A17.4.5.2(b)
Maximum quantities for use; and
A17.4.5.2(c)
If performing controlled detonations, procedures for dealing with unexploded ordinance will
be written in the WASP.
A17.4.6
Volatilizing Chemicals
A17.4.6.1
Solvents and other chemicals that volatilize must be used inside a chemical fume hood or
under localized exhaust
d
.
A17.4.6.2
Instrumentation that uses volatilizing chemicals should be operated in a chemical fume hood
or under exhaust when possible.
A17.4.6.3
Instrumentation that uses volatilizing chemicals that cannot be placed in a hood or used
under localized exhaust
d
shall have all chemical containers sealed or filtered.
A17.4.6.4
Small quantities of volatilizing chemicals may be used outside of a fume hood for routine
decontamination or cleaning of equipment or work surfaces.
A17.4.7
Pyrophoric Materials
d
A17.4.7.1
Pyrophoric materials
d
should be stored according to their respective SDS
d
.
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A17.4.7.2
Flame-resistant lab coats must be worn while working with pyrophoric materials
d
.
A17.4.7.3
Researchers using energetic materialsd must complete and submit an application to and receive
approval from the ILSC before procurement or synthesis of materials.
A17.4.8
Mercury
A17.4.8.1
All devices and equipment containing mercury must be contained in secondary containment
d
unless actively being used.
A17.4.8.2
Additional PPE
d
, such as disposable shoe covers and chemically-resistant aprons, may be
required for work areas using unsealed, free mercury.
A17.4.8.3
Work areas housing mercury-containing equipment must be designed with the appropriate
barriers including sealed HVAC systems and a possible floor trap.
A17.4.9
Toxin
d
Handling
A17.4.9.1
Avoid handling dry forms of toxins
d
when possible.
A17.4.9.2
Clean room gloves are recommended for handling dry forms of toxins
d
that are electrostatic.
A17.4.9.2
Handle toxins
d
within a fume hood, biological safety cabinet or glove box. Do not use toxins
d
within a laminar flow hood.
A17.4.9.2(a)
Toxins
d
that are electrostatic or particularly hazardous should be used with a glove bag within
a fume hood, biological safety cabinet or glove box.
A17.4.9.3
Consider toxin
d
, diluent / solvent and infectious material when selecting gloves and other
PPE
d
.
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A17.4.9.4(a)
When handling toxins that present a cutaneous (i.e. affecting the skin) or percutaneous (i.e.
permeable through skin) hazard, select gloves that are known to be impervious to the toxin
and diluent / solvent.
A17.4.9.4(b)
If not handling within a glove bag, a barrier lab coat with glove cuffs worn over sleeves is
recommended to minimize skin exposure.
A17.4.9.5
Decontamination procedures must be specified for individual toxins
d
and be included in the
Work Area Safety Plan (WASP) as outlined in Section A11.1.8.5.
A17.4.10
Nanoparticles
d
A17.4.10.1
Dry, powder nanomaterials
d
of unknown toxicity / reactivity or nanoparticles
d
in solution that
may become dry or aerosolized during manipulation shall be used in fume hoods, biological
safety cabinets (Class I or II), or glove boxes.
A17.4.10.2
Administrative
d
and engineering controls
d
for the storage, use and disposal of nanomaterials
d
must be outlined in the WASP (see Section A11) and/or SOPs (see Section A12).
A17.4.10.3
A general risk assessment
d
must be performed for the nanomaterialsd in bulk and in non-
nanoparticled forms (e.g., contained in solid matrix, suspension in solution or slurry,
powdered form, etc.) and included in the WASP.
A17.4.10.4
Proper training on methods involving nanomaterials
d
will be provided by the PI/supervisor.
A17.4.10.5
Chemicals that present a physical hazard caused by a secondary event not related to direct
contact (e.g., fire, explosion, corrosion of equipment, etc.) shall be handled as outlined in in
the WASP (see Section A11) and / or individual SOPs (see Section A12).
A17.4.11
Picric Acid
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A17.4.11.1
Picric acid must be stored hydrated at all times.
A17.4.11.2
A usage log must be maintained for the use of picric acid.
A17.5
Spill Prevention Measures
A17.5.1
Secure containers and equipment to minimize the possibility of tipping.
A17.5.2
Keep containers and experimental equipment as low as possible.
A17.5.3
Plan experimental reactions to anticipate and to provide controls for undesired outcomes
such as overheating.
A17.5.4
Check the material and construction of chemical containers and equipment with a goal of
maintaining structural integrity.
A17.5.5
Use manageable volumes of chemicals.
A17.5.6
Use secondary containment
d
during procedures requiring chemical transfers.
A17.6
Chemical Spill Response
A17.6.1
If the spill involves: 1) greater than four (4) liters of any material, 2) toxic, flammable, corrosive,
or reactive materials, 3) unknown materials, 4) mercury and / or 5) laboratory personnel
d
are not
comfortable responding to the spill, they may use the following procedure:
A17.6.1.1
Stabilize any reactions (if possible);
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A17.6.1.2
Immediately evacuate the lab
d
; and
A17.6.2.3
Contact EHS at 742-3876 immediately for clean-up. Personnel should be immediately available
to convey spill details.
A17.6.2
Spill kits
d
must be appropriate for the chemicals used in the work area. Spill kits
d
supplied by
EHS may not be appropriate for all chemicals.
A17.6.3
General spill response should be evaluated on a case-by-case basis as outlined by 29 CFR
1910.120(q). Lab personnel
d
may clean the spill themselves following the guidance in Appendix
AC if the following criteria are met:
A17.6.3.1
The spill is easily controlled (i.e. a manageable volume and state);
A17.6.3.2
Personnel have been trained on proper spill response and are comfortable cleaning up the spill;
A17.6.3.3
Personnel have access to adequate spill response materials and equipment;
A17.6.3.4
The hazards of the spill are known;
A17.6.3.5
The hazards presented by the spill do not exceed the hazards of routinely working with the
chemical; and
A17.6.3.6
There is a limited possibility of the spill escalating to an emergency situation (e.g., fire, oxygen
deprivation, IDLH, etc.).
A17.6.4
If the spill involves a biological material refer to Section B6 in the Biosafety chapter of the
University Laboratory Safety Manual.
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A17.6.5
If the spill involves radiological materials refer to Section V.(G) in the Radiation Safety chapter
of the University Laboratory Safety Manual.
A17.7
Chemical Review
A17.7.1
Chemicals that have been in inventory for five years shall be assessed by the PI to determine if
the containers and/or chemicals are in acceptable condition to keep in service. These same
chemicals will need to be assessed again every five years.
A17.7.1.1
Once a year each PI that has a chemical inventory assigned to them will be sent a list of
chemicals to review by EHS. This list will be generated from the inventory system currently in
use by EHS.
A17.7.2
Chemical containers shall be assessed by the PI to determine if they have been compromised
through degradation or wear of usage.
A17.7.2.1
If the container is in acceptable condition, ensure the labeling is in accordance with the Globally
Harmonized System.
A17.7.2.2
If the container is compromised, transfer the contents to a new compatible container and label
in accordance with the Globally Harmonized System.
A17.7.3
The chemicals shall be assessed by the PI to determine if the chemicals are acceptable for use
or should be disposed of through EHS.
A17.7.3.1
If chemicals are determined to be acceptable for use, ensure they are to be stored in accordance
to Appendix AA.
A17.7.3.2
If chemicals are determined to not be acceptable or are no longer wanted, label the chemical for
disposal in accordance to Section A19 and submit a waste request for pickup.
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A17.7.4
Upon completion of the Chemical Review the PI will acknowledge this review was completed by
submitting a Chemical Review Form.
A18 RESPIRATORY PROTECTION PROGRAM
A18.1
Respirators shall be selected and used in accordance with the requirements of 29 CFR 1910.134
and TTU OP 60.05.
A18.1.1
Respirators shall be used only where engineering
d
or administrative controls
d
are not practical
and where a respirator-assigned protection factor is sufficient for worker protection.
A18.1.2
The department / supervisor shall provide, at no cost to the employee, the proper respiratory
equipment as determined by EHS.
A18.1.3
Prior to use of any respiratory protective equipment, all personnel required to wear a respirator
for job duties will:
A18.1.3.1
Submit the Occupational Health Program Enrollment Form to EHS;
A18.1.3.1(a)
Personnel requiring a respirator for job duties shall be enrolled in the Occupational Health
Program (OHP) (see Section A15 for more information on the OHP);
A18.1.3.2
Be deemed physically capable of wearing a respirator by a licensed physician using the OSHA
Respirator Medical Evaluation;
A18.1.3.3
Take and pass Respirator Protection Program online training provided by EHS; and
A18.1.3.4
Be fit tested by EHS for a respirator appropriate to the hazard(s).
A18.1.4
All personnel enrolled in the Respiratory Protection Program must complete all steps outlined
under Section A18.1.3 annually.
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A18.1.5
Voluntary use of respirators must complete all steps outlined in Section A18.1.3.
A19 WASTE MANAGEMENT AND DISPOSAL
A19.1
Training for Non-Municipal Wastes
A19.1.1
All requestors must complete online Waste Request training through the EHS website before
submitting pick up requests for universal, chemical, untreated biological or radioactive waste.
A19.2
Waste Segregation and Labeling
A19.2.1
Waste disposal must follow TTU OP 63.06. All universal, chemical, untreated biological and
radioactive waste must be segregated from municipal solid waste
d
to be collected and disposed
of through EHS.
A19.2.1.1
Universal waste is defined in 40 CFR 273.
A19.2.1.1(a)
A completed Universal Waste label must be affixed to waste items/container prior to EHS pick
up. Labels may be obtained from EHS upon request.
A19.2.1.2
Hazardous waste is defined in 40 CFR 261.3.
A19.2.1.2(a)
When waste is first added to a container, waste containers shall be labeled as “Hazardous
Waste” with a waste label provided by EHS with hazardous characteristic(s) indicated as they
pertain to the container contents.
A19.2.1.2(a)(i)
Building – Building name;
Room Number – Room number where waste is being generated; and
A19.2.1.2(b)
During waste collection prior to EHS pick up, complete the remaining waste identification fields.
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A19.2.1.2(b)(i)
pH of contents – Provide pH if known. At minimum, identify as acidic, basic or neutral.
A19.2.1.2(b)(ii)
Contents – Provide full name of each individual chemical waste added to the container upon
addition to the container. Abbreviations or formulas are not acceptable.
A19.2.1.2(b)(iii)
Hazard – Indicate toxic, reactive, flammable, corrosive, poison and / or carcinogenic, etc. as
applicable to the container contents.
A19.2.1.3
Biological waste receptacles must be labeled with a biohazard symbol (see Section B7.4.1.2 in
the Biosafety chapter of the University Laboratory Safety Manual).
A19.2.1.4
Radioactive waste receptacles must be labeled with “radioactive material” labels (see Section
II.H.14 in the Radiation Safety chapter of the University Laboratory Safety Manual).
A19.3
Waste Containers
A19.3.1
Chemical Waste Containers
A19.3.1.1
The container must be in good condition and compatible with the contents to be added.
A19.3.1.2
Chemical containers being repurposed as waste or secondary containers must meet the
following requirements:
A19.3.1.2(a)
Container must be triple rinsed. Each rinse must be at least 1/10 the volume of the container
and collected as hazardous waste. Repurposed containers are not required to be rinsed if
chemical waste is the same as the original contents.
A19.3.1.2(b)
Labels on repurposed containers must be completely covered or removed such that all writing
and symbols are completely illegible prior to affixing EHS Waste label.
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A19.3.1.3
Metal cans are not to be used with corrosive chemical waste.
A19.3.1.4
Food or drink containers are not acceptable as hazardous waste containers.
A19.3.1.5
Venting caps must be used with wastes that have the potential to build up pressure. Caps are
available free of charge from EHS and the Chemistry Department stockroom.
A19.3.1.6
Sharps
d
containers used in chemical laboratories
d
must have the following features: 1) heavy-
duty plastic (e.g., laundry detergent container), 2) stay upright during use, 3) able to close with
a tight-fitting, puncture-resistant lid, 4) leak-resistant.
A19.3.2
Radioactive Waste Containers
A19.3.2.1
Containers for radioactive waste are provided by the Radiation Safety Officer. See Section
II.H.14 in the Radiation Safety Manual for more guidance.
A19.3.3
Glass Waste Containers
A19.3.3.1
Glass waste must be segregated from other solid municipal waste and disposed of in a sturdy,
puncture-resistant, closable box labeled as broken glass. Specific glass disposal boxes are
available from various laboratory vendors.
A19.4
Satellite Accumulation Areas
d
(SAAs)
A19.4.1
All chemical waste shall be managed and stored in the designated Satellite Accumulation Area
(SAA) within work areas. Tubs and SAA signage are provided by EHS. Additional secondary
containers shall be supplied by the PI.
A19.4.2
A waste determination shall be conducted for all waste generated.
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A19.4.2.1
Incompatible wastes (e.g., halogenated and non-halogenated, acid and base, inorganic and
organic, etc.) shall not be mixed. A different container, compatible with the waste, shall be used
to store the waste material.
A19.4.2.2
Waste generation and disposal procedures for all waste streams shall be outlined in the WASP
(see Section A11) and / or individual SOPs (see Section A12).
A19.4.2.3
Contact EHS if mixed waste
d
is to be generated.
A19.4.2.4
Contact EHS for disposal and handling instructions of high hazard waste (e.g., dried picric acid,
ether with high levels of peroxides, explosives, energetic materials
d
, toxic gases, etc.).
A19.4.3
The contents of the SAA shall be inspected weekly for the following: identification of leaking or
compromised containers and spills; containers are kept closed; containers are labeled as
Hazardous Waste; if containers are greater than 3/4 full, submit a Waste request.
A19.4.4
Waste accumulation should not exceed three-quarters (3/4) of the volume of the container.
A19.4.5
Hazardous Waste stored in the SAA shall not exceed 55 gallons of hazardous waste, 1 quart of
acutely hazardous waste, or 1 Kilogram of solid acutely hazardous waste.
A19.4.6
Hazardous waste containers shall always remain closed except for the following: adding waste;
proper operation of equipment; and the prevention of a dangerous situation (buildup of
pressure).
A19.4.7
Waste containers stored on the floor shall be placed in secondary containment
d
to collect spills.
A19.4.8
Waste containers must be kept free of contamination (e.g., outside of liquid collection containers
and inner portions of solid collection containers).
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A19.4.9
Incompatible waste streams shall be segregated into separate secondary containment within the
SAA. (e.g., flammable waste and inorganic acid waste.)
A19.4.9.1
Only appropriately labeled, sealed containers with a corresponding EHS Transaction Number
will be collected during routine collection. The Transaction Number is obtained from the waste
request confirmation email.
A19.4.10
Waste picked up by EHS will be handled according to 40 CFR 262.
A19.5
Glass Waste
A19.5.1
Glass must be decontaminated before disposal in a glass disposal box.
A19.5.2
Full glass disposal boxes should be taped closed and disposed of in a dumpster by the
accumulator.
A20 TRANSPORT AND SHIPMENT OF CHEMICALS
A20.1
Transport of Chemicals on or to TTU Property
A20.1.1
Do not take chemicals to public areas
d
or leave items unattended during transport.
A20.1.2
Chemicals discussed in Section A17.4 may not be transported from their approved storage and
use areas.
A20.1.3
Chemicals must be properly packaged in secondary containment
d
or original shipping packaging
during transport. Absorbent pads are recommended when transporting liquids.
A20.1.4
Chemicals are not to be opened during transport for any reason.
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A20.1.5
A TTU vehicle must be used when transporting DOT-regulated materials on public roadways.
An appropriate spill kit
d
must accompany the transport. Exemptions to this policy may be
addressed though EHS.
A20.1.5.1
TTU personnel transporting DOT-regulated materials must take the DOT-driver training prior to
transporting items. This training must be renewed every two years.
A20.1.6
Transporting chemicals between buildings on foot must be done using a laboratory cart. An
appropriate spill kit
d
should accompany the transport.
A20.1.7
Spills between work areas inside of a building may be cleaned up by the transporter. Spills that
occur outside of buildings must be cleaned up by EHS. Personnel should notify EHS immediately
at 742-3876.
A20.2
Shipment of Hazardous Materials
A20.2.1
EHS shall be notified about all chemical or biological shipments when:
A20.2.1.1
Shipments to or from the University are intiated by TTU personnel (i.e. TTU personnel is the
shipper
d
); or
A20.2.1.2
TTU personnel are importing materials to the University or exporting materials from the
University.
A20.2.1.3
EHS can assist in identifying applicable shipping requirements.
A20.2.2
Personnel offering hazardous materials for shipping must have completed Hazardous Material
Shipping training through EHS or be able to submit a valid certificate showing completion from
an acceptable entity;
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A20.2.3
A completed Material Shipping Form must be submitted to EHS prior to shipment. A SDS
d
for
the material must be provided to EHS if one is not found in ChemWatch
d
.
A20.2.4
All shipments must meet the requirements put forth in of the Department of Transportation 49
CFR 100-185 and the International Air Transportation Association Dangerous Goods
Regulations.
A20.2.4.1
In accordance with 29 CFR 1910.1200 (b)(3)(iv), hazardous chemical containers must be
labeled with: 1) product identifier, 2) signal word, 3) hazard statement(s), 4) pictogram(s),
precautionary statement(s), and 6) name, address, and telephone number of the chemical
manufacturer, importer, or other responsible party.
A20.2.4.1(a)
The required information in A20.2.4.1 must be located together on the label, tag or mark.
A20.2.4.1(b)
The required information in A20.2.4.1 must not conflict with the requirements outlined in DOT 49
CFR 100-185.
A20.2.5
Chemical shipments being returned to the vendor must meet the requirements outlined in
Section A20.2.
A20.2.5.1
Return of chemicals to the vendor due to vendor error is not advised. Contact EHS regarding
chemical returns.
A20.2.6
Proprietary materials may be subject to a Material Transfer Agreement (MTA) if the material was
developed or recovered at Texas Tech University/Texas Tech University Health Sciences
Center. Visit http://www.depts.ttu.edu/vpr/ors/preaward/forms-boilerplates.php for more
information.
A20.2.7
For details regarding the transport and shipment of biological materials, see Section B12 in the
Biosafety chapter of the University Laboratory Safety Manual.
A21 CHEMICAL GATEWAY
d
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A21.1
Procurement of Chemicals for Laboratories
d
A21.1.1
Laboratory
d
and non-laboratory chemical purchases are approved by EHS.
A21.1.2
Laboratory
d
chemical deliveries must be shipped to TTU Central Receiving, 3122 Main Street,
Lubbock, TX 79409.
A21.1.2.1
Compressed gases are to be delivered to the immediate work area.
A21.1.3
Chemicals shall be purchased through TechBuy
d
.
A21.1.3.1
The principal investigator responsible for the chemical and the building and room number where
the chemical will be stored must be included on the Purchase Order.
A21.1.4
Chemicals unavailable for purchase through TechBuy
d
may be purchased using a TTU
Procurement Card. EHS approval must be granted prior to purchase.
A21.1.5
Procurers should review Safety Data Sheets
d
(SDSs) for chemicals not previously purchased to
ensure proper administrative
d
and engineering controls
d
are in place to address hazards.
A21.1.6
For procurement of biological material, see Section B8.3 in the Biosafety chapter of the
University Laboratory Safety Manual.
A21.1.7
For procurement of radioactive material, see Section II.H.3a in the Radiation Safety chapter of
the University Laboratory Safety Manual.
A21.2
Chemical Inventory for Laboratories
d
A21.2.1
In general, items with CAS number(s) will be entered into the PI’s online chemical inventory.
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A21.2.1.1
Chemical mixtures will be barcoded according to the most relevant CAS number as determined
by EHS.
A.21.2.2
Chemical containers must be properly labeled as defined by 29 CFR 1910.1200 (f)(6)(ii) before
inventory.
A21.2.2.1
Inadequately labeled chemicals will be held at the Chemical Gateway
d
until full GHS label
information is submitted to EHS by the responsible party.
A21.2.3
Properly labeled chemicals will be barcoded when entered into the PI’s online chemical
inventory.
A21.2.3.1
The large number on the barcode designates the chemical storage group as defined in Appendix
AA.
A21.2.3.2
Chemicals with a NFPA health hazard rating of 3 or 4 will have a blue dot affixed to the EHS
barcode. Such chemicals should be treated with caution.
A21.2.3.3
Chemicals in storage Group 9 (Compatible Pyrophoric and Water Reactive Materials) shall be
stored according to their respective SDS.
A21.2.4
When a chemical container is emptied, the yellow portion of the EHS barcode must be removed,
affixed to a Barcode Return Form and returned to EHS at Campus Mail Stop 1090.
A21.2.5
PI inventory access is granted after all required EHS safety training is completed and WASP
(see Section A11) is submitted to EHS.
A21.2.6
A Chemical Transfer Sheet must be completed and submitted to EHS for barcoded chemicals
being permanently transferred from their storage locations.
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A21.2.7
A Barcode Request Form must be completed for chemicals received without a barcode. Submit
completed forms to ehs.lab.safety@ttu.edu. Barcode(s) will be campus mailed to the Mail Stop
indicated on the form.
A21.3
Damaged packages may not be accepted by TTU Central Receiving personnel.
A21.3.1
EHS will notify the PI of rejected chemical purchases and offer assistance in initiating a
replacement.
A21.4
Accepted packages containing compromised chemical containers will be treated as hazardous
waste.
A21.4.1
EHS will notify the PI of compromised containers and initiate obtaining a replacement with the
vendor.
A21.5
Incoming chemical shipments from collaborators or other institutions must be disclosed to EHS
prior to the arrival of the shipment.
A21.6
Barcoded chemical containers will be repackaged in original shipping packaging and delivered
to the designated location by EHS.
A22 CHEMICAL FUME HOODS
A22.1
Chemical Fume Hood Operating Procedures
A22.1.1
Chemical fume hoods are required to be functioning properly.
A22.1.2
Specific measures shall be in place and taken to ensure proper and adequate performance of
chemical fume hoods.
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A22.1.3
Each PI/supervisor must ensure that all personnel within their work area(s) are trained in the
safe use of chemical fume hoods (see Section A14).
A22.1.4
Chemical fume hoods are required to have a visual indicator of air flow.
A22.1.5
All manipulations must be at least six (6) inches inside the chemical fume hood face. A line
drawn on the work surface six inches inside the face can be an effective reminder.
A22.1.5.1
Laboratory equipment shall be located as far back in the chemical fume hood as practical.
A22.1.6
Chemical fume hood exhaust slots shall not be blocked.
A22.1.7
Elevate large pieces of equipment off the work surface.
A22.1.8
Chemical fume hoods shall be kept clear of excess storage.
A22.1.9
The chemical fume hood sash should be kept as low as possible to perform work and not raised
above the indicated sash height except when loading / unloading large equipment.
A22.1.10
The chemical fume hood sash must be fully closed when not actively manipulating materials
inside the chemical fume hood.
A22.2
Chemical Fume Hood Surveillance Program
A22.2.1
Chemical Fume Hood Flow Requirements
A22.2.1.1
Chemical fume hoods shall have an average airflow of 80 - 100 feet per minute.
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A22.2.1.2
Chemical fume hoods where radioactive material is used shall have an average airflow of 100 -
120 feet per minute.
A22.2.1.3
“Low flow” chemical fume hoods shall be certified based on manufacturer specifications.
A22.2.2
Routine Chemical Fume Hood Performance Surveys
A22.2.2.1
Hood face velocity surveys will be conducted annually by EHS.
A22.2.2.2
Calibrated airflow measuring devices capable of accurately measuring air velocity in the range
of 0 to 1500 feet per minute will be used.
A22.2.2.3
A typical chemical fume hood survey procedure involves performing a multi-point traverse in the
plane of sash travel. The average face velocity (the arithmetic mean of these point readings) is
then calculated and recorded.
A22.2.2.4
Additional notations or comments, such as excessive storage in the chemical fume hood,
sashes or unusual velocity readings are noted during the survey.
A22.2.2.5
If the chemical fume hood is performing to established standards, an adhesive sticker is
completed and posted on the sash of the hood at the time of the survey.
A22.2.2.6
The supervisor will be notified of any unusual findings or extreme deficiencies of the chemical
fume hood by a posted 'out-of-service' tag on the sash of the fume hood.
A22.2.2.6(a)
TTU Physical Plant must be contacted by laboratory personnel
d
to address the functioning of the
chemical fume hood.
A22.2.2.6(b)
Once the issue with the chemical fume hood is resolved, EHS needs to be notified to return to
the laboratory
d
to test the chemical fume hood for proper operation.
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A23 NON-COMPLIANCE
A23.1
Section A24, laboratory
d
closure, will be followed in situations where non-compliance resulted in
conditions immediately dangerous to life and/or health or an incident
d
occurred.
A23.1.1
Non-compliance will be addressed on a case-by-case basis. The following will be considered
non-compliance:
A23.1.1.1
Work areas in which critical findings
d
are not corrected upon follow-up survey
d
which will occur
no less than 30-calendar days after the initial survey
d
.
A23.1.1.2
Work areas where the specific finding(s)
d
on three consecutive surveys
d
are identical.
A23.1.1.3
Laboratory personnel, Principal Investigators, or other personnel who fail to comply with safety
policies or direct instruction from a safety authority (e.g., EHS, DSO, supervisor, instructor,
etc.).
A23.2
The following measures will be taken to restore safety in non-compliant work areas.
A23.2.1
The Department of Environmental Health & Safety (EHS) will inform the Institutional Laboratory
Safety Committee (ILSC) of incidences of work area non-compliance. The nature of the
finding(s)
d
and any history of delinquency will also be presented to the ILSC for their
consideration.
A23.2.2
The ILSC will determine any additional timeline allowed for findings
d
to be corrected and the
consequences if findings are left unaddressed.
A23.2.3
Non-compliant work areas will be placed on a quarterly
d
inspection schedule. The duration of
the quarterly
d
survey
d
schedule will be determined by the ILSC.
A23.2.4
Information from the committee’s decisions regarding A23.2.2 and A23.2.3 will be conveyed in
a letter from the committee. This letter will be electronically delivered to the work area
supervisor’s university email account. A hard copy of the letter will also be sent via campus mail.
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A copy of the letter will also be sent in hard copy and electronically to the corresponding
department chair, dean, department safety officer and college safety officer.
A23.2.5
Cases of serial non-compliance will result in laboratory
d
closure.
A23.3
The following measures will be taken to restore safety compliance with non-compliant individuals
in research spaces.
A23.3.1
The non-compliant individual may be removed from the work area if deemed necessary.
A23.3.2
Provisions for return to the work area will be dictated by the safety authority to include
remediation to address the non-compliant behavior.
A23.3.3
EHS or safety authority will inform the supervisor in writing if lab personnel are removed from
the work area.
A23.3.3.1
The supervisor will be informed in writing if the work area is deemed unsafe with the letter copied
to departmental chairperson, academic Dean, and VPR office.
A23.4
The following measures will be taken to restore safety compliance with non-compliant individuals
in teaching spaces.
A23.4.1
The non-compliant individual may be removed from the work area if deemed necessary,
including Campus Security as appropriate.
A23.5
Repeated instances of non-compliance will be referred to the Director or Department Chair
responsible for that unit that will include a conference with EHS and may be considered
excessive non-compliance and initiate procedures outlined in Section A4.6.
A24 LABORATORY OR STUDIO SPACE CLOSURE
A24.1
Conditions for Closure
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A24.1.1
Closure of a work area is considered on a case-by-case basis.
A24.1.1.1
Closure refers to a spectrum of restrictions which include but is not limited to: signage restricting
entry, prohibited entry and / or work during specified work hours or re-keying of the work area(s).
A24.1.1.2
Personnel will be allowed to enter the work area if the environment is deemed safe by the CHO
to stop or stabilize operations to prevent incidents during closure.
A24.1.2
A work area that poses an immediate danger to life or health (IDLH situation) may be closed
immediately by EHS.
A24.1.3
A laboratory
d
or studio space that is chronically and / or seriously non-compliant with the
practices outlined in the University Laboratory Safety Manual or the Work Area Safety Plan
(WASP) may be closed as recommended by the relevant institutional safety committee(s).
A24.1.4
A laboratory
d
or studio space in which an event has occurred that requires EHS investigation
may be closed.
A24.1.4.1
If a significant event occurs during normal business hours, an evaluation will be performed to
determine if the work area is compliant with applicable regulations.
A24.1.4.1(a)
If there are no issues or if issues can be resolved by the end of that work day, the work area will
not be re-keyed.
A24.1.4.1(b)
If the issues are unable to be addressed that work day, the work area will be re-keyed and will
stay re-keyed until all issues have been addressed.
A24.1.4.2
If a significant event occurs after normal business hours, the work area may be closed or re-
keyed until an evaluation can be performed the following business day to determine if the work
area is compliant with applicable regulations.
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A24.2
Procedures for Closure
A24.2.1
The Office of the Vice President for Research, in consultation with the CHO, DSO / department
and relevant institutional safety committee(s), will issue a written memorandum (or email, as
appropriate) to the supervisor(s), Department Chair and Dean of the College which includes: 1)
the reason(s) for (potential) closure, 2) corrective action(s) to be taken, 3) modification(s) to
administrative
d
or engineering control(s)
d
, 4) a correction period
d
and any other pertinent
information (e.g., work restrictions, allowable maintenance operations, etc.).
A24.2.2
The PI(s)/supervisor(s) and/or suitable departmental representative will be invited via explicit
email to the relevant institutional safety committee(s) meeting(s) to address the compliance
issues.
A24.2.2.1
The PI(s)/supervisor(s) and/or suitable departmental representative (e.g., department chair) will
be excused prior to final discussion and vote.
A24.2.3
The relevant institutional safety committee(s) will decide the merits of the appeal and either issue
a revised correction period
d
to readdress the compliance issues, accept the appeal without
closure, or continue with the original correction period
d
.
A24.2.4
Supervisor Actions
A24.2.4.1
The supervisor shall report, in writing, any condition(s) outside of their control which delay
corrective action(s) to the relevant institutional safety committee(s) and / or EHS;
A24.2.4.2
The supervisor may appeal, in writing, the work area closure outlined in Section A23.2.1 to the
relevant institutional safety committee(s) subsequent to the closure.
A24.2.5
If the issues described in Section A23.2.1 are not corrected as required by the relevant
institutional safety committee(s) in the time indicated, the work area(s) may be closed and re-
keyed until the compliance issues are corrected.
A24.2.6
Conditions for Resumption
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A24.2.6.1
The issues described in Section A23.2.1 must be corrected before the work area is reopened.
A24.2.6.1(a)
The work area will remain closed until the EHS can perform an evaluation to ensure the work
area is in compliance with applicable regulations.
A24.2.6.2
The work area will be returned to the department once all compliance issues are resolved, the
investigation into the incident is complete and/or the work area is compliant with applicable
regulations.
A24.3
EHS will offer assistance and additional training as needed to resolve compliance issue(s) and
complete corrective action(s).
A25 DECOMMISSIONING A WORK AREA
A25.1
General Information
A25.1.1
Supervisors vacating a work area are required to properly dispose of any hazardous materials
and decontaminate the work area and equipment prior to departure. See Appendix AK for the
Laboratory Decommissioning Checklist.
A25.1.1.1
Laboratory personnel
d
are responsible for packing and moving the laboratory
d
. Labels with the
PI’s name, a content description and any hazard information shall be affixed to all boxes.
A25.1.1.2
All waste generated in the work area must be disposed of properly through EHS.
A25.1.2
The supervisor will notify EHS that a work area is to be decommissioned no less than 30
calendar days prior to departure.
A25.1.2.1
Laboratories
d
that have or have had radioactive materials are required to notify the Radiation
Safety Officer (RSO) of the move 30 days prior to departure or when known. The RSO will direct
the laboratory decommissioning of these spaces and will clear the laboratory
d
once
decommissioning is complete.
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A25.1.3
EHS will inspect the work area to identify the hazards to be addressed. A second inspection will
be conducted to confirm all identified hazards are mitigated and to clear the work area for
renovation and / or new occupancy.
A25.1.4
If a supervisor departs before the work area is decommissioned, the department will take over
the area and complete decommissioning as time allows.
A25.2
Allowable Material Transfers
A25.2.1
Hazardous materials left in a work area by a PI become the property of EHS upon the PI’s
departure. Materials will be reallocated or destroyed.
A25.2.2
Opened and unopened chemicals may be transferred to a different PI at TTU by submitting a
Chemical Transfer Form to EHS.
A25.2.3
Transfer of materials under the perview of the Institutional Laboratory Safety Committee,
Institutional Biosafety Committee or Radiation and LASER Safety Committee must be
coordinated through the relevant institutional safety committee(s)
d
.
A25.2.4
Equipment may be transferred to a different PI at TTU following appropriate decontamination
before removal from the work area. Receiving party may request EHS clearance of equipment.
A25.2.4.1
Thermometers and other loose items shall be removed from equipment and packaged
separately.
A25.2.4.2
Oil and water shall be drained from pumps, baths and other equipment and disposed of in the
appropriate waste stream.
A25.2.4.3
Furniture and fixtures are to be left in the laboratory
d
unless an item is essential to a piece of
equipment that is eligible to be moved.
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A25.2.5
Compressed gases shall be capped and secured. Arrangements shall be made with the vendor
if gases are to be moved to a new campus location. Empty tanks shall be returned to the
vendor. Contact EHS for disposal of non-returnable tanks.
A26 REVIEWS AND UPDATES
A26.1
The University Chemical Hygiene Plan will be reviewed and, if necessary, updated annually.
The ILSC is responsible for initiating this review.
A26.2
A list of departmental representatives
d
will be updated annually by the CHO as received by
department heads.
A26.3
The departmental representatives
d
shall review and evaluate the effectiveness of the CHP at
least annually and forward any suggestions or updates to the CHO for review and filing with the
ILSC.
B-i
TABLE OF CONTENTS
RECENT CHANGES B-iv
B1 PURPOSE AND POLICY STATEMENT B-1
Purpose B-1
Policy B-2
B2 IMPORTANT CONTACT INFORMATION B-3
Emergency Assistance Information B-3
University Emergency Assistance Numbers B-3
Safety and Compliance Committee Contact Information B-4
B3 USEFUL ACRONYMS AND DEFINITIONS B-5
Acronyms B-5
Definitions B-8
B4 RESPONSIBILITIES B-13
Department of Environmental Health and Safety B-13
Principal Investigators B-14
Institutional Biosafety Committee B-16
B5 BIOCONTAINMENT B-17
Biosafety Levels B-17
Table 1. Summary of Biosafety Levels B-19
Animal Containment B-19
Arthropod Containment B-20
Plant Containment B-20
B6 CLASSIFICATION OF BIOLOGICAL MATERIALS B-20
Introduction B-20
Risk Groups B-21
Genetically Engineered Microorganisms and Organisms B-22
Human and Non-Human Primate Materials B-25
Biologically Derived Toxins B-26
Prions and Prion-like Proteins B-26
B-ii
Respiratory Viruses B-27
B7 EMERGENCY PROCEDURES B-28
Biological Spills B-28
BioSpill Kit Contents B-28
General Spill Clean Up Guidelines B-29
With broken glass B-31
Human Fluids B-31
In a Biosafety Cabinet B-31
In a Centrifuge B-32
Illness or Injury Involving Biological Materials B-32
Fires Involving Biological Materials B-33
B8 DECONTAMININATION AND DISPOSAL B-34
Factors Contributing to Destruction/Inactivation of Biological Materials B-34
Properties of Chemical Disinfectants B-35
Management of Biologically Contaminated Materials and Waste B-39
Collection and Disposal Containers B-40
Treatment of Biologically Contaminated Materials and Waste B-41
Regulations Pertaining to Chemical Disinfection of Biological Wastes B-42
Steam Disinfection (Autoclaving) B-44
Equipment specifications B-44
Preparing Materials and Loading the Autoclave B-48
Summary of Biological Waste Treatment and Disposal by Generators B-50
Biowaste Pick-up by EHS B-52
Disposal of Animal Tissues, Carcasses, & Bedding B-54
Plant & Seed Devitalization B-54
Other Common Waste Issues in Biological Laboratories B-54
B9 BIOLOGICAL LABORATORY OPERATION B-56
Risk Management B-56
Identification of Hazards B-56
Risk Assessment B-56
B-iii
Risk Control B-59
Biological Work Area Safety Plan (BioWASP) B-60
Personal Protective Equipment (PPE) B-61
Working with Biological Materials B-63
The IBC Protocol Application B-64
BSL1 Requirements B-67
BSL2 Requirements B-69
ABSL1 Requirements B-70
ABSL 2 Requirements B-71
ACL 1 Requirements B-72
ACL 2 Requirements B-73
PCL1 Requirements B-75
PCL 2 Requirements B-75
Collection and Manipulation of Human Materials B-76
Basics to Aseptic Technique B-76
Sharps Management B-77
Entry of non-Lab Personnel into Containment Level 2 Spaces B-78
B10 COMMON LABORATORY EQUIPMENT USAGE B-80
Biosafety Cabinets B-80
Laminar Flow Hood B-85
Centrifuge B-85
Vacuum Lines and Pumps B-85
B11 DECONTAMINATION AND DECOMMISIONING OF LABORATORY EQUIPMENT B-86
General Information B-86
Hazard Assessment B-87
EHS Clearance of Decontaminated Equipment B-87
Considerations for Common Equipment B-88
B12 DECOMMISIONING A LABORATORY SPACE B-90
General Information B-90
Decontamination B-90
B-v
RECENT CHANGES
2023 update
We would like to reiterate that checklists for basic biosafety at BSL1 and BSL2 containment were
amended to reflect the requirements in the 6
th
edition of the BMBL in November of 2021. Certain
requirements for all laboratories from the CHP have been reiterated in the BSL1 checklist. These
are not new requirements.
Verbiage has been clarified regarding sinks and sharps containers at BSL1. A plumbed sink and
eyewash are both required in the immediate (vs adjacent) work area at BSL1. There is no
delineation of BSL1 vs other biocontainment in the regulations for the management of sharps. The
use of FDA-approved containers (i.e., puncture-proof and securable) is required for the disposal of
sharps in all biological laboratories.
Guidelines for double gloving have been added.
Policy changes
Special criteria have been added for animal (ABSL), plant (PCL), and arthropod (ACL)
containment. These sections will continue to be expanded and updated as program needs are
assessed. The checklists are located in section B9.2.3 Special Considerations for Certain
Research Foci. References to biosafety level have been changed to containment level given the
formalization of these new types of biocontainment areas.
B9.2.1 Regarding IBC protocol registration has been amended to address the transition to the
online cloud-based Cayuse application. As announced in January 2023, all new protocols,
protocol renewals, and protocol amendments will be completed within the Cayuse system. To get
started in Cayuse, researchers and laboratory personnel will need to complete the personnel form
to be added to the system. More information is provided on the IBC registration page:
https://www.depts.ttu.edu/ehs/academicsafety/Biosafety/protocolregistration-bio.php
B6.5 Biologically Derived Toxins section was added. These materials are subject to IBC oversight.
Responsibilities to the PI and IBC in section B4 were also added to reflect this change.
B6.6 Prions and Prion-like Proteins was added. These materials are subject to IBC oversight.
Responsibilities to the PI and IBC in section B4 were also added to reflect this change.
B6.7 Respiratory Viruses was added. These materials are subject to work using BSL2 Enhanced
requirements.
B9.2.2.1(a) Cleaning equipment (i.e., brooms, mops, buckets, etc.) is dedicated to the work area
for all containment levels.
B10.1.4.4 was amended to state that the PI is responsible for coordination and completion of
annual BSC certification. This change was made so that our policies are not misinterpreted to
imply that PIs are financially liable for certification. The financially responsible party (or parties) for
BSC certification is determined by the department/college/school.
B-1 BSM Table of Contents
B1 PURPOSE AND POLICY STATEMENTS
B1.1
Purpose
This document serves as a statement of official Texas Tech University policy to establish and
maintain compliance with the documents listed below. Where there is conflict or overlap between
state or federal regulations and TTU policies, the most protective provisions shall be used.
The chapters that comprise the University Laboratory Safety Manual are managed by separate
institutional committees; changes may be made in one document prior to another. If there are
questions about conflicting information, please contact EHS regarding the situation so that such
matters can be addressed.
Biological laboratories are subject to additional requirements outlined in other sections of the
University Laboratory Safety Manual (LSM) as they apply to the work area – this includes the
appendices. Some information from other sections is referenced in this manual.
National Institutes of Health Guidelines for Research Involving Recombinant or Synthetic Nucleic
Acid Molecules (NIH Guidelines), April 2019.
Biosafety in Microbiological and Biomedical Laboratories (BMBL), 6th edition.
Select Agent Regulations 7 CFR 331, 9 CFR 121, and 42 CFR 73.
OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030.
Transportation of Hazardous Materials Regulations 49 CFR Subchapter C
International Air Transport Administration
Texas Administrative Code: 25 TAC 1 Subchapter K, and 30 TAC 326
Texas Tech University Operating Policies
B-2 BSM Table of Contents
B1.2
Policy
Texas Tech University is actively committed to preserving the health and safety of its students,
staff, and faculty and to protecting the environment and the surrounding community. It is
recognized that use of microorganisms, organisms containing recombinant/synthetic nucleic acids,
disease vectors, and human and animal materials is necessary in many university research and
teaching laboratories.
To ensure the safe handling of these materials, Texas Tech University requires compliance with
the guidelines and regulations listed in section B1.1, as well as other resources as they apply to
the Biosafety Program. Compliance with other applicable federal, state, local and University
regulations not specifically mentioned in section B1.1 is also required.
In an effort to facilitate a culture of safety at Texas Tech University, biosafety training pertinent to
the content of this manual is required for all individuals prior to beginning work with biological
materials as appropriate and biennially thereafter for all students, faculty, and staff working with
such materials.
Texas Tech University policy requires compliance to state and federal regulations regarding the
use of potentially hazardous biological materials; thus, certain research involving such materials
requires proposal submission and review regardless of sponsorship prior to work commencing.
The most current copy of the University Laboratory Safety Manual (LSM) is available for download
from the EHS website at https://www.depts.ttu.edu/ehs/. The direct link to the LSM is
https://www.depts.ttu.edu/ehs/academicsafety/labsafetydocs/LabSafetyManual.pdf.
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B2 IMPORTANT CONTACT INFORMATION
B2.1
IF YOU HAVE AN EMERGENCY AND REQUIRE FIRE & RESCUE, POLICE, OR EMERGENCY
MEDICAL SERVICE, CALL 911.
B2.2
University Emergency Assistance Numbers
B2.2.1
Environmental Health & Safety
• Emergency during University Operating Hours 806-742-3876
24-Hour Emergency Contact (Maintenance & Operations – including EHS)
• 806-742-4OPS (4677)
B2.2.2
University Police Department
• Emergency 911
• Non-Emergency 806-742-3931
B2.3
Safety and Compliance Contact Information
B2.3.1
Environmental Health & Safety (EHS) Contacts and Information
EHS: https://www.depts.ttu.edu/ehs/; Directory: https://www.depts.ttu.edu/ehs/staff/index.php
Email: safet[email protected]
Academic Safety (Lab): https://www.depts.ttu.edu/ehs/academicsafety/index.php
Email: ehs.lab.safety@ttu.edu
Environmental Protection (Waste): https://www.depts.ttu.edu/ehs/environmental/index.php
Email: ehs.environmental.safety@ttu.edu
Occupational Health Program: https://www.depts.ttu.edu/ehs/occupationalsafety/OHP/index.php
Email: ehs.[email protected]
Safety Training: https://www.depts.ttu.edu/ehs/Training/index.php
Email: ehs.safety.t[email protected]
TTU System Risk Management: https://www.texastech.edu/offices/risk-management/
Office Phone: 806-742-0212
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B2.3.2
Compliance Committee Contact Information
Institutional Biosafety Committee Webpage:
http://www.depts.ttu.edu/ehs/academicsafety/icc/ibc.php
Email: ibc.[email protected]
Institutional Laboratory Safety Committee Webpage:
http://www.depts.ttu.edu/ehs/academicsafety/icc/ilsc.php
Email: ilsc.[email protected]
Institutional Animal Care and Use Committee Webpage: http://www.depts.ttu.edu/iacuc/
Email: iacuc@ttu.edu
Radiation and Laser Safety Committee Webpage:
http://www.depts.ttu.edu/ehs/academicsafety/icc/irlsc.php
Institutional Review Board Webpage: http://www.depts.ttu.edu/research/irb/
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B3 USEFUL ACRONYMS AND DEFINITIONS
B3.1
Acronyms
AAALAC – Association for Assessment and Accreditation of Laboratory Animal Care
ABLS1 – Animal Biosafety Level 1
ABSL2 – Animal Biosafety Level 2
ABSL3 – Animal Biosafety Level 3
ABSA – American Biological Safety Association
ACL1 – Arthropod Containment Level 1
ACL2 – Arthropod Containment Level 2
ACS – Animal Care Services
BMBL – Biosafety in Microbiological and Biomedical laboratories
BSC – Biosafety Cabinet
BSL – Biosafety Level
BSL1 – Biosafety Level 1
BSL2 – Biosafety Level 2
BSL/ABSL2 - Ag – Animal Biosafety Level 2 Agriculture
BSL3 – Biosafety Level 3
BSL/ABSL3 - Ag – Animal Biosafety Level 3 Agriculture
BSM – University Biosafety Manual
BSO – Biological Safety Officer
CDC – Center for Disease Control
CFR – Code of Federal Regulations
CHO – Chemical Hygiene Officer
CHP – Chemical Hygiene Plan
Co-PI – Co-Principal Investigator
DOT – Department of Transportation
DSO – Departmental Safety Officer
EHS – Environmental Health and Safety
EPA – Environmental Protection Agency
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ERP – Emergency Response Plan
FAA – Federal Aviation Administration
FWS – US Fish & Wildlife Service
GMO – Genetically Engineered/Modified Organism
HAZWOPER – Hazardous Waste Operations and Emergency Response
HEPA – High Efficiency Particulate Air
IACUC – Institutional Animal Care and Use Committee
IATA – International Air Transport Administration
IBC – Institutional Biosafety Committee
IFDC – Institutional Financial Disclosure Committee
ILSC – Institutional Laboratory Safety Committee
IRB – Internal Review Board
IRLSC - Institutional Radiation and LASER Safety Committee
ISO – International Organization for Standardization
LSM – University Laboratory Safety Manual
NIH – National Institutes of Health
NIH-OSP – National Institutes of Health, Office of Science Policy
NIOSH – National Institute for Occupational Safety and Health
OHP – Occupational Health Program
OSHA – Occupational Safety and Health Administration
PCL1 – Plant (or environmental) Containment Level 1
PCL2 – Plant (or environmental) Containment Level 2
PI – Principal Investigator
rNA/sNA – recombinant / synthetic nucleic acid
RG – Risk Group
RSO – Radiation Safety Officer
SA – Select Agent(s)
SCAN – Safety Concern and Near-Miss
SDS – Safety Data Sheet
SOP – Standard Operating Procedure
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B3.2
Definitions
Aseptic technique - a set of practices that when used, serve to minimize, or prevent contamination
to the worker, the work area, the items being manipulated, and/or others.
Administrative Controls – (i.e., work practice controls) are work procedures such as written safety
policies, rules, supervision, schedules, and training implemented to reduce the duration, frequency,
and severity of exposure to a hazard.
Antisepsis – the application of a liquid antimicrobial chemical to living tissue with the intent to
prevent infection. Antiseptics and germicides are used to prevent infection on living
humans/animals and are thus not disinfectants but drugs, regulated by the FDA.
Biological Risk Assessment – Regarding biological risks, the continual process of identifying the
hazardous characteristics of an agent or material (if known); the activities that can result in
exposure to an agent; the likelihood that such exposure will cause disease; and the probable
consequences of such an infection. Generally speaking, risk assessment is the continuous and
evolving analysis of hazards through the sciences and perceptions that are associated with the
materials, personnel, and work procedures/operations; evaluating the probability an identified
hazard will result in an effect (as a function of frequency and severity of the risk).
Biological Risk Management – The continual process of developing strategies (i.e., identifying
actions, equipment, training, PPE, etc.) and implementations of these strategies to control, reduce,
and/or eliminate risks posed by identified hazards.
Biohazard – a material/substance that harbors or could potentially harbor a biological agent that
presents a potential risk to the health of humans, animals, or the environment.
Biosafety –the containment principles, technologies, and practices that are implemented to prevent
the unintentional exposure to or accidental release of biological materials; synonymous with
biological safety.
Biosafety Cabinet (BSC) – containment equipment designed to protect personnel and the
environment from biohazards present within the cabinet when used properly. Some BSCs also
protect the materials within the cabinet from contamination. There are three classes of cabinets
(Class I, II, and III); class II BSCs are further divided into types: A1 (formerly A), A2 (formerly B3),
B1, B2, and C1(new type as of 2017). Class and type are determined by differences in inflow
velocity, ducting/exhaust, and portion of air recirculated within the BSC interior.
Biosafety Level (BSL) – In the United States, this refers to ascending levels of containment for
handling biological agents that pose different levels of risk to the workers and the environment;
consist of combinations of laboratory procedures, practices, safety equipment, and laboratory
facilities which allow manipulation of biological agents of increasing danger to life and health. In
the BMBL document put forth by CDC & NIH, four levels of containment are identified; these levels
build on each other from 1-4 as containment needs increase.
Biosecurity –the protection, control and accountability for biological materials and research-related
information within laboratories in order to prevent their unauthorized access, loss, theft, misuse,
diversion or intentional release; synonymous with biological security.
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Biowaste – comprised of animal waste (carcasses, body parts/fluids and bedding of animals
intentionally exposed to potential pathogens), animal cell cultures, human and non-human primate
blood/body parts/cultures, microbiological waste (cultures, stocks, specimens, transfer devices,
etc.) pathological waste, and sharps as these terms are defined in 25 TAC §1.132; any enriched
sample/specimen; samples/specimens that are reasonably considered to contain, have be
purposefully exposed to, or tested positive for a pathogen.
(Biological) Work Area Safety Plan – a laboratory-specific manual that identifies the hazards that
will or may be encountered, and that specifies practices and procedures designed to minimize or
eliminate exposures to these hazards. Personnel must be advised of special hazards and are
required to read and follow the required practices and procedures. May also be referred to as a
bioWASP, WASP, biosafety manual, etc. See B9.1.3.1.
Chemical disinfectant – chemicals used to render a contaminated material safe for further
handling. Except for, bleach, ethanol or isopropanol, only use chemical disinfectants that are
registered by the EPA. Lists are available at http://www.epa.gov/oppad001/chemregindex.htm
-cidal – kills or inactivates an agent or material. (e.g., bactericidal, fungicidal, sporicidal,
tuberculocidal, virucidal, etc.)
Cleaning – the removal of foreign material, such as soil or other organic material, from objects or
surfaces through water with detergents/enzymes. Cleaning is necessary for high-level disinfection
and sterilization as inorganic and organic matter interferes with the efficacy of these processes.
Additionally, failure to remove material may result in buildup and/or biofilm formation; thus, further
difficulties to disinfect and/or sterilize for further applications.
Contact time – the duration of exposure required for a disinfectant to effectively destroy or
irreversibly inactivate a biological agent.
Contamination – the presence of an unwanted or potentially hazardous agent, material or
substance.
Containment – Series of barriers that provide protection to workers and the environment.
Containment level – laboratory classification for the nature of the biohazards present; may be a
general biosafety level (BSL) or denote specific hazards such as plants (PCL), animals (ABSL), or
arthropods (ACL).
Co-Principal Investigator – see principal investigator
Decontamination – the removal or neutralization of a hazardous/unwanted agent or the
destruction/removal of microorganisms to some acceptable level, which may not necessarily be
zero, but is generally considered safe. Cleaning, sanitation, disinfection, antisepsis, and
sterilization are all forms of decontamination.
Dignitary – any representative from a federal or state regulatory agency, industry, law enforcement
officials, investors, etc.
Disease vector – any agent which acts as an intermediary to carry and/or transmits an infectious
agent to another living organism, primarily concerns arthropods.
Disinfection – the use of a (generally) chemical or thermal procedure or procedures that eliminates
nearly all recognized pathogenic microorganisms/agents on inanimate objects; efficacy is
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dependent on multiple factors. Disinfection destroys or irreversibly inactivates all infectious fungi
and bacteria but not their spores, thus does not ensure “kill” level. Disinfectants can be “general”
or “hospital’ grade. Hospital grade disinfectants are required in areas where human materials are
used. These disinfectants consist of EPA-registered tuberculocidal agents, a registered germicide
on the EPA Lists D & E or a freshly made 1:10 dilution of household bleach.
Engineering Controls – includes designs or modifications to plans, facilities, equipment, ventilation
systems, and processes that reduce the source of exposure.
Exposure – The condition of having contact with a potentially harmful agent, material or substance.
What is defined as “exposure” will differ with the hazard. Routes of exposure in a laboratory are
injury/injection, absorption, ingestion and inhalation.
Fomite – an inanimate object or surface that can, when contaminated, serve as a source of agent
transmission.
Generator – in regard to biowaste, the party responsible for producing the waste.
Genetically Engineered/Modified Organism or Microorganism (GMO, GMMO) – micro- or macro-
organisms which contain recombinant and/or synthetic nucleic acid molecules.
Greenhouse – The term "greenhouse" refers to a structure with walls, a roof, and a floor designed
and used principally for growing plants in a controlled and protected environment; may also be
referred to as “glasshouse”. The walls and roof are usually constructed of transparent or
translucent material to allow passage of sunlight for plant growth. The term "greenhouse facility"
includes the actual greenhouse rooms or compartments for growing plants, including all
immediately contiguous hallways and head-house areas, and is considered part of the confinement
area.
Incident – an event or occurrence that results in one of the following: 1) damage to property, 2)
damage to person(s), and/or 3) exposure to person(s) that requires medical attention, including the
use of available safety equipment and/or first aid.
Institutional Compliance Committee – a committee established by the University and/or required by
federal/state law to maintain compliance with regulatory agencies and oversee and authorize
certain activities. The ILSC, IBC, IRB, IACUC, IRLSC, and IFDC are the institutional compliance
committees at Texas Tech University.
Laboratory – a facility equipped for experimental or observational study, for testing and/or analysis
and that contains or functions to collect chemical, biological, mechanical, radiological, and/or
LASER materials/equipment for these purposes.
Laboratory Attire – for traditional lab spaces, this consists of long hair tied back, no exposed skin
from the waist down, and solid shoes that cover the top of the foot. Contacts are allowed at the
discretion of the PI. Jewelry should be minimal but is best to be removed prior to entering the lab.
Proper attire for field work is dictated by a risk assessment.
Laboratory Personnel – anyone working in a TTU laboratory including principal investigators, staff,
students, visiting researchers, volunteers, etc.
Minor – individual under the age of 18 years old.
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Mixed Waste – waste generated in which at least two of the following are present: chemical,
biological and / or radiological hazards.
Municipal Solid Waste – defined in Texas Administrative Code 30 TAC 330.3.
Non-laboratory Personnel – any TTU personnel whose primary work location is not a laboratory.
Personal Protective Equipment (PPE) – Personal protective equipment includes all clothing and
work accessories designed to serve as a barrier against laboratory hazards. Basic PPE
requirements for most campus laboratories include solid shoes, a lab coat and safety glasses
though other PPE may be required. Examples include gloves, face shields, surgical masks,
respirators, head/shoe covers, splash goggles, impermeable lab coats or suits, fire retardant
coats/suits, steel-toed shoes, respirator(s), scrubs, solid-front gowns, aprons, etc.
Primary containment – consists of techniques and equipment that when used properly, prevent the
release of biological material. Such items include laboratory equipment (centrifuges with sealed
rotors or safety cups, biosafety cabinets), splash shields, keyboard covers, and personal protective
equipment.
Principal Investigator – the primary individual responsible for preparing, conducting, and managing
sponsored research and/or teaching (including internal funding) and the subsequent management
of the work areas and personnel pertinent to execution of research/teaching. Only TTU faculty can
be listed as a PI on an IBC application. Co-PIs share equal liability and responsibility regarding the
adherence to TTU safety policies. Research scientists and postdoctoral fellows may be listed as
Co-PIs if they fulfill those responsibilities.
Portable Sink – a sink designed to be mobile and contains a reservoir for containing gray water;
may or may not be equipped with a water source.
Public Area – any area where non-laboratory personnel may be present such as common
corridors, stairways, elevators, office spaces, etc.
Risk –The likelihood of an outcome. For biosafety purposes, risk is the likelihood that a particular
event which may possibly result in adverse outcomes will occur. Such events may include
exposure to or misuse, release, loss, theft, etc. of a biohazard.
Risk Group (RG) – classification of agents based on the hazard posed by assessing characteristics
of the agent such as pathogenicity, virulence, and naturally occurring route of transmission. Both
the NIH and WHO have outlined criteria for 4 risk groups (the most dangerous agents being RG4).
Risk Mitigation – process of communicating and offsetting risks associated with identified hazards.
Recombinant and synthetic nucleic acid molecules (rNA/sNA) – (i) molecules that a) are
constructed by joining nucleic acid molecules and b) that can replicate in a living cell, i.e.,
recombinant nucleic acids; (ii) nucleic acid molecules that are chemically or by other means
synthesized or amplified, including those that are chemically or otherwise modified but can base
pair with naturally occurring nucleic acid molecules, i.e., synthetic nucleic acids, or (iii) molecules
that result from the replication of those described in (i) or (ii) above.
Responder – any trained person designated by the employer, including employees from within the
immediate release area, to respond to an incidental release of hazardous material.
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Safety Concerns and Near Misses (SCAN) – an event or occurrence that was caught before an
incident/accident occurred, did not result in harm/damage but could have; unsafe practice(s),
condition(s), and/or environment(s) that could result in an incident/accident.
Sanitation – the reduction of microbial load on an inanimate object/surface to an acceptable level.
Secondary containment – consists of facility design and construction that functions to protect
workers, the public, and the environment. Laboratories may include advanced features such as
directional air flow (negative pressure in lab spaces), air treatment systems, or air locks at lab
entrances, and may be as simple as restricted access in lab corridors, impervious lab furniture and
bench tops, and locking doors.
Sharps – any object / device used to puncture or cut. Sharps, according to 25 TAC §1.132 include
but are not limited to the following when contaminated: hypodermic needles; hypodermic syringes
with attached needles; scalpel blades, razor blades, disposable razors, and disposable scissors
used in surgery, labor and delivery, or other medical procedures; intravenous stylets and rigid
introducers (e.g., J wires); glass Pasteur pipettes, glass pipettes, specimen tubes, blood culture
bottles, and microscope slides; broken glass from laboratories; and tattoo needles, acupuncture
needles, and electrolysis needles. Regardless of contamination, hypodermic needles and
hypodermic syringes with attached needles are considered sharps.
Shipper – trained individual legally able to determine shipment packaging, labeling, and marking
and signs any declaration and/or shipping documents for shipping biological materials.
Spill Kit – a compilation of appropriate absorbent materials, cleaners, disinfectants, chemical
neutralizers, personal protective equipment, and other equipment (e.g., container for clean-up
materials, scoop, broom, disposal bags, waste labels, etc.) used to contain and clean up spills. See
B7.1 for spill response and kit guidance.
Static – repression of growth or multiplication of an agent in its presence. (e.g., bacteriostatic,
fungistatic, etc.)
Sterilization – implies destroying all viable organisms and their spores on the surface of an article
or in a fluid; measured as the probability of a single viable microorganism surviving the process.
Vacuum Line Trap – often consists of suction flasks in sequence to create a trap to prevent
contamination of the vacuum system with potentially biohazardous materials (see Appendix AE for
guidance on vacuum line trapping).
Volunteer – individual who is assigned to perform duties for a department or area of TTU without
compensation or the expectation of compensation, beyond reimbursement for pre-approved
specified expenses. Potential volunteer workers may be members of the public, TTU alumni,
students, faculty, staff or retired TTU faculty or staff (definition from TTU OP 70.21).
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B4 RESPONSIBILITIES
The Principal Investigator (PI) is directly and primarily responsible for the safe operation of the
laboratory. While safety is a shared responsibility among all laboratory personnel, the PI’s
knowledge and judgment are critical in assessing risks and appropriately applying the principles in
this manual.
A PI may choose to appoint a laboratory supervisor to assist in addressing their required
responsibilities. Each laboratory should appoint a safety captain per responsibility A5.5.17 of the
Laboratory Safety Manual (LSM). In addition to the help of laboratory personnel, many resources
exist to assist PIs with their safety and compliance responsibilities, including the Department of
Environmental Health & Safety (EHS), the Institutional Biosafety Committee (IBC), the Institutional
Laboratory Safety Committee (ILSC), the Institutional Radiation and Laser Safety Committee
(IRLSC), the Institutional Animal Care and Use Committee (IACUC), Animal Care Services (ACS),
the Institutional Review Board (IRB), and Departmental and/or College Safety Officers (DSOs and
CSOs, respectfully).
Please see Section A5 of the LSM, as well as the pertinent sections of the radiation and laser
safety manuals, for additional responsibilities as they apply to the respective disciplines.
B4.1
Regarding biological safety, Environmental Health & Safety (EHS) shall:
B4.1.1
Prepare this Biosafety Manual, with revisions as necessary;
B4.1.2
Provide online access to the University Laboratory Safety Manual;
B4.1.3
Investigate laboratory Safety Concerns & Near Misses (SCANs), incidents and accidents;
B4.1.4
Collect and dispose of biological waste in areas without access to functional autoclaves;
B4.1.5
Design, provide, and coordinate safety trainings as requested or as needs are identified;
B4.1.6
Assist laboratory personnel with risk assessments as requested;
B4.1.7
Monitor laboratories for compliance with all elements of the University Laboratory Safety Manual
and applicable TTU operating policies (TTU OPs);
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B4.1.8
Assist faculty with submission of IBC protocol applications and maintain accepted protocol files;
B4.1.9
Promote and assist in the University’s vision of excellence in the laboratory by promoting
awareness of issues that laboratories face in today’s fast-paced and competitive research and
teaching environments;
B4.1.10
Search out new ways and ideas to meet the ever-changing regulatory requirements while
promoting research and teaching in the safest environment possible;
B4.1.11
Coordinate the IBC and help develop and implement the safety programs of this committee;
B4.1.12
Facilitate the testing of active University autoclaves with biological indicators at least annually and
those which process biowaste at the frequency required by state law (i.e., provide indicators for
testing, the SOP, and treatment logs - see Appendices BE and BF);
B4.1.12(a)
Incubate biological indicators for units located on Main Campus, provide copy of the testing record
to users, and maintain records of EHS-facilitated testing (off-campus units will be provided
biological indicators and provide EHS with a copy of the testing results); and
B4.1.13
Recommend Occupational Health Program enrollment for biological work as appropriate.
B4.2
With regard to biosafety, Principal Investigators (PI) shall:
B4.2.1
Assess the risks of their experiments and consult with EHS as needed;
B4.2.2
Ensure the safe and secure operation of their laboratory;
B4.2.3
Coordinate the annual service and certification of biosafety cabinets (BSCs);
B4.2.4
Provide documented in-lab training and assess worker proficiency in regard to safe work practices
1) before work begins, 2) when procedures change or new procedures/equipment are introduced,
and 3) refresh such training & evaluation annually thereafter;
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B4.2.5
Complete the applicable EHS safety training(s) at the required frequency and ensure all laboratory
personnel complete and renew their safety training(s);
B4.2.6
Properly manage (segregate, contain, and dispose) generated biological wastes;
B4.2.7
Comply with the LSM and all applicable TTU OPs related to safety and health;
B4.2.8
Comply with all applicable University, local, state, and federal regulations and guidelines;
B4.2.9
Register experiments with the IBC (and other applicable committee(s) as required), when work
involves:
1. Recombinant and/or synthetic nucleic acid (rNA/sNA) activities;
2. Materials or agents potentially infectious to humans, plants, and/or animals – including the
storage or concentration of any potentially biohazardous materials;
3. Except for general surveillance, arthropods that serve as vectors of disease to humans,
plants, or other animals, and arthropods that are considered an environmental hazard;
4. Use of soil seed, plants, plant pathogens (e.g., bacteria, viruses, fungi, or parasites) or other
material received under a USDA APHIS compliance agreement or permit;
5. Use of potentially infectious human and/or non-human primate materials;
6. Use of cell lines that pose a danger to humans, animals, and/or plants, and/or those
immortalized by means that render them dangerous to humans, animals, and/or plants;
7. The use of biologically derived toxins;
8. Work involving prions or prion-like proteins;
9. Any Select Agent or Toxin as listed in 7 CFR 331, 9 CFR 121, and/or 42 CFR 73.
10. Necropsy of animals not under the care of the University Veterinarian; necropsy that
includes hands-on student involvement; and necropsy of animals with unknown health
status and/or animals reasonably suspected or known to be infectious;
11. Other work as deemed necessary for review by the Biological Safety Officer; and/or
12. Work with other potentially biohazardous materials conducted at, or sponsored by the
University for compliance with the guidelines in the CDC/NIH Biosafety in Microbiological
and Biomedical Laboratories (BMBL) and approve those research projects that meet or
exceed the requirements in the BMBL.
B4.2.10
Adhere to the conditions stipulated on approved IBC protocols;
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B4.2.11
Report changes to personnel, facilities, materials, and/or methods on an existing IBC protocol
through the amendment process and receive IBC approval before work begins in the laboratory.
B4.2.12
Write and implement a laboratory-specific biosafety manual (bioWASP) which covers, at-minimum,
all topics listed in section B9.1.3.1(e) of this manual. This manual is available and accessible in
hard copy in the lab, and biennially reviewed at minimum and updated as necessary;
B4.2.13
Notify EHS of all shipments of biological materials, including plasmids and nucleic acids, by
submitting a materials shipping form and a copy of all shipping documents to EHS before the
shipment departs; and
B4.2.14
Notify custodial services if their laboratory is a BSL2/PCL2/ACL2 space; custodial services is
aware of such areas if a red dot is placed outside the door.
B4.2.15
Follow IBC-approved SOPs within the B-section of the Laboratory Safety Manual Appendices as
written or submit deviations and justification to the IBC for approval.
B4.3
The Institutional Biosafety Committee (IBC) shall:
B4.3.1
Produce and update the Texas Tech University Biosafety Manual and oversee its implementation
in the research laboratories and applicable work areas of Texas Tech University;
B4.3.2
Develop policies and procedures relating to potentially biohazardous materials, and implement
biological safety programs for Texas Tech University;
B4.3.3
Review and recommend to EHS the need for general and specific training programs for university
activities involving materials potentially biohazardous to humans, plants, and animals, and to
review the appropriateness and effectiveness of such training programs;
B4.3.4
Determine the risk group and containment level for biological materials;
B4.3.5
Ensure recombinant/synthetic nucleic acid research conducted at or sponsored by the University is
compliant with the NIH Guidelines, assess the safety of recombinant/synthetic nucleic acid
research experiments and any potential risk to laboratory personnel, public health or the
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environment, and approve those research projects that are found to meet or exceed requirements
of the NIH Guidelines;
B4.3.6
Review all research and teaching activities involving the materials outlined in B4.2.9.
B4.3.7
Approve PIs, and their work with materials outlined in B4.3.6 and notify the PI of the results of the
IBC's review;
0B4.3.8
Report any significant problems with or violations of the NIH Guidelines and any significant
research-related accidents or illness to the appropriate institutional official(s) and to the NIH Office
of Science Policy (NIH-OSP) as required by the NIH guidelines (immediately and with a formal
report within 30 days); and
B4.3.9
Follow the guidelines for membership defined by the NIH Guidelines, with adjustments as needed
to properly conduct review of research at Texas Tech University.
B5 BIOCONTAINMENT
Four basic levels of biocontainment, or biosafety levels (BSLs), are defined in both the BMBL
(pg.27) and the NIH Guidelines (Section II-B, referred to as BLs). Only BSLs pertinent to University
research are discussed below. The levels build upon each other in ascending order by degree of
protection provided to personnel, the environment, and the community such that the requirements
for BSL2 are those for BSL1 with additional, defined protection measures. Each level consists of
combinations of laboratory practices, safety equipment, and laboratory facilities which provide
containment to allow manipulation of biological agents of increasing danger to life, health, and/or
the environment. As the science and discipline of biosafety has evolved biocontainment
designations for animal (ABSL), plant (PCL), and arthropod (ACL) have been better defined.
B5.1
General Biosafety Levels
BSL1 – BSL1 laboratory facilities and practices are suitable for work involving well-characterized
agents not known to consistently cause disease in immunocompetent adult humans. Standard
microbiological practices without the need for special primary or secondary barriers, other than
basic PPE (see LSM A4.3) and a sink for hand washing.
BSL2 – BSL2 laboratory facilities and practices are suitable for work involving agents that pose a
moderate hazard to personnel and/or the environment. Treatment for disease is generally
available; however, illness is sometimes fatal. Specific training is required; restricted access is
required while work is being conducted. The use of a biosafety cabinet may be required for certain
procedures and/or agents.
BSL2 Enhanced – BSL2 facility that has upgraded administrative controls and PPE. Agents are
still risk group 2 but the methods require additional precautions. Risks and the additional controls
to mitigate these risks are discussed in detail in the lab-specific safety manual and the IBC
B-18 BSM Table of Contents
protocol. Laboratories with this designation will be provided with signage for both BSL2 and BSL2
Enhanced designations so that signage accurately reflects the work being conducted in the
designated space. This is not an officially recognized BSL; however, the TTU IBC sees value in
labeling areas of elevated risk at our institution.
BSL3 – BSL3 laboratory facilities and practices are suitable for work with indigenous or exotic
agents that may cause serious or potentially lethal disease typically through the inhalation route of
exposure. Treatment for exposure or vaccines may be available. Specific training, additional PPE,
BSC use, and special engineering and design features are required.
Most microbiological work at Texas Tech University is conducted using BSL1 or BSL2
containment. The University does have active BSL3 research spaces. Inspection and certification
of a facility as BSL3 is conducted by the CDC in addition to EHS. Program details regarding BSL3
practices and procedures on not a part of this manual as a biosecurity measure.
B-19 BSM Table of Contents
TABLE 1. SUMMARY OF RECOMMENDED BIOSAFETY LEVELS
Agents Practices
Safety Equipment
(Primary Barriers)
Facilities
(Secondary Barriers)
BSL1
•
Not known to
consistently
cause disease in
non-
immunocompromi
sed adults;
minimal hazard to
personnel &
environment
•
Standard
Microbiological
Practices
• Biohazard warning
signs as appropriate
•
No additional safety
equipment required.
• PPE: protective clothing
and eye/face protection;
gloves.
• Long hair secured.
•
Sink
• Door
• Eye wash
• Windows are sealed or
fitted with screens
• Impervious surfaces
• Adequate lighting
BSL2
• Associated with
human disease;
moderate hazard
to personnel &
environment
• Primary routes of
exposure routes
are percutaneous
injury, ingestion,
mucous
membranes
• Human materials,
clinical samples,
and unknowns
BSL-1 practice plus:
• Limited access
• Fever monitoring or
other medical
surveillance as
determined by risk
assessment.
• Equipment and lab are
regularly
decontaminated.
• BSC and other physical
containment devices
used for manipulations
of agents when splashes
or aerosols may be
generated
• PPE: Barrier lab coats
are preferred. Additional
PPE as dictated by risk
assessment (i.e. double
gloves, respirators, etc.).
BSL-1 plus:
• Autoclave available
• Self-closing doors
• Vacuum lines are
protected by both liquid
disinfectant traps and in-
line HEPA filters or their
equivalent
• Sink preferred at exit
• Sealed windows are
preferred
BSL3
• Agent may have
serious or lethal
consequences
• Primary route of
exposure is
inhalation
• Materials likely to
contain such
agents
(indigenous or
exotic).
• BSL-2 practice plus:
• Controlled access
• Decontamination of all
waste
• Decontamination of lab
clothing before
laundering
• Medical surveillance
required
• All agents are
transported as
Category A
• BSC or other physical
containment devices
used for all open
manipulations of agents
• PPE: protective lab
clothing; double gloves;
eye/face protection;
respiratory protection as
needed
BSL-2 plus:
• Physical separation from
access corridors
• Double-door access
• Exhausted air not
recirculated
• Negative airflow into
laboratory
• Hands-free sink at exit
and each zone
• Sealed penetrations
• Designed for complete
decontamination
• Negative airflow with
visual monitoring
B5.2
Animal Biocontainment
Four biosafety levels are also described in the BMBL and NIH Guidelines for activities involving
infectious disease work with vertebrates - Animal Biosafety Levels 1, 2, 3, and 4, (ABSL1, ABSL2,
ABSL3, ABSL4). As with general biosafety and containment, they provide increasing levels of
protection to personnel and the environment. Only ABSL1 and ABSL2 are described below. In
addition to ABSL levels described by the BMBL, the United States Department of Agriculture
(USDA) has developed facility parameters and work practices for handling agricultural pathogens,
ABSL-2Ag through ABSL-4Ag. See Appendix D of the BMBL for additional information.
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Animal work can present unique hazards not found in standard biological laboratories. The co-
application of BSL and ABSL are determined by a protocol-specific risk assessment.
Work involving animals in conjunction with potentially infectious materials or work
involving animal pathogens must be approved by both IACUC and the IBC; IBC approval
should be sought first as it is likely required for IACUC approval.
Please see the IACUC website for additional details and IACUC protocol submission forms. The
checklists for the CDC import permit program are helpful tools in assessing animal containment.
Harmonized checklists from the BMBL are in sections B9.2.3.1 and B9.2.3.2.
B5.3
Arthropod Biocontainment
Resources used as guidance for arthropod biosafety, biosecurity, and biocontainment:
Arthropod Containment Guidelines (currently version 3.2) as published by the American Committee
of Medical Entomology and the American Society of Tropical Medicine and Hygiene.
USDA-PHIS Containment Guidelines for nonindigenous phytophagous arthropods and their
parasitoids and predators.
CDC Import Permit checklists for arthropod containment.
These resources have been used to develop harmonized checklists for research involving housing
arthropods. Checklists for ACL1 and ACL2 are in sections B9.2.3.3 and B9.2.3.4, respectfully.
B5.4
Plant Biocontainment
Resources used as guidance for plant biosafety, biosecurity and biocontainment:
A Practical Guide to Containment: Plant Biosafety in Research Greenhouses
USDA-APHIS Containment Guidelines for the following: 1) Plant Pathogenic Bacteria, 2) Fungal
Plant Pathogens, 3) Viral Plant Pathogens and their Vectors, 4) Pathogenic Nematodes, and 5)
Noxious Weeds and Parasitic Seed Plants.
These resources in addition to the NIH Guidelines have been used to develop harmonized
checklists for research involving plants. Checklists for PCL1 and PCL2 are in sections B9.2.3.5
and B9.2.3.6.
B6 CLASSIFICATION OF BIOLOGICAL MATERIALS
B6.1
Introduction
The NIH and the CDC publish containment measures for work with infectious microorganisms.
These different categories of biological containment are addressed in Section B5 above.
Classification of an organism into a risk group involves evaluation of multiple factors. Information
for certain agents can be found in Appendix B of the NIH guidelines and in the Agent Summary
B-21 BSM Table of Contents
Statements in the BMBL. The categorization of biological agents into risk groups (RGs) is done
according to the hazard they pose to personnel and the environment.
As indicated in B4.3.4, the IBC determines the containment level and classification of agents at
TTU. “No one should conclude that the absence of an agent summary statement for a human
pathogen means that the agent is safe to handle at BSL-1 or without a risk assessment to
determine the appropriate level of containment.” (BMBL 6
th
ed. pg 5)
B6.2
Risk Groups
A risk group (RG) is a category that applies to a biological agent, material, or substance. Risk
groups are considered when determining at which BSL work should be conducted during a risk
assessment. A biological risk assessment must be completed before any work with a biological
material begins. The RG of an agent does not always indicate the BSL at which that agent is to be
handled, because what is being done with the agent may modify the BSL necessary for safe
handling of the material. New or emerging pathogens may not be classified, and classified agents
may develop the ability to become more pathogenic and warrant greater caution or an elevation in
RG. Performing frequent risk assessments addresses these situations.
Risk groups are based on the current state of knowledge and vary with geographic region such
that indigenous agents are often handled at a lower level regionally than exotic agents. The
following factors are generally considered when determining the RG of an agent:
• Pathogenicity
• Mode of transmission
• Host range
• Indigenous or exotic
• Risk to personnel & environment
• Availability of effective vaccines and treatment
Both the WHO and the NIH guidelines have outlined criteria for risk groups. They are similar, but
not the same. The NIH guidelines are the authoritative document in the United States and define
risk groups based on the following general descriptions:
RG 1 – This RG includes agents that are not associated with disease in healthy adult humans and
present minimal risk to personnel & the environment. Please see section B9.1 for further
discussion regarding host susceptibility considerations. Examples include E. coli K-12 and B.
subtilis.
RG 2 – This RG includes agents that are associated with human disease which is rarely serious
and for which preventative or therapeutic interventions are often available; materials present
moderate risk to personnel & the environment, or the hazards are unknown.
RG 3 – This RG includes agents that are associated with serious or lethal human disease for which
preventative or therapeutic interventions may be available. These agents present high individual
risk but lower community risk and may be indigenous or exotic. The risk to the environment varies
with the agent.
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RG4 – This RG is not applicable to work performed at Texas Tech University. It includes agents
that are likely to cause serious or lethal human disease for which preventative or therapeutic
interventions are not usually available. Agents in this category present high risk to the individual,
community, and environment.
The American Biological Safety Association has assimilated a risk group database:
https://my.absa.org/tiki-index.php?page=Riskgroups. This tool pulls information from a variety of
sources about an agent’s risk group; however, it does not contain information regarding biological
toxins.
Vendor designations can serve as a guideline; however, these designations are primarily for
shipping purposes. Vendors do not govern or regulate biosafety at Texas Tech University.
B6.2.1
Methods used in conjunction with the concentration, volume, and other characteristics of a
biological material may increase the BSL at which a material needs to be handled.
B6.2.2
Initial processing of environmental or “unknown” samples, specimens, and/or identification
of isolates shall be done at BSL2 containment unless additional information suggests the
presence of an agent of higher risk (thus requiring BSL3 containment) or permission for
use of BSL1 containment procedures and practices has been granted by the IBC.
Selected groups of biological materials are discussed below for additional clarification.
B6.3
Genetically Engineered/Modified Organisms (GMOs/GMMOs)
All work with genetically engineered organisms is to be done in compliance with the NIH
Guidelines. These guidelines classify recombinant/synthetic nucleic acid experiments into four risk
groups as discussed in the previous section. The USDA requires permits for field testing of
genetically engineered plants. A summary (current as of April 2019) is below; please refer to the
NIH Office of Science Policy (NIH-OSP) website for the most current guidelines. Certain
experiments require approval by the NIH-OSP in addition to the TTU IBC.
B6.3.1
Experiments covered by the NIH Guidelines per Section III
All Experiments involving rDNA molecules require registration with the IBC regardless of
NIH exemption per Section III-E or -F.
B6.3.1.1
Experiments that require NIH Director Approval and IBC approval before initiation (Section
III-A) include those:
(a) Experiments involving the deliberate transfer of a drug resistance trait to microorganisms
that are not known to acquire the trait naturally, if such acquisition could compromise the
ability to control disease agents in humans, veterinary medicine, or agriculture.
B-23 BSM Table of Contents
B6.3.1.2
Experiments That Require NIH OSP and Institutional Biosafety Committee Approval Before
Initiation (Section III-B):
(a) Experiments involving the cloning of toxin molecules with LD50 of less than 100 nanograms
per kilogram body weight (e.g., microbial toxins such as the botulinum toxins, tetanus toxin,
diphtheria toxin, and Shigella dysenteriae neurotoxin).
B6.3.1.3
Experiments Involving Human Gene Transfer that Require Institutional Biosafety Committee
Approval Prior to Initiation (Section III-C):
(a) Experiments involving the deliberate transfer of recombinant or synthetic nucleic acid
molecules, or DNA or RNA derived from recombinant or synthetic nucleic acid molecules,
into one or more human research participants.
B6.3.1.4
Experiments that Require Institutional Biosafety Committee Approval Before Initiation
(Section III-D):
(a) Experiments that use Risk Group 2, 3, 4, or restricted agents as host-vector systems;
(b) Experiments in which DNA from risk group 2, 3, 4, or restricted agents is cloned into
nonpathogenic, prokaryotic, or lower eukaryotic host-vector systems;
(c) Experiments that involve the use of infectious DNA/RNA virus, or defective DNA/RNA virus
in the presence of helper virus in tissue culture systems;
(d) Experiments that involve whole plants or animals;
(e) Experiments that involve more than 10 liters of culture; and/or
(f) Experiments that involve influenza viruses.
B6.3.1.5
Experiments that must be registered at the time of initiation include those (Section III-E):
(a) Involving the formation of recombinant or synthetic nucleic acid molecules containing no
more than 2/3 of the genome of any eukaryotic virus;
(b) Involving nucleic acid molecule-modified whole plants, and/or experiments involving
recombinant or synthetic nucleic acid molecule-modified organisms associated with whole
plants, except those that fall under Section III-A, III-B, III-D, or III-F of the Guidelines.
(c) Biosafety level 1 experiments involving the generation of transgenic rodents in which the
animal’s genome has been altered by stable introduction of recombinant or synthetic nucleic
acid molecules, or nucleic acids derived therefrom, into the germline.
B6.3.1.6
Experiments exempt from the NIH Guidelines that require registration with the IBC but may
be initiated immediately (Section III-F):
(a) Those synthetic nucleic acids that: (1) can neither replicate nor generate nucleic acids that
can replicate in any living cell, and (2) are not designed to integrate into DNA, and (3) do
B-24 BSM Table of Contents
not produce a toxin that is lethal for vertebrates at an LD50 of less than 100 nanograms per
kilogram of body weight.
(b) Recombinant or synthetic nucleic acid molecules that are not in organisms, cells or viruses
and that have not been modified/manipulated to render them capable of penetrating cellular
membranes.
(c) Recombinant or synthetic nucleic acid molecules that consist solely of the exact
recombinant or synthetic nucleic acid sequence from a single source that exists
contemporaneously in nature.
(d) Those that consist entirely of nucleic acids from a prokaryotic host including its indigenous
plasmids or viruses when propagated only in that host (or a closely related strain of the
same species), or when transferred to another host by well-established physiological
means.
(e) Those that consist entirely of nucleic acids from an eukaryotic host including its
chloroplasts, mitochondria, or plasmids (but excluding viruses) when propagated only in that
host (or a closely related strain of the same species).
(f) Those that consist entirely of DNA segments from different species that exchange DNA by
known physiological processes, though one or more of the segments may be a synthetic
equivalent. See NIH Guidelines, Appendices A-I through A-VI, for a list of natural
exchangers that are exempt from the NIH Guidelines.
(g) Those genomic DNA molecules that have acquired a transposable element, provided the
transposable element does not contain any recombinant and/or synthetic DNA.
(h) Those that do not present a significant risk to health or the environment as determined by
the NIH Director following appropriate notice and opportunity for public comment.
i. Recombinant or synthetic nucleic acid molecules containing less than one-half of
any eukaryotic viral genome (all viruses from a single family being considered
identical), that are propagated and maintained in cell in tissue culture unless they
are subject to the guidelines in Section III-B, -C, or -D.
ii. Use the following host-vector systems:
• E. coli K12 (with the exception of those experiments listed in Appendix C-II-A of
the NIH Guidelines);
• Saccharomyces cerevisiae and Saccharomyces uvarum (with the exception of
experiments listed in Appendix C-III-A of the NIH Guidelines);
• any asporogenic Bacillus subtilis and Bacillus licheniformis (which does not
revert to a spore-former with a frequency greater than 10-7 may be used for
cloning DNA (with the exception of those experiments listed in Appendix C-V-A
of the NIH Guidelines); and
• Kluyveromyces lactis, provided laboratory-adapted strains are used, (with the
exception of experiments listed in Appendix C-IV-A of the NIH Guidelines),
(i) Recombinant or synthetic nucleic acid molecules derived entirely from extrachromosomal
elements of the organisms listed in Appendix C-VI of the NIH Guidelines (including shuttle
vectors constructed from vectors described in Appendix C), propagated and maintained in
organisms listed Appendix C-VI of the NIH Guidelines (with the exception of experiments
listed in Appendix C-VI-A of the NIH Guidelines).
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(j) Involve purchase or transfer of transgenic rodents for experiments at BSL1 according to
Appendix G-III-M of the NIH Guidelines.
(k) The generation of certain BSL1 transgenic rodents via breeding per Appendix C-VIII of the
NIH Guidelines.
B6.3.1.6(l)
While considered “exempt,” the BMBL guidelines still apply to the above-listed
experiments. The Biosafety Officer (BSO) a proxy, and/or IBC Chair will review the
application form and confirm that the work is classified correctly according to the NIH
Guidelines.
B6.4
Human and Non-Human Primate Materials
B6.4.1
Regulations
Work with human material is regulated by the Occupational Safety and Health Administration
(OSHA) Bloodborne Pathogens Standard, 29 CFR, Part 1910.1030. The University uses this
standard in conjunction with the BMBL and TTU OP 60.24 to provide a safe working environment
for TTU personnel.
Research involving the collection of samples from human subjects likely requires both IBC and IRB
approval.
B6.4.2
Training Requirements, Medical Surveillance, and IBC Review
B6.4.2.1
Biosafety and Bloodborne Pathogen training are required for faculty who oversee and
personnel who work in environments were human and or non-human primate material is
handled.
B6.4.2.2
Individuals who may contact human or non-human primate materials must be enrolled in
the OHP and offered the Hepatitis B vaccine series. This serves as the documented offering of
the vaccine; the OHP will handle any necessary medical surveillance. The extent of in-laboratory
medical surveillance should be discussed between the PI & EHS. Consult EHS if you have
questions regarding vaccination or medical surveillance. These measures will be documented on
the IBC protocol.
B6.4.2.3
Work with human and/or non-human primate materials requires a certified BSL2 laboratory
space and IBC protocol review. In accordance with the BMBL, all human and /or non-human
primate material should be presumed infectious and handled using BSL2 work practices and
containment; this concept is called “Universal Precautions”.
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B6.4.2.4
The use of 10-20% household bleach or a hospital-grade disinfectant, registered with the
EPA for effectivity against, common bloodborne pathogens (HIV, HEP-B, HEP-C, and
Mycobacterium tuberculosis), is required for areas where human/non-human primate
materials are handled.
B6.4.3
Human and non-human primate material includes the following:
1. All fluids and excretions (blood, blood components, urine, saliva, semen, vaginal secretions,
cerebrospinal fluid, excrement, synovial fluid, sweat, etc.),
2. Unfixed tissues,
3. Fixed or unfixed brain tissue,
4. Cells (including established cell lines for cell culture), and
5. Any other material of human or non-human primate origin (apart from hair and nails).
Please contact EHS at 806-742-3876 if you have questions regarding a specific material or project.
B6.5
Biologically Derived Toxins
The BMBL requires that all biologically derived toxins be handled at BSL2 or greater containment.
Powdered forms of toxins should be replaced with toxins in suspension when possible and always
handled within containment (BSC or fume hood) using appropriate PPE to address the toxin.
Specific handling, decontamination, and waste procedures will be specified for the toxins used in
the IBC protocol.
B6.5.1
BSL2 is the minimum-required biosafety level for research involving biologically derived
toxins. Depending on the toxin and quantity, BSL3 containment may be required.
B6.5.2
In all cases of biologically derived toxin-related research, and IBC protocol is required.
B6.6
Prions and Prion-like Proteins
Prions and prion-like proteins are resistant to inactivation by heat and chemicals. Prions are
efficiently transmitted within species but can cross species barriers with reduced efficiency.
Presently, scrapie and chronic wasting disease are not known to infect humans. Prions are
transmissible by inoculation, ingestion, or transplantation of infected tissues or homogenates. Prion
infectivity is high in the brain and other central nervous system tissues and lower in lymphoid
tissues including the spleen, lymph node, gut, bone marrow, blood, and some special tissues
(placenta); at this time, aerosols do not appear to be a natural route of transmission but cannot be
excluded in a lab setting.
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B6.6.1
BSL2 is the minimum-required biosafety level for research involving prions or prion-like
proteins. Depending on the nature of the research, BSL3 containment may be required.
B6.6.2
In all cases of prion-related research, including sample screening, an IBC protocol is
required.
B6.6.2.1
Principal investigators may request a waiver from the IBC protocol requirement for sample
screening purposes. Contact the IBC at ibc.e[email protected]du regarding a waiver.
B6.7
Respiratory Viruses
Work with agents transmitted through respiratory exposure is a serious laboratory hazard. When
work involves the use of animals, the hazardous characteristics of zoonotic agents require careful
consideration when completing the biological risk assessment. (BMBL Section II – Biological Risk
Assessment, pg 13)
Specific considerations for Influenza Viruses
New subtypes can result from reassortment of human, swine, and avian influenza A virus genes.
Influenza A viruses of different antigenic subtypes occur naturally in many domestic and wild avian
species and have formed sustained lineages in swine, equine, and canine species. Avian origin
influenza A viruses also sporadically infect multiple other mammalian species. Interspecies
transmission and reassortment of influenza A viruses have been reported to occur among humans,
pigs, and wild and domestic fowl. The influenza A viruses responsible for the 1918, 1957, 1968,
and 2009 pandemics contained gene segments closely related to those of avian or swine influenza
A viruses.
When considering the biocontainment level and practices and procedures for work with influenza
recombinant or reassortant viruses, the IBC, will consider but not limit consideration to the
following when conducting the protocol-driven risk assessment:
• The gene constellation used;
• Any mutations that are introduced and may result in enhancement of a pathogen’s
transmissibility and/or virulence;
• Clear evidence of reduced virus replication in the respiratory tract of appropriate animal
models, compared with the level of replication of the wild-type parent virus from which it was
derived;
• Evidence of clonal purity and phenotypic stability; and
• The number of years since a virus that was antigenically related to the donor of the
hemagglutinin and neuraminidase genes last circulated.
If adequate risk assessment data are not available, a more cautious approach to containment,
utilizing elevated Biosafety Levels and practices, is warranted.
(BMBL Section VIII-E: Viral Agents, pg 259-263)
B-28 BSM Table of Contents
Sample screening is subject to B6.2.2 which states, “Initial processing of environmental or
“unknown” samples, specimens, and/or identification of isolates shall be done at BSL2 containment
unless additional information suggests the presence of an agent of higher risk (thus requiring BSL3
containment) or permission for use of BSL1 containment procedures and practices has been
granted by the IBC.
B6.7.1
Propagation of risk group 2 respiratory viruses of human origin or influenza viruses of any
origin requires, at minimum, the use of the BSL2-enhanced designation which includes the
following protective equipment measures:
1. Inclusion in the EHS Occupational Health Program and laboratory surveillance policies such
as fever/symptom watch, and receipt of the seasonal influenza shot.
2. Inclusion in the EHS-OHP respiratory protection program and use of respiratory protection
(N-95 or equivalent),
3. Use of either a disposable, barrier-style lab coat or a reusable, barrier-style lab coat that is
exclusive to use during respiratory viral work, and
4. Double gloving, including the taping of the inner glove over the cuff of the barrier coat so
that the outer glove can easily be changed as needed.
B6.7.3
Work stipulations for non-influenza respiratory viruses of non-human origin will be dictated
through biological risk assessment during the IBC review process.
B7 EMERGENCY PROCEDURES
B7.1
Biological Spills
B7.1.1
Spills involving biohazards require immediate and proper response.
A spill of biological materials outside of a BSC is a breach of containment that can result in
exposure to personnel directly involved and to others in the lab. The nature of the material, as well
as the quantity and location of the spill will affect spill response. Most spills can be managed by
laboratory personnel; however, certain situations may require verbal or physical assistance from
EHS.
A quick assessment of the spill using these parameters will help determine if and to what degree
EHS assistance is needed.
1. Nature of the Biohazard
• Risk Group
• Composition (liquid, solid, sample, etc.)
• Risk of aerosolization
• Genetic modification
2. Quantity
• Spill volume
• Concentration of biohazard (raw sample vs cultured material)
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3. Location
• Contained (in a BSC or closed safety cup) vs uncontained
• Equipment considerations
• Lab vs field
B7.1.2
ANY spill of genetically modified and/or RG2 material MUST be immediately reported to
EHS.
B7.1.3
Biological Spill Kit
The kit for chemical spills, supplied by EHS, does not meet the requirements for a biological spill
kit.
A biological spill kit shall be kept in each laboratory where work with biological materials is
conducted. The kit(s) are to be kept in an accessible location, preferably where spills are
most likely to occur.
B7.1.3.1
It is the responsibility of the laboratory to gather and compile the supplies for the kit
according to their individual needs.
If you have access to an autoclave, you should select a leakproof container which is autoclavable
for broken glass and/or other materials so that it can be autoclaved immediately after collection.
B7.1.3.2
Basic equipment includes:
(a) Spill SOP and a Sign to communicate there is a spill to others who may enter the work
area;
(b) Sorbents (i.e., large cloth towels, paper towels, pig pads, solidifying powder, consider dams
if large volumes of materials are handled);
(c) PPE (household rubber gloves, booties, disposable lab coat, etc.);
(d) Forceps and long tongs (or other tools) to pick up and collect broken glass and indirectly
handle sorbent materials. Wisk brooms should not be used unless a solidifier was used and
are either disposed of as biowaste or are suitable for disinfection;
(e) Biohazard bags and zip ties; and
(f) Quick mop, such as a Swiffer®, to disinfect the outlying spill zone.
While not listed as an element for the kit, fresh disinfectant must always be available while
work with potentially infectious material is being conducted in the laboratory.
B7.2
General Spill Cleanup Guidelines for Biological Spill Response
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Each laboratory has a unique combination of hazards and thus requires customized laboratory
procedures for controlling spills. The guidelines are to develop procedures for managing biological
spills in the laboratory. Contact EHS if you are not comfortable addressing a spill.
1. Safety First.
a. Alert others working in the area. This helps prevent spill spreading. Post a sign as
appropriate.
b. Remove contaminated PPE and garments. If your lab coat, gloves and/or clothing
was contaminated in the spill promptly remove them (decontaminate gloves,
removed coat, remove gloves) turning the exposed surface to the inside, place in a
biohazard bag and thoroughly wash the affected area(s) with soap and water. Seek
immediate medical attention if needed and notify the PI of the incident. Do not
launder lab coats or contaminated clothing at home or public facilities. Autoclave or
soak coats/clothes in disinfectant solution to decontaminate before laundering. Use
a qualified laundry service to launder lab garments. If you wish to autoclave and do
not have access to one, contact EHS.
2. Assess and address the spill.
a. Identify the spill zone (3-5ft outward from the smallest visible droplet). Evacuate
the immediate area if appropriate, call EHS if needed.
b. Don clean PPE before addressing the spill. Regularly assess PPE during spill
cleanup and replace as needed (especially gloves and booties). Wear at least
gloves, safety glasses and a lab coat. Booties are highly recommended to prevent
contamination to footwear and contain contamination.
c. Work from the spill from the outside of the spill inward. Cover spilled material
with towels / paper towels / pig pads. Such materials may be soaked in disinfectant
prior to application, or the disinfectant may be poured over the spill after covering the
spill. Do not neglect furniture, equipment, and vertical surfaces (cabinets, walls,
doors). If biological fluid solidifiers such as BioSorb or SaniSorb are used, follow the
manufacturer’s instructions.
3. Treat and complete.
a. Allow appropriate contact time for disinfectant. Don fresh PPE as needed.
b. Collect absorbent materials; this waste may be disposed of as municipal waste or
as biowaste waste per the lab-specific SOP. Autoclaving spill materials may be
contraindicated based on chemical disinfectant used. Contact EHS with questions.
c. Use a mop to disinfect spill area again with prepared disinfectant and allow
adequate contact time. Do not neglect vertical surfaces. A quick mop, such as a
Swiffer®, makes this easy.
4. Sanitize and SCAN.
a. Wash hands with soap and water when finished. Don clean PPE before
continuing work.
b. Report the Spill. Submit a SCAN report using the Quick Link on the EHS website:
http://www.depts.ttu.edu/ehs/about/scan.php If the spill resulted in an personnel
exposure, and incident report should be filed.
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B7.2.1
Spill Involving Broken Glass
Do not enter the spill zone to remove glass prior to addressing the spill. Always handle
spill materials involving glass indirectly using forceps, tongs or another device. Place glass
in a sharps container or other rigid, leakproof container.
It is preferable that contaminated broken glass be disposed of into a sharps container to prevent
unnecessary handling of the contaminated glass.
If disinfected, you may transfer glass to broken glass box – again, do not handle glass with your
hands. See section B8.11.2 for specific glass disposal details.
Notify the PI and submit a SCAN report regarding the incident:
http://www.depts.ttu.edu/ehs/about/scan.php
B7.2.2
Spill of Human Fluids
Follow the guidelines in B7.2 above to address the spill. If bleach is used, avoid autoclaving clean
up materials; deadly chlorine gas can be produced and the bleach will corrode the inside of the
unit.
Notify the PI and submit a SCAN report regarding the incident:
http://www.depts.ttu.edu/ehs/about/scan.php
If the spill resulted in direct exposure of personnel to human materials, try to collect a sample of the
material in the event testing is requested by the physician. An incident report needs to be filed
with Risk Management. Access to the online form for Risk Management is available on the EHS
website at: http://www.depts.ttu.edu/ehs/about/incident-reporting.php. Call EHS so that exposed
individuals can be evaluated by a physician and prophylaxis can begin immediately
B7.2.3
Spill of a BSL3 material
Follow the protocol in the laboratory-specific safety manual for the materials involved in the
spill.
B7.2.4
Spill in a Biosafety Cabinet
1. Leave the cabinet turned on and sash at the working height during clean up.
2. Alert others of the spill. If the spill entered the grills of the BSC, contact EHS.
3. Sanitize gloves or remove outer gloves before exiting the BSC. Remove any
contaminated PPE and wash effected areas with soap and water before proceeding.
4. Don clean PPE. Remove any glass as described in B7.2.1. For small spills start at number
‘5’ in section B7.2 above and proceed accordingly. The pour-over method is easier within
the BSC. Disinfect the surfaces of materials and equipment within the BSC.
5. Repeat disinfection of the spill area again.
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6. Discard all clean-up materials into the biohazard waste container within the BSC.
Decontaminate and removed outer glove. Wash hands and exposed skin areas with soap
and water.
7. Report the spill to EHS.
8. Don fresh PPE before resuming work.
B7.2.5
Spills in a Centrifuge
1. Alert others to not disturb the unit. Close centrifuge lid and let sit for 20 minutes to allow
aerosols within the centrifuge to settle.
2. While you are waiting, disinfect the exterior of the centrifuge by saturating with disinfectant
soaked paper towels and allowing appropriate contact time. Follow with water or 70%
ethanol/isopropanol.
3. Open the centrifuge. At this point, you can disconnect power or turn off the unit during
cleaning if you wish.
4. If you are using safety cups or a sealed rotor, move the rotor to the biosafety cabinet to
disinfect. If not, remove rotor and set aside in a leakproof tub for disinfection.
5. Carefully remove any pieces of debris from the centrifuge interior using forceps and place in
a biowaste bag or sharps container.
6. Submerge rotor in disinfectant or autoclave if possible; otherwise, cover spill with paper
towels. Do not use a spray bottle as this can aerosolize contaminants. Pour disinfectant on
towels and remaining interior of centrifuge using a laboratory soak bottle or pour
disinfectant. Let disinfectant sit appropriate contact time per the manufacturer.
7. Follow with DI-water then 70% ethanol or isopropanol to remove disinfectant residue.
8. Submit a SCAN report: http://www.depts.ttu.edu/ehs/about/scan.php
B7.2.6
Spill of Biological Radioactive Material
Follow procedures in the laboratory-specific manual and Radiation Safety Manual. If you
have questions, contact the Radiation Safety Officer at 806-742-3876.
DO NOT USE BLEACH SOLUTIONS ON IODINATED MATERIALS: RADIOIODINE GAS MAY BE
RELEASED.
DO NOT AUTOCLAVE CONTAMINATED WASTE UNLESS APPROVED BY THE RADIATION
SAFETY OFFICER.
Submit a SCAN report regarding the incident at the EHS website:
http://www.depts.ttu.edu/ehs/about/scan.php
B7.3
Illness or Injury Involving Biological Materials
B-33 BSM Table of Contents
B7.3.1
Severe Injuries
Call 911 for assistance and transportation to the nearest emergency room. Accompany the injured
person to the medical facility and provide information to medical personnel about the
accident/exposure. Report the accident to the PI and EHS.
An incident report will need to be filed immediately so that the individual is eligible for workers
compensation. Access to the online form for Risk Management is available on the EHS website at:
http://www.depts.ttu.edu/ehs/about/incident-reporting.php.Minor incidents not requiring medical
attention should be reported to the PI and then to EHS by using the SCAN system at the following
link: http://www.depts.ttu.edu/ehs/about/scan.php.
B7.3.2
Contamination to the Body
Immediately remove contaminated clothing and flush skin with water. Wash with soap (work into
lather for 30 seconds) and water and flush the area for 5 minutes. Contact the most convenient
local emergency room to obtain care if needed. Report the injury to the PI and to EHS and seek
additional medical assistance if necessary.
An incident report will need to be filed immediately so that the individual is eligible for workers
compensation. Access to the online form for Risk Management is available on the EHS website at:
http://www.depts.ttu.edu/ehs/about/incident-reporting.php.
B7.3.3
Splash to the Eye
Use the emergency eyewash to immediately flush the eye with a gentle stream of clean, temperate
water for 3-5 minutes. Hold the eyelid open. Be careful not to wash the contaminant into the other
eye if it was unaffected by the incident. Contact the most convenient local emergency room to
obtain care if needed. Report the accident to the PI and EHS and seek additional medical
assistance if necessary. NOTE: If chemicals were involved, refer to SDS.
An incident report will need to be filed immediately so that the individual is eligible for workers
compensation. Access to the online form for Risk Management is available on the EHS website at:
http://www.depts.ttu.edu/ehs/about/incident-reporting.php.
B7.4
Fires
1. Without placing yourself in danger, secure biological materials by closing the BSC
sash or placing them in a closed incubator, fridge, or freezer and proceed with the R-A-C-E
process
Remove persons from the immediate area.
Alert others of the situation.
Contain fire and smoke (i.e., shut doors).
Evacuate or extinguish.
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2. You are not required to use a fire extinguisher. Only use an extinguisher if you:
(a) Feel confident and not threatened,
(b) Are knowledgeable and TRAINED on how to properly operate a fire extinguisher,
and
(c) Using the fire extinguisher does not put you in danger.
3. Activate the building fire alarm and leave the building at once according to building
evacuation procedures.
4. Meet the fire department outside and tell them of the fire location and details of any
materials potentially involved.
5. Submit a SCAN or Incident Report for any fire:
http://www.depts.ttu.edu/ehs/about/scan.php
B8 DECONTAMINATION AND DISPOSAL
B8.1
Factors Contributing to the Destruction/Inactivation of Biological Materials
B8.1.1
Biological factors
1. Microbial load (number and variety of organisms present)
2. Organism life cycle (spore former?)
3. Innate resistance to chemical agent or conditions
4. Presence of biofilms
B8.1.2
Physical and chemical factors
1. Temperature
2. pH
3. Presence of organic and/or inorganic matter.
• Organic matter can create physical barriers reducing contact and bind antimicrobial
agents decreasing overall concentration of the effective agent in a solution or cause
proteins to agglutinate and protect infectious materials. Inorganic matter can create a
physical barrier in the formation of salt crystals.
4. Disinfectant concentration and condition (i.e., expired, mixed with tap water, etc.)
5. Duration of exposure to disinfectant or sterilization process (i.e., contact time).
B8.1.3
Disinfectants must be appropriate for the agent(s) and work.
B8.1.4
Disinfectants must be prepared and used according to the manufacturer’s instructions;
prepared solutions are marked with the expiration date related to the shelf life of prepared
disinfectant per the label.
B-35 BSM Table of Contents
B8.1.4.1
Bleach solutions are prepared on the day of use unless dictated otherwise in an IBC
protocol.
B8.2
Properties of Chemical Disinfectants
There is no such thing as a perfect chemical disinfectant; there are pros and cons to each.
Common disinfectant types are discussed below and in Appendix BB. Please note that this is not
an exhaustive list of disinfectants.
B8.2.1
Iodophors
Use:
• Recommended dilution is 75-5,000 mg/L (ppm), or approximately 0.5% concentration
• Effective against vegetative bacteria, fungi, and viruses
• Generally safe for stainless steel items and centrifuges
• Some are antiseptics (e.g., betaydyne, scrubodyne)
• Some are surface disinfectants (e.g., Wescodyne™ Steris Corporation)
B8.2.1.1
Pros:
(a) Effectiveness reduced by organic matter (but not as much as with hypochlorites).
(b) Stable in storage if kept cool and tightly covered. Built-in color indicator; if solution is brown
to dark yellow, it is still active.
(c) Generally non-staining
(d) Active in hard water
(e) Relatively harmless to humans
(f) Not as corrosive as chlorine products; leaves a film of residue which allows for residual
antimicrobial activity making it ideal for biosafety cabinets
B8.2.1.2
Cons:
(a) Can stain and discolor equipment in some conditions
(b) Can be corrosive to silver, copper, and aluminum but relatively harmless to stainless steel
(c) Can foam
(d) Cannot be used above 110°F (iodine vaporizes) and is not as effective in low temperature
environments (cold rooms, refrigerators, etc.)
(e) Cannot be used in conjunction with other products
(f) Expensive
B8.2.2
Sodium Hypochlorite (household bleach)
B-36 BSM Table of Contents
Use:
• User dilution is 1:5 to 1:100 in water; 20% to 1% dilution. Contact time varies with agent to be
neutralized and concentration of solution. Strips to test ppm free chlorine can be purchased.
• Only Clorox brand bleach has been approved by the EPA as a disinfectant; however, any brand
of sodium hypochlorite will meet the requirements of Texas law.
• For chemical disinfection of biowaste a minimum of 1:10 dilution of bleach for no less than 3
minutes is required by Texas law.
• Effective against vegetative bacteria, fungi, most viruses at 1:100 dilution. Contact time varies
with agent to be neutralized and concentration of solution.
• Minimum 1:10 dilution is required for BSL2 activities; 1:5 dilution is needed to inactivate
Mycobacterium and should be used for human materials.
• Available free chlorine is maximized when the solution is pH 5-7.
• Store prepared solutions in brown plastic bottles to protect from light to extend shelf life of
prepared solutions.
B8.2.2.1
Recipe for large quantity ~ 1 % solution with 800 ppm available chlorine:
(a) 1:64 dilution of Clorox in water (2oz in 1 gallon of water)
(b) 2oz of 5% distilled white vinegar (cooking vinegar)
(c) Make daily! (Microbe 6:257, June 2006)
B8.2.2.2
Pros:
(a) Broad spectrum effectiveness
(b) Readily available and inexpensive
(c) High concentrations can kill spores and remove biofilms
B8.2.2.3
Cons:
(a) Contact times and concentration vary with application and agent
(b) Very corrosive, especially to stainless steel
(c) Must be prepared daily for guaranteed ppm of free chlorine
(d) Rapidly inactivated by organic matter, light, and some metals
(e) WARNING!!!! Bleach in combination with other cleaners can produce deadly, toxic
compounds
i. Bleach + 4% phosphoric acid cleaner = chlorine gas
ii. Bleach + Ammonia containing cleaner = chloramine vapors and potentially
hydrazine
B8.2.3
Alcohols (ethanol, isopropanol)
B-37 BSM Table of Contents
Use:
• The effective dilution for decontamination is 60-80%; 70% is ideal
• Effective against a broad spectrum of bacteria and many viruses
• Ethanol is preferred to isopropanol given it has a slightly more broad-spectrum kill. Ethanol
inactivates all lipophilic viruses and many hydrophilic viruses. Isopropanol is not active against
hydrophilic viruses but virucidal against lipophilic viruses.
• Alcohol waste from submersion must be disposed of as chemical waste
• Use the C1* V1 = C2 * V2 formula to calculate the concentration you wish to make
B8.2.3.1
Pros:
(a) Fast acting and quick drying
(b) Leaves no residue
(c) Relatively inexpensive
(d) Broad spectrum effectiveness against bacteria and viruses
(e) Maintains activity in presence of organic matter
(f) Non-corrosive
B8.2.3.2
Cons:
(a) Not effective against bacterial spores, C. difficile, and Helicobacter
(b) Evaporate rapidly not allowing for extended contact time unless an item is immersed
(c) FLAMMABLE; use only on small surface areas and in well-ventilated areas
(d) Certain agents require a lengthy contact time (30 minutes or more)
(e) Weakens acrylic, polypropylene, PVC and polycarbonate plastics and rubber overtime or
with prolonged or repeated use
(f) Coagulates proteins and can attach them to surfaces (i.e., cannot penetrate protein-rich
materials (e.g., dried blood/plasma)
(g) Can compromise latex and vinyl gloves with extended exposure (1 hour)
(h) Dissolves adhesives in instruments (e.g., microscopes)
(i) Easily passes through nitrile and can carry other chemicals with it.
B8.2.4
Quaternary ammonium salts/Amines (“Quats”)
B8.2.4.1
Use:
• Dilute according to manufacturer instructions
• Spectrum of effectiveness varies with manufacturer; generally effective against Gram positive
bacteria, Gram negative bacteria and enveloped viruses
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• Quats sold as hospital-grade disinfectants are generally bactericidal, fungicidal, and virucidal
• Examples include Lysol, BacDown
• 4th generation QUATs maintain effectiveness in the presence of organic material and hard
water
B8.2.4.2
Pros:
(a) Can be used to both clean and sanitize
(b) Non-corrosive
(c) Readily available, generally inexpensive
(d) Low-level human toxicity
(e) Excellent for walls, furniture, and floors
B8.2.4.3
Cons:
(a) Non-sporicidal
(b) Some not effective against non-enveloped viruses, spores or fungi
(c) Hard water and organic matter can reduce effectiveness
(d) Cellulose-containing materials can absorb active ingredients
(e) Some people are prone to allergies and skin-reactivity
(f) Does leave residue
B8.2.5
Phenolics
B8.2.5.1
Use:
• Dilute according to manufacturer instructions
• Effective against bacteria, fungi, and enveloped viruses
• May be a good choice for decontaminating centrifuges which spin blood products
B8.2.5.2
Pros:
(a) Tuberculocidal
(b) Maintain good activity in the presence of organic material and hard water
(c) Residue has some residual activity after drying (follow with EtOH for sensitive applications)
B8.2.5.3
Cons:
(a) Ineffective against non-enveloped viruses, spores and some Gram-negative bacteria
(b) Toxic to infants and the environment
(c) Prolonged exposure can cause allergies and skin irritation
B-39 BSM Table of Contents
B8.2.6
Hydrogen Peroxide (3-8%) or Vapor-phase Hydrogen Peroxide (VHP)
B8.2.6.1
Use:
• Surface sterilant
• Broad-spectrum effectiveness
• Requires specialized equipment (VHP)
• Aqueous H2O2 concentration 3-8% for spray application and >30% for vaporization
• Vaporization equipment should only be operated by trained personnel. All personnel with
access to equipment or laboratory space should understand the hazards associated with VHP
and signs of exposure. Following SOPs is critical.
B8.2.6.2
Pros:
(a) Environmentally safe by-products (H2O, O2)
(b) Rapid kill action
(c) No disposal issues, odor or irritation when diluted (3-8%)
(d) Readily available and inexpensive
(e) Good compatibility with sensitive equipment, electronics and furnishings
(f) VHP offers low temperature sterilization and is a safer alternative to formaldehyde or
ethylene oxide gas
(g) VHP is cost effective after initial setup
B8.2.6.3
Cons:
(a) Little penetration
(b) Concentrations >7.5% can cause discoloration of metal finishes
(c) Compatibility concerns with brass, zinc, copper, and nickel/silver plating
(d) Oxidizing capability is rapidly inactivated by organic material; cellulose cannot be processed
(e) Nylon items can become brittle
(f) Vapors have no color and are odorless; inadvertent exposure can cause serious health
effects
(g) VHP is expensive to implement
B8.3
Management of Biologically Contaminated Materials and Biowaste
The treatment and disposal of biological waste (i.e., biowaste) is regulated by TCEQ.
B-40 BSM Table of Contents
B8.3.1
Work areas which generate biological waste must segregate biological waste from other
hazardous wastes and general, non-hazardous (municipal) wastes for treatment.
B8.3.1.1
Biologically contaminated materials and biowastes are not transported in public areas
without secondary containment (see B8.6.3.1) or left uncontained or unattended prior to
initiation of disinfection.
B8.3.2
Collection and/or Disposal Containers
Each PI which produces biowaste is responsible for purchasing appropriate containers in
an adequate number and biohazard bags for the collection, containment, and disposal of
biological wastes generated.
B8.3.2.1
The number of containers should be such that a container is easily accessible from the
immediate workstation so that containers are not moved about the space to accommodate
waste.
B8.3.2.1(a)
Sharps Containers
Use FDA-approved sharps containers to dispose of sharps & contaminated glass in
biological laboratories. They are available in various sizes and have the following features:
i. Puncture-resistant rigid plastic
ii. Red
iii. Labeled as containing a “Biohazard” and "Sharps"
iv. Lid design traps items so they cannot be retrieved, is puncture/leak resistant and locks
tightly
v. Have a line that indicates when the container is full.
These containers may be purchased from local sources, including the Physical Plant Central
Warehouse, Chemistry Stockroom, and medical supply stores, as well as from laboratory product
distributors.
B8.3.2.1(b)
Do not purchase or use "needle-cutter" devices; use of such devices can generate aerosols
and leaves sharp barbs.
B8.3.2.2
Biohazard / Autoclave Bags and Holders
Autoclave bags (commonly referred to as “biobags or biohazard bags”) can be purchased from
laboratory product distributors in a variety of sizes and thicknesses. These bags are tear resistant
B-41 BSM Table of Contents
but can be punctured; they may also burst in the autoclave when sealed because they are
impermeable to steam.
B8.3.2.2(a)
Biobags must be made of polypropylene.
B8.3.2.2(b)
Biobags must have a biohazard symbol; the bag can be purchased in red, orange, and clear.
Avoid yellow biohazard bags; yellow is associated with other types of hazardous waste on campus.
B8.3.2.3
Except for bench-top pipette tip collection bags, biobags must be placed inside a rigid
container with closable lid (latching or step can style) labeled with the biohazard symbol
while waste is being collected.
B8.3.2.3(a)
If a normal trash bin is used to hold a biohazard bag, the trash bin must: 1) Be labeled with
a biohazard symbol, 2) Never used for non-biohazardous waste, 3) and have inner and outer
surfaces that are able to be disinfected.
B8.3.2.4
Benchtop biowaste collection must be managed in one of the following ways:
(a) wire bag holders with or without the optional lid;
(b) labeled beaker with appropriately diluted bleach or other EPA-approved disinfectant
for the agent(s) that is disposed of at the end of work; and/or
(c) beaker or other container that is lined with a biohazard bag. If the container does not
allow view of the biohazard symbol on the bag it must be labeled with a biohazard
sticker.
B8.3.2.4(d)
Benchtop biowaste collection must be done using materials that withstand frequent surface
disinfection. Biokeeper boxes and similar containers are one-time use and must be closed
and disposed of as biowaste once full rather than emptied and reused.
B8.3.2.5
Biowaste must not exceed three-quarters of the volume of the bag and/or container.
B8.4
Treatment of Biologically Contaminated Materials and Biowaste
As stated in B8.3.1, all biological wastes must be segregated from other waste streams and require
treatment prior to disposal.
Thus, to facilitate regulatory compliance and consistency of treatment practices, EHS has instituted
a waste program that includes autoclave use and monitoring (see section B8.6.4).
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Regulations Pertaining to the Treatment of Biowaste
The following is taken directly from the Texas Administration Code (TAC); please refer to 30 TAC
§326, 30 TAC §330 and 25 TAC §1.132 for definitions related to the regulations. For example,
“bulk” according to the TAC consists of amounts greater than or equal to 100 mL.
Medical waste consists of waste associated with many biological laboratory activities and includes:
animal waste, bulk blood, bulk human blood, bulk human body fluids, microbiological waste,
pathological waste, and materials listed in 49 Code of Federal Regulations, Part 173, §173.134(a).
The term does not include medical waste produced on a farm or ranch as defined in 34 TAC
§3.296(f) (relating to Agriculture, Animal Life, Feed, Seed, Plants, and Fertilizer).
B8.4.1
According to the TAC, “medical waste” (i.e., biowaste) requires treatment prior to final
disposal. This treatment may be performed by the generator or transferred offsite and
performed by a third party.
B8.4.2
Biowaste to be transferred to a third party for treatment must be properly prepared for
transport by the generator (i.e., proper preparation of biobarrels). See Appendix BG.
B8.4.3
Biowaste that is treated by the generator must be treated using a TCEQ-approved method
of treatment for the specific type of biowaste. Approved methods are listed in 25 TAC §1.136.
Methods accessible at TTU include chemical disinfection with an approved disinfectant or steam
disinfection (i.e., autoclaving).
B8.4.4
A written SOP for biowaste treatment, including preparation of any chemicals used and
preparation of materials for autoclaving, must be in place in work areas treating their
biowaste.
B8.4.5
Treatment of all biowaste must be recorded. The biowaste treatment record must be
maintained by the generator for no less than 3 years.
Biowaste treatment log pages that meet the state requirements are available in in Appendix BF or
can be downloaded from the EHS website: http://www.depts.ttu.edu/ehs/academicsafety/lab/tools-
templates.php
B8.4.5.1
Record of Biowaste Treatment
Laboratories must maintain a written record that, at a minimum, contains the following
information for each batch of waste treated:
(a) Date of treatment;
(b) Amount of biowaste treated;
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(c) Method/conditions of treatment;
(d) The name (printed) and initials of the person(s) performing treatment; and
(e) The written procedure for the operation and testing of any equipment used and a written
procedure for the preparation of any chemicals used in treatment.
B8.5
Regulations pertaining to chemical disinfection of biological wastes
Failure to properly follow TCEQ biowaste regulations can result in fines to the University.
B8.5.1
Only EPA-registered disinfectants approved by the Texas Department of Agriculture or
properly diluted household bleach (1:10 household bleach to water minimum) shall be used
for chemical decontamination of biological wastes.
B8.5.1.1
Freshly prepared disinfectants are required for chemical treatment of biowastes.
B8.5.1.2
Expired stock or dilutions of disinfectants shall not be used for any purpose.
B8.5.2
Should you choose to decontaminate liquid biowaste by chemical disinfection, a validated
standard operating procedure for the specific liquid matrix to be decontaminated must be
followed.
B8.5.2.1
The method must be validated by the PI according to 25 TAC §1.135.
B8.5.3
All label instructions for dilution and contact time must be followed.
In failing to do so, the PI assumes full liability for any incidents/injuries which result from off-label
use and is potentially subject to enforcement action under the Federal Insecticide, Fungicide, and
Rodenticide Act (FIFRA).
B8.5.4
All stock solutions of chemical disinfectants shall be stored according to the label/SDS. Do
not store solutions of incompatible chemicals under sinks (e.g., bleach with ammonia-containing
cleaners). Consult the label for disposal. If you have questions, call EHS.
B8.5.5
When diluted household bleach is used for chemical disinfection of biowaste, a 1:10
dilution of bleach to water is freshly prepared (B8.5.1) and items shall be totally immersed
for a period of time not less than three minutes or as required by the work-specific protocol
– whichever is longer.
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B8.5.6
Solid biowaste immersed in a liquid chemical agent must be thoroughly drained before
disposal.
B8.5.6.1
Agars and related biological substrates are not considered solid wastes capable of
chemical disinfection.
B8.6
Steam Disinfection (Autoclaving)
Autoclaves use pressurized steam to destroy microorganisms and are the most widely used and
accepted system available for the decontamination of laboratory biowaste and the sterilization of
laboratory equipment, glassware, media, and reagents.
There are four parameters which must be met for effective steam sterilization: steam, pressure,
temperature, and time. Should a cycle fall short in reaching the minimum target required in one of
these areas, sterilization will not be accomplished.
To ensure consistent sterilization practices, EHS has instituted a program for autoclave use and
monitoring. Mechanical, chemical, and biological monitors should be used to evaluate unit
performance in accordance with the program and TCEQ regulations.
B8.6.1
Autoclaving should be used, whenever possible, as the preferred means of
decontamination of laboratory biowaste. See B8.6.7.2 and B8.6.7.3 for proper autoclaving of
bagged biowaste.
B8.6.2
It is the PI’s responsibility to ensure operator competence and devise SOPs for the proper
methods of cleaning instruments, preparing packages, loading and operating the autoclave,
and maintaining an autoclave log that meets the requirements of B8.4.5.1.
B8.6.2.1
Those using building autoclaves are to record biowaste treatment runs in the provided
logbooks.
B8.6.3
Equipment Specifications
Pressure-cooker style autoclaves and home-built reactor pressure vessels are not to be
used.
B8.6.3.1
Autoclave Pressure Relief Devices
All autoclaves and reactor pressure vessels must be protected with a rupture disc as the
primary pressure relief device.
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Rupture discs are thin metal discs which are designed to burst at a specific pressure. Spring
loaded relief valves may be used as a secondary pressure relief device.
B8.6.3.2
Precautionary notes regarding autoclaves
Many new laboratory pressure reaction vessels will not be stamped with the ASME or CE
marking. Choosing manufacturers that are known to follow ASME codes is a way to
ensure that pressure vessels meet manufacturing requirements.
Modifications to pressure vessels may impede or impair designed safety features.
B8.6.4
Regulations Pertaining to Steam Disinfection of Biological Wastes (autoclaving)
B8.6
.4.1
Biowaste that must be transported outside of the laboratory for autoclaving must be
transported in a durable, leak-proof container labeled with the biowaste symbol.
B8.6
.4.2
To allow sufficient steam access to and penetration of the biowaste, the biowaste shall be
packaged according to the recommendations provided by the manufacturer and loaded into
the chamber so as to not exceed the capacity limits as set by the manufacturer.
B8.6
.4.2(a)
Bags to be autoclaved must be secured at the top such that steam is able to enter and vent
from the bag.
Do not twist, knot, or tape the bag shut in such a way that prevents steam entering/escaping the
bag.
B8.6.4.2(b
)
Chemical indicators (e.g., autoclave tape) must be used in association with autoclaved
biowaste.
B8.6
.4.3
For biowaste treatment, the temperature in the chamber of the autoclave must reach at least
121°C and there must be at least 15 pounds per square inch gauge pressure for at least 30
minutes. The 30 minutes does not include unit pressurization and depressurization, only time held
at 121°C (25 TAC §1.133).
B8.6
.4.4
The autoclave must be operated according to the manufacturer’s instructions.
B8.6
.4.5
Any markings that identify the waste as a biowaste (e.g., biohazard symbol) shall be
covered with a label that identifies the waste as treated medical waste.
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B8.6.4.5(a)
A label that states the contents of the disposable container have been treated in
accordance with the provisions of 25 TAC §1.136 must be affixed to the biowaste bag over
the biowaste symbol. Contact EHS for labels.
B8.6.4.5(b)
The treated and labeled biowaste bag must be placed in a black garbage bag and disposed
of in the municipal waste dumpsters by laboratory personnel.
B8.6.4.5(c)
Treated biohazard bags must be secured in a black bag before final deposition in the
building dumpster.
B8.6.4.6
Required Frequency of Biological Testing
B8.6.4.6(a)
For building-supported autoclaves, the department representative or building manager in
conjunction with EHS shall:
i. Demonstrate a minimum four log ten reduction (10^4 log) (as defined in 25 TAC §1.135
(relating to Definitions)) on routine performance testing using a biological indicator
containing pertinent Bacillus species (as defined in 25 TAC §1.135).
ii. Conduct testing on autoclaves which process the quantities listed below at the applicable
intervals:
• For generators of more than 50 pounds but less than or equal to 100 pounds per month,
testing shall be conducted at least monthly;
• For generators of more than 100 pounds but less than or equal to 200 pounds per month,
testing shall be conducted at least biweekly; and
• For generators of more than 200 pounds per month and persons that treat medical wastes
off-site, testing shall be conducted at least weekly.
B8.6.4.6(b)
EHS will facilitate annual testing of PI-owned autoclaves. PIs who have autoclaves in their
laboratories which process biologically contaminated materials and/or biowaste is
responsible for conducting testing at the applicable frequency listed in B8.6.4.6(a)ii as it
applies to their waste throughput. Contact EHS for biological indicators.
B8.6.5
Monitoring Autoclave Performance
As indicated above, autoclaves used to decontaminate laboratory biowaste must be tested
periodically to assure effectiveness to protect human health and the environment.
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B8.6.5.1
Mechanical monitors include thermometers, pressure gauges and displays on the autoclave.
Correct readings do not ensure sterilization; but incorrect readings could be an indication of
problems.
EHS recommends utilizing the printer for autoclaves as a regular means to monitor and log
autoclave performance. A cycle print-out is available on most campus units; printers on
these units should be maintained with ink and paper. EHS strongly recommends printers on
campus units.
B8.6.5.2
Autoclave performance shall be evaluated with chemical and biological tests. Indicators
shall be placed in autoclave locations that are the slowest to heat.
There are two types of tests are frequently used to evaluate autoclave efficacy:
(a) Chemical indicators
(b) Biological indicators
Please see the Appendix BE for forms and the SOP for the Autoclave Testing Program. If you
need assistance or have questions about monitoring, please contact EHS at 806-742-3876.
B8.6.5.2(a)
Chemical Indicators
As stated in B8.6.4.2 (b), heat-sensitive indicator tape or an equivalent chemical indicator shall be
used when autoclaving biowaste materials.
Chemical indicators use temperature-, pressure- and/or vapor- sensitive chemicals to assess
physical conditions during autoclaving and are generally inexpensive and easy to use. Multi-
parameter and single-parameter chemical indicators are available for autoclaves. Refer to the
manufacture for placement of chemical indicators within the load. Heat-sensitive indicator tape is a
chemical indicator and should be used on all materials within every autoclave load.
Chemical indicators should be used in conjunction with biological indicators - not replace them.
Chemical indicators only assess if the physical parameters of sterilization were met; biological
indicators are the only means to prove sterilization has been achieved.
B8.6.5.2(b)
Biological Indicators
Biological indicators contain heat-resistant spores that are destroyed when an autoclave is
functioning properly (generally Geobacillus stearothermophilus for heat treatment. Other spore
types are used for chemical sterilization.). Biological indicators are the most accepted and widely
used means of monitoring sterilization processes.
EHS provides biological indicators for state-required testing and assessing autoclaves after
repairs. EHS will test all University autoclaves with biological indicators at least annually.
Autoclave testing frequency will follow state guidelines at minimum (See B8.6.4.6(a) ii). The
procedure and treatment log sheets can be found in Appendices BE and BF.
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Biological indicators shall be used when:
i. The autoclave has been repaired
ii. New waste cycle parameters (i.e., settings) are set
iii. Biowaste loading procedures or materials have changed
Biological indicators should also be used when:
i. A new type of packaging material or tray is used
ii. New personnel are trained
NOTE: These evaluations fall outside the periodic testing facilitated by EHS and will be at the
laboratory’s expense.
B8.6.5.2(c)
Failed Indicators
If an autoclave fails a biological test:
i. Post an “out of service” sign on the unit and contact the appropriate party to initiate a
service call.
ii. Do not use the autoclave until it has been inspected, repaired, and successfully challenged
with a biological indicator in 1-3 consecutive “dummy” or non-hazardous loads with control
tests for each.
iii. Off-campus and PI-owned units will need to record and report all results to EHS. Please
see the procedure in Appendix BE and contact EHS with further questions.
B8.6.6
Autoclave Container Selection
B8.6.6.1
Polypropylene Containers and Pans
Polypropylene (recycle #5) is a plastic capable of withstanding autoclaving but resistant to heat
transfer. Therefore, materials contained in a polypropylene pan will take longer to autoclave than
the same materials in a stainless-steel pan.
Do not use polyethylene (recycle #1) or high-density polyethylene (recycle #2) plastics for
autoclaving.
B8.6.6.2
Stainless steel Containers, Pans, and Baskets
Stainless steel is a good conductor of heat and is less likely to increase sterilizing time; however, it
is more expensive than polypropylene.
B8.6.7
Preparation and Loading of Materials
For efficient heat transfer, steam must flush the air out of the autoclave chamber.
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Before using the autoclave, check the drain screen at the bottom of the chamber and clean
it if it is blocked. If the sieve is blocked with debris, a layer of air may form at the bottom of the
autoclave, preventing efficient operation.
B8.6.7.1
Liquids
(a) Fill liquid containers only half full. Loosen caps or use vented closures. Avoid large bottles
with narrow necks and sealed containers as they may explode.
(b) Cover bottles without a lid loosely with aluminum foil.
(c) Place bottles in an autoclavable secondary container to catch spills. Add water to the
bottom of the container to reduce the likelihood of cold spots in processing. See section
B8.6.6.
B8.6.7.2
Packets and Bags
(a) Always put bags of biological waste into an autoclavable secondary container to catch
spills. See section B8.6.6 for guidance regarding secondary containers.
(b) Fill bags no more than three-quarters full. Do not over fill bags.
(c) Position biohazard bags on their sides, with the bag neck closed loosely.
i. Use indicator tape or twist ties to loosely secure the top of the bag.
ii. Do not overfill bags or twist/knot the tops of bags. This prevents adequate steam
entry into the bag and may result in incomplete sterilization of materials.
(d) In the case of a vial, insert a blunted needle into the septum.
(e) Place a strip of indicator tape on bag if not otherwise used to secure the top of the bag.
(f) Add water to the bottom of the bin to facilitate heat
(g) Packaging materials for packets must allow steam penetration and maintain sterility after
processing. There are several methods to accomplish this. Call EHS at 806-742-3876 if
you have questions.
B8.6.7.3
Autoclave Loading
B8.6.7.3(a)
Loading procedures must allow adequate steam circulation and will vary with items to be
autoclaved and unit configuration. Do not exceed the capacity of the unit. (25 TAC §1.133).
Refer to your unit’s user guide if you have questions regarding either of these procedures.
B8.6.7.3(b)
Wear lab coat, eye protection, heat-protective gloves, and solid shoes. Carry your lab coat
on a cart- do not wear your PPE if you must travel in public corridors to the autoclave.
i. Select containers with the lowest sides and widest diameter possible for the autoclave.
ii. Remove container lid if present.
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iii. Leave space around each item.
iv. Drill a hole inside of container or pour water in the bottom of the tub to facilitate heat
transfer, add moisture to dry loads, and eliminate the air gap.
v. Use perforated trays and/or wire baskets for items that will not generate spills.
B8.6.8
Cycle Selection Guidance
• Use liquid cycle (slow exhaust) when autoclaving liquids, to prevent contents from boiling over.
• Select fast exhaust cycle for glassware.
• Use fast exhaust and dry cycle for wrapped items.
B8.6.9
Time Selection Guidance
(a) Consider the size of the articles to be autoclaved and the overall amount in the load. For
example, a 2-liter flask containing 1 liter of liquid takes longer to sterilize than four 500 mL
flasks each containing 250 mL of liquid and 4 flasks containing 1 liter will take less time than
10 flasks containing 1 liter.
(b) Material with a high insulating capacity, such as animal bedding and high-sided
polypropylene containers, increases the time needed for the load to reach sterilizing
temperatures thus the load will require extended time to achieve sterilization.
(c) All biologically contaminated materials should be autoclaved for a minimum of 30 minutes at
121°C and 15 psi. The 30-minute minimum does not include heat and pressurization
priming or depressurization; account for these periods separately when calculating total
cycle time for your unit if it is not already programed.
B8.6.10
Removing the Load
(a) Wear lab coat, eye protection, heat-protective gloves, and solid shoes. Carry your lab coat
on the cart - do not wear your PPE if you must travel in public corridors to the autoclave.
(b) Check that the chamber pressure ias zero.
(c) Standing behind the door while you open it, slowly crack open door to vent steam. Beware
of this rush of steam.
(d) If liquids were processed, open autoclave door and allow liquids to cool for 20 minutes
before removing.
B8.7
Summary of Biological Waste Treatment and Disposal by Generators
By law, biowaste is to be treated in accordance with 25 TAC 1.136 (B8.4.3). Please contact EHS if
you have questions as to how to address your biologically contaminated materials or biowaste.
Steam Disinfection of Solids
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• Collect disposable, solid materials contaminated by a biological agent, excluding sharps, into
an autoclave bag within an appropriate container.
• When half to three-quarters full, prepare bag as described in B8.6.7.2 and autoclave the bag as
described in section B8.6.4.3.
• Allow bag to cool, affix a “treated” sticker to the bag and place autoclave bags in black trash
bags. Contact EHS if you need more “treated” stickers (See B8.6.3.5(a)).
• Laboratory staff dispose of treated waste in the building's outdoor dumpster.
Chemical Disinfection of Solids
This method is for reusable laboratory supplies, pipet tips, serological pipets, reusable syringes
and items of that nature – not petri dishes with cultures, contaminated food products and similar
biowastes. Contact EHS for guidance and if you have any questions about treating your biowaste
.
• A pre-cleaning step to remove debris may be required for certain items.
• Prepare qualifying disinfectant per the manufacturer’s guidelines or a 1:10 dilution of household
bleach and water.
• Fully submerge biologically contaminated materials in solution (i.e., suck solution into pipet
tips). All surfaces must have contact with the disinfectant.
• Allow contact time per the manufacturer’s instructions, or if bleach is used, no less than 3
minutes or according to the lab-validated waste disinfection method - whichever is longer.
Different agents require different contact times with bleach. Contact EHS if you plan on
chemically disinfecting your biologically contaminated materials or biowaste.
Steam Disinfection of Liquids
If liquid biowaste is mixed waste, contact EHS. Autoclaving and chemical disinfection may not be
recommended. Contact EHS for the final disposal of your treated liquid waste. Some items are
not accepted in the sanitary sewer or can damage plumbing.
• Fill liquid containers only half full. Loosen caps or use vented closures. Avoid large bottles
with narrow necks when possible.
• Cover bottles without a lid loosely with aluminum foil.
• Place bottles in an autoclavable secondary container to catch spills.
• Autoclave for at least 30 min at 121°C and 15 psi of pressure on a cycle with slow exhaust.
The 30min time point does not include warm up or cool down.
• Allow liquids to cool before final disposal.
Chemical Disinfection of Liquids
Contact EHS if you plan to not use a bleach solution to disinfect your biowaste. Make sure that
bleach will not adversely react (e.g., produce chlorine gas) with your biowaste.
Should you choose to decontaminate liquids by chemical disinfection, a validated standard
operating procedure for the specific liquid matrix must be followed. Different materials/agents
require different bleach concentrations and contact times.
• Add, at minimum, an equivalent volume of freshly prepared 10-20% household bleach solution
to the container with the liquid waste. Gently mix.
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• Allow contact time per SOP.
• Dispose of solution by pouring down the sink.
• Flush with copious amounts of water to prevent damage to plumbing.
• Wash container as usual and rinse well before further use.
B8.8
Biological Wastes Picked up by EHS
B8.8.1
Sharps Waste
Sharps, according to 25 TAC §1.132 include but are not limited to the following when
contaminated: hypodermic needles; hypodermic syringes with attached needles; scalpel blades,
razor blades, disposable razors, and disposable scissors used in surgery, labor and delivery, or
other medical procedures; intravenous stylets and rigid introducers (e.g., J wires); glass Pasteur
pipettes, glass pipettes, specimen tubes, blood culture bottles, and microscope slides; broken
glass from laboratories; and tattoo needles, acupuncture needles, and electrolysis needles.
Regardless of contamination, hypodermic needles and hypodermic syringes with attached needles
are considered sharps.
Sharps must be segregated from other wastes.
B8.8.1.1
Safe Disposal of Sharps:
(a) FDA-approved containers (i.e., puncture-proof and securable) are required for the disposal
of sharps.
(b) Use care and caution when cleaning up after procedures that require the use of sharps.
(c) Do not recap or remove needles from syringes. Recapping requires an EHS-approved
SOP.
(d) Do not recap or remove scalpel blades by hand.
(e) Discard needle and syringe as an intact unit immediately after use into puncture-resistant
sharps containers.
(f) Do not overfill sharps containers. Replace when waste reaches indicator line on container
or when 3/4 full.
(g) Dispose of ALL sharps containers through EHS waste disposal. “Biological” is the indicated
waste type unless radioactive materials are present.
i. Sharps that have contacted radioactive materials require a separate sharps
container appropriately labeled for the radioactive hazard. When full, dispose of
sharps container through EHS as “Radioactive” waste. See the Radiation Safety
Manual for details.
In the event of a sharps-associated injury, notify the PI and/or senior lab personnel and seek
treatment if needed. Fill out and turn in an incident report within 24hrs of the injury. Access to the
online form for Risk Management is available on the EHS website at:
http://www.depts.ttu.edu/ehs/about/incident-reporting.php.
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Call EHS if you have any questions at 806-742-3876.
B8.8.2
Biological Waste Barrels (biobarrel)
Biological waste barrels with liners are provided by EHS to laboratories for biological waste
disposal in certain cases. Laboratories that may need barrels might include those which:
1. Lack access to an autoclave or the autoclave is out of service;
2. Perform research which periodically generates large amounts of biowaste that is not
manageable in available autoclave(s);
3. Perform research which includes inoculated or naturally infected live animals, whole
carcasses of unpreserved animals, whole cuts of meat or other dense items which will not
autoclave properly.
4. Other special cases as determine by EHS (mixed waste, high hazard, etc.).
B8.8.2.1
Biobarrel Use
Biobarrel use is addressed in EHS SOP 6.5, Use of EHS-provided Biobarrels. Violations of the
points below can result in delayed waste pick up or revocation of barrel privileges in locations of
elected barrel use. See Appendix BG for details.
(a) Properly segregate biowaste from non-biowaste.
(b) Accumulate biowaste in smaller, appropriate biowaste receptacles. Do not place
loose materials directly into the biobarrel.
(c) Do not place large quantities of liquid biowaste into biobarrels (e.g., spent cell-culture
media, liquid microbial culture media, supernatants, etc.).
(d) Secure individual biowaste bags prior to placement in the biobarrel.
(e) Tie off biobarrel bag liner when biobarrel is ¾ full. Biobarrels cannot weigh more
than 40 lbs.
(f) Avoid compressing waste in the biobarrel.
(g) Biobarrels are to remain closed except when a biowaste bag is actively being
transferred to biobarrel.
B8.8.2.2
Biobarrel Pick-Up
(a) Liners must be “tied off” (i.e., knotted – sides pulled up and tied together)
(b) Lid must be secured.
(c) Weight must not exceed 40lbs.
(d) Submit biowaste pick-up request online through the EHS website:
http://www.depts.ttu.edu/ehs/.
(e) The number of barrels picked up will be the number of barrels replaced. This number can
be modified in the comment section of the waste request, but the requested number may
not necessarily be granted.
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A biobarrel usage poster is available on the EHS website:
https://www.depts.ttu.edu/ehs/academicsafety/lab/tools-templates.php. You can also contact EHS
for a printed copy.
B8.8.3
Multi-hazard or Mixed Waste
Avoid generating mixed waste; if unavoidable, keep volume of mixed waste to a minimum.
Do not steam or chemically disinfect mixed waste without EHS consult.
B8.9
Disposal of Animal Tissues, Carcasses and Bedding
B8.9.1
Disposal of non-farm/agriculture-related animal tissues, unpreserved carcasses and bedding is to
be coordinated with EHS and ACS. Freeze / refrigerate tissues and carcasses until pick-up to
prevent odor as needed.
B8.9.2
Preserved carcasses, drained of preservatives, can be disposed of as municipal waste.
B8.9.2.1
Collect all liquid preservatives and dispose of them as hazardous waste. Place carcasses
in a black trash bag and dispose of it in the building’s dumpster.
If you have questions, please call EHS at 806-742-3876.
B8.10
Plant and Seed Devitalization
Genetically modified plants and seeds must be rendered non-viable prior to disposal. Some
collaborators or funding agencies may require a maceration step or incineration.
B8.11
Special Considerations for Toxin Neutralization
Neutralization methods must be specific to the toxin and will be described in the IBC
protocol.
B8.12
Special Considerations for Prion/Prion-like Protein Neutralization
Neutralization methods must be specific to the prion/prion-like protein and will be described
in detail the IBC protocol.
B8.13
Other Waste Issues in Biological Laboratories
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B8.13.1
Reusable Labware
Items such as contaminated culture flasks, media bottles, test tubes, instruments, equipment
tubing, etc. are decontaminated by lab personnel before washing (and repackaging) by one of two
methods:
• Autoclave items that have been collected in autoclavable containers.
• Chemically disinfect items by soaking in a fresh 10% sodium hypochlorite solution for a
minimum of 20 minutes before washing. For heavily soiled items, remove as much of the
visible contamination as possible over an autoclave bag (for autoclaving or EHS waste
collection) then soak in fresh 10% household bleach. Repeat as necessary. Follow
disinfectant step(s) with a thorough water rinse. The rinse is especially important for items
vulnerable to corrosion and remove bleach residue.
B8.13.2
Glass
B8.13.2.1
Non-contaminated glass waste must be segregated from other solid municipal waste and
disposed of in a sturdy, puncture-resistant, closable box labeled as broken glass (CHP,
A19.3.4.1).
There are autoclavable, benchtop boxes you can purchase for easy disposal of pipettes, slides and
other small glass items (Terminal® Biohazard Benchtop Keeper™ and Terminal® Pipet Keeper™
Containers, Whitney Products).
B8.13.2.2
Full glass disposal boxes should be taped closed and disposed of in a dumpster by the
laboratory (i.e., accumulator) (CHP, A19.5.2).
B8.13.2.3
Do not handle broken glass with your hands. Use forceps, tongs, or some other tool to
collect and handle broken glass. Decontaminate collection tools after collection of
contaminated glass.
B8.13.2.4
Biologically contaminated glassware should be immediately disposed of in a sharps
container. This minimizes handling of the contaminated hazard.
If disposal in a sharps container is not possible, glass must be decontaminated before
disposal in the glass disposal box (CHP, A19.5.1). Glass can be decontaminated by steam of
chemical disinfection. Autoclaving is the recommended decontamination method.
(a) Autoclave in a puncture-proof, autoclavable container; or
(b) Place in a wire sieve then soak in freshly prepared 10% household bleach solution or other
approved chemical disinfectant solution for the appropriate contact time.
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B9 BIOLOGICAL LABORATORY OPERATION
Biological risk management approaches vary with the agent(s), procedure(s), and location(s)
associated with the work. Adequate and appropriate risk management is essential to the safe
operation of the biological laboratory.
B9.1
Risk Management
Risks must be identified and addressed prior to beginning laboratory work and repeated
when any changes are made to the agent, procedure, equipment, employee, or facility.
All biological work carries some level of risk. Worker training and competency are paramount for
personnel, laboratory, and environmental safety.
Biological risk assessment (RA) is a continuous and evolving process dependent on the quality
and quantity of current information and recommendations of appropriate, realistic methods of
containment. A RA should be performed by those most knowledgeable of the agent or technique
and is thus a pivotal responsibility of PIs and is shared and supported by EHS, the IBC, and other
Institutional Committees as applicable.
Information identified in a RA will provide a framework for appropriate PPE, laboratory practices,
engineering controls and safety equipment to manage the identified risks. The three basic steps to
risk management are hazard identification, risk assessment and risk control.
B9.1.1
Identification of Hazards
1. Identify the agent(s) if they are known. Samples of unknown status and environmental
samples should be handled with universal precautions at BSL2 unless permission has been
granted otherwise by the IBC (see B6.2.2).
2. Identify all procedures and equipment which will be applied to the agent.
3. Identify the location(s) where work will be done.
4. Identify who will be performing the work.
Identification of the above research elements will help you to properly evaluate the three central
components of a RA (agent, environment, and host) which need to be addressed when considering
biological risks.
Several factors about each component and relationships
between components are evaluated in step 2: Risk
Assessment.
B9.1.2
Biological Risk Assessment (RA)
Biological risk assessment is generally not as prescriptive as
a risk assessment for a chemical or physical hazard as it
involves living organisms that exist in a state of natural
variation.
Barbara Johnson, PhD, RBP - Understanding, Assessing, and
Communicating Topics Related to Risk in Biomedical Research
Facilities, ABSA Anthology of Biosafety IV - Issues in Public
Health, Chapter 10 (2001), http://www.absa.org/0100johnson.html.
FIGURE1. Risk Assessment Triad
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B9.1.2.1
Biological Agent(s)
Given the ubiquitous nature of some microbes, it is important to consider naturally occurring strain
variation and the potential for differential expression of virulence factors.
This variation, in conjunction with the dynamics of the host-agent relationship, complicates
calculating infectious dose; however, relative estimates can be made regarding the risk an agent
poses when the following elements of an agent are considered:
• Pathogenicity and resilience
• Naturally occurring mode(s) of transmission
• Likely mode(s) of transmission in the laboratory
• Natural reservoirs
• Host range (e.g., zoonosis or reverse zoonosis)
• Vectors
• Availability of treatment/prevention measures
See B6.2 regarding risk groups. Risk groups are a starting point for a RA based on what is known
about an agent; however, risk group alone is not a substitute for a RA.
B9.1.2.1(a)
Additional Factors to Consider Concerning Biological Agents
• Concentration (natural burden vs lab culture)
• Volume
• Exposure associated with procedures (i.e., aerosolization, injection, involvement of vectors or
animals, etc.)
• Life cycle stage(s) to be encountered/manipulated
These factors may increase/decrease the containment level required for an agent regardless of the
risk group (B6.2.1).
B9.1.2.2
The Environment
Environmental factors to be considered in a RA primarily concern agent containment and
environmental impact. Environmental factors may include:
• Ventilation and laboratory design
• Laboratory procedures and training
• Containment equipment
• Established and updated operating procedures
• Personal Protective Equipment availability and usage
• Laboratory sanitation and biowaste management
• Use of animals and/or vectors
• Presence of host species and/or agent vectors outside containment
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• Field work
B9.1.2.3
The Host
The human factor is the most difficult hazard to control.
Lab personnel are encouraged to alert their PI or laboratory supervisor if they have a health
condition that can affect their safety in the lab so that duties can be properly assigned.
Lab personnel are strongly encouraged to inform their personal physician of all hazardous
material they handle in the laboratory.
Lab personnel and visitors are to be informed of the hazards to which they may be exposed;
this includes potential routes of exposure, symptoms, and treatment options and availability.
B9.1.2.3(a)
The human immune system can be affected by multiple factors that can modify the host response
to an exposure; such factors may include but are not limited to:
• Genetic predisposition
• Pregnancy
• Stress and fatigue
• Medications
• Chronic conditions (e.g., diabetes, HIV, allergies, autoimmune disease, etc.)
• Acute conditions (e.g., common cold, open wound/laceration)
• Treatment sensitivities
• Vaccination status
• Age
• Composition of natural flora
B9.1.2.3(b)
Some medications may alter your state of mind leaving you less coordinated, alert, and capable in
the laboratory.
B9.1.2.3(c)
You are only as safe as those with whom you work. Behavioral factors that can affect worker
safety in the laboratory include:
• Education
• Lack of training or recurrent training or poor training
• Failure to use PPE, use of PPE in poor condition, or improper use of PPE
• Poor or improper laboratory habits (lab-specific safety culture)
• Complacency
• Distractions
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B9.1.2.3(d)
The above primarily focuses on humans as a host. Host range (plant species and non-human
animal species) must also be explored as it pertains to the agent(s).
B9.1.2.4
Risk Matrices
While assessing risks, it is also important to prioritize the risks you are evaluating and direct
attention to those with the greatest probability of occurrence and can cause the most harm. The
risk matrices below can help guide prioritization.
The agent risk groups are listed across the top. The hazard level of the procedure to be used is on
the far left; procedures that use aerosol-generating equipment or sharps would be considered to
have a high probability of an accident/incident occurring.
TABLE 2. Example Risk Matrix Regarding Agent
Table adapted from Biological Safety: Principles
and Practices 4th Ed., Fleming and Hunt,
ASM Press 2006.
B9.1.3
Risk Control
Once hazards are identified and the risk they pose assessed,
control measures can be implemented. Hazard controls may
be on an administrative, facility, or laboratory level and can
range from alternate methodologies or PPE to facility design
and biosafety cabinets.
A key element in risk control is the laboratory-specific
biosafety manual, also referred to as a Biological Work Area
Safety Plan (bioWASP/WASP). This document may either be
an amendment to an existing WASP or a stand-alone
biosafety-specific document in addition to your general WASP
or your IBC protocol.
The (bio)WASP serves as the foundation for administrative risk
control measures (Administrative Controls) as it addresses
laboratory and facility operations, training requirements,
application of primary and secondary containment measures, emergency procedures, exposure and
health monitoring guidelines and any other necessary materials for a safe laboratory environment.
Additionally, personal protective equipment is an essential element in controlling exposure to
potentially hazardous biological material. It must be appropriately selected for the task, worn and
removed properly, and be in good condition (see section B9.1.3.2).
Probability of accident
RG3
RG2
RG1
High
High
Medium
Low
Medium
High
Medium
Low
Low
Medium
Low
Very low
Negligible
Low
Low
Very low
Elimination
Substitution
Engineering
Administrative
Behavior
PPE
FIGURE 2. Hierarchy of Controls
NIOSH, Hierarchy of controls.
https://www.cdc.gov/niosh/topics/hierarchy/default.html
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B9.1.3.1
Biological Work Area Safety Plan
B9.1.3.1(a)
A laboratory-specific biological work area safety plan (Bio-WASP) is required for work with
biological materials at any containment level.
B9.1.3.1(b)
The bio-WASP will be reviewed as part of the IBC review/approval process.
B9.1.3.1(c)
The bio-WASP must be available & accessible in the work area.
B9.1.3.1(d)
The bio-WASP shall be reviewed at least biennially and updated necessary when new
biological materials, equipment, or methods are introduced.
B9.1.3.1(e)
The Biological Work Area Safety Plan (bio-WASP) should cover the items outlined below and be
specifically tailored to the needs of the individual work area and research.
i. General operations – Laboratory access and guidelines for workers/non-workers;
entry/exit procedures; procedures for identifying, reporting, and correcting problems; facility
procedures; pest management; general laboratory safety guidelines; lab notebook.
ii. Safety equipment and personal protective equipment – PPE requirements; proper
donning and doffing procedures for PPE; maintenance and decontamination of reusable
PPE; use, decontamination, and maintenance of equipment (BSC, autoclaves, eyewash,
showers, etc.).
iii. Emergency procedures – Accidents: spill, release, exposure, fire, etc.; documentation
and reporting requirements; terrorist threat; etc. See section B.7 for compliance
requirements and procedure guidelines.
iv. Training – Documented understanding of the bio-WASP manual; notification of the risks
associated with the materials to which workers may be exposed; frequency of in-lab
proficiency testing and other trainings/assessments; etc.
v. Practices and procedures – Safe handling, storage, and decontamination of biological
materials; handling of frozen samples; use of secondary containers; transporting samples;
aseptic technique and proper hand washing; management of sharps; waste handling and
disposal; facility decontamination and housekeeping; etc.
vi. Standard operation procedures (SOPs) are required for all laboratory functions (CHP,
A12.1) and must be reviewed and approved by the supervisor/PI (CHP, A12.2). Use of
images, pictures and flowcharts in SOPs is helpful. Written procedures should include the
information outline sections A12.1.1-A12.1.11 of the CHP.
vii. Health and medical monitoring – Signs/symptoms of exposure for all materials; fever
monitoring; OHP enrollment; vaccination requirements and or titer testing if required; etc.
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viii. Biosecurity – Security measures taken to protect and control the use of biological
materials and research-related information (e.g., doors remaining locked, restricted access,
materials secured at the close of the workday, locking freezers, inventory and material
management procedures, adequate documentation, etc.); measures to assess personnel
are at the discretion of the PI, the granting agency, and/or the institutional Facility Security
Officer (in ORS).
Please contact EHS at 806-742-3876 or email lab safety at ehs.lab.safety@ttu.edu if you have
questions about bio-WASP content or for a review of your bio-WASP.
B9.1.3.2
Personal Protective Equipment (PPE)
Personal protective equipment includes all clothing and work accessories designed to serve as ‘the
last line of defense” against work hazards.
PPE should be dedicated to a specific work area and not moved among work areas; this is a
requirement for all areas operating at level 2 containment (i.e., ABSL2, BSL2, ACL2, etc.). If
you need PPE in another location (i.e., autoclave), carry it with outside surfaces folded
inward or place it on a cart.
Proper laboratory attire and PPE requirements for laboratory spaces are addressed in
section A4.3 of the CHP and shall be followed unless specific guidance pertaining to
biosafety is addressed in this section (B9.1.3.2), B9.2.2, or elsewhere in the biosafety
manual.
B9.1.3.2(a)
Gloves
Disposable gloves are commonly used in laboratories and are required for working with chemical
and biological materials. Double gloving may be recommended or required with certain materials
or procedures.
Nitrile gloves are recommended for working with chemicals; most glove manufacturers have done
performance test data for common chemicals. You are encouraged to research the protection
offered by your glove selection. Glove producers like Kimberly-Clark and Ansellpro offer glove
selection tools to help select proper gloves for your hazards.
Proper use of gloves includes the following:
i. Wash hands prior to donning gloves to remove lotions which may compromise glove
integrity.
ii. Glove cuffs should be worn OVER lab coat cuffs.
iii. When double gloving, the following tips can help:
a. Use different colors for inner and outer gloves.
b. Use extend-cuff gloves for the outer glove.
c. Turn the inner glove inside out to assist in donning the outer glove.
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d. Use 1.5 inch blue painter’s tape to secure inner glove to lab coat or Tyvek sleeve.
Tab the end of the tape to facilitate easy removal of the inner glove. Taping the
inner glove facilitates easy removal of the outer glove as needed during work.
iv. Avoid touching your face, eyewear, personal items (e.g., cell phone) with your gloves.
v. Gloves shall be removed in such a way as to not contaminate the wearer or aerosolize
material on the gloves.
vi. Used disposable gloves shall be discarded immediately after removal and never reused.
vii. Gloves should be changed frequently and between procedures. Gloves shall be changed
when they are visibly contaminated and when integrity has been compromised.
viii. Frequent decontamination of gloves with 70% ethanol is encouraged in biological
applications.
ix. Gloves are not to be worn outside the workspace or common areas.
x. In general, gloves worn in biological laboratories are disposed of as biowaste.
xi. Hands should be washed anytime gloves are removed. Hands must be washed before
leaving the laboratory/work area. Camp sinks should be used for field work where facilities
are unavailable.
xii. Be aware of the use of laboratory chemicals that may breakdown a glove’s integrity (e.g.,
ethanol). Ethanol’s effect on glove integrity is generally not a concern unless other
chemicals which present a health hazard are being handled.
xiii. Specialty gloves (natural rubber, cryogenic, neoprene, thermal, PVC, Silver Shield®, etc.)
may be needed for certain procedures. Such PPE must be available, in good condition and
specified in the written procedure when required.
B9.1.3.2(b)
Eye and Face Protection
Proper use eye and face protection includes the following:
i. Body and eye protection must be worn when biological hazards are not behind a physical
barrier (e.g., closed cabinet, closed refrigerator, closed drawer, closed incubator, etc.).
ii. Regular prescription glasses are not a substitute for safety glasses.
iii. Over-the-glasses safety glasses should be available on-hand for workers who wear
glasses. Contact lenses may or may not be worn at the PIs discretion.
iv. The type of eye and face protection needed for a certain laboratory may vary with
procedure and must be ANSI-certified for the hazards encountered (i.e., impact,
splash/spray, UV light, lasers, etc.).
A brief description of common laboratory eye protection is below.
Safety glasses – Protective eyeglasses with impact-resistant lenses and safety frames constructed
of metal or plastic; primarily provide impact protection and should be used in conjunction with a
face shield or splash shield if splashes or sprays are likely; some provide UV protection.
Goggles – Tight-fitting eye protection that completely covers the eyes, eye sockets and the facial
area immediately surrounding the eyes. Some goggles may only offer impact-only protection and
are not designed to offer protection against splashes and spays. Splash goggles are specifically
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designed to protect against splashes and sprays and must be worn when working with chemical /
biological agents or procedures that present a splash hazard.
Laser safety glasses/goggles – Provide protection from laser light; make sure your eye protection
addresses your laser class.
Face shields – Headgear providing a transparent sheet of plastic covering the entire face. They
protect against nuisance dusts and some splashes or sprays of hazardous liquids but may not
provide adequate protection against impact or splash hazards and are to be worn with eye
protection (i.e., safety glasses or goggles).
B9.1.3.2(c)
Body Protection
Different types of body protection (e.g., coats, coveralls, scrubs, gowns, and aprons) provide
different types of protection based on the design and material composition. Some may be particle
resistant, waterproof, flame resistant, and/or chemical resistant.
Proper use of body protection includes the following:
i. Lab coats must fall below the waist; knee-length is recommended.
ii. The lab coat selected shall address the hazards in the laboratory.
• A barrier coat is strongly recommended in containment level 2 work areas or for
those working in biosafety cabinets; this coat has knit cuffs and snaps up to the neck
to prevent exposure to potentially infectious materials.
iii. Laboratory coats should be comfortable and well-fitting; an improper fit may endanger the
user.
iv. Reusable body protection must be laundered when soiled and at regular intervals (e.g.,
monthly) to minimize contamination. Be sure the laundry service used is qualified to
manage the potential exposure to whatever may be present on the coats. Autoclaving or
bleaching coats prior to laundering is prudent but only necessary in the event of a spill or
other visible contamination.
v. Used laboratory coats shall not be stored in non-laboratory areas. Freshly laundered,
unused, laboratory coats may be stored in passageways if absolutely necessary.
vi. Body protection from containment level 2 work areas is work-area specific and shall not be
worn outside the work area or taken to other work areas. If needed for use of a communal
autoclave, they shall be transported on a cart with the materials to be autoclaved. Ideally a
designated coat is set aside for this purpose.
vii. Consider sleeve covers, protective suits, booties, aprons etc. as needed for hazards
associated with your work.
viii. Consult EHS if you have questions about PPE or if you feel respiratory protection is
needed.
B9.2
Working with Biological Materials
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Federal and state regulations and guidelines govern laboratory safety to protect personnel, the
public, and the environment from biological hazards. Many granting agencies, including NIH,
require that grant recipients certify that they adhere to these guidelines and regulations. Failure to
provide evidence of adherence, if requested, can result in suspension and/or withdrawal of funds
from the University.
B9.2.1
The IBC Protocol Application
The principal investigator is responsible for the preparation and submission of the IBC Application
Form to the IBC for any project involving the items stated in B4.2.9 (restated below). Approval is
required before work begins in most cases.
Principle Investigators are required to submit work for IBC review for any of the following:
• Recombinant and/or synthetic nucleic acid (rNA/sNA) activities;
• Materials or agents potentially infectious to humans, plants, and/or animals – including the
storage or concentration of any potentially biohazardous materials;
• Except for general surveillance, arthropods that serve as vectors of disease to humans, plants,
or other animals, and arthropods that are considered an environmental hazard;
• Use of soil seed, plants, plant pathogens (e.g., bacteria, viruses, fungi, or parasites) or other
material received under a USDA APHIS compliance agreement or permit;
• Use of potentially infectious human and/or non-human primate materials;
• Use of cell lines that pose a danger to humans, animals, and/or plants, and/or those
immortalized by means that render them dangerous to humans, animals, and/or plants;
• The use of biologically derived toxins;
• Work involving prions or prion-like proteins;
• Any Select Agent or Toxin as listed in 7 CFR 331, 9 CFR 121, and/or 42 CFR 73.
• Necropsy of animals not under the care of the University Veterinarian; necropsy that includes
hands-on student involvement; and necropsy of animals with unknown health status and/or
animals reasonably suspected or known to be infectious;
• Other work as deemed necessary for review by the Biological Safety Officer; and/or
• Work with other potentially biohazardous materials conducted at, or sponsored by the
University for compliance with the guidelines in the CDC/NIH Biosafety in Microbiological and
Biomedical Laboratories (BMBL) and approve those research projects that meet or exceed the
requirements in the BMBL.
The IBC protocol review is facilitated through the Cayuse Hazard Safety module. This is a
cloud-based platform for IBC protocol management and maintenance. No other form of
application or application amendment will be accepted.
EHS is available to consult and answer questions regarding form completion and any other
pertinent documentation prior to IBC review.
B9.2.1.1
Documents Required for Application Submission
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The following documentation must be attached to your protocol in Cayuse:
(a) Safety plans (i.e., bio-WASP, field safety plan);
(b) Signed Personnel Assurance sheet for the personnel listed;
(c) State and/or federal permits for research materials on your protocol;
(d) Co-PI forms for Co-PIs listed on the protocol;
(e) Supporting documents such as SOPs, MOUs, or literature cited on your application; and
(f) OHP clearances from the occupational health provider (when required).
B9.2.1.2
Steps for Protocol Registration
These steps and links are available on the IBC Protocol Registration Page:
https://www.depts.ttu.edu/ehs/academicsafety/Biosafety/protocolregistration-bio.php.
(a) Register yourself and lab members to be listed on your protocol in Cayuse using the online
Cayuse Personnel Description Form:
https://www.depts.ttu.edu/ehs/academicsafety/Biosafety/ibccayuse-personnel.php.
(b) Complete and Submit your Protocol in Cayuse.
• A Researcher Toolbox has been created that has work aids for completing and
managing your protocol in Cayuse. The Toolbox is located at:
https://www.depts.ttu.edu/ehs/forms/TTUIBC_ResearcherToolbox.php
• You can view the status of your protocol at any time in Cayuse.
• Co-PIs and lab managers can create and amend a protocol on behalf of a PI, but only
the PI of record can submit the protocol.
(c) The Review Process.
• The PI submits the completed IBC application and attaches any associated documents
as those outlined in B9.2.1.1 within the Cayuse Hazard Safety module. These include:
the WASP, Other supporting documentation (i.e., SOPs, federal permits, literature,
etc.), OHP clearances, and Personnel Assurances and Co-PI Forms.
• The IBC Office may review the submission for completion and request changes prior to
forwarding the application to the committee.
• The protocol is distributed to the IBC committee members for review. Committee
member comments (if any) are collected by the IBC Office and sent back to the
submitting PI.
• If severe concerns are expressed by the committee or the protocol is called for full
committee review, the IBC may invite the PI to attend the upcoming meeting to discuss
their proposed work in-person.
B9.2.1.3
Conditions of Approval
(a) The laboratory spaces where work is to be conducted must meet the
biocontainment requirements for the work to be performed as determined by the
IBC.
(b) Requested clarifications or changes to the IBC Application by the IBC must be
addressed by the PI. The PI must either submit answers or a rebuttal to all committee
member comments no less than 5 days before the upcoming meeting to have the final
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review of their application on the meeting agenda. A list of meeting dates is on the IBC
homepage: https://www.depts.ttu.edu/ehs/academicsafety/icc/ibc.php.
(c) Protocols are discussed and approval granted at the monthly IBC meetings. In
special situations, approval may be granted outside of the formal meeting.
B9.2.1.4
Post-Approval Requirements
Print your protocol and associated attachments in hard copy and have lab members listed
on the document review. Maintain a copy of your current protocol in the work area. A
dedicated binder for this purpose will be provided by EHS at PI request.
B9.2.1.4(a)
Required Renewal and Annual Updates
PIs must submit an annual continuing review to the IBC and renew active protocols every
three years. If a protocol is completed prior to the continuing review or 3-year renewal period,
please contact the IBC Office by email at ibc.ehs@ttu.edu.
B9.2.1.5
Amending the IBC Application
All protocol amendments, including personnel amendments, are performed in Cayuse.
B9.2.1.5(a)
Amendments to the IBC Application are required when there are modifications to any of the
following:
i. PIs;
ii. Personnel;
iii. Research locations;
iv. Materials (e.g., vectors, gene targets, organisms, cell lines, tissues, disinfectants, etc.);
v. Methods; and /or
vi. When new hazards are introduced and not otherwise addressed in the protocol.
B9.2.1.5(b)
Amendments are subject to the conditions of approval in B9.2.1.3.
B9.2.1.5(c)
Certain amendments such as personnel and facilities are approval administratively through
the IBC Office. Changes to materials and methods are only administratively approved when
there is no change in the risks or objectives associated with the work previously approved
by the IBC. This is at the discretion of the Biosafety Officer or their proxy and may or may
not include the IBC Chair or Associate IBC Chair given the nature of the amendment.
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B9.2.2
Licensing of a Lab Space
B9.2.2.1
The following is required for laboratory work to be performed using BSL1 containment.
Laboratories working at BSL1 must:
(a) A lockable door which remains closed at all times;
i. A self-closing door is ideal.
(b) Have a sink for handwashing;
(c) Have an eyewash;
(d) Have adequate illumination;
(e) Have screens for windows, or seal windows, when windows are present;
(f) Have an integrated pest management plan;
(g) Have appropriate signage on the door;
(h) Have access to a copy of the most current edition of the CDC document Biosafety in
Microbiological and Biomedical Laboratories (BMBL);
i. Electronic access must be independent of the internet and not tied to a specific
computer (i.e., flash drive or equivalent external storage device) that is accessible in
the lab.
(i) Have access to a copy of the most current edition of the NIH Guidelines for Research
Involving Recombinant DNA Molecules if a laboratory is doing rNA/sNA work;
i. Electronic access must be independent of the internet and not tied to a specific
computer (i.e., flash drive or equivalent external storage device) that is accessible in
the lab.
(j) Post emergency numbers in a visible location preferably on the door, near the phone or
both;
(k) Properly manage biowaste from generation to disposal (See section B8.3.);
(l) Have appropriate, labeled biological waste containers readily available (See section
B8.3.2.3.);
(m) Have waste segregation procedures and disposal plans in place for general waste, liquid
biological waste, solid biological waste, sharps, glass, etc.;
(n) Follow the practices outlined in B9.2.3.9 regarding the use of sharps;
i. An SOP guides the use and disposal of sharps in the work area.
ii. Mechanical means are readily available and used to replace blades on reusable
sharps.
(o) Use plasticware as a substitute for glass when possible;
(p) Have mechanical means to handle broken glass (i.e., tongs, forceps, dust broom, etc.);
(q) Have a hard copy of the current (bio)WASP available and accessible in the laboratory;
(r) Document worker understanding of the (bio)WASP and that they have been informed and
understand the hazards associated with their work;
(s) Have hard copies of EHS-required training certificates for all personnel;
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i. A sign indicating the location of training records must be in the laboratory if these
records are stored in a different location.
(t) Have personnel complete rNA/sNA training when recombinant or synthetic nucleic acid
methodologies are used;
(u) Provide specific, in-laboratory training regarding duties, potential hazards, manipulations
of infectious agents, necessary precautions to minimize exposures, and hazard/exposure
evaluation procedures (e.g., physical hazards, splashes, aerosolization) are provided to
all personnel.
i. This training is documented, and proficiency level(s) are checked.
ii. Annual updates and additional training are required when equipment, procedures, or
policies change.
iii. EHS can work with the PI to facilitate this as needed.
(v) Put procedures in place to minimize the creation of aerosols;
(w) Post spill protocols;
(x) Don appropriate PPE at all times;
i. Gloves must be worn when working with biological materials or agents or may come
in contact with contaminated surfaces or equipment. (See B9.1.3.2(a) for specifics.)
ii. Long hair is secured.
iii. Skin below the waste is covered as appropriate for laboratory and field
environments.
iv. Solid shoes are worn.
v. Eye, face, and body protection is appropriate to the work being conducted. (See
B9.1.3.2(b) and B9.1.3.2(c) for specifics.)
(y) Wash hands before leaving the laboratory;
(z) Routinely decontaminate reusable PPE, the laboratory, and equipment within the
laboratory;
(aa) Immediately decontaminate surfaces, areas, and PPE after all splashes and spills;
(bb) Have a biological-specific spill kit and fresh disinfectant readily available at all times
while work is ongoing;
(cc) Not allow animals and plants that are not associated with the work being performed to
be present in the laboratory;
(dd) Use an overflow flask in-between suction flask and pump / building vacuum line when
suctioning potentially infectious substances;
(ee) Advise all persons entering the facility of the potential hazards, instruct them on the
appropriate safeguards, and require them to read and follow instructions on practices
and procedures.
(ff) Remove PPE in a manner that minimizes personal contamination and transfer of
infectious materials outside of the areas where infectious materials are manipulated.
(gg) Place all biological materials/agents in a durable, leak-proof container during collection,
handling, processing, storage, or transport to and within the laboratory.
(hh) Consumables and personal use products are kept outside of the work area (i.e., food,
drink, vapes, cosmetics, etc.).
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(ii) Mouth pipetting is prohibited. Mechanical pipetting devices are used.
(jj) Cleaning equipment (i.e., brooms, mops, buckets, etc.) is dedicated to the work area.
When a biosafety cabinet (BSC) is present, the following applies:
(kk) Locate the BSC away from doors, room ventilation, heavily traveled areas, and other
disruptive equipment so as to not disturb airflow within the BSC;
(ll) Certify the BSC annually (i.e., within the past 12 months); and
i. If the BSC’s certification is expired, a sign is posted indicating the cabinet must not
be used.
ii. If the BSC has malfunctioned, a sign is posted indicating the cabinet must not be
used.
(mm) Use the BSC appropriately as outlined in B10.1.
When a laminar flow hood (clean bench) is present, the following applies:
(nn) Use a laminar flow hood appropriately as outlined in B10.2.
B9.2.2.2
The following is required in addition to B9.2.2.1 for a laboratory to be licensed as BSL2
space and maintain that laboratory designation.
Laboratories working at BSL2 must meet BSL1 (B9.2.2.1) and:
(a) Preferably locate a sink near the exit;
(b) Have self-closing doors;
(c) Have personnel complete Biological Safety training;
(d) Have personnel complete Bloodborne Pathogen training and OHP enrollment when
human materials are used;
i. OHP enrollment is facilitated by EHS
(e) Have restricted access to the lab;
i. Untrained persons who must enter the laboratory must be escorted at all times. In
general, minors, custodial staff, and maintenance workers are not allowed in the
laboratory. See section B9.2.4 for more details.
(f) Secure laboratory work, and decontaminate lab work surfaces at the end of each
workday;
(g) Evaluate the need for medical surveillance, OHP enrollment and immunization
requirements and implement as appropriate:
i. Dependent on materials or agents to be used.
ii. Evaluated in conjunction with IBC review.
(h) Place biohazard signage on lab equipment that contacts biological agents/materials;
(i) Maintain a log of the routine decontamination of laboratory equipment;
(j) Decontaminate the general laboratory area (including floor) weekly unless work variability
warrants a less-rigorous disinfection schedule as determined by the IBC.
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(k) Conduct all aerosol-generating procedures that involve the manipulation of potential
infectious materials in a biosafety cabinet or other physical containment device when
possible.
i. In instances where a biosafety cabinet is not feasible, additional PPE may be used
as determined by the risk assessment done in conjunction with IBC review.
(l) Incorporate an in-line HEPA filter between the overflow flask and vacuum source when
suctioning potentially infectious substances.
(m) Test PI-owned autoclaves within the laboratory that are used for biowaste at the
applicable frequency described in B8.6.4.6(a).
B9.2.2.3
Prior to BSL2 work, a survey is needed to confirm a work area meets the criteria for BSL2.
If you have questions about these requirements, please contact EHS at 806-742-3876.
After inspection, once all criteria are met, a sign designating the lab space as BSL2 will be
provided and affixed to the outside door by EHS.
B9.2.2.4
New laboratories/work areas must be commissioned prior to work being conducted
regardless of the containment level.
B9.2.3
Special Considerations for Certain Research Foci
B9.2.3.1
Animal Use Considerations
The following is required for animal work to be performed using ABSL1 containment.
Laboratories working at ABSL1 must meet BSL1 and:
(a) Have exterior doors that are self-closing;
(b) Have exterior doors that are self-locking;
(c) Have windows that are resistant to breakage;
(d) Have a sink for handwashing located at the exit of are areas where infectious agents are
handled or where animals are housed;
(e) Have a safety shower;
(f) Have internal facility fixtures (e.g., light features, air ducts, and utility pipes) and
penetrations in floors, walls, and ceiling surfaces (including openings around ducts, doors,
doorframes, outlets, and switch plates) installed to facilitate cleaning and minimize
accumulation of debris and fomites;
(g) Have interior surfaces that are water, slip, and chemical resistant;
(h) Have floors with drains sloped toward the drain;
(i) Have traps on drains filled with water, appropriate disinfectant, or sealed;
(j) Have ventilation that meet the standards of the Guide for the Care and Use of Laboratory
Animals;
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(k) Have ventilation systems able to withstand high heat and moisture loads produced from
cleaning;
(l) Have the facility maintained to facilitate cleaning and housekeeping;
(m) Have furniture minimized and able to withstand anticipated loads and uses;
(n) Maintain a log of access to the facility;
(o) Include animal specific policies regarding biosafety, biosecurity, emergencies and animal
disposition during emergencies in the (bio)WASP;
(p) Have medical staff informed of the animal specific occupation hazards within the facility
involving research, animal husbandry, care, and manipulation;
(q) Include animal allergy prevention as a part of medical surveillance;
(r) Have PPE (i.e., gowns, uniforms, scrubs, laboratory coats, or other PPE) available in
areas where animals are housed or animal manipulation areas;
(s) Have eye protection disposed of with other contaminated waste or decontaminated after
each use;
(t) Not allow protective outer clothing to be worn outside of areas where infectious materials
and/or animals are housed of manipulated;
(u) Not allow gowns and uniforms to be worn outside of the facility;
(v) Have the final rinse temperature of cage washers be 180 °F;
(w) Have PPE that is appropriate for large animal use;
(x) Have bite or scratch resistant gloves for animal work when appropriate;
(y) Remove or recap needles following approved methods;
(z) Have male and female animals separated with double barriers or measures to prevent
reproductive transmission except where needed for experimentation;
(aa) Have genetically engineered neonates permanently marked within 72 hours of birth;
(bb) Have transgenic animals contain distinct, biochemically stable, and assayable DNA
sequences for identification from among non-transgenic animals;
B9.2.3.2
The following is required for animal work to be performed using ABSL2 or ABSL2-Ag
containment.
Laboratories working at ABSL2 must meet BSL2 and:
(a) Have a sink for handwashing available at the exit of each segregated area, if the
segregated area is where infectious agents or animals are manipulated or housed;
(b) Have an autoclave available;
(c) Have inward airflow;
(d) Discharge exhaust air outside without recirculation to other rooms;
(e) Have ventilated cage systems designed for microorganisms containment;
(f) Have HEPA filters and housing certified annually on actively ventilated cage systems;
(g) Have sealed exhaust plenums, and failure alarms for actively ventilated cage systems;
(h) Have primary containment equipment appropriate for the animal species in containment,
such as solid walls and bottoms in cages or housing areas, or microisolator lids;
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(i) Transport biological materials from animal containment in non-breakable, sealed primary
containers which are enclosed in non-breakable, sealed secondary containers;
(j) Disinfect all transport containers prior to removal from the facility;
(k) Decontaminate cages prior to washing where infected animals were housed;
(l) Use alkaline digestion or incineration for decontamination and disposal of carcasses;
(m) Maintain a log of decontamination process routine verification;
In addition to ABSL2, areas working at ABSL2-Ag must:
(a) Have entrances through a series of barriers or procedures that provide a distinct
separation between containment and non-containment areas;
(b) Have a boot wash at the entry/exit of the animal room or containment barrier;
(c) Replace boot wash disinfectant solution according to the manufacturer’s instructions;
(d) Have floors, ceilings, and walls of animal rooms made from monolithic materials that are
durable and resistant to disinfection which may include pressurized sprays, hot water,
steam, or chemicals;
(e) Have air handling services where large animals are housed or manipulated that are
capable of minimizing emissions and particulates in addition to meeting animal welfare
requirements;
(f) Have electrical wiring and equipment that are installed in wet or hazardous locations
sealed and grounded with animal welfare considered;
(g) Have pens, gates, and/or animal restraint systems appropriate for the animal species with
consultation from veterinary staff;
(h) Have equipment that is sealed or coated such that it is resistant to disinfection and
cleaning or is completely disassembled for complete decontamination;
(i) Have equipment that is free of pinch points and sharp edges that could injure animals or
personnel;
(j) Have equipment for cold storage and decontamination of large animal carcasses and
solid/liquid waste;
(k) Have policies integrated into the (bio)WASP to limit contact between containment staff
and susceptible animals to the outside of the containment area;
(l) Have all staff trained to handle time-sensitive emergencies involving personnel pinned or
entangled by animals or equipment;
(m) Establish systems for a minimum of two workers to be present in the containment area at
all times (i.e., a “buddy system”), or have another means of monitoring worker safety in
containment.
(n) Have agent or infected animal manipulations performed exclusively in a BSC, or if not
possible due to animal size limitations, another primary containment device;
(o) Have contaminated effluent collected for decontamination and validated for inactivation
before discharge into drainage systems;
B9.2.3.3
Arthropod Use Considerations
The following is required for arthropod work to be performed using Arthropod Containment
Level 1 (ACL1).
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Laboratories working at ACL1 must meet BSL1 and:
(a) Have exterior doors locked at all times;
(b) Have door openings covered (i.e., rigid panels, glass, screens, plastic sheets, or cloth) so
that they minimize the escape and entrance of arthropods;
(c) Have windows that prevent escape by smallest of arthropods contained within as well as
prevent the entry of wild arthropods;
(d) Have interior walls that are light colored;
(e) Have interior floors that are light colored, smooth, and uncovered;
(f) Have electrical boxes, lighting, switches, wiring, conduit, and other penetrations sealed
with caulk, foam, or other appropriate material able to withstand disinfection;
(g) Have work surfaces and laboratory furniture that are white or light gray, water resistant,
impervious to arthropods, and resistant to disinfection and heat;
(h) Have benches, cabinets, and equipment easy to inspect for escapees;
(i) Locate furniture and incubators containing arthropods such that accidental contact and
release are minimized (i.e., out of the flow of general traffic, avoiding hallways, or in
closets);
(j) Reduce harborage and breeding areas;
(k) Maintain a log of escapees;
i. If exotic arthropods are in use, maintain a log of exterior escapees;
ii. If escapees are found, review work practices before continuing work;
(l) Wear clothing that minimizes exposed skin;
(m) Wear laboratory coats, gowns, and uniforms that are white;
(n) Not allow the entry of overcoats, hats, purses, or other personal items into the
containment area;
(o) Have cages that hold arthropods effective at preventing the escape of all life stages;
(p) Label containers and cages that hold arthropods with the species, strain/origin, date of
collection, and responsible investigator;
(q) Clean cages and other culture containers to prevent arthropod survival and escape (e.g.,
heated to, or chilled below, lethal temperature);
(r) Kill all life stages of arthropods with hot water or freezing before disposal;
B9.2.3.4
The following is required for arthropod work to be performed using Arthropod Containment
Level 2 (ACL2).
Laboratories working at ACL2 must meet BSL2 and:
(a) Have doors that have physical barriers (i.e. overlapping sheets and screens) or air
curtains;
(b) Have a contiguous double-door vestibule that prevents flying and crawling arthropods
from escaping as the entrance;
(c) Have the doors of the entrance not opened simultaneously;
(d) Have doors that are windowless, or block the windows of interior doors, seal the windows,
and use break resistant materials;
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(e) Have internal doors that open outward or are sliding, and are closed at all times when
arthropods are present;
(f) Have downdraft fans in the vestibule and internal corridor to help prevent flying arthropod
escape;
(g) Have ceilings that are as low as possible;
(h) Minimize light fixtures, pipes, ducting, electrical boxes, switches, wiring, conduit, and other
penetrations and seal them with caulk, foam, or other appropriate material able to
withstand disinfection;
(i) Have light fixtures that are flush to the ceiling;
(j) Eliminate harborage and breeding areas;
(k) Have equipment that may store or accumulate water, such as a humidifier, screened or
chemically treated to prevent arthropod access or breeding;
(l) Have a negative pressure gradient into the containment area;
(m) Have ventilation systems with filters or barriers that prevent the escape of arthropods;
(n) Have vacuum systems with filters or barriers that prevent the escape of arthropods;
(o) Have floor drains and other plumbing features covered by appropriately sized mesh or
filters to prevent arthropod escape;
(p) Have a communication and/or a computer system that allows for communication and data
transfer between the interior and exterior of the facility;
(q) Have an autoclave available in rooms where arthropods are present;
(r) Maintain an annual log of facility inspections to ensure maintenance and alterations have
not compromised containment;
(s) Maintain a logbook of visitors;
(t) Use vacuum devices dedicated to a single facility;
(u) Manipulate non-flying arthropods in a dedicated area within a BSL2 space using a moat
system if a dedicated insectary is not available;
(v) Store all supplies for insect maintenance in a designated area in cabinets or drawers that
are tight fitting;
(w) Store arthropod diet in sealed containers;
(x) Have cages that are shatter-proof and screened to prevent escape during holding,
removal, and introduction;
(y) Transfer arthropods between holding and manipulation areas in non-breakable, secure
containers;
(z) Have cages or containers clearly labeled to distinguish infected and uninfected
arthropods;
(aa) Have all infectious or potentially infectious samples labelled;
(bb) Have infected or potentially infected arthropods autoclaved after being rendered non-
viable;
(cc) Open packages with foreign sourced materials in a BSC;
(dd) Have vector packing materials autoclaved immediately after removal of cultures and
specimen from the package;
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B9.2.3.5
Plant Research
Permits from the USDA must be obtained for the inter- and intrastate movement of certain plant
and soil materials.
The following is required for plant work to be performed using Plant Containment Level 1
(PCL1).
Laboratories working at PCL1 must meet BSL1 and:
(a) Adhere to all USDA-PPQ requirements;
(b) Sterilize or disinfect all incoming material to prevent entrance of external vectors;
(c) Not allow overcoats, hats, backpacks, purses and other personal objects in the
containment areas;
(d) Maintain a log of in progress experiments;
For PCL1 work in greenhouses:
(e) Have doors between the greenhouse and the facility that close completely and seal to
their frames;
(f) Have audible alarms on emergency exits that activate when opened;
(g) Have floors constructed of materials impervious to the organisms and that can withstand
repeated disinfection;
(h) Have translucent materials strong enough to guarantee security and frames to support the
walls and ceilings;
(i) Have weatherproof electrical boxes, receptacles, light fixtures, and switches;
(j) Maintain a log of leak testing;
B9.2.3.6
The following is required for plant work to be performed using Plant Containment Level 2
(PCL2).
Laboratories working at PCL2 must meet BSL2 and:
(a) Have exterior doors locked at all times;
(b) Have windows, penetrations, and translucent panels sealed to the frame with caulk or
other appropriate materials;
(c) Not allow drop in ceilings when BSCs are not used for containment;
(d) Have connections in air ducts, plenums, and vents sealed with caulk or other appropriate
materials;
(e) Have outlets and inlets (i.e., external exhaust, outside air intake, and internal air diffusors,
sewer drains, traps & vents, etc.) filtered with appropriately sized mesh or filters;
(f) Have HEPA filters changed annually or when the maximum resistance is met, and have
them recertified annually or when they are changed;
(g) Have an autoclave available;
(h) Use a BSC to work with pathogenic bacteria, nematodes, fungi, and viruses;
(i) Sterilize filters before disposal;
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(j) Autoclave or incinerate contaminated organisms as soon as they are detected, even if that
requires destruction of a beneficial culture;
(k) Autoclave or incinerate packing materials after the removal of specimen and cultures;
(l) Autoclave laboratory coats, coveralls, and other clothing before removal from the facility;
(m) Not allow offices within containment areas;
(n) Open foreign sources packages in a BSC or in one enclosed space that is easy to
disinfect;
(o) Maintain a log of experimental plants, microorganisms, and/ or animals when they are
brought into the facility or removed;
For PCL2 work in greenhouses:
(p) Use one primary entry/exit;
(q) If detached from the main facility, have interlocking vestibules at each door with 6 feet
between the doors from threshold to threshold;
(r) Emergency doors are not used as an entrance, have external handles removed, and have
internal hinges;
(s) Have airlock, directional airflow, filtration, and ventilation that prevent organism escape from
containment;
(t) Have electrical boxes, lighting, switches, wiring, and conduit sealed with caulk, foam, or
other appropriate material capable of withstanding disinfection;
(u) Have a communication system between the interior and exterior of the facility to prevent
organism escape from containment;
B9.2.3.7
Collection and Manipulation of Human Material
Resources used as standards for the collection and manipulation of human materials:
CLSI GP41: Collection of Diagnostic Venous Blood Specimens
CLSI GP44-A4: Procedures for the Handling and Processing of Blood Specimens for Common
Laboratory Tests; Approved Guideline – 4
th
Ed.
WHO guidelines on drawing blood: best practices in phlebotomy
AABB: Fundamental Standards for Blood Collection and Transfusion 1
st
Ed.
B9.2.3.7(a)
The reuse of “stress ball” style squeezing devices is not allowed for blood collection. Use a
racquet ball or other device that can easily be decontaminated.
B9.2.3.8
Basics to Aseptic Technique (reference EHS SOP 3.2)
Proper aseptic practices are an essential tool in biological research.
Aseptic techniques will vary by laboratory and task, only general concepts are addressed below.
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(a) Zone workspaces within the area from clean to dirty, with the most contaminated or risky
work being performed as far away from egress locations as possible. Perform sensitive
tasks that do not involve biological materials in a laminar flow hood (i.e., media prep,
equipment assembly, etc.).
(b) Manipulation of biological material should be done in a BSC when feasible, this is
especially important when force is applied to a material as aerosols may be produced.
(c) Use laminar hoods and BSCs correctly. Misuse can contaminate you, your product, and
the environment.
(d) Keep work surfaces uncluttered and free of non-essential materials.
(e) Arrange workflow from clean to dirty to avoid passing contaminated material over non-
contaminated material.
(f) Decontaminate work area before beginning work.
(g) Regularly decontaminate equipment.
(h) Change gloves frequently and practice good hand hygiene. Disinfect the outer surface of
gloves with 70% ethanol or other disinfectant regularly.
(i) Wear proper, well-fitting PPE. Lab coat/gown shall be buttoned all the way and glove
cuffs should cover coat or gown cuffs.
(j) Work vigilantly and deliberately when handling materials.
(k) Work near a proper flame when working on an open bench top, if work requires. A proper
flame has a bright, inner pale blue cone surrounded by a more translucent outer cone.
(l) Avoid placing caps/covers on the work surface, and when you must, place them face
down on the work surface.
(m) Use tools (forceps, tube openers, etc.) to open and close tubes containing biological
material and decontaminate them between samples.
(n) Clean up spills appropriately and immediately.
B9.2.3.9
Proper Use of Sharps (reference EHS SOP 4.1)
Disposal of sharps is in section B8.8.1.
(a) Avoid using sharps whenever possible; use blunted needles and plastics instead.
(b) Use devices with safety features to isolate sharps and be familiar with function and
features prior to use.
(c) Use disposable sharps instead of reusable sharps to avoid hazards associated with
decontaminating the items.
(d) Be prepared to use the device the moment the sharp is exposed and secure or discard
immediately after use.
(e) Stabilize hands or use a one-handed technique when uncapping devices to prevent recoil
injuries.
(f) When drawing solutions from a vial, immobilize the syringe on the hypothenar eminence
located at the base of the hand and insert the vial on the needle.
(g) Do not bend, break, or otherwise manipulate needles by hand.
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(h) Do not remove needles. Discard needles and syringes as an intact unit immediately after
use into an FDA-approved sharps container.
(i) Do not recap needles or other sharps. If needles must be recapped a valid written reason
for recapping, as well as a protocol must be submitted to and approved by EHS.
Appropriate documented training must be given to each individual and a documented
demonstration of proficiency must be recorded.
(j) Use care and caution when cleaning up after procedures that require the use of sharps.
(k) Reusable sharps must be placed in a closable, rigid container for transport,
decontamination, and storage. The sharp end of items must be secured in such a manner
as to prevent accidental injury.
(l) Sharps containers shall be immediately accessible. Locate sharps containers in areas in
which needles are commonly used.
(m) Do not hand-pass exposed sharps. Place sharps in a predetermined neutral zone to pass
objects to others.
(n) Do not overfill sharps containers. Remove from service when at the fill line (e.g., 3/4 full),
close, autoclave if desired, and dispose of in accordance with University Operating Policy
60.10.
In the event of a needle stick or other sharps-related injury: Expose the wound; express the wound,
cleanse the wound, and then bandage the wound. Notify the PI and seek follow up treatment as
needed. An incident report must be filed with EHS within 24 hours of the event.
Access to the online form for Risk Management is available on the EHS website at:
http://www.depts.ttu.edu/ehs/about/incident-reporting.php.
Near misses should be reported to EHS by submitting a SCAN form on the EHS website
https://www.depts.ttu.edu/ehs/about/scan.php.
B9.2.4
Entry Procedures for Non-Laboratory Personnel into Containment Level 2 Laboratories
As described in section B9.2.2.2(e), only authorized personnel are allowed in Containment Level 2
laboratory spaces; however, at times, entry of non-laboratory personnel may be necessary.
B9.2.4.1
Occasions of Entry by Custodial Personnel
Custodial Services can be reached during university business hours at 806-742-9777. A red dot
will be placed on the door by custodial staff as a signal not to enter the laboratory space. This is a
requirement for Containment Level 2.
B9.2.4.1(a)
Once a laboratory is designated as containment level 2 the PI or laboratory manager must
notify custodial services that they are not to enter the laboratory.
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B9.2.4.1(b)
General laboratory wastes (non-contaminated waste) shall be placed outside the laboratory
for custodial pick up.
B9.2.4.1(c)
Arrangements can be made with custodial for semiannual/annual floor waxing.
The laboratory must be properly disinfected prior to custodial entry, all chemical and
biohazardous materials must be stored.
While in the laboratory, custodial personnel must:
i. Don clean PPE upon entry into the laboratory; PPE is supplied by the PI.
ii. Be escorted by laboratory personnel at all times.
iii. Wash their hands prior to leaving the laboratory.
B9.2.4.2
Occasions of Entry by Maintenance Personnel
B9.2.4.2(a)
If maintenance workers must enter a laboratory space, they first must notify the PI or
designated emergency contact. Experiments in progress should be secured and suspended if
possible.
B9.2.4.2(b)
While in the laboratory, maintenance personnel must:
iv. Don clean PPE upon entry into the laboratory; PPE is supplied by the PI.
v. Be escorted by laboratory personnel at all times.
vi. Wash their hands prior to leaving the laboratory.
B9.2.4(c)
Should maintenance workers enter a lab space for emergency purposes outside of business hours,
they must notify the PI or emergency contact prior to entry and still follow B9.2.4.2(b).
B9.2.4.3
Occasions of Entry by Others
Entry into laboratory areas by non-laboratory personnel is addressed in A6 of the University
Laboratory Safety Manual. The expectations for notification and communications of visitors to the
lab should be outlined in the bioWASP or IBC protocol. The following outline additional
requirements for Containment Level 2 research areas:
(a) Visitors must be escorted at all times by lab personnel with the approval of the PI.
(b) Visitors shall be notified of the hazards present in the laboratory and wear the same PPE as
workers are required to as stated in A6.2. If PPE is refused or clean PPE is unavailable,
then entry into the laboratory shall be denied.
(c) Hands must be washed after PPE is removed, prior to leaving the laboratory.
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(d) Minors under the age of 16 are not permitted in Containment Level 2 spaces under any
circumstances.
(e) Minors ages 16-17 may work in accordance with the specifications of section A8.3.1 of the
University Laboratory Safety Manual unless the building or laboratory-specific manual is
more restrictive.
B10 COMMON LABORATORY EQUIPMENT USEAGE
SOPs are required for all laboratory equipment. See LSM A12.1.
B10.1
Biosafety Cabinets
The biosafety cabinet (BSC) is designed to provide protection to the user and the environment
when appropriate practices and procedures are followed; certain BSC classes also protect the
materials within the cabinet. The three types of BSCs (Class I, II, III) are described in Appendix BD.
The common element to all classes of biosafety cabinets is the high efficiency particulate air
(HEPA) filter. This filter removes particulates of 0.3 microns with an efficiency of 99.97%; however,
particles both larger and smaller than 0.3 microns are removed with increased efficiency.
B10.1.1
Chemical and Radioactive Materials in the BSC
Based on the unit’s design, work with chemicals or radioactive materials may require
special measures, or such work may be prohibited within the BSC. EHS approval is needed
before work with chemical or radioactive materials occurs within the BSC.
While the HEPA filter can protect the worker from most biological hazards when used properly, it
does not remove radiation, hazardous chemicals, vapors, or gases. A brief outline of common
limitations according to the BMBL is below. If you have questions regarding what type of BSC you
have or if your work can be done safely within your BSC, please contact EHS at 806-742-3876.
1. Flammable or otherwise volatile chemicals are not used in a Class II, Type A BSC. Limit
the use of ethanol to decontamination of gloves and surface decontamination of the BSC.
This cabinet generally exhausts HEPA filtered air back into the workspace and recirculates
the remainder. The electrical systems of Class II BSCs are not spark-proof. Thus, this
practice creates an avoidable hazardous situation which may result in fire or personnel
exposure to toxic chemical vapors; however, many liquid chemicals, including nonvolatile
antineoplastic agents and chemotherapeutic drugs can be safely handled within Class II,
type A and B BSCs.
2. BSCs should not be used for labeling biohazardous materials with radioactive isotopes.
Hard-ducted, ventilated containment devices incorporating both HEPA and charcoal filters
in the exhaust systems are necessary for the conduct of this type of work.
3. Work with chemical carcinogens and other toxic substances within a Class II BSC requires
additional treatment measures for the exhausted air. Careful evaluation must be made of
potential problems associated with decontaminating the cabinet and the exhaust system in
this case. Air treatment systems, such as a charcoal filter in a bag-in/bag-out housing may
be required so that discharged air meets applicable emission regulations.
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For these reasons, a chemical fume hood is to be used for procedures using volatile, toxic
or carcinogenic chemicals.
B10.1.2
Biological Materials
Certain biological materials and procedures may require the use of a BSC. The requirement
for a BSC at BSL2 is determined by a risk assessment during IBC review.
A biosafety cabinet should be used to protect you and the environment in the following
conditions:
1. When performing procedures with a high potential for creating aerosols or those that might
cause splashing, spraying or splattering of droplets of biological materials.
(a) Any procedure that imparts energy to a liquid sample or microbial suspension such as
centrifuging, grinding, blending, vortexing, sonicating, vigorous shaking/mixing/pipetting,
opening containers of materials whose internal pressures may be different from ambient
pressures (e.g., cryovials, lyophilized samples, fermenters, etc.), and inoculation and
tissue harvest procedures involving inoculated animals.
2. When large quantities or high concentrations of organisms are used.
3. For processing of human materials or samples where disease status is unknown.
This is not an exhaustive list, only a collection of general guidelines. When in doubt, use the BSC
or call EHS with your questions 806-742-3876.
B10.1.3
Handling and manipulation of BSL3 agents is ALWAYS performed in a BSC. Additional
PPE, including respiratory protection, may also be required.
B10.1.4
Installation, Maintenance and Certification
1. BSCs should be installed away from the lab entry in an area with restricted foot traffic and
little equipment which creates air movement that may disrupt the protective air curtain of the
BSC. The overall air balance of the laboratory and adequate clearance for air intake, work,
and ducting are also considerations when selecting your cabinet and its location. Consult
EHS for assistance in determining your BSC’s location.
2. Biosafety cabinets are highly customizable; however, certain features are prohibited or not
recommended.
(a) Sinks are not allowed in BSCs.
(b) Ultraviolet (UV) lamps are not recommended in BSCs. If installed, lamps must be
properly maintained and never used as the sole source of decontamination.
• Check manufacturer guidelines for maintenance and frequency of replacement. BSC
UV lamps must be properly maintained and never used as the sole source of hood
decontamination.
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General maintenance includes:
i. Cleaning bulbs weekly to remove dust and debris which may lessen effectiveness of
UV light.
ii. Checking bulb regularly with a UV meter to ensure a germicidal intensity of UV light
is being emitted.
iii. Closing the sash when the lamp is on and turning off the lamp when room is
occupied.
3. Biosafety cabinets require regular maintenance and certification by a professional
technician to assure that it protects you, your experiments, and the environment.
(a) Each cabinet must be certified when it is installed and annually after installation.
(b) Moving the cabinet or repairs made to the cabinet void any current certification such that
if the cabinet is moved from the original place it was installed and certified, or if any
repairs are made, recertification is required before use is resumed.
(c) If a cabinet needs repairs to plenums of the unit, it must be fumigated by a third party
prior to repairs.
(d) Switches and repairs of that nature can be completed in-house by qualified lab
personnel, a third party, or the physical plant so long as the BSC plenums are not
accessed or compromised.
4. Annual BSC certification is the PI’s responsibility to coordinate and is completed by a third
party (not TTU-EHS); please call EHS if you need a list of vendors.
Call EHS for assistance with cabinet selection and installation guidance.
B10.1.5
Guidelines for Operation of a Class II Biosafety Cabinets
Proper PPE is required while working in the BSC. At minimum, a fastened lab coat, gloves,
and safety glasses are required. Glove cuffs should cover jacket cuffs, especially when handling
sensitive materials or potentially infectious agents. Additional PPE requirements are necessary for
handling and manipulation of BSL3 agents.
B10.1.5.1
Preparation
(a) Prepare a checklist to minimize arm movements in and out of the BSC which disrupts the
delicate protective air curtain.
(b) Check certification date on BSC. Certification must be within the past 12 months. If
certification has expired, DO NOT USE THE BSC.
(c) Turn on fluorescent light and turn off the UV light if in use.
(d) Ensure the sash is in the appropriate position. Turn on the blower fan. If blower was off,
allow at least 5 minutes before beginning cabinet disinfection.
(e) Compare the pressure reading on the magnehelic gage to the certification sticker. If the
gage reads at or within 10% greater pressure than the inspected value, the BSC may be
used. If the gage reads lower than the inspected reading or more than 10% greater, then
do NOT use the BSC. Post an out of order sign and call a vendor for repairs.
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(f) Check gauges/monitors to ensure the unit is functioning properly. Do not work in a BSC
while a warning light or alarm is signaling.
(g) Disinfect the interior surface of the sash, interior walls, then work surface with a disinfectant
determined by the risk assessment to address the particular agent.
i. Do not raise the sash beyond operable height.
ii. Ethanol may not be adequate as the sole disinfectant for the interior surfaces of the
BSC. Contact time is abbreviated within the cabinet while the blower is running thus
appropriate contact time may not be met.
iii. Bleach should be used with caution to disinfect BSCs given it’s corrosivity. If used,
follow with an ethanol or sterile water rinse to avoid corrosion of the stainless-steel.
(h) Plastic-backed absorbent liners may be used so long as they do not obstruct the front or
rear grille openings. Use of this material facilitates clean up and reduces spatter in the event
of a spill. Liners must be decontaminated or placed in a closed autoclave bag within the
BSC before removal from the BSC. It can be folded – absorbent side together, plastic
backing out - and placed in a biowaste bin after a spill or when work is complete.
(i) Disinfect the surfaces of all materials to be placed in the cabinet with 70% ethanol or other
disinfectant – allow adequate contact time. Only the items necessary for the immediate
work should be placed in the BSC.
i. Keep the front and rear grills clear. Place materials on metal risers or shelves to
help reduce disturbance to the grill area.
ii. Arrange workflow should be clean to dirty.
iii. Extra supplies (gloves, extra tips, etc.) should be stored outside the BSC. Keep the
work area free of unnecessary equipment/supplies which may affect proper airflow
and subsequently, your protection.
iv. Bulky items should be placed to the rear and to one side of the work surface.
v. Place supplies, especially aerosol-generating equipment such as vortexes, as far
back as possible in the cabinet.
vi. Biowaste must be contained or decontaminated within the cabinet. Movement of
hands in and out of the cabinet to discard pipettes and other materials creates
turbulence that disrupts the air barrier which maintains sterility inside the cabinet and
protects the worker. Taking exposed contaminated materials outside the BSC
unnecessarily introduces contamination to the environment outside the BSC. Only
horizontal pipette discard trays should be used. A shallow pan filled with a
disinfectant suitable for biowaste treatment (i.e., not ethanol) is a good option.
Contact EHS if you have questions.
vii. Include disinfectant and paper towels in your supply list to manage spills quickly if
they occur.
(j) Use a surface-decontaminated tub to move materials in groups into and out of the BSC to
minimize disruptions to the air curtain.
(k) Locate liquid waste traps with disinfectant inside the cabinet and use a hydrophobic filter to
protect the vacuum lines. If traps must be located on the floor outside the BSC, place them
in a secondary container to prevent spilling.
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(l) Place the sash at the proper height for operation. Keep your head out of the hood; adjust
your chair so that your face is above the sash opening. The BSC is now ready for biological
materials.
B10.1.5.2
Working in the BSC
(a) Once arms are in the BSC, delay work by 1 min to allow the air curtain to stabilize.
(b) Work as far to the back (beyond the grille) of the BSC workspace as possible.
i. Work at least 6 inches beyond the front grille.
ii. Move smoothly and deliberately in and out of the BSC, perpendicularly to the unit –
avoid side-to-side, sweeping movements.
iii. Do not rest your arms on front grille.
(c) Always use good aseptic and microbial technique when working in a BSC.
i. Use mechanical pipetting aids.
ii. Keeping clean materials away from aerosol-generating activities to minimize cross
contamination.
iii. Work with sensitive materials in the air split.
iv. Keep open tubes/bottles in a vertical position and do not place lids on the work surface.
v. Hold the lid above the sterile surface of petri or tissue culture dishes.
vi. Recap or recover items as soon as possible.
(d) The agent is the last item added to the BSC.
(e) Remove outer glove if double gloving or decontaminate gloves before entry into and
removal from the BSC.
(f) Open flames shall not be used inside a BSC. Flames disrupt the airflow and contribute to
the heat load inside the BSC. Flames have also burned holes through HEPA filters and
caused explosions in BSCs.
(g) Disposable sterile loops/needles should be used in place of metal loops or needles to avoid
incinerator or bead bath use.
(h) Follow spill protocols in the event of a spill (see section B7.2.4). Leave the BSC running
while you are cleaning up the spill. If you are uncertain on how to manage a spill, please
call EHS for assistance at 806-742-3876.
(i) When work is completed with the BSC still running, first contain, surface disinfect, and
remove the agent. Contain and remove the agent, then proceed to decontaminate the
surfaces of supplies and equipment and remove them from the cabinet – working clean to
dirty and using the tub in-tub out method. Wipe down the interior surface of the sash,
interior walls, and the work area with a disinfectant determined by the risk assessment.
Remove all materials from the BSC (except for pipettors if you choose). Close the sash if
desired and turn off the BSC unless laboratory protocol states the BSC is to be kept
running.
(j) If a UV light is used in the BSC, it may be turned on at this point if others are not working
nearby. UV radiation shall not take the place of chemical disinfection in the cabinet interior.
B-85 BSM Table of Contents
B10.2
Laminar Flow Hood
A laminar flow hood or "clean air bench" is not a BSC. In these units, HEPA-filtered air is
discharged horizontally across the work surface and toward the user, or vertically, downward onto
the work surface ultimately exposing the user to the contents. Laminar hoods only provide product
protection. They can be used for certain clean activities, such as dust-free assembly of sterile
equipment or electronic devices, media dispensing, and most nucleic acid work.
Laminar hoods do not require annual certification; however, EHS recommends they be certified
annually to protect the integrity of your work.
B10.2.1
Laminar hoods shall never be used as a substitute for a BSC. The following materials are
not to be used in laminar flow hoods:
1. Flames;
2. Any viable organism / material including cells for cell/tissue culture;
3. rNA/sNA work if the host-vector system is classified as RG2, is self-replicating, or has the
capability to insert itself into DNA; and/or
4. with any other potentially infectious / hazardous materials.
B10.3
Centrifuge Containment and Safety
B10.3.1
When centrifuging materials:
1. Examine centrifuge tubes and bottles for cracks or stress marks before using them;
2. Use the proper size of rotor or bucket for your tubes/bottles/plates;
3. Never overfill centrifuge tubes since leakage may occur when tubes are filled to capacity;
4. Fill centrifuge tubes no more than 3/4 full; and
5. Use a tube/plate/bottle with an equivalent amount of water as a balance when odd numbers
of items are centrifuged.
B10.3.2
Centrifuge safety buckets and sealed rotors protect against the release of aerosols and are
required for the centrifugation of RG2 material.
B10.3.3
When centrifuging potentially infectious material, delay the opening of the centrifuge at
least 5 minutes or open safety buckets/rotor within a BSC.
B10.4
Vacuum Lines
B-86 BSM Table of Contents
B10.4.1
All vacuum lines used to aspirate supernatants, tissue culture media and other liquids that
may contain potentially infectious or genetically modified materials must be protected from
contamination using a collection flask and overflow flask containing a disinfectant.
B10.4.1.1
Collection and Overflow Flasks
Collection tubes should extend at least 2 inches below the sidearm of the flask. Locate the
collection flask inside the biosafety cabinet instead of on the floor so the liquid level can be seen
easily, and the flask emptied before it overflows. The second flask (overflow) may be located
outside the cabinet.
B10.4.1.1(a)
If flasks are used at floor level, place them in a sturdy leak-proof container to prevent
breakage and spills. In BSL2 or BSL3 laboratories, the use of Nalgene flasks is strongly
recommended to reduce the risk of breakage associated with infectious materials.
B10.4.2
Vacuum Line Filter
A hydrophobic filter will prevent fluid and aerosol contamination of central vacuum systems or
vacuum pumps. The filter will also prevent microorganisms from being exhausted by a vacuum
pump into the environment. Hydrophobic filters or Vacushields™ are available from several
scientific supply companies (e.g., EMD Millipore Millex™ Filters: Inlet and Outlet for Latex Tubing
or Vacushield™ Vent Device, Pall® Life Sciences).
B10.4.2.1
When working with agents that require Containment Levels 2 & 3, a hydrophobic in-line
vacuum filter shall be used.
B10.4.2.2
Vacuum line filters are disposed of as biological waste and require treatment prior to
disposal.
B11 DECONTAMINATION AND DECOMMISSIONING OF LABORATORY EQUIPMENT
B11.1
General Information
This is not an all-inclusive list of hazards and equipment. It is the responsibility of the PI to ensure
that all equipment is properly and adequately decontaminated. Check with the equipment
manufacturer for recommendations regarding decontamination procedures.
B11.1.1
Regular decontamination of equipment is required in any biological laboratory.
Decontamination logs are required at Containment Level 2 or greater.
B-87 BSM Table of Contents
B11.1.2
Equipment in need of repairs, maintenance, or removal from areas where rNA/sNA and/or
potentially infectious materials are stored and/or manipulated must be autoclaved or
thoroughly chemically decontaminated then cleared by EHS prior to repairs, maintenance
or removal.
B11.1.3
The Equipment Decontamination Form is to be filled out and submitted to EHS if the
equipment is to be sent for repairs/maintenance or otherwise removed from the laboratory.
This form is available on the EHS website.
B11.1.4
It is the responsibility of the PI to contact the manufacturer to address additional
considerations. Should further questions regarding decontamination exist, please contact EHS.
B11.1.5
Decontaminate all interior and exterior surfaces of the equipment – do not neglect tubing
and other accessories or components.
B11.1.6
Personnel shall always wear appropriate PPE while performing decontamination; at
minimum, gloves, lab coat, and protective eye wear should be worn.
B11.2
Hazard Assessment
Additional hazards may be associated with the equipment (i.e., chemical and/or radioactive). If
other hazards are present, contact EHS.
B11.2.1
Biological Hazard
Disinfect all surfaces with an appropriate chemical agent, or if possible, autoclave parts or
equipment that can withstand autoclave conditions using a biowaste setting (30 minutes @ 121°C,
15 psi). Contact EHS if other hazards are present.
B11.3
EHS Clearance of Decontaminated Equipment
B11.3.1
It is the laboratory’s responsibility to ensure that equipment is thoroughly decontaminated.
Once the equipment has been decontaminated, the PI or lab supervisor will need to fill out and
submit the Equipment Decontamination Form. Upon receipt of the form, EHS will come to inspect
the equipment.
B-88 BSM Table of Contents
B11.3.2
Equipment shall not be removed from the laboratory for repairs, surplus, disposal, etc. until
EHS has cleared the equipment.
B11.4
Considerations for Common Equipment
This is a guideline – it is not an exhaustive list of equipment, nor may it cover all features of the
equipment listed.
Biological contamination is addressed here. Autoclave items when possible and allow allotted
contact time for disinfectant used during the decontamination process when chemical disinfection
is used. If an item was used for chemical or radioactive storage and/or manipulation, refer to the
CHP or Radiation Safety Manuals as applicable to the equipment and hazards.
B11.4.1
Refrigerators and Freezers
Remove all contents and either appropriately store or dispose of them. Defrost the equipment if
necessary. All liquid should be collected and treated as biohazardous waste. Decontaminate all
surfaces with appropriate chemical disinfectant.
B11.4.2
Incubators
Follow manufacturer’s guidance. Remove thermometers; properly secure any mercury
thermometers. Drain and collect water from water-jacketed incubators for disinfection. If water
doesn’t have a disinfectant present already, disinfect water by autoclaving or chemically by adding
enough bleach to achieve a 10% solution; allow bleach solution to sit for at least 20 minutes then
pour down a drain. If water was visibly contaminated, fill the water jacket with disinfectant. After
the allotted contact time, drain and flush with copious amounts of DI water.
Some incubators have a sterilization cycle. Disinfect all interior surfaces based on the risk
assessment then run the sterilization cycle. Follow with 70% ethanol if a different disinfectant was
used to remove any residue. Some disinfectants can leave residues that can be absorbed by
media and be cytotoxic.
For incubators without a sterilization cycle, autoclave the removable parts able to withstand
autoclave conditions using biowaste settings unless otherwise specified by the manufacturer.
Chemically decontaminate the remaining surfaces.
B11.4.3
Biosafety Cabinets
Biosafety cabinets require decontamination by a third party before the cabinet is removed from a
lab or repaired (B10.1.4.3(b)). Decontamination requires fumigation with formaldehyde, chlorine
dioxide or vapor phase hydrogen peroxide. The company contracted shall provide a certificate of
decontamination once completed. The BSC will require recertification prior to use.
B-89 BSM Table of Contents
B11.4.4
Laminar Flow Hood
Laminar flow hoods should not need fumigation to disinfect as only non-hazardous items should
have been handled in them and the HEPA filter only filters lab air. Decontaminate all surfaces with
70% ethanol or other desired disinfectant.
B11.4.5
Centrifuges
Remove tube adaptors and the rotor if possible. Autoclave rotors when indicated by manufacturer;
otherwise, soak snap-on lids, adaptors, and rotors in a manufacturer-approved disinfectant
appropriate for agent(s) for appropriate contact time. Rinse with DI/RO water, dry, and follow with
70% ethanol or isopropanol. Disinfect the exterior of the centrifuge in the same manner.
B11.4.6
Water baths
Disinfect water chemically by adding enough bleach to achieve a 10% solution. Scrub inside of
water bath to release any biofilms/mold/algae and allow to sit for 20 minutes. Dispose of water in
drain and chemically disinfect the lid and outside of the bath. Rinse to remove bleach.
B11.4.7
Balances/Scales
Remove parts that can be removed. Disinfect with appropriate disinfectant, follow with 70%
ethanol or water if needed.
B11.4.8
Automated Liquid Handling systems
These systems should have decontamination instructions from the manufacturer. In the absence
of instructions, drain and capture any liquids from the system and autoclave or chemically disinfect
collected liquid by adding enough bleach to achieve a 10% solution, allow contact time and
discard.
Flush system with a 10% bleach solution; follow with a copious amount of DI or RO water. After
the water rinse, flush the system with 70% ethanol (trap waste for EHS disposal) and flush system
with sterile DI or RO water.
B11.4.9
General Reusable Laboratory Supplies
Items such as pipettes, serological pipetting devices, hot plates, stir plates, vortexes, chairs,
furniture, storage cabinets, glassware, etc. should be sanitized with an appropriate disinfectant to
neutralize any agents to which these items have been exposed. Check with the manufacturer
regarding the potential for autoclaving an item. Disassemble equipment where possible, allow
adequate contact time for disinfectant to work and be sure to clean corners, crevices, and crannies
that are hard to reach.
B-90 BSM Table of Contents
B12 DECOMMISSIONING A LABORATORY SPACE
B12.1
General Information
This requirement is designed to assist PIs who are vacating a laboratory space at the University for
any reason. These guidelines ensure that the laboratory space will be cleared of hazardous
materials so as to protect contractors and other personnel and to expedite laboratory assignment
to new occupants. Also see LSM A25.
The PI is to notify EHS that the laboratory will be vacated 30 days prior to departure or when
known. Upon notification, EHS will inspect the laboratory to identify the hazards that must be
addressed before the PI departs. The laboratory will be inspected again prior to PI departure to
ensure that all hazards are addressed and to verify the clearance of the laboratory space.
If a PI departs before the laboratory is decommissioned, the department assumes the
responsibility of the laboratory and its contents unless otherwise indicated below.
B12.2
Decontamination
The entire laboratory and its contents shall be decontaminated or neutralized prior to the PI
departing the laboratory.
Certain equipment may require decontamination by a third party. Appropriate disinfectants must
be used to address the agent(s) that have been stored and/or manipulated in the laboratory.
Allow adequate contact time for disinfectants and autoclave when possible.
Refer to sections B8 and B11 for more information on disinfectants and decommissioning of
laboratory equipment, respectively.
B12.2.1
All laboratory benches, equipment, glassware, storage areas, shelves, fixtures, and
furniture must be decontaminated with an appropriate disinfectant for agents present in
laboratory.
B12.2.2
Leave hazard labels in place on equipment.
B12.2.3
Fume hoods, glove boxes, and BSCs must be decontaminated. BSCs require a third party for
decontamination if they are to be removed from the work area.
B12.3
Packing and Moving
B12.3.1
Laboratory personnel are responsible for moving the laboratory. Consult the Lab Move
guidelines on EHS’s webpage for guidance.
B-91 BSM Table of Contents
B12.3.2
Assume all chemicals, biological materials, and gases are regulated. Contact EHS with
questions regarding the transportation of any hazardous materials.
B12.3.3
A PI may transfer biological materials to an existing PI; however, the PI receiving the
materials is responsible for attaining an IBC protocol and containment level for the received
materials when required. See section B4.2.9 for project types that require IBC review and
receive approval before a transfer is made. Contact EHS if you have any questions at 806-742-
3876.
B12.3.3.1
Any biological materials that require an IBC protocol that are not transferred to a new PI
and covered with a protocol become the property of EHS and will be destroyed.
B12.4
Waste Disposal
All chemical, biological, and radioactive waste must be disposed of in their respective waste
streams. See A25.1.1.2.
B12.4.1
Biological Waste
All biological materials must be appropriately destroyed, transferred to a new PI or
moved/shipped to their new location in a DOT/IATA-compliant manner. Contact EHS
regarding the transportation of biological material.
B12.4.1.1
Prior to the PI departing the laboratory, all sharps and other biohazardous waste shall be
disposed of in accordance with Section 8 of the Biosafety Manual.
B12.4.2
General Waste
Any waste (boxes, trash, broken glass, etc.) shall be properly disposed of prior to the PI
departing the laboratory.
B13 TRANSPORT AND SHIPMENT OF BIOLOGICAL MATERIALS
B13.1
Transport of Biological Materials on or to Texas Tech University Property
The following procedures are to be followed when transporting biological materials to or
between laboratories on Texas Tech properties.
Please call EHS at 806-742-3876 if you have any questions regarding the transport of materials on
or to TTU property. The use of personal vehicles is discouraged and done at the owner’s risk.
B-92 BSM Table of Contents
University vehicles are encouraged for all transport, and as stated in LSM A20.1.5, transport of
DOT-regulated materials on public roadways requires the use of a University vehicle.
B13.1.1
Conditions
B13.1.1.1
Do not take biological materials to non-lab areas or leave items unattended during
transport.
B13.1.1.2
The destination lab must be the same containment level and classification/level as the
materials being transported.
B13.1.1.3
Materials must be properly packaged as outlined in B13.1.2.
B13.1.1.4
The package is not to be opened in transport between laboratories for any reason.
B13.1.1.5
If traveling, have a biological spill kit with you in case of a spill. In the event of a spill,
submit a SCAN. If a spill occurs between laboratories on campus, notify EHS immediately
at 806-742-3876.
B13.1.2
Packaging
B13.1.2.1
For RG1 or materials that require Containment Level 1 biological materials or specimens
that may potentially contain such materials:
(a) Primary specimen container shall be leak-proof, sealed, and labeled with the following
information: Name or initials, date, identifying number, name, or other information.
(b) Primary specimen containers shall be wrapped in absorbent material (if liquid in nature) and
placed in a rigid secondary, leak-proof container with a locking lid.
B13.1.2.2
For RG2 or materials that require Containment Level 2 biological materials or specimens
that may potentially contain such materials:
(a) Primary specimen container shall be leak-proof, sealed, and labeled with the following
information: Name or initials, date, identifying number, name, or other information
(b) Primary specimen container shall be wrapped in absorbent material (if liquid in nature) and
placed in a secondary sealed, leak-proof container (e.g., Ziploc bag).
(c) The packaged material should then be placed in a rigid transport container, such as a
cooler, labeled with biohazard stickers and the name of the PI.
B-93 BSM Table of Contents
B13.2
General Shipping Information
Shipping and receiving of infectious agents, biological products/specimens, clinical specimens, and
other potentially hazardous substances is controlled by multiple agencies. Regulations are not
always uniform, and permits are often required. These regulations are continually modified, and
new ones are added across regulating entities.
Non-compliance with regulations can result in financial penalties to the shipper and potentially to
the University. Even with training, EHS recommends that the shipper check with applicable
regulatory agencies prior to shipping potentially hazardous materials. See LSM A20.
B13.2.1
Shippers or employees handling hazardous goods (chemical or biological) are required to
take Hazardous Shipper Training pertinent to their duties.
B13.2.1.1
The training must be renewed every two years so long as duties regarding shipping are
ongoing.
B13.2.2
The Department of Environmental Health & Safety is to be notified of all shipments of
biological materials initiated by TTU personnel 2 business days before the shipment is to
occur.
B13.2.3
A copy of all shipping documents must be submitted to EHS for regulated materials before
the shipment departs.
Please contact EHS at 806-742-3876 to schedule your training prior to your shipment. Once
training is complete the certificate is current for 2 years.
B13.3
Permits and Documentation
When applicable, the responsible party (i.e., PI or lab supervisor) must secure permits for
transport prior to shipment and the permit(s) must accompany the shipment and/or
transport.
Permits take time to process. Be proactive in obtaining proper permit(s) for materials you plan on
shipping or receiving well in advance (several months). While it may not take that long to obtain a
permit, allowing ample time will ensure materials can be transported on the desired schedule.
Items that do not require a permit to ship and/or receive may still require special packaging.
B13.3.1
CDC Import Permits
B-94 BSM Table of Contents
The Centers for Disease Control and Prevention’s Import Permit Program (IPP) regulates the
importation of infectious biological agents, infectious substances, and vectors of human disease
into the United States. Inter-state transfer of previously imported materials also requires the
receiving party to obtain a permit.
Prior to issuing an import permit, IPP reviews all applications to ensure that entities have
appropriate safety measures in place for working safely with the imported materials; anticipate an
inspection by the CDC if you obtain an import permit. More information regarding CDC permits can
be found at: https://www.cdc.gov/cpr/ipp/index.htm.
B13.3.1.1
The CDC Import Permit Program (IPP) sites 42 CFR 71.54 to address the import regulations for
infectious biological agents, substances, and vectors. See their website for the most current
information: https://www.cdc.gov/cpr/ipp/regulations.htm. They also have a decision tool available
to help you determine if an import permit: https://www.cdc.gov/cpr/ipp/etool.htm, as well as, an
FAQ page: https://www.cdc.gov/cpr/ipp/faq.htm
B13.3.2
USDA permits
APHIS or APHIS-PPQ issues permits for export and import for, intra-/inter-state transit of, and
release within the United States of regulated animals/animal products, veterinary biologics,
plants/plant products, pests, organisms, soil, and genetically engineered organisms. See the
APHIS website for more information: https://www.aphis.usda.gov/aphis/resources/permits.
Animal materials (especially food animal-related materials) whether offered for import, export, or
interstate transport, require evaluation through the USDA-APHIS Veterinary Services Permitting
Assistant. Should your animal materials not be subject to a permit, in most cases, a Letter of
Conditions will be automatically generated for the materials. This letter must accompany the
shipment. If a permit applies, you will be routed to the permitting application. There is a "Guide
Me" function for assistance with the permitting assistant or you can reach out to EHS by phone
(806.742.3876) or email ehs.lab.safety@ttu.edu.
B13.3.2.1
Animal and animal products - Includes live animals, semen, embryos, and materials derived from
animals or exposed to animal-source materials such as animal tissues, blood, cells or cell lines of
livestock or poultry origin, RNA/DNA extracts, hormones, enzymes, microorganisms including
bacteria, viruses, protozoa, and fungi. In addition, animal materials including dairy products (except
butter and cheese), and meat products (e.g., meat pies, prepared foods) from countries with
livestock diseases exotic to the U.S.
B13.3.2.2
Veterinary Biologics - Includes vaccines, bacterins, antisera, diagnostic kits, and other products of
biological origin.
B13.3.2.3
Biotechnology products - Includes genetically engineered organisms considered to be regulated
articles.
B-95 BSM Table of Contents
B13.3.2.4
Plants, Organisms, and Soil
Organism and Soil Permits: Include plant pests such as arthropods and mollusks (insects and
snails); plant pathogens such as fungi, bacteria, nematodes, mycoplasma, viroids and viruses;
biological control agents, bees, Plant Pest Diagnostic Laboratories, Soil Microbe Isolation
Laboratories, Federal Noxious Weeds and Parasitic Plants.
Plants and Plant Products Permits: Include Plants for Planting such as nursery stock, small lots of
seed, and Postentry; Plant Products such as fruits and vegetables, timber, cotton and cut flowers;
Protected Plants and Plant Products such as orchids and Threatened and Endangered plant
species; Transit Permits to ship regulated articles into, through, and out of the U.S.; and Controlled
Import Permits to import prohibited plant materials for research.
Transit Permits: Required by the Animal and Plant Health Inspection Services (APHIS) in advance
of arrival for the unloading, landing or other movement of plants, plant products, plant pests, or soil
in cargo through the United States.
Permit Website: https://www.aphis.usda.gov/aphis/ourfocus/planthealth/import-information/permits
B13.3.3
FWS Permits
U.S. Fish and Wildlife Service permits are required for certain live animals, including bats. Please
call 1-800-344-WILD or go to https://www.fws.gov/permits/?ref=topbar for further information.
Check with the individual states’ wildlife service about permits as well.
B13.3.4
Select Agent Transport
Importation of select agents or biological toxins requires the intended recipient to be registered with
the Select Agent Program and submit required paperwork to obtain approval to import the select
agent or toxin prior to each importation event (see 42 CFR 73 and/or 9 CFR 121). Select agents
are listed online: https://www.selectagents.gov/SelectAgentsandToxins.html. Please contact EHS
at 806-742-3876 if your work includes any of the agents listed.
B13.3.5
Export Control
If you plan to export biological materials, contact EHS for guidance.
The export of a wide variety of microorganisms and toxins of human, plant, and animal diseases
may require a license from the Department of Commerce, Bureau of Industry and Security.
Further information may be obtained by calling the Department of Commerce, Bureau of Industry
and Security at 202-482-4811 or through the internet at https://www.bis.doc.gov/Licensing.
Other agencies such as the FDA or DEA may regulate the goods you wish to transport. Please
consult the FDA and DEA regulations for guidance related to the item you wish to export and do
not rely solely on the Export Administration Regulations for information about other agencies’
export control requirements.
B-96 BSM Table of Contents
B13.3.5.1
All products and technology that leave the country are subject to TTU OP74.10. Before you travel
or ship items outside the country, consult the TTU Export Control webpage:
https://www.depts.ttu.edu/research/integrity/export-control/ or contact Export Control directly with
questions by email to Allie Matviko, amatviko@ttu.edu.
B13.3.6
Additional Documentation
The shipper is required to initiate and secure all applicable non-permit documentation prior
to transport of the materials. Letters of disclosure, material transfer agreements, SDS sheets,
packing lists, customs declaration forms, hazard declaration forms and other documentation may
be required to successfully complete your shipment.
Additional documentation is often needed in the transfer of scientific materials to and from the
University. Contact EHS at 806-742-3876 if you have questions regarding the documentation
needed for your shipment.
A Material Transfer Agreement (MTA) is required if the biological material was developed or
recovered at Texas Tech University/Texas Tech University Health Sciences Center as it is
considered the proprietary property of Texas Tech University/Texas Tech University Health
Science Center. The MTA form is available on the Office of Research Services website at:
http://www.depts.ttu.edu/research/ors/preaward/forms-boilerplates.php. Questions regarding the
need for an MTA can be addressed by Cui Romo: cui.romo@ttu.edu.
B13.4
Packaging
Items are required to be properly identified, packaged, marked, and labeled for shipment.
Various agencies such as the International Air Transport Association (IATA) and the Department of
Transportation (DOT) have developed guidelines and procedures to facilitate the safe shipment of
potentially infectious substances and other hazardous materials.
As previously mentioned, these regulations are frequently updated. It is important to check with
the carrier you have chosen (and country of destination if shipping internationally) to determine
their specific requirements for shipping the material(s) in question.
B13.4.1
Permitting is not associated with the need for, or lack thereof, special packaging and labeling
requirements. Call EHS at 806-742-3876 if you have questions about a shipment and/or to
schedule your training prior to your shipment.
Reuse of packaging is discouraged; consult EHS prior to re-use of packaging.
B13.4.2
Shippers are responsible for procuring appropriate packaging for their shipment.
C-i
TABLE OF CONTENTS
SECTION I – MANAGEMENT OF BROAD LICENSE
Introduction ........................................................................................................................ C-I-1
A. Definitions and Acronyms .......................................................................................... C-I-1
B. Radiation Protection Program .................................................................................... C-I-1
C. ALARA Program – General I-3 .................................................................................. C-I-3
D. Radiation Safety Management .................................................................................. C-I-4
E. Radiation Safety Committee ...................................................................................... C-I-4
1. Purpose and Structure ......................................................................................... C-I-4
2. Duties (RSC Charge) ........................................................................................... C-I-4
3. Radiation Safety Committee Membership ............................................................ C-I-5
4. RSC Appointment ................................................................................................ C-I-5
5. RSC Operation Procedures .................................................................................. C-I-5
6. RSC Responsibilities ............................................................................................ C-I-6
F. Radiation Safety Officer ............................................................................................. C-I-7
1. Responsibilities .................................................................................................... C-I-7
2. RSO Duties .......................................................................................................... C-I-7
G. Radiation Safety Office .............................................................................................. C-I-9
H. Personnel Monitoring Procedures ........................................................................... C-I-11
I. Bioassay Procedures ............................................................................................... C-I-13
SECTION II – SUB-LICENSE PROGRAM SAFETY
Introduction ...................................................................................................................... C-II-1
A. Definitions ................................................................................................................ C-II-1
B. Sub-License Application Procedures ....................................................................... C-II-1
1. Qualifications for Sub-License ............................................................................ C-II-1
2. Procedures for Obtaining a Sublicense .............................................................. C-II-2
3. Sublicense Renewal and/or Amendment ........................................................... C-II-2
C. Absence of Sub-Licensee from Campus ................................................................. C-II-3
D. Procedure for Termination of a Sublicense .............................................................. C-II-4
E. Sub-licensee Inspection/Monitoring Program .......................................................... C-II-5
C-ii
F. Sub-License Programs and Procedures .................................................................. C-II-7
G. Maximum Permissible Doses, Dose Limits .............................................................. C-II-8
H. Policies and Procedures for Radioactive Material Use ............................................ C-II-9
1. Facilities ........................................................................................................... C-II-10
2. Record Keeping ............................................................................................... C-II-11
3. Control of Radioactive Material ........................................................................ C-II-13
4. Transfer and/or Shipping of Radioactive Material ............................................ C-II-15
5. Storage of Radioactive Material ....................................................................... C-II-15
6. Radiation Surveys ............................................................................................ C-II-16
7. Deactivation/Reactivation of Radiation Use Areas ........................................... C-II-17
8. General Services for Radiation Use Laboratories ............................................ C-II-19
9. Custodial Service for Radiation Use Areas ...................................................... C-II-20
10. Building, Maintenance, and Construction (BM&C) Services ............................. C-II-20
11. Other Services .................................................................................................. C-II-21
12. Portable Moisture Density Gauges ................................................................... C-II-21
13. Radioactive Material in Animals ....................................................................... C-II-23
14. Radioactive Waste Disposal Program .............................................................. C-II-24
a. General ....................................................................................................... C-II-24
b. Waste Types ............................................................................................... C-II-24
c. Responsibilities of the Generator (Sub-licensee) ........................................ C-II-25
d. Laboratory Waste Handling/Storage ........................................................... C-II-26
e. Animal Carcasses and Waste ..................................................................... C-II-27
f. Waste Pickup .............................................................................................. C-II-27
g. Sanitary Landfill Disposal ............................................................................ C-II-28
h. Disposal through Natural Decay ................................................................. C-II-29
i. Sanitary Sewerage Disposal ....................................................................... C-II-29
j. Other Disposal Information ......................................................................... C-II-29
15. Additional Policies and Procedures .................................................................. C-II-30
a. Radioactive Material Use ............................................................................ C-II-30
b. Gas Chromatographs .................................................................................. C-II-31
c. Sealed Sources .......................................................................................... C-II-32
C-iii
d. Use of Hoods .............................................................................................. C-II-32
I. Procedures for Individual Users and Workers Using Radiation Under
Sub-Licenses .......................................................................................................... C-II-33
J. General Laboratory Radiation Safety Rules .......................................................... C-II-36
SECTION III – RADIATION PRODUCING MACHINE SAFETY PROGRAM
Introduction ..................................................................................................................... C-III-1
A. Radiation Producing Machines (X-ray) ................................................................... C-III-1
1. Registration ....................................................................................................... C-III-1
2. Proposed Devices ............................................................................................. C-III-1
3. Personnel Protection ......................................................................................... C-III-1
4. Facilities ............................................................................................................ C-III-1
5. Radiation Surveys and Record Keeping Requirements .................................... C-III-2
B. Radiofrequency and Microwave Devices ................................................................ C-III-5
1. Protection from Microwave Oven Radiation ...................................................... C-III-5
a. Non-Public Use ............................................................................................ C-III-5
b. Public Use .................................................................................................... C-III-5
2. Safety Tips for Microwave Oven Users ............................................................. C-III-7
SECTION IV EMERGENCY PROCEDURES
Introduction ..................................................................................................................... C-IV-1
A. General Information ................................................................................................ C-IV-1
1. Organization and Authority ................................................................................ C-IV-1
B. Fires, Explosions, or Major Emergencies ............................................................... C-IV-2
C. Accidents Involving Possible Radiation Overexposure ........................................... C-IV-2
D. Accidents Involving Significant Releases of Radioactive Material .......................... C-IV-3
E. Personnel Injuries ................................................................................................... C-IV-3
F. Policies for Radioactive Spills ................................................................................. C-IV-3
G. Loss or Theft of Radiation Equipment .................................................................... C-IV-4
H. Malfunction of Radiation Producing Equipment ...................................................... C-IV-4
I. Vehicle Accident During PMDG or RAM Transportation ......................................... C-IV-4
J. Reporting of Radiation Incident .............................................................................. C-IV-4
C-iv
K. Decontamination Procedures ................................................................................. C-IV-5
1. Pre-operation Procedures ................................................................................. C-IV-5
2. Operation Procedures ....................................................................................... C-IV-5
3. Post-operation Procedures ................................................................................ C-IV-5
4. Minor Spills ........................................................................................................ C-IV-6
5. Personnel Contamination .................................................................................. C-IV-6
L. EMERGENCY PHONE NUMBERS ........................................................................ C-IV-7
SECTION V – RADIATION SURVEYS
A. Guidelines for Surveys of Radiation Levels ............................................................. C-V-1
1. Survey Information ............................................................................................. C-V-1
2. Performing a Survey ........................................................................................... C-V-1
3. Results/Reporting ............................................................................................... C-V-2
B. Surface Contamination Surveys .............................................................................. C-V-2
1. General Information ........................................................................................... C-V-2
2. Frequency .......................................................................................................... C-V-6
3. Records .............................................................................................................. C-V-6
SECTION VI – FORMS AND RECORDS
Contact the Radiation Safety Officer for Forms .............................................................. C-VI-1
SECTION VII – APPENDICES
RADIATION SAFETY INFORMATION AND RESOURCES
Appendix A – Reference Information ............................................................................. C-VII-1
A Glossary of Terms ..................................................................................................... C-VII-1
B Index of Abbreviations and Acronyms ....................................................................... C-VII-6
C List Of Symbols For Radiation Units And Terms ....................................................... C-VII-7
Appendix B - Texas Regulations for Control of Radiation References .......................... C-VII-8
Appendix C – Radiation Survey Instrument Calibration Procedures .............................. C-VII-9
C-II-1
SECTION I – MANAGEMENT OF BROAD LICENSE
Introduction
The purpose of this manual is to provide users and non-users of radioactive material, and
radiation producing equipment the more significant facts and figures about radiation. Overviews
of state regulations, and direct Policies and Procedures concerning different areas of radiation
use at Texas Tech University are covered. The Regulations, Policies and Procedures, etc. set
forth in this guide have one single straight forward purpose, to protect Texas Tech University
faculty, staff, students, and visitors against unnecessary and potentially harmful radiation
exposure.
A DEFINITIONS OF KEY TERMS AND ACRONYMS
Agency - means the Bureau of Radiation Control, Texas Department of Health.
ALARA - means “as low as reasonably achievable”.
BRC - means the Bureau of Radiation Control, Texas Department of Health.
License - means Texas Radioactive Material License No. L01536, issued by the Agency.
Registration - means Texas Registration of Radiation Producing Machines No. R00574.
RSC - means the Radiation Safety Committee of Texas Tech University.
RSM - means TTU’s Radiation Safety Manual.
RSO - means the Radiation Safety Officer
RSS - means the Radiation Safety Specialist.
RST - means the Radiation Safety Technician
TAC - means the Texas Administrative Code.
TRCR - means the Texas Regulations for Control of Radiation.
US NRC - means the United States Nuclear Regulatory Commission.
US DOT - means the United States Department of Transportation
B RADIATION PROTECTION PROGRAM
B1
Objective
This program is designed to limit occupational and public doses of radiation to “as low as
reasonably achievable” to protect the staff, employees, and students of Texas Tech University
(TTU); to protect members of the general public; and to comply with 25 TAC §289.202(e) [Texas
Regulations for Control of Radiation (TRCR) 21.101].
B2
Method
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Texas Tech University (TTU) has established this Radiation Safety Manual (RSM) to provide
safety guidance to its staff and students when working with radioactive material, x-ray producing
devices, and lasers.
B3
Date of Implementation
December 1, 1999, upon approval by the RSC.
B4
Review
This program will be reviewed no later than the anniversary month of its inception, each year.
B5
Program Elements
B5.a
Personnel Monitoring Requirements and Dose Limits: Specific procedures are provided in II.G.
of the RSM. Specific ALARA procedures are addressed in II.B.19 of the RSM. Both areas have
steps listed in various general procedures. If this program is adhered to, the limits specified in
25 TAC §289.202(f) through §289.202(o) [TRCR 21.201 through 21.302] should not be
exceeded.
B5.b
Radiation surveys: Radiation surveys are discussed in II.H.6. of the RSM.
B5.c
Access Controls for Radiation Areas: Access to the radiation areas is controlled by II.J. of the
RSM. In addition, certain elements of storage, use, and maintenance/service procedures
contain steps which specifically address access controls.
B5.d
Respiratory Protection: Addressed in II.J. of the RSM.
B5.e
Security of Radiation Sources (Storage/Use): Specific procedures for storage security are
addressed in II.H.1. of the RSM and provides for security during certain activities (storage, use,
and transport) as procedural steps.
B5.f
Posting of Areas and Rooms: II.H.1. of the RSM provides for posting of warning signs.
B5.g
Labeling of Containers: II.H.1. of the RSM provides procedures for labeling of containers.
B5.h
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Receipt of Packages Containing Radioactive Material: Radioactive material receipt procedures
are specified in II.H.3.b. of the RSM.
B5.i
Waste Storage, Processing, Transfer and/or Disposal Procedures: Transfer/waste procedures
are specifically addressed in II.H.14 of the RSM and transport procedures are addressed in
II.H.4.
B5.j
Management of Required Records: Records management procedures are addressed in II.H.2.
of the RSM.
B5.k
Reports of Incidents: The RSO is responsible for reporting incidents. The specific procedures
are found in Section V of the RSM.
C ALARA PROGRAM – General
C1
Maximum permissible dose: A sub-licensee (TTU) may not permit an individual in a restricted
area to receive a total effective dose equivalent greater than that permitted under II.G. of the
RSM. There should not be any situations at TTU where dose equivalents for external and
internal exposures exceed those listed in II.G. of the RSM.
C2
Individual’s Dose Assessment: Before any initiating work in a restricted area, the RSO shall
make a determination of the total effective dose equivalent for each individual, in accordance
with TAC §289.202(j).
C3
Prohibition: No sub-licensee or employee shall possess, receive, use, or transfer radioactive
material in such a manner as to cause an individual in a restricted area to be exposed to airborne
radioactive material in an average concentration in excess of the limits specified in Table II of
subsection TAC §289.202(ggg)(2).
C4
Prohibition of Use by a Minor: There shall be no use of radioactive material or radiation producing
equipment by employees under 18 years of age (minors), pregnant females, or females
suspecting pregnancy at Texas Tech University. However, exceptions may be granted by the
RSC, following the requirements of TAC §289.202.
D RADIATION SAFETY MANAGEMENT
The TTU radiation safety program is controlled by the RSC and radiation safety is monitored by
TTU’s Radiation Safety Office which is directed by the RSO. Should an operation be presenting
a threat to the staff or students of TTU, or to any member of the general public, the RSO has the
C-II-4
authority to cause any radiation user of radiation sources to cease and desist from operations
until such time as the radiation threat is removed or mitigated.
E RADIATION SAFETY COMMITTEE
E1
Purpose and Structure
The RSC is composed of a group of administration, faculty, and staff appointed by the Executive
Vice President and Provost to establish policies and regulations governing the use of ionizing
and non-ionizing radiation. The president has designated the Office of the Associate Vice
President for Operations as his duly authorized representative on matters relating to Radiation
Safety.
E2
Duties (RSC Charge)
The RSC will:
E2.a
establish policies and procedures, as well as provide administrative advice regarding radiation
and laser safety;
E2.b
approve or disapprove all applications, amendments, and renewals relating to the use of
radioactive materials, lasers, or radiation producing equipment;
E2.c
receive and review reports from the RSO on monitoring, surveillance, and personnel exposure;
E2.d
monitor procurement, use, and disposal procedures;
E2.e
take appropriate corrective action on radiation/laser incidents, including administrative guidance
and license suspension or revocation;
E2.f
provide a representative to the University Safety and Health Committee; and
E2.g
serve as an avenue of appeal in cases of dispute and exception to actions by the RSO.
E3
Radiation Safety Committee Membership
C-II-5
The committee shall be composed of:
E3.a
Three faculty members who regularly uses radioactive materials;
E3.b
Two faculty members who regularly uses lasers;
E3.c
At least one faculty member who regularly uses radiation producing equipment;
E3.d
At least two faculty/staff members who are non-users of radioactive materials, lasers, or radiation
producing equipment;
E3.e
Vice Provost for Research or designated representative;
E3.f
RSO (Ex-Officio); and
E3.g
Associate Vice President for Operations, (Ex-Officio).
E4
Radiation Safety Committee Appointment
The members of the committee will be appointed by the Executive Vice President and Provost.
Members of the committee, other than those specified by virtue of their position, will be
nominated by the committee chairperson and the Associate Vice President for Operations. The
RSO will serve as Executive Secretary to the committee. Each member will serve a term of
three years except when lesser terms may be required to maintain balanced membership and
continuity of committee operations. Reappointments are permissible.
E5
Radiation Safety Committee Operating Procedures
E5.a
The RSC shall schedule a regular meeting for each month of the year. Additional meetings may
be called as necessary. The RSO will prepare and distribute a written agenda to committee
members at least one day before each scheduled meeting.
E5.b
C-II-6
A quorum, at least one-half of the voting members, is required to conduct official business. The
RSO, Chairperson, and Vice Provost for Research (or designated representative) must be
present to constitute a quorum.
E5.c
Sub or ad hoc committees may be appointed by the Chairperson as needed.
E5.d
If a committee member is unable to continue serving on the committee for any reason, the
member shall notify the Chairperson so that a replacement may be appointed promptly.
E5.e
If a committee member fails to attend three consecutive meetings or one-half of the called
meetings in a twelve-month period, without just cause, the Chairperson will contact that member
to determine if that person should be replaced. If so, the Chairperson will ask the Associate Vice
President for Operations to arrange for a replacement under the appointment procedures of the
committee.
E6
Radiation Safety Committee Responsibilities
The RSC shall:
E6.a
Establish policies regarding radiation and laser safety;
E6.b
Provide administrative advice to the RSO on matters regarding radiation and laser safety;
E6.c
Receive, review, and act on all applications for the use of radiation sources in any areas used
by TTU personnel;
E6.d
Receive and review periodic reports from the RSO on monitoring, contamination, and personnel
exposure;
E6.e
Periodically review the overall use of radiation and laser sources at TTU from the standpoint of
operational hazards;
E6.f
Receive and review all reports from the RSO concerning radiation and laser incidents at TTU;
E6.g
C-II-7
Conduct necessary investigations, hearings, and/or appropriate corrective action on any
radiation or laser over-exposure or spill occurrence at TTU;
E6.h
Meet at least monthly during the academic year;
E6;i
Perform an annual audit of the Radiation Safety Program; and
E6.j
Upon committee action, issue sublicenses which will be duly signed and approved by the
Chairperson of the RSC.
F RADIATION SAFETY OFFICER
F1
Responsibilities
The Radiation Safety Officer (RSO) will be a trained health physicist who is responsible for
TTU-wide compliance with these policies and the regulations. The RSO will also provide a
variety of technical services necessary to maintaining radiation safety and compliance with
regulatory requirements.
F2
RSO Duties
The duties of the RSO include:
F2.a
Overseeing all operating, safety, emergency, as low as reasonably achievable (ALARA)
procedures, and health physics procedures and activities, including both personnel and
environmental monitoring, and reviews them annually;
F2.b
Furnishing consulting services to personnel at all levels of responsibility on all aspects of
radiation protection, including instruction of radiation safety classes;
F2.c
ensuring that required radiation surveys and leak tests are performed and documented in
accordance with TAC §289.252 and the Radiation Safety Manual, including any corrective
measures when levels of radiation exceed established limits;
F2.d
Receiving, delivering, and shipping all radioactive materials coming to or leaving TTU property;
F2.e
Monitoring all accelerators and other machines capable of producing penetrating radiation;
F2.f
C-II-8
Distributing and processing personnel monitoring equipment including maintaining records of
internal and external personnel exposure, notifying individuals and their supervisors of
exposures approaching the maximum permissible limits, and recommending appropriate
remedial action;
F2.g
Investigating the circumstances and causing a report to be submitted to the agency for each
known or suspected case of radiation exposure to an individual or radiation level detected in
excess of limits established by TAC §289.252 and each theft or loss of source(s) of radiation, to
determining the cause(s), and to taking steps to prevent recurrence;
F2.h
Investigating the circumstances and causing a report to be submitted to the agency for each
known or suspected case of release of radioactive material(s) to the environment in excess of
limits established by TAC §289.252;
F2.i
Instructing personnel in proper procedures for the use of radioactive materials;
F2.j
Supervising and coordinating the waste disposal program, including keeping of waste storage
and disposal records;
F2.k
Storing of all licensed radioactive materials not on sub-licenses;
F2.l
Ensuring the proper storing, labeling, transport, and use of sources of radiation, storage, and/or
transport containers;
F2.m
Performing and/or supervising all in-house sealed source leak tests;
F2.n
Maintaining an inventory of all radioactive materials, radiation producing equipment, and lasers
on TTU property;
F2.o
Supervising decontamination of radioactive material accidents;
F2.p
Maintaining a continuous program of environmental radiation hazard evaluation through routine
lab inspections and hazard elimination;
F2.q
C-II-9
Maintaining radiation safety program records in the Radiation Safety Office;
F2.r
Reporting regularly to the RSC;
F2.s
Maintaining a thorough knowledge of management policies and administrative procedures of
TTU;
F2.t
Prohibiting and preventing, by immediate suspension or termination if necessary, any unsafe or
illegal use of radioactive material, radiation producing equipment, or lasers.
F2.u
Maintaining files on each sub-licensee in the Radiation Safety Office, and providing each sub-
licensee with a copy (and updates) of the “Radiation Safety Manual - Texas Tech University
Policies and Procedures for Radiation Safety”; and
F2.v
Performing other tasks requested by the RSC.
G RADIATION SAFETY OFFICE
The Radiation Safety Office conducts operations and services to support TTU’s radiation safety
program.
G1
The Radiation Safety Office will be under the supervision of the RSO and will be staffed with at
least one trained and qualified radiation safety technician, one trained and qualified
radiation/laser safety specialist, and with part/full time clerical staff as necessary to fulfill the
duties and obligations of the radiation safety program.
G2
The Radiation Safety Technician will support the RSO and the RSC by performing assigned
routine safety functions which include, but are not limited to:
G2.a
Performing and documenting radiation surveys of radiation levels in TTU facilities;
G2.b
Performing and documenting radiation surveys of contaminated, or potentially contaminated,
surfaces and areas in TTU facilities;
G2.c
Placing, or verifying the correct placement of, required warning labels and signs on containers,
room entrances, and areas according to the requirements of this manual;
G2.d
C-II-10
Controlling movement and storage of packages and containers of radioactive materials and
wastes;
G2.e
Performing and documenting leak tests of sealed sources;
G2.f
Inspecting radiation survey instruments to assure current calibration;
G2.g
Testing fume hoods to assure proper operation;
G2.h
Performing calibration of radiation survey instruments according to the procedures listed in
Appendix C of this manual; and
G2.i
Other duties as assigned by the RSO or RSC or directed by the TTU Administration.
G3
The Radiation/Laser Safety Specialist will support the RSO and the RSC by performing assigned
routine safety functions which include, but are not limited to:
G3.a
Processing and approving orders of radioactive materials;
G3.b
Receiving and delivering all incoming radioactive materials;
G3.c
Maintaining the inventory of all radioactive materials;
G3.d
Performing inspections, surveys, and audits;
G3.e
Ordering, delivering, and retrieving dosimetry badges and maintaining the dosimetry program;
G3.f
Assisting with the radioactive waste program;
G3.g
Maintaining records for the above functions; and
G3.h
C-II-11
Other duties as assigned by the RSO or RSC or directed by the TTU Administration.
G4
Radiation Safety staff will coordinate with the sub-licensee prior to entering any area under the
sub-licensee’s supervision or control.
H PERSONNEL MONITORING PROCEDURES
Introduction
This section will give direct information regarding the initiation, requirements, use, and
termination of the personnel monitoring service for radiation exposure at Texas Tech University.
H1
Requirements
The regulations require that personnel monitoring devices (i.e. film badges) be provided and
records be kept for an individual who receives, or is likely to receive, a dose in any calendar year
in excess of 10% of the values discussed in II.G. Exemptions may only be granted by the Bureau
of Radiation Control (BRC) of the Texas Department of Health (TDH).
H2
Method
The radiation reaching the badges, being worn for monitoring, exposes the badge or chip.
Special filters in the badge holder allow distinguish between varying degrees of radiation
penetration, thus indicating the exposure received by the person wearing the badge. The only
purpose of the badge is to record the exposure of an individual. The badge does not protect an
individual from radiation.
H3
Monitoring periods
Monitoring periods vary according to badge type and use. Each individual should check to see
the length of the monitoring period they will be following. A general rule to follow will be: film
badge - monthly, TLD badge - quarterly. ANY individual not returning a badge of any type will
be subject to a dose assessment in accordance with TAC §289.202 and BRC Regulatory Guide
5.7. The dose assessed could result in the maximum permissible exposure for that time period,
possibly resulting in the loss of the right to work with radioactive material and/or radiation
producing equipment.
H4
Procedures
H4.a
Requests for Dosimetry
H4.a.1
ALL personnel working with radioactive material or radiation producing equipment will be
required to file a "Request for Dosimetry Service". The RSO will make a determination from the
C-II-12
information given on the "Request" as to the type of monitoring needed for that particular
individual. Personnel exempted from badge-type dosimetry will be those who work only with
pure alpha emitters, or beta emitters having a maximum energy of less than 0.2 MeV, in which
case an internal dosimetry program is required if the committed effective dose equivalent
exceeds 10 percent of annual limits of intake (ALI) as listed in Columns 1 and 2 of Table I of
TAC §289.202(ggg)(2). The RSO will determine who will be issued badge-type dosimetry.
H4.a.2
Any person filing a "Request for Dosimetry" that has worked with radioactive material, radiation
producing equipment, or has been previously monitored for radiation exposure at a pervious
institution(s) will be asked to fill out the information needed on the "Request for Dosimetry" form
and the "Previous Exposure History Request".
H4.a.3
After receiving the "Request" the RSO will order the dosimetry (if needed). No use of radioactive
material or radiation producing equipment will be allowed until confirmation from RSO or
dosimetry has been received.
H4.b
Termination of Service
The following rules should be followed for dosimetry service termination:
H4.b.1
Individual user should give a minimum 30 day notice of his/her intent to be deleted from the
service. This should be done in advance of a new monitoring period, therefore allowing enough
time to ensure that deletion will be completed without a new badge being issued.
H4.b.2
Individual user will return badge to sub-licensee or RSO upon completion of work with ionizing
radiation or before leaving Texas Tech.
H4.b.3
All individuals are urged to request their permanent exposure history from TTU. The Radiation
Safety Office will forward permanent exposure histories in accordance with TAC §289.202.
Please allow enough time for final badge to be developed, interpreted, and results sent to Texas
Tech.
H4.c
Procedures for Wearing of Badges
Rules regarding the wearing and use of personnel monitoring devices:
H4.c.1
Attach the badge holder to the area of your garment most likely to be exposed to the radiation.
H4.c.2
C-II-13
When not in use, leave the badge in a radiation free area. DO NOT take the badge home, leave
it in your car, or other areas subject to exposing the badge to significant changes in heat,
humidity, or light, unless on official business for TTU involving ionizing radiation.
H4.c.3
NEVER wear another person's badge.
H4.c.4
Report the loss of a badge or holder to the RSO immediately.
H4.c.5
NEVER put a badge in a situation where it could become contaminated by radioactive material
or exposed to unnecessary radiation. Specifically, never wear ring badges on the outside of
gloves, never leave badges lying near radioactive material or radiation producing equipment,
even for short periods of time.
H4.c.6
THE BADGE ISSUED TO YOU IS YOUR RESPONSIBILITY.
H4.c.7
Take care not to send your badge to the laundry with your lab coat.
H4.c.8
NEVER puncture, remove, or alter in anyway the badge holder or its contents.
H4.c.9
REMEMBER - A rule cannot be written to cover every possible situation, use COMMON SENSE
when no rule is available.
H4.c.10
Reports of exposure to ionizing radiation are kept by the Radiation Safety Office. Any individual
may request (in writing) top review his/her exposure reports at any time. However, the request
should indicate the report(s) needed for review.
I BIOASSAY PROCEDURES
I1
Requirement
Staff and students must submit to the appropriate bioassay procedure if indicated by any of the
conditions described below. It is conceivable, although not likely, that a person not involved in
any operation using radioactive materials might be exposed. In that event, those individuals
must also have the appropriate bioassays performed.
I2
Urinalyses
I2.a
C-II-14
Any person who uses 8 mCi (millicuries) or more of hydrogen-3 (tritium) in any single operation
or within a one (1) week period will submit to a urinalysis. Urine samples will be taken before
work begins and weekly during use. Results will be provided to the person, regardless of
outcome.
I2.b
Any person who uses 20 mCi (millicuries) or more of carbon-14 in any single operation will
submit to a urinalysis. Urine samples will be taken before work begins and weekly during use.
Results will be provided to the user, regardless of outcome.
I3
Thyroid counts
Thyroid scans will be conducted on any individual that handles, in open form, volatile Iodine-125
in amounts greater than:
I3.a
0.1 mCi: when the procedure or set of procedures is performed in an open area and NOT within
a fume hood; and/or
I3.b
1.0 mCi: when the procedure or set of procedures IS performed within a fume hood.
• Note 1: the RSO must be contacted if amounts greater than 10 mCi of Iodine-125 are to
be handled.
• Note 2: All procedures involving greater than 1.0 mCi of volatile Iodine-125 will be
performed within a fume hood. Refer to PPRP Section VI (A.7,A.11,J.6). Thyroid scans
will be performed prior to handling volatile Iodine-125 in the amounts indicated above and
between 6 hours and 72 hours after the procedure or set of procedures. Contact the RSO
to set up the thyroid scans.
• Note 3: Reference "Regulatory Guide 8.2 - Applications of Bioassay for I-125 and I-131",
U.S. Nuclear Regulatory Commission or applicable guides approved by the Bureau of
Radiation Control.
I4
Additional Requirements
I4.a
Periodic bioassays may be necessary for any individual who is suspected of having ingested,
inhaled, or absorbed any radioactive material. The type of bioassay will be determined by the
RSC upon consultation with appropriate regulatory agencies or health physics consultants, if
necessary.
I4.b
In Vitro bioassays, other than urinalysis, will be performed when determined by the RSC, after
consultation with appropriate regulatory agencies or health physics consultants.
I5
C-II-15
Records
All results of bioassays will be recorded and filed in the individual's personnel monitoring file.
END OF SECTION
C-II-1
SECTION II – SUB-LICENSE PROGRAM SAFETY
Introduction
This section will detail the procedures and requirements for obtaining a sub-license for radioactive
material, radiation producing equipment, and lasers. Also included will be procedures for renewals
and amendments.
A DEFINITIONS
Broad License – the specific radioactive materials license issued to TTU by the Bureau of
Radiation Control of the Texas Department of Health. This license authorizes all radioactive
materials use programs to be conducted at the discretion of the RSC.
Sub-license – an authorization issued by the RSC to use radiation sources.
Sub-licensees - Authorized users, usually faculty members, whose training and experience are
such that they have been sub-licensed by the RSC to use ionizing and/or non-ionizing radiation
in their research and educational activities.
B SUB-LICENSE APPLICATION PROCEDURES
B1
Qualifications for Sub-License
B1.1a
The applicant must have sufficient training and experience in the use of the radioactive material,
radiation producing equipment, or laser(s) requested to ensure that proposed work is conducted
and/or supervised in a safe manner.
B1.1.b
The applicant must submit an application for the particular sub-license needed, and a resume of
use and experience within the area of interest shown by the application. This resume may include
papers written referencing the use of that particular material or instrument, and/or any formal
training courses or continued education.
B1.1.c
The applicant must specify on the application the types and amounts of radioactive materials or
radiation producing machines to be licensed as well as the procedures involved.
B1.1.d
The RSC will authorize issuance of the sub-license if it determines that all requirements have been
met.
B1.1.e
The RSC may require an applicant to attend the TTU Radiation Safety Shortcourse and/or obtain
experience by working under an active sub-license for a specified period.
B1.1.f
Requirements for Individuals Working Under an Applicant's Sub-license:
C-II-2
B1.1.f.1
Workers (technicians, students, graduate assistants, post doctorals, etc.) must attend the local
Radiation Safety Shortcourse.
B1.1.f.2
The shortcourse will be four hours for workers who can prove by appropriate certificate that prior
radiation safety training was completed within the last five years.
B1.1.f.3
The shortcourse will be eight hours for workers who have finished at least two years of college
but have not had prior training within the last five years.
B1.1.f.4
For workers who have not had prior training and have completed less than two years of college
education, 24 hours of training will be required.
B2
Procedures for Obtaining a Sub-license
B2.a
The RSO will first review all applications.
B2.b
If an application (for amendment or renewal only) is properly completed by the applicant or
authorized user and a qualifying inspection (for new laboratories) or a recent inspection of the
laboratory by the TTU Radiation Safety Office shows that the laboratory is in compliance with state
and local regulations, interim approval not to exceed 30 days may be granted by the RSO.
B2.c
Final approval of all applications is required by the TTU RSC at its regular monthly meeting.
B2.d
To be considered for final approval all applications including amendment and renewals must be
submitted at least two working days before the next regularly scheduled meeting.
B2.e
All applications must be filled out completely and signed by the applicant. All applications not
filled out completely and correctly will be returned to the applicant for re-submission.
B3
Sub-license Renewal and/or Amendment
B3.a
Term of Sub-license
Texas Tech University sub-licenses remain in effect for two years from date of issue.
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B3.b
Renewal
Although the Radiation Safety Office will generally remind sub-licensees of a pending expiration,
it is the sole responsibility of the sub-licensee to submit the renewal application timely to avoid
expiration of a sub-license before receipt of renewal application by the Radiation Safety Office.
B3.c
Actions or activities requiring an amendment to a sub-license:
B3.c.1
If there is a change in the terms and conditions of sub-license or if procedures authorized by it
change] (personnel, lab relocation, etc.);
B3.c.2
If an increase in maximum allowable activity is expected or needed;
B3.c.3
If a different isotope is needed;
B3.c.4
If isotope(s) on sub-license are no longer needed;
B3.c.5
If there is a change in equipment (X-ray or Laser inventory);
B3.c.6
If there is a significant change in submitted Operating Procedures.
B3.c.7
If significant changes occur in the normal operation of sub-license procedures, for example, the
use of animals, increased waste disposal, etc.
B3.c.8
Application forms for license renewal or amendment are available from the Radiation Safety Office
or may be found in this manual.
C ABSENCE OF SUB-LICENCEE FROM CAMPUS
A sub-licensee who expects to be absent from the campus for a time period of greater than three
weeks must:
C1
Suspend or terminate the use of radionuclides or radiation producing equipment.
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C2
Notify the RSO as to the responsible individual (another sub-licensee) who will take over
supervision of the use of the various radionuclides or radiation producing equipment to be used.
This sub-licensee must be competent in the use and regulations concerning the radionuclides to
be used or the radiation producing equipment to be used.
C3
Should arrangements for either 1 or 2, above, NOT be made, the RSC, with may 1) suspend the
sub-license or 2) revoke the sub-license, and 3) name a responsible sub-license to act for the
absent sub-licensee.
C4
A sub-licensee leaving the campus for a visiting professorship at another institution:
C4.a
May transfer the radioactive material to that institution pending notification of approval by the
Radiation Safety Offices of both institutions;
C4.b
Transfer the radioactive material to another TTU sub-licensee pending approval of the RSO;
C4.c
Placed the radioactive material in storage with the RSO; or
C4.d
Dispose of the radioactive material.
D PROCEDURE FOR TERMINATION OF A SUB-LICENCE
Procedure for Termination of a Sub-license - The following procedure shall be used should a
sub-licensee desire to terminate his/her radioactive material or radiation producing equipment
sub-license.
D1
A letter of intent to terminate the sub-license will be submitted to the RSO. This letter will include:
D1.a
The date of termination.
D1.b
The listing of the sub-licensee's authorized laboratories, including storage and waste areas. A
diagram of all these areas should accompany this letter of intent.
D1.c
A statement that all radioactive materials, and radioactive wastes used and/or stored will be
removed. They must be transferred either to the RSO for storage or disposal, or properly transferred
to another sub-licensee who is properly authorized to possess the materials and activities under
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consideration, without exceeding his/her limits, or makes application to amend the radionuclides
and activities to his/her sub-license. NOTE - This would also apply to radiation producing
equipment.
D1.d
The terminating sub-licensee will provide copies of the results of an IN DEPTH contamination
survey on the laboratories, equipment, storage and waste areas authorized on his/her sub-license.
If contamination levels greater than those listed in TAC §289.202(ggg)(6) are found, the
contaminated areas and/or equipment will be decontaminated until allowable limits are reached.
D1.e
Upon receipt of the letter of intent, the RSO will conduct a close-out survey of the affected areas
and equipment.
D1.f
Based on a review of the letter of intent, the results of the close-out survey, and the disposition of
the radioactive material or radiation producing equipment, the RSO will make his recommendations
to the RSC at its next monthly meeting, which in turn will consider and vote on the request to
terminate the sub-license.
D1.g
Upon termination, all signs and labels, indicating that the areas were authorized for use of
radioactive material, shall be removed by radiation safety personnel. The areas are now
considered for unrestricted use. Areas with radiation producing equipment may or may not qualify
for unrestricted use.
D1.h
ON TERMINATION, FURTHER USE OF RADIOACTIVE MATERIAL BY THE SUB-LICENSEE
AND INDIVIDUAL WORKERS OF THAT SUB-LICENSE IS STRICTLY PROHIBITED.
D1.i
All equipment and personnel monitoring devices (i.e. survey meters, shielding, film badges, etc.)
not owned by the terminating sub-licensee must be returned to the radiation safety office or to
owners of the equipment at this time.
D1.j
Should a sub-licensee permanently leave TTU and neglect to officially terminate his/her sub-
license, the RSO upon notification will contact the absent sub-licensee's Department Chairperson.
The Department Chairperson will be responsible for initiating the sub-license termination
procedures as outlined above.
E SUB-LICENSEE INSPECTION / MONITORING PROGRAM
Sub-licensee Inspection/Monitoring Program- The following procedures outline the TTU
inspection/monitoring program conducted for evaluation of programs operated under sub-
licenses.
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E1
General
A radiation program the size of TTU requires periodic monitoring, inspection, and evaluation. It is
the responsibility of each sub-licensee to ensure his/her monitoring is complied with by performing
required radiation surveys. It is the responsibility of the RSO to make periodic inspections and
surveys of each sub-licensee to ensure he/she is in compliance with all state and local regulations.
E1.a
The entire program at TTU is periodically evaluated by the TTU-RSC and by the Texas BRC for
compliance.
E1.b
This system of "checks and balances" assures TTU and the general public that the radiation
program at TTU operates safely and efficiently.
E2
Frequency of Inspections
E2.a
The RSO shall make inspections of radioactive material sub-licensees on a quarterly basis.
E2.b
The RSO shall make inspections of radiation producing equipment sub-licensees on an annual
basis.
E2.c
Sub-licensees who have had their area deactivated do not have to be inspected.
E3
Inspection Policy/Responsibilities
E3.a
The RSO shall inspect facilities for compliance with all applicable regulations - state, federal, and
local.
E3.b
The RSO shall make a record of each inspection and keep those on file in the Radiation Safety
office.
E3.c
The RSO will forward a formal report of inspection (Form RS-24) to each sub-licensee within two
weeks of final evaluation of his/her inspection results, noting corrective action needed.
E3.d
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Each sub-licensee will revise or correct his/her individual program as noted in the report under
"Corrective Actions". Questions or problems should be addressed to the RSO or the RSC.
E3.e
The RSO will report all major deficiencies as well as any instance of non-compliance for a sub-
license, applicable rules, or statutes, to the RSC.
E3.f
The RSO shall make follow-up inspections of all sub-licensees having deficiencies deemed serious
by the RSC within 60 days of report.
E3.g
All inspection statistics should be evaluated by the RSC.
E3.h
Sub-licensees having repeated deficiencies (same deficiency during two consecutive inspections)
will be reported to the RSC and the RSC will issue written notice.
E3.i
Sub-licensees found to repeat a deficiency a third time (same deficiency during three consecutive
inspections) will be reported to the RSC. The RSC will issue a written notice and require the sub-
licensee to meet with the committee during next scheduled meeting to explain their actions.
E3.j
The RSC may terminate a sub-license if serious deficiencies are continued.
F SUB-LICENSE PROGRAMS AND PROCEDURES
F1
Sub-Licensee/Authorized User Responsibilities
F1.a
Each authorized user has the following obligations:
F1.a.1
Ensuring that the individual user responsibilities are discharged by those under their control and
supervising their work;
F1.a.2
Working within the limits of the User's sub-license;
F1.a.3
Instructing those employees for whom they are responsible in the use of safe techniques and in
the application of approved radiation safety practices and ensuring attendance in required
radiation safety courses;
F1.a.4
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Furnishing the RSO with information concerning individuals and activities in their areas;
F1.a.5
Ensuring that all surveys and safety checks required for their particular area of interest are
carried out and recorded properly;
F1.a.6
F1.a.6
Contacting the RSO whenever major changes are anticipated in operational procedures, new
techniques, alterations in physical plant, or when new operations that might lead to personnel
exposure;
F1.a.7
Complying with the regulations governing the use of radioactive materials, radiation producing
equipment, or lasers, as established by the Texas Regulations for Control of Radiation, Texas
Regulations for Control of Laser Radiation Hazards, and Texas Tech University Policies and
Procedures for Radiation protection;
F1.a.8
Keeping stocks of stored radioactive material to a minimum;
F1.a.9
Complying with proper procedures for termination of equipment, or termination of sub-license
involving the use of radioactive material, radiation producing equipment, or lasers;
F1.a.10
Complying with the proper procedures for handling radiation incidents;
F1.a.11
Obtaining prior approval, by completing and submitting an application for amendment/renewal
form, for the addition/deletion of rooms, radioisotopes, or personnel, for the increase/decrease
of radioactive material, or for additions or changes to procedures.
F1.b
Responsibilities of Authorized Users - Authorized users (workers, employees, etc.) faculty,
students, other professionals, as well as technical and other workers engaged in education,
laboratory research, and research support activities which involve actual use and handling of
materials and devices producing ionizing and non-ionizing radiation. These personnel will work
under the immediate supervision of a sub-licensee.
G MAXIMUM PERMISSIBLE DOSES, DOSE LIMITS
G1
Like other materials with potential health hazards, regulatory control is applied to exposures
involving radiation workers throughout the nuclear industry as well as medical and research
facilities. Workers exposed to ionizing radiation as part of their normal duties assume an
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occupational risk and therefore are regulated under a "maximum permissible dose". The Texas
Regulations for Control of Radiation and Title 10 Code of Federal Regulations Part 20 currently
accepts the following as "maximum permissible dose":
G2
No sub-licensee or employee shall possess, use, receive, or transfer sources of radiation in such
a manner as to cause any individual in a restricted area to receive in any period of one calendar
quarter from all sources of radiation a total occupational dose in excess of the limits specified as
follows:
G2.a
The annual occupational dose shall not exceed the more limiting of:
G2.a.1
The total effective dose equivalent being equal to 5 rems (0.05 sievert); or
G2.a.2
The sum of the deep dose equivalent and the committed dose equivalent to any individual organ
or tissue other than the lens of the eye being equal to 50 rems (0.5 sievert).
G2.b
The annual occupational dose to the lens of the eye, to the skin, and to extremities will not
exceed:
G2.b.1
an eye dose equivalent of 15 rems (0.15 sievert), and
G2.b.2
a shallow dose equivalent of 50 rems (0.5 sievert) to the skin or to any extremity.
G2.c
The annual occupational dose to minors will not exceed 10 percent of the limits specified in (a.)
and (b.) above [reference TAC §289.202(l)].
G2.d
The annual occupational dose to an embryo or fetus during the entire pregnancy of a declared
pregnant woman will not exceed 0.5 rem (0.005 sievert). Refer to TAC §289.202(m).
G2.e
The total effective dose equivalent to individual members of the public will not exceed 0.1 rem
(1.0 millisieverts) in a year, and that the dose rate in any unrestricted area from external sources
will not exceed 0.002 rem (0.02 millisieverts) in any one hour.
H POLICIES AND PROCEDURES FOR RADIOACTIVE MATERIAL USE
This section will give specific Policies and Procedures for the use of radioactive material.
Pertinent facilities, record keeping, handling of radioactive material, radiation contamination
C-II-10
surveys, custodial service for radioactive material areas, neutron meters, radioactive material in
animals and radioactive waste.
H1
Facilities
H1.a
Work areas(s) (benches, hoods, trays, etc.) will have a non-absorbent surface.
H1.b
Laboratories will have wall coverings of a washable, hard, heat-chemical resistant paint (i.e.
epoxy).
H1.c
Laboratories will have protective floor coverings and ventilation capable of handling and storing
the isotopes and activities being requested. (reference CRC Handbook of Laboratory Safety, p.
437-439)
H1.d
Storage areas, work areas, refrigerators, freezers, fume hoods, and lab entrances will be posted
with the correct warning signs. (signs available from Radiation Safety)
H1.e
Storage areas (cabinets, refrigerators, freezers, fume hoods, laboratories, etc.) will be secured
to prevent unauthorized removal of radioactive material.
H1.f
Storage containers will have radioactive material labels with date, type, and activity of isotope(s).
This will apply to any container with radioactive material that will be in use more than one (1)
working day.
H1.g
Work area air levels shall be kept below 10% of those limits given in TAC (§289.202(ggg)(2). If
circumstances require concentrations in air to exceed 10% of the above, then the RSO will need
to be notified.
H1.h
All signage (sub-license, Notice to Employees, emergency numbers, etc.) shall be posted in
prominent view.
H1.i
Remote handling devices will be used when handling energetic beta or gamma sources. In
general this refers to sources above approximately two-tenths of one MeV (0.2) that might be
indirectly unshielded or potentially contaminated. If a person is unsure as to the proper action
to take consult the RSO.
H1.j
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Each laboratory will have a [calibrated] survey meter capable of detecting radioactive material(s)
used in that particular laboratory if the radioisotopes and activities of those isotopes are
detectable with a meter. This survey meter is not to be used for actual contamination surveys,
only for dose level surveys, spot contamination surveys, and personnel exit surveys.
NOTE - All costs for procurement, calibration (annually), and repair will be assumed by the sub-
licensee. Survey meters are available (limited number) from Radiation Safety for short-term
loan. Also the calibration of certain types of survey meters is available through the radiation
safety office.
H1.k
Work areas may need a fume hood in order to comply with regulatory limits. The following lists
some minimal features the fume hoods should have:
• NOTE - Fume hoods should be used anytime a person is handling unsealed, potentially
volatile forms of radioactive material. Operations involving the use of more than 0.1
millicuries of Iodine-125 or Iodine-131 in volatile form shall be conducted within a properly
operating fume hood.
H1.k.1
Fume hoods shall be labeled if radioactive materials are to be used or stored in the hoods.
H1.k.2
The velocity of the air flow shall be such that there can be no escape of air into the work place
from the fume hood under normal conditions, including opening of doors and windows, suction
of other fume hoods, and air conditioning systems. The velocity of the air flow shall be no less
than 80 lfpm and no more than 120 lfpm.
H1.k.3
The gas, water, and electrical appliance should be operable from the outside of the fume hood.
H1.k.4
The fume hood shall have a counter-balanced sash made of tempered safety glass.
H1.k.5
The fume hood should have a layer of absorbent paper with water-proof backing covering the
entire work surface.
H1.k.6
The inspections shall be conducted by the Department of Environmental Health and Safety.
H2
Record Keeping
H2.a
Wipe survey results
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Survey records shall be continual, observing no stops in record keeping and according to TAC
requirements. Surveys shall be in proportion to isotope use, hence the records shall be the
same.
H2.b
Isotope Use Forms - All isotope use forms (Form RS-14) shall be kept by the sub-licensee. The
use forms shall be separated by those in use and those exhausted. The Radioisotope Use Form
is a 3 part form used to indicate, and verify the sub-licensee's use and disposal of radioactive
material. At such time when the radioactive material is no longer useful or is exhausted, the total
amount used, disposed, or released to atmosphere must be written on the "use form".
H2.c
Request for Radioactive Waste Disposal
All Requests for Radioactive Waste Disposal (Form RS-14A) shall be kept by the sub-licensee.
Form RS-14A is a multi-part form used for waste identification, disposal information, and hazard
identification. The form is used to comply with Texas Regulations for Control of Radiation, Dept.
of Transportation Regulations, Code of Federal Regulations Part 49, Environmental Protection
Agency Regulations, Texas Water Commission, and Disposal Site Regulations.
H2.d
Inventory
All sub-licensees will keep a copy of the most recent semi-annual radioactive material inventory.
H2.e
Inspection Reports
All sub-licensees should keep their semi-annual inspection reports (Form RS-24).
H2.f
Amendment and Renewals
All sub-licensees should keep a copy of their amendments and renewals.
H2.g
Organization
All survey records shall be kept in format so as not to confuse routine inspections or audits.
Records shall be sectioned so as to separate use forms, inventories, survey records, etc. Use
forms should be separated by isotope and kept in chronological order by date received.
H2.h
Availability
Records shall be kept in an area of the laboratory free of contamination and shall be available
during routine monitoring of the lab by Radiation Safety personnel and/or regulatory agencies.
C-II-13
H3
Control of Radioactive Material
H3.a
Ordering Radioactive Material – General Procedure
H3.a.1
Requestor calls the Radiation Safety Office at 742-3876
H3.a.2
The requestor shall have the following information for Radiation Safety:
• Sub-licensee
• Isotope
• Activity (in millicuries ONLY)
• Chemical form
• Requestors phone number
• Local point of contact
• Vendor
• Account Number
• Total dollar amount
H3.a.3
The Radiation Safety Office will:
• check the sub-licensee's current inventory to verify that the isotope and requested activity
does not exceed the sub-licensee's limit.
• check the TTU Broad License to verify that the isotope and requested activity do not
exceed the TTU Broad License Limit.
• check the compliance, records, and violations of the sub-licensee.
NOTE - Should the purchase exceed either the sub-license or Broad License limits the RSO will
call the requestor and ask him/her to amend the order to an acceptable limit or amend his/her
current inventory by resubmitting of Radioactive Material Inventory.
H3.a.4
The Radiation Safety Office will call Purchasing and provide the needed information. The buyer
will give the Radiation Safety Office the P.O. number.
H3.a.5
The buyer will then verify the account funds and call the requestor, giving him/her the P.O.
number. Requestor calls the vendor providing the needed information.
H3.a.6
C-II-14
ALL radioactive material shipments must be shipped to the following address:
ATTN: Radiation Safety Officer
Administrative Support Center
2903 4
th
Street, Room 122
Texas Tech University
Lubbock, Texas 79409
H3.a.7
Requestor will then complete the regular purchase order form. The requestor shall type or write
(legibly) the words "Radioactive Material" on the purchase order form.
H3.b
Receipt and Accountability of Radioactive Material
H3.b.1
Receipt
• The receipt of all radioactive material shipments should be during normal business hours,
unless special arrangements have been made with the Radiation Safety Office. When
ordering radioactive material, the requestor should emphasize this to the vendor and
make sure the vendor will ship accordingly.
• Upon receipt, the package(s) will be monitored in accordance with TAC §289.202(ee).
H3.b.2
Accountability
A "Radioactive Material Use Form" (Form RS-14) will be prepared and issued to sub-licensee
upon his/her receiving the shipment.
• The "Radioactive Material Use Form" is a 3 part form used to document a sub-licensees
use and disposal of that particular shipment. When the material is no longer useful or
exhausted the sub-licensee will verify that all use and disposal (dry, liquid, atmosphere,
etc.) has been recorded on the form. It shall be the responsibility of the sub-licensee to
apply mathematical decay calculations in order to determine the amount used and/or
disposed.
NOTE - Only sub-licensees or personnel named on the sub-license will be allowed to sign for
and receive the shipment.
• Upon final use (described above) the sub-licensee shall verify the aforementioned, then
date, sign and return the YELLOW copy to the Radiation Safety office.
• After receiving the yellow copy the Radiation Safety Office will audit the "use form" and if
filled out correctly will delete the shipment from the sub-licensee's inventory and the TTU
Broad License.
H3.b.2.1
Semi-annual radioactive material inventories are required of all sub-licensees. Sub-licensees
will submit the inventory as requested by the RSO.
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Remember - It is the responsibility of the sub-licensee to apply any mathematical decay
calculations.
H4
Transfer and Shipping of Radioactive Material
H4.a
Transfer
There shall be no transfer of radioactive material from one sub-licensee to another sub-licensee,
nor outside of TTU, without the approval of the RSO.
H4.b
Shipping
• If radioactive material is to be shipped from TTU, the shipper must notify the Radiation
Safety Office.
• The RSO will then assist the shipper in preparing the package for shipment according to
Department of Transportation Regulations, Texas Regulations for Control of Radiation,
and Nuclear Regulatory Commission (NRC) Regulations.
NOTE - The recipient of any regulated radioactive material to be shipped from TTU must provide
evidence of an NRC (or agreement state license) by furnishing a copy of his/her license to the
Radiation Safety Office. This must be done prior to shipment.
H5
Storage of Radioactive Material
H5.a
Radioactive material shall be stored only in approved areas.
H5.b
The storage container shall be of such construction to prevent unneeded external exposure to
radiation present therein. Furthermore, the container shall be "double-contained" meaning the
container shall be able to hold/or absorb twice the volume of the material therein.
H5.c
Storage of radioactive material, animal containing radioactive material and parts thereof shall be
such as to prevent unauthorized removal.
H5.d
All refrigerators and freezers for storage of radioactive material shall be equipped with hasps
and combination locks. A copy of the combination shall be forwarded to the Radiation Safety
Office.
H6
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Radiation Surveys
H6.a
Each sub-licensee shall perform or have performed by individuals listed on sub-license,
laboratory surveys where radioactive material or radioactive waste is being used or stored.
H6.b
These surveys shall be performed in direct proportion to isotope use. Surveys shall be continual,
even during periods of inactivity.
H6.b.1
Using filter paper (Whatman 1-4.25cm or equivalent), wipe an area of 100 cm
2
.
NOTE: Using an "S" motion of about 12-16 inches will give approximately this area. Although
there is no set minimum or maximum for the number of wipes for a laboratory, one should make
sure the number of wipes taken show radioactive material use areas, radioactive material
storage areas, rad-waste storage areas, and heavy traffic areas (door knobs, floors, phones,
cabinets, etc.).
H6.b.2
Count the wipes with a radiation detection system capable of monitoring the desired radiation
energy and type. NOTE - Survey meters are not capable of being used for quantitative analysis
(i.e. counting purposes). They should only be used for routine surveys, personnel lab exit
surveys, and contamination location.
H6.b.3
Results of the smear surveys should be corrected for efficiency and reported in units of activity
(i.e., dpm, Bq, etc.).
H6.b.4
The following shall be maintained in the survey log book:
• survey date and name of surveyor
• counts per minute
• results in units of activity
• map of laboratory
• swipe locations
• efficiency of counter
H6.b.5
All results shall be recorded whether positive or negative.
H6.b.6
If results show removable contamination of more than 1000 dpm for beta emitters (Hydrogen-3,
Carbon-14, Phosphorus-32, Phosphorus-33, Sulfur-35, Calcium-45, Zinc-65), or 200 dpm for
Iodine-125, notify the Radiation Safety Office and begin decontamination procedures.
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NOTE: be sure to always do a background count with each survey and indicate on your machine
copy results which sample is the background count
H6.b.7
Equipment in a radiation laboratory shall not be removed from that laboratory until demonstrated
by the RSO to be free of radioactive contamination.
H6.b.8
Equipment to be repaired by persons outside the laboratory shall be demonstrated to be free of
radioactive contamination by the RSO. Emergency equipment repair by outside personnel shall
be supervised by the RSO. It is the responsibility of the laboratory personnel to request this
supervision from the Radiation Safety Office.
H6.b.9
Routine surveys by the Radiation Safety Office in no way release a sub-licensee from his/her
obligation to their surveys.
H6.b.10
In general, NO radioactive contamination can be tolerated. Exceptions to this will include certain
hood trays, dry boxes, stainless steel trays, absorbent paper, or other equipment which is used
frequently for active work and which will be clearly marked with standard radiation caution signs
and stickers. However, these items shall be decontaminated or disposed of after experiment or
use and before deactivation or termination of sub-license.
H6.b.11
Decontamination
ALL decontamination will be carried out by the sub-licensee responsible for the contamination
under the supervision of the RSO. All costs for decontamination shall be assumed by the sub-
licensee.
H7
Deactivation/Reactivation of Radiation Use Areas
Should a sub-licensee foresee a period of time in which he/she does not plan to use radioactive
material or radiation producing equipment in a particular laboratory(s)the affected laboratory(s)
may be deactivated, though maintaining a valid sub-license, by meeting the following criteria:
H7.a
A letter of intent to deactivate an authorized radiation use area will be submitted to the RSO.
This letter will include:
• The room number(s) and diagram of the laboratory(s) to be deactivated.
• A statement that all radioactive materials used and/or stored in the affected laboratory(s)
will be removed.
• If radiation producing equipment is involved then the statement shall be that all involved
equipment in the affected laboratory(s) will be secured against any use.
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NOTE - The radioactive material may be transferred either to the RSO for storage or disposal,
or transferred, upon coordination through the RSO, to another sub-licensee who is authorized
to possess the materials and activities under consideration, without exceeding his/her sub-
license limits, or makes application to the RSC to amend the isotopes and activities.
H7.b
The sub-licensee will provide copies of the results of an IN-DEPTH contamination survey of the
laboratory’s, equipment, storage and waste areas to be deactivated. If excessive contamination
levels are found, the contaminated areas and/or equipment will be decontaminated until
allowable limits are reached.
H7.c
Upon receipt of the letter of intent, the RSO will perform a close-out survey of the affected areas
and equipment.
H7.d
Based on a review of the letter of intent, the results of the close-out survey, and the disposition
of the radioactive material or radiation producing equipment, the RSO will make his
recommendations to the Chairperson of the RSC who, in turn, will authorize deactivation of
the laboratory(s).
H7.e
Upon deactivation, all signs and labels, indicating that the areas were authorized for use of
radioactive material, or radiation producing equipment shall be removed. Areas with radiation
producing equipment may or may not qualify for unrestricted use, if equipment is still in use that
produces ionizing radiation.
H7.f
At this point, further use of radioactive material and/or radiation producing equipment is strictly
prohibited.
H7.g
All equipment and personnel monitoring equipment (i.e. survey meters, shielding, film badges,
etc.) not belonging to the deactivating sub-licensee will need to be returned at this time.
H7.h
The term of deactivation of an authorized radiation use area will be a MINIMUM OF SIX (6)
MONTHS AND A MAXIMUM OF UP TO TWO (2) YEARS (or until the sub-license is due for
renewal). At the end of a deactivation period the sub-license may request, in writing, to renew
the deactivated status of the laboratory(s) for another term.
H7.i
During the period in which a radiation use area is deactivated, the sub-license will remain in an
active status. If all laboratories of a sub-license have been deactivated, the sub-license will
require only minimal maintenance, i.e., periodic renewal and changes in radiation worker status.
If there are still active laboratories on the sub-license, all current rules, regulations and policies
governing that sub-license (relative to the active laboratories) remain in effect. Since deactivated
C-II-19
laboratories are no longer considered radiation use areas, the requirements for periodic surveys
no longer applies. However, the sub-licensee is still responsible for the retention of ALL records
and files which were generated for that laboratory(s) while it was an active radiation use area.
H7.j
A sub-licensee may REACTIVATE a laboratory(s) any time he/she desires AFTER the initial six
month period if the following criteria are met:
H7.j.1
A written request to reactivate a radiation use laboratory(s) must be made to the RSO.
H7.j.2
A diagram of the laboratory(s) must accompany the request, indicating radiation work areas,
storage areas, waste container location, "hot sinks", etc. A laboratory will be reactivated ONLY
under the initial conditions and configuration at the time of its deactivation. Any changes in work
areas, storage areas, etc. must be made by amendment application AFTER the laboratory has
been reactivated.
H7.j.3
The RSO will review the request and inspect the laboratory area(s) and make his
recommendations to the Chairperson of the RSC.
H7.j.4
After the Chairperson has approved the reactivation of a radiation use area it will, again, be
subject to the posting, required records, safety procedures, and survey/safety check
requirements as stipulated by state, federal, and Local TTU regulations and policies.
H7.j.5
At this time, radioactive materials and/or radiation producing equipment may again be used and
stored in that particular laboratory(s). However, the radiation producing equipment will be
subject to a survey conducted by the RSO to ensure the unit(s) meet all state and local
requirements for radiation levels.
H8
General Services for Radiation-Use Laboratories
All laboratories must be surveyed (wipe tests and visual inspection) for any possible radioactive
contamination within 24 hours of the scheduled cleaning or other services. The lab shall remain
clean until after the services, and it is the responsibility of the sub-licensee to assure this.
Records of these surveys must be kept. Unacceptable removable contamination or radiation
exposure rates will result in the suspension of general services. Supervision by the sub-licensee,
a worker on that sub-license, or radiation safety personnel is required during all services with
the exception of after hours, routine, custodial services.
H8.a
Any laboratory found (during routine inspections) not to be performing required periodic surveys
will be suspended from general services.
C-II-20
H9
Custodial Service for Radiation Use Areas
H9.a
To obtain special custodial service (i.e., scrubbing, stripping, and finishing floors), call Custodial
Services (744-1866).
H9.b
Prior to scheduling the cleaning, the following preparations must be made:
• The floor must be cleared of all obstacles such as boxes, books, containers, and radiation-
labeled items. This must be done by authorized personnel. Visual surveys of the lab
must accompany the wipe tests.
• Custodial Services will schedule the work and call to confirm the date with the requester.
• The custodians will leave a checklist in the laboratory. The checklist must be completed
and signed by the lab personnel.
H9.c
Radiation laboratories requesting cleaning service will be furnished with a Request for Custodial
Service door card. The door card must be signed by the sub-licensee or RSO, and left on the
outside of the door on the day the work is to be accomplished.
H9.d
The sub-licensee or a worker on that sub-license IS required to be in the lab during the cleaning.
H9.e
To obtain routine custodial service, call Custodial Services (744-1866) to receive a door card.
Routine custodial service includes only sweeping floors, empty trash containers, and replace
paper in paper dispensers.
H9.e.1
The Sub-licensee will simply complete, sign and date a door card.
H9.e.2
Place the card on the outside of the laboratory door before 6:00 PM on the day of the routine
cleaning. These cards are only good for one day. These cards assure the custodians that there
are no radioactive items with which they might come in contact.
H9.e.3
The sub-licensee or a worker IS NOT required to be in the lab during the routine cleaning.
Routine cleaning will probably be scheduled between 6:30 PM and 8:00 PM.
H10
Building, Maintenance and Construction (BM&C) Services
C-II-21
H10.a
The RSO or sub-licensee can give clearance for BM&C to perform work in an authorized
use/storage area. The laboratory must be surveyed within 24 hours of the scheduled work.
H10.b
All “hot” items (marked with rad-tape) to be serviced must be surveyed and cleared prior to the
requested work to be done. The items must be released by the RSO, or documented and
released by the Sub-licensee.
H10.c
The sub-licensee or a worker IS required to be in the lab during the BM&C services.
H11
Other Services
H11.a
Departmental technicians can occasionally enter and perform routine duties provided they do
not handle “hot” (labeled with radiation tape) items, and provided they are granted permission
by the Sub-licensee.
H11.b
Company technicians and servicemen servicing or checking items in authorized it must have the
permission of the RSO. The Sub-licensee will be required to the lab surveyed within 24 hours
of their visit. All “hot” items that will be serviced must be checked, and cleaned and rechecked
if necessary. Records of these surveys must be kept.
H11.c
The sub-licensee or a worker IS required to be in the lab during the services.
H12
Portable Moisture Density Gauges
(neutron probe; often referred to as Neutron Meters, Neutron Probes, PMDG's, etc.)
H12.a
These policies and procedures shall apply to all portable devices using the thermalization of
neutrons to measure water contents of porous materials or gamma rays for density
measurement of specific materials.
H12.b
In addition to the Texas Regulations for the Control of Radiation, the following policies and
procedures will apply to the TTU license:
H12.b.1
C-II-22
Each PMDG located at TTU will have a designated authorized user who is responsible for safe
storage, scheduling and preventive maintenance. Hereafter, this individual is known as the
primary authorized user.
H12.b.2
Subject to the discretion and scheduling of the primary authorized user, other as to isotope and
activity.
H12.b.3
The primary authorized user should establish a log to be kept at the location for permanent
storage of the specific PMDG.
H12.b.4
It is the responsibility of the authorized user to:
(a) enter notations in the PMDG log as to the date, time of day, the authorized users name
and destination. Date and time will be logged upon return of the PMDG to permanent
storage.
(b) determine that the individual user has been approved for using that type of radiation
equipment by the TTU Radiation Safety Office.
(c) determine that the PMDG is in operating condition before it is removed from the vicinity
of the permanent storage area. If the PMDG should become inoperable while it is in the
custody of an authorized user, it is that user's responsibility to repair the PMDG
expeditiously.
(d) assure all necessary paper work such as a Bill of Lading, etc. accompanies the PMDG
during transport. All paper work must be in the cab of truck, or glove box of car, NOT in
the PMDG transport box.
H12.b.5
PMDG's may be temporarily transferred from other agencies for use by TTU personnel on TTU
property. However, the transfer must be coordinated in advance through the RSO.
H12.b.6
The PMDG will always be stored and transported in its DOT approved storage box. When
transporting the probe on public highways in the open beds of pickups and trucks, the case will
be anchored securely.
H12.b.7
Personnel monitoring badges shall be worn during transport and use of the PMDG.
H12.b.8
The RSO shall be notified before any PMDG is released for repair.
NOTE - Should the PMDG become lost, stolen, lodged in a monitoring tube, etc., notify the RSO
immediately. If lodged, DO NOT try to retrieve the probe, wait for RSO supervision.
C-II-23
H12.b.9
All PMDG's are required to have semi-annual leak tests and are to be included in semi-annual
radioactive material inventories.
H12.c
These procedures do not change the responsibilities either for the authorized or individual users,
as outlined in other sections of this guide to Policies and Procedures for Radiation Protection at
TTU.
H13
Radioactive Material in Animals
The following procedures are to be used by researchers using radioactive materials in animals.
H13.a
Prior approval to use animals in research shall be obtained by application or amendment through
the RSC. Procedures must be outlined in detail showing activities, disposal procedures,
surveys, potential problem areas, etc.
H13.b
Policies concerning animal use:
H13b.1
Animal cages are to be labeled with warning stickers.
H13b.2
After sacrificing the animal, the researcher or his technician shall wrap the animals in some type
of absorbent paper, the animals shall then be placed in double bags (provided by RSO).
H13b.3
All bedding and food shall be placed separately in double bags.
H13b.4
The bags should be sealed with yellow tape and SHALL BE labeled with the following
information:
(a) Isotope
(b) Total microcuries
(c) Date of administration
(d) Total gram weight
NOTE: Bags and tape shall be kept near animal housing.
H13b.5
The animal carcasses, bedding, and food shall be stored in a freezer until Radiation Safety
Personnel receive it for disposal.
C-II-24
H13b.6
At least 24 hours notice shall be given to Radiation Safety for a pick up time.
H13b.7
Contaminated cages, feeders, and water bottles must be washed separately from normal
cleaning. If a suspended rack is used then the entire unit must be cleaned.
NOTE: Gloves are to worn during cleaning operations and disposed of as radiation waste.
H13b.8
Surveys shall be performed and recorded in accordance with Item D of this section.
H13b.9
All cages, feeders, racks, and water bottles must be demonstrated to be free of contamination,
by the researcher, to the RSO.
H14
Radioactive Waste Disposal Program
H14.a
General
Radioactive waste materials which includes solid, bulk liquid, liquid scintillation vials, and animal
carcasses resulting from the use of radioactive material in laboratories shall be stored in
designated containers and retained for collection by the RSO.
All radioactive wastes shall be disposed of in such a manner as to prevent the occurrence of a
hazard to the health of TTU personnel, to the value of property, and to the welfare of the public.
Final disposal of all radioactive wastes, with the exception of trace amounts through the sanitary
sewer system, will be accomplished by the RSO.
H14.b
Waste Types
There are basically four types of waste generated at TTU: dry solid, bulk liquid, liquid scintillation
vials (LSV), and animal carcasses. Although some predetermined operations may develop
gaseous wastes.
H14.b.1
Dry solid wastes containing radioactive materials are nonhazardous or hazardous. Dry solid
radioactive waste that contains a hazardous component (mixed waste) cannot be generated
without permission from the RSC. Otherwise, all dry solid waste must be in the chemical form
that is nonhazardous and acceptable for disposal in the Lubbock Municipal Landfill.
H14.b.2
Liquid wastes are separated into two categories: (1) aqueous bulk liquids and (2) mixed waste
(organic) bulk liquids.
C-II-25
H14.b.2.a
Aqueous liquids are bulk liquids with a pH between 5 and 9, and which contain no biological,
pathogenic, or infectious material, and have no hazardous characteristic. Aqueous
biodegradable scintillation cocktails fall within this category. NOTE: Organic non-biodegradable
scintillation fluids, hazardous liquids, as well as oils, other organic fluids, strong acids and bases
are NOT considered aqueous fluids and should never be mixed with them.
H14.b.2.b
Mixed (organic) bulk liquids are radioactive bulk liquids that contain a hazardous component and
meet the characteristics of hazardous material. Bulk liquids are considered mixed if they consist
of hazardous chemicals such as toluene, xylene, or other flammable, toxic, or reactive fluids.
NOTE: Regulations mandate that the generator (sub-licensee) be able to verify the contents of
all wastes and their associated hazard classification.
H14.b.2.c
Liquid scintillation vials are glass or plastic vials with a capacity of less than 50 ml each which
contain, or have contained, liquid scintillation fluid. Biodegradable scintillation cocktails such as
Opti-flour, Aqua-sol, Ready-Safe, etc. should be used unless there is absolutely no way to avoid
using the nonaqueous scintillation cocktails. NO blood or aqueous non-scintillation vials are to
be placed in the LSV containers. Stock solution vials (NEN, ICN, etc.), liquid scintillation counter
standards, or vials with non-scintillation fluids are not acceptable in LSV containers. NEVER
mix dry solid or biological wastes in LSV containers.
NOTE: If any non-scintillation material is found in a LSV container, the container will be returned,
or if found during an inspection the generator will be responsible for correction of the situation.
If the hazard is considered not in the best interest of ALARA the generator may be held
responsible for additional broker or disposal sites. Flagrant or repeated violations will be reported
to the RSC.
H14.b.3
Animal carcasses
This would consist of any animal used and/or sacrificed (during research) that contains
radioactive material. This would include all parts of these animals (e.g. body, internal organs,
etc.).
H14.c
Responsibilities of the Generator (sub-licensee):
H14.c.1
Proper collection and storage of all radioactive waste.
H14.c.2
Compliance with state and local regulations and control of the wastes until removal by the RSO.
H14.c.3
C-II-26
Insurance that all radioactive waste materials are separated according to (liquid, scintillation
vials, or dry solid) and(less than 300 days and greater than 300 days).
H14.c.4
Completion of all necessary paperwork prior to removal of wastes by the RSO. NOTE: The
RSO will not pickup wastes without completed paperwork (Form RS-14A).
H14.c.5
The generator shall not at any time permit the disposal of radioactive material or radioactive
waste into general waste pathways, other than trace amounts into the sanitary sewer system.
H14.c.6
If one wishes to retain and re-use glassware containing radioactive material the following
procedure shall be followed:
• Pour off radionuclide(s) into an approved storage bottle.
• Rinse and pour this into the waste storage bottle.
• Repeat Step 2.
• Further rinses may be placed in the sewer followed by an adequate dilution of tap water
in a designated and labeled sink only.
H14.c.7
Regardless of the frequency of disposal and the individual concentrations, the total activity
disposed into the sewer by each individual sub-licensee SHALL NOT EXCEED ONE uCi PER
DAY.
H14.d
Laboratory Waste Handling and Storage
H14.d.1
The RSO will provide small sturdy cardboard boxes (i.e., 10"x10"x15") and 4 mil plastic bags for
dry solid wastes and animals and polyethylene carboys (2.5 to 5 gallons) for liquid waste. These
containers shall be labeled with "radioactive material" labels.
H14.d.2
Wastes will be separated by the generator and stored according to physical form (dry solid,
animal, liquid, scintillation vials) and half-life (less than 300 days and greater than 300 days).
Chemically hazardous wastes should be held to a minimum.
H14.d.3
Wastes must only be stored in restricted areas where they can be secured against unauthorized
removal.
H14.d.4
Liquid wastes shall be stored in unbreakable polyethylene carboys and provided double
containment.
C-II-27
H14.d.5
Aqueous liquid wastes shall be neutralized prior to deposition in a waste container to prevent
any violent or hazardous chemical reactions.
H14.d.6
Each laboratory having radioactive waste containers shall display a "radioactive waste" sign in
the area designated for radioactive waste.
H14.d.7
Any material that could cause puncture of the skin (i.e. syringe needles, broken glass, razor
blades, etc.) shall be placed in puncture-resistant containers and labeled as such before
placement into dry solid containers.
H14.d.8
ALL radiation labels, signs, tape, symbols, etc. indicating there is or was radioactivity in the
waste shall be removed or defaced BEFORE placing waste in dry solid container [reference TAC
§289.202(cc)(2)].
H14.d.9
All animal carcasses and parts thereof containing radioactive material or contaminated with
radioactive material shall be stored frozen.
H14.d.10
Waste Records are required to assure that the radionuclides and activities determined for the
disposal purposes of each container are accurate. An inventory log sheet (developed by each
sub-licensee) or the radioisotope use form on or near waste receptacles is a practicable way to
account for the contents.
NOTE: It is the responsibility of the generator to keep an accurate isotope and activity log for
each waste container. Routine pickups, inspections and record keeping audits by the RSO are
used to evaluate a generator’s (sub-licensee) waste management controls.
H14.e
Animal Carcasses and Animal Waste
Animals sacrificed containing radioactive material shall be prepared and stored frozen. The sub-
licensee is responsible for the storage (frozen) of the animals until such time that the RSO can
arrange for animal disposal through a contracted radioactive waste broker or landfill disposal
according to procedures accepted by TAC requirements.
H14.f
Waste Pickup
H14.f.1
Request for removal of radioactive waste from the lab by radiation safety may be made by
telephone to the RSO.
C-II-28
H14.f.2
The generator (sub-licensee) will be responsible for accurately filling out the "Request for
Radioactive Waste Disposal" form (Form RS-14A). This form is available from the RSO. The
form details information needed for accurate disposal of the waste. Each type of waste (physical
form) will require a separate form.
NOTE: Wastes will not be picked-up without this form filled out completely and signed by the
generator. It is the responsibility of the generator to indicate any known or suspected hazardous
characteristics. This would include ignitability, corrosiveness, reactivity, toxicity, or other
hazardous characteristics.
H14.f.3
NO radioactive waste having biohazardous characteristics shall be released from a laboratory
for pick-up prior to autoclaving or otherwise suitable deactivation of any infectious agent(s).
H14.g
Sanitary Landfill Disposal
Certain radionuclides may be disposed of in a Type I municipal solid waste site such as the City
of Lubbock Landfill (permit #69) by the TTU Radiation Safety Office as authorized by the Bureau
of Radiation Control.
The radionuclides authorized for disposal are the less than 300 day half-life isotopes listed in the
appendix of TAC §289.202, and can be disposed of in a Type I municipal solid waste site
provided that the waste is dry and non-hazardous and the concentration and activity limits
specified in TAC §289.202 are not exceeded.
Non-hazardous dry waste from in vitro clinical or in vitro laboratory testing containing 0.05
microcuries or less of Hydrogen-3 (tritium), Carbon-14, or Iodine-125 can be discarded without
regard to its radioactivity; this waste should be physically delivered to the landfill.
Animal carcasses containing 0.05 microcuries or less of Hydrogen-3, Carbon-14, or Iodine-125,
per gram of animal tissue per animal can be disposed of without regard to its radioactivity.
H14.g.1
The disposal is approved by the Bureau of Radiation Control and the Texas Natural Resource
Conservation Commission and is in compliance with all requirements of TAC §289.202 and other
applicable regulations.
H14.g.2
The burial is made a matter of record by listing the activity, radionuclides, biological materials,
date, and name of the individual supervising the burial.
H14.g.3
Tissue in animal carcasses are frozen.
H14.g.4
The burial is coordinated with landfill personnel at least 24 hours in advance.
C-II-29
H14.g.5
The waste material is transported to the burial site by an individual familiar with the concepts of
radiation safety and is authorized by the RSO.
H14.g.6
The authorized individual will not leave the burial site until they are assured that all animal waste
materials are covered by a minimum of four feet of fill.
H14.h
Disposal Through Natural Decay
The Radiation Safety Office is the only entity at TTU authorized to supervise long term retention
of radioactive material for the purpose of decay. After retention for a suitable time interval
(several half-lives), the RSO shall evaluate the remaining activity and properly document the
evaluation.
If the evaluation demonstrates that the activity(s) are below the "exempt quantities of
concentrations" [reference TAC §289.202(ggg)(3) – Table III], the RSO may authorize the
disposal of the material as conventional waste, provided all radioactive material labels, symbols,
etc. are removed and the waste contains no hazardous characteristics.
H14.i
Sanitary Sewerage Disposal
H14.i.1
The Radiation Safety Office is the only entity at TTU authorized to dispose of radioactive
materials through the sanitary sewer.
H14.i.2
All sanitary sewer disposals shall be in accordance with TAC §289.202(gg). Furthermore, these
disposals shall be made a part of the RSO's disposal records.
H14.i.3
Any liquids containing radioactive material with hazardous characteristics will not be disposed
of by this manner. These will be disposed of as mixed waste or hazardous waste.
H14.j
Other Disposal Information
H14.j.1
The generator (sub-licensee) is responsible, upon receipt of the isotope, for recording the
use and recording the disposal of radioactive material on the Radioactive Material Use Form
(Form RS-14).
H14.j.2
The generator (sub-licensee) shall maintain copies of all disposal forms with other required
record keeping.
C-II-30
H14.j.3
Tritium (
3
H) stored in a closed plastic bag will produce HTO and be released through the plastic.
Tritium contaminated objects should be temporarily stored in an open tray pending placement in
a waste disposal barrel.
H14.j.4
Lids shall remain on all waste containers at all times.
H14.j.5
Plans for proper disposal of infectious agents or highly toxic or hazardous substances shall be
made early in the design stage of the experiment. Proposed procedures involving unusual waste
disposal problems will be considered individually by the RSC and/or the RSO.
H14.j.6
The RSO shall maintain proper disposal records for all TTU campus-wide radioactive waste
disposals in accordance with the TAC §289.202.
H14.j.7
Bulk liquid waste that contains greater than or equal to 75% water, less than or equal to 15%
methanol, less than or equal to 10% acetic acid, and a less than 300 day half-life radioisotopes
(i.e., S-35 and P-32) may be stored and decayed. After the radioisotope component has
decayed, the liquid may be tested for its hazardous characteristic and then disposed of
accordingly.
H15
Additional Policies and Procedures
H15.a
Radioactive Materials Use
H15.a.1
Proper marking of laboratories, areas, and equipment.
a) A "CAUTION RADIOACTIVE MATERIALS" sign must be conspicuously posted on the
doors to laboratory areas where radioactive materials are being used or stored in
accordance with TAC §289.202(z) and §289.202(aa). The signs must not be removed
from any room except by the RSO following a deactivation or termination inspection or
survey.
b) Storage areas shall be conspicuously marked with a "CAUTION RADIOACTIVE
MATERIALS" label. This label shall also state the isotope activity and date.
c) A "CAUTION RADIATION AREA" sign(s) shall be posted for any area where radiation
levels could result in an individual(s) to receive a dose equivalent in excess of 5 millirem
in any one hour at 30 cm from a radiation source or surface from which radiation
penetrates.
d) A "CAUTION HIGH RADIATION AREA" sign(s) shall be posted for any area where
radiation levels could result in an individual(s) to receive a dose equivalent in excess of
C-II-31
100 millirems in any one hour at 30 cm from any source of radiation or from any surface
from which radiation penetrates.
e) All equipment contaminated with radioactive material shall be marked with signs, decals,
or other conspicuous means. Equipment labeled as contaminated SHALL NOT be
removed for unrestricted use, disposal, or transfer as uncontaminated. Labeling will not
be required of equipment used transiently in laboratory procedures during the presence
of the user.
f) All radioactive refrigerators and freezers shall be posted with "Caution Radioactive
Material" labels and "Food Must Not Be Stored In This Refrigerator" labels.
g) All signs needed for proper labeling of the laboratory are available from the Radiation
Safety Office. All sub-licensees are responsible for equipment, source, and area labeling
tape, as well as work area absorbent paper, and any other specialized signage needed.
H15.a.2
Shielding of Sources
a) Radioactive sources or stock solutions in the laboratory shall be shielded in such a
manner to keep exposures ALARA, never to exceed 100 mrem in any five consecutive
days.
b) A beta shield will be required for procedures involving greater than 1 mCi of P-32.
c) Proper shielding materials shall be obtained by each sub-licensee for his/her particular
use so as to comply with Item a. (above). Various shielding materials (limited supply) are
available on temporary loan from the Radiation Safety Office.
H15.a.3
Aerosols, Dusts, and Gaseous Products
a) Procedures involving aerosols, dusts, or gaseous products, or procedures which might
produce airborne contamination shall be conducted in an approved hood, dry box, or
other approved closed system.
b) All releases from such systems into the work place shall not exceed 10% of the applicable
annual limit on intake (ALI) listed in Columns 1 and 2 of Table I of TAC §289.202(ggg)(2).
However, when practical, traps should be incorporated to ensure that environmental
releases are ALARA.
c) Radioactive gases or materials with radioactive gaseous daughters must be stored in gas
tight containers and must be kept in areas having approved ventilation.
d) Microcentrifuge tubes placed in heat blocks must be done within a hood if the activity of
the isotope in the microcentrifuge tube is >20 uCi. I.E., if there are 10 tubes per heat
block, then the total activity must be 20 uCi for this procedure to be performed in the
open.
H15.b
Gas Chromatographs
H15.b.1
C-II-32
Radioactive material in gas chromatography units (GC) shall be regulated the same as any other
radioactive material at TTU.
H15.b.2
In addition, each gas chromatograph containing a radioactive foil must have a label showing the
radiation caution symbol with the words "Caution Radioactive Material” and the type and activity
of the radioactive material.
H15.b.3
The radioactive foil shall not be removed or transferred from its identifying cell or laboratory
without prior RSO approval.
H15.b.4
The sub-licensee shall post the following notice on the outside of each gas chromatograph unit:
"This equipment contains a radioactive source registered with the Depart of Environmental
Health and Safety. Notify the Radiation Safety Office before removing the source from this
equipment or area, or upon change in are responsibility."
H15.b.5
Individuals using radioactive material components in gas chromatography equipment must vent
the cell exhaust through plastic tubing into a hood, or radiation safety approved trap to avoid
contamination of work areas from the release of radioactive tagged samples introduced into the
system.
H15.b.6
The RSO will perform leak tests at the minimum of every 6 months, store radioactive foils, and
maintain necessary records.
H15.c
Sealed Sources
Sealed sources of radioactive material, unless otherwise noted in this manual shall be tested for
leakage of radiation on a semi-annual basis [reference TAC §289.201].
H15.d
Use of Hoods
H15.d.1
Hoods used for radioactive work should be tested by the Department of Environmental Health
and Safety to insure the fume hood meets the minimum requirements for air velocity at the face
of the hood.
H15.d.2
Hoods should be checked at least annually for radioactive material contamination by performing
a smear survey of the interior and if P-32 or I-25 are used in the hood, a scan with a survey
meter should be performed.
C-II-33
H15.d.3
No more than 10 mCi of any volatile isotope should be used in a hood without first contacting
the RSO.
I POLICIES AND PROCEDURES FOR RADIOACTIVE MATERIAL USE UNDER SUB-
LICENSES
I1
Each individual user shall work under an Authorized Sub-license and SHALL use the following
procedures to assure safety in the work environment and compliance with TTU’s radiation safety
policies and practices:
I1.a
ALL users of radiation sources SHALL fulfill TTU’s radiation safety training requirements PRIOR
to using radiation sources.
I1.b
Radiation exposure of all individuals shall be maintained ALARA.
I1.c
The prescribed personnel monitoring devices (such as film badges and pocket dosimeters)
SHALL BE WORN in radiation areas and while using radiation sources.
I1.d
Personnel monitoring devices shall be protected from inadvertent exposure and damage and
shall be returned to the Radiation Safety Office as scheduled.
I1.e
When working with unsealed radioactive material, the user’s hands, shoes, clothing and body
SHALL be surveyed for radioactive contamination. at the conclusion of the work (Note: periodic
surveys should be performed during operations using radioactive materials).
I1.f
If radioactive contamination is detected on an individual’s hands, shoes, clothing or body, the
contamination will be removed before the individual is permitted to leave the restricted or
laboratory area.
I1.g
The following protective equipment shall be worn, and protective procedures followed, at all
times when working with radiation sources:
I1.g.1
wear protective clothing, gloves, and (in some cases) shoe covers when working with unsealed
radioactive materials;
C-II-34
I1.g.2
using protective barriers and shields whenever possible -- also protective eyewear if laser
hazards exist;
I1.g.3.
use mechanical devices (tongs, remote handling tools, etc.) to assist in reducing exposure;
I1.g.4
perform all work with radioactive materials within the confines of an approved fume hood or glove
box – except where a safety review has determined it is safer to work in an open area;
I1.g.5
PIPETTING BY MOUTH IS STRICTLY PROHIBITED when working with radioactive materials
AND/OR with chemically and biologically hazardous substances; and
I1.g.6
respiratory protection may NOT be used as a safety function. [Note: Procedures involving
radioactive materials that rely on respiratory protection devices require specific approval from
the Bureau of Radiation Control, Texas Department of Health. Approval will require participating
individuals to receive training in use of respiratory protective devices, passing a respiratory
physical, and fit testing by the Environmental Health and Safety Office].
I1.g.7
Eating, drinking, smoking, applying makeup, etc. in radiation laboratories and areas where
unsealed radioactive materials are stored or used is strictly PROHIBITED.
I1.g.8
Radiation use and storage areas SHALL NOT be used jointly for storage of radioactive material
and material for human consumption.
I1.h
Each user shall maintain good personnel hygiene and occupational safety habits (such as not
working with radioactive material if there is a break, cut, scratch, etc. in the skin below the wrist
and always washing hands and arms thoroughly before handling any object near the face.
I1.i
Areas where radioactive material, radiation producing equipment, and/or lasers are used, shall
be periodically surveyed and checked for contamination, excessive radiation levels (ionizing,
non-ionizing), and proper operation of all warning devices and interlocks according to the
procedures required in this manual. Records of these surveys and checks shall be maintained
for review and inspection by the Radiation Safety Office and the regulatory agency.
I1.j
C-II-35
Radiation use/storage areas, devices, and containers shall be periodically inspected for proper
display of required warning signs and labels.
I1.k
Each radiation-use laboratory and work area:
1) shall be maintained neat and clean;
2) shall be free from unnecessary equipment and material:
3) shall store and transfer/transport radioactive materials in a manner that prevents
breakage or spillage (use double containers, for example);
4) shall provide for adequate shielding;
5) shall have work areas covered with absorbent material and/or stainless-steel trays or
pans to limit and collect spillage in case of accident; and
6) all laboratory equipment (such as glassware), stock radioactive material, and radioactive
waste, shall be labeled and isolated appropriate storage facilities. Equipment that has
been used in work with unsealed radioactive materials shall not be used for other work
and shall not be sent from the area to central cleaning facilities, repair shops, or to surplus,
until it has been demonstrated and certified by the Radiation Safety Office to be free of
radioactive contamination.
I1.l
Emergency repair of contaminated equipment by shop personnel or by commercial service
contractors will not be performed except under the direct supervision of the RSO or his/her
designee. Timely requests for such supervision shall be made to the RSO to allow for
scheduling.
I1.m
A member of the laboratory staff shall be present to provide specific information when service
personnel are permitted to work on equipment in radiation areas.
I1.n
Each user/individual SHALL:
1) IMMEDIATELY REPORT accidental exposure, inhalation, ingestion, or injury involving
radioactive materials, X-ray radiation, or laser radiation to his/her supervisor AND to the
RSO;
2) IMMEDIATELY conduct the required/recommended corrective measures and procedures
– unless otherwise directed by the RSO;
3) Individual(s) shall cooperate in any and all attempts to evaluate his/her exposure;
4) Perform emergency decontamination procedures, when required or necessary, and take
the necessary precautions to prevent the spread of contamination to other areas and
equipment;
5) Comply with requests from the RSO for bioassays, body burden measurements and/or
the submission of urine samples for internal radioassay; and
C-II-36
6) Comply with the required procedures for handling radiation incidents. according to
Section V - Emergency Procedures and TTU Operating Procedure 78.05 Vol.II.
J GENERAL LABORATORY RADIATION SAFETY RULES
The following rules are to be used with the ALARA concept in mind. The TTU Radiation Safety
Manual, in addition to the state and federal regulations and guidelines, are minimal requirements
that are designed to enable ALARA controls and keep exposures well under the maximum limits.
This list should be posted conspicuously in each laboratory area:
J1
NO PIPETTING BY MOUTH
J2
No open toed shoes (i.e. sandals, flip-flops, etc.) in radioactive material laboratories.
J3
All radioactive material containers must be labeled as to isotope, activity, and date.
J4
NO eating, drinking, smoking, food storage, application of cosmetics, or food preparation in
radiation labs.
J5
Place rad-waste in appropriately labeled waste receptacles.
J6
NEVER mix different forms of rad-wastes.
J7
Remove protective clothing and gloves before leaving radiation lab.
J8
Monitor hands, shoes, and clothing before leaving radiation lab.
J9
Personnel exposures shall be kept ALARA by using time, distance, and shielding safely and
effectively.
J10
Use the fume hood when needed.
J11
perform all required surveys and safety checks.
C-II-37
J12
All spills and accidents must be reported immediately to the RSO. If you are unsure as to the
proper course of action to take in any given situation, always consult your supervisor or call the
Radiation Safety Office (742-3876).
END OF SECTION II
C-III-1
SECTION III – RADIATION PRODUCING MACHINE SAFETY PROGRAM
Introduction
This section will outline Policies and Procedures for radiation producing equipment. The equipment
referred to will be analytical X-ray equipment, research accelerators, and other ionizing radiation
producing equipment. These Policies and Procedures, established with the utmost concern for
ALARA, are in addition to Texas Regulations for Control of Radiation Parts 34, 35, and other
applicable regulations.
A RADIATION PRODUCING MACHINES (X-RAY)
A1
Registration
The Texas Regulations for Control of Radiation require that radiation producing machines be
registered with the Bureau of Radiation Control, Texas Department of Health.
A2
Proposed devices
Registration of proposed devices must be conducted through the RSO.
A3
Personnel Protection
A3.a
Personnel Monitoring
All operating personnel and personnel in the immediate area shall wear a film badge or other
personnel monitoring device, as supplied by the RSO.
A3.b
Personnel Safety
Personnel specifically responsible for such equipment used or to be used shall:
A3.b.1
Ensure that all rules and regulations (TTU, state and local) have been implemented and are
followed; and
A3.b.2
Ensure that all users have attended the TTU Radiation Safety Shortcourse, given by the RSO, for
radiation producing equipment prior to using the radiation producing equipment.
A4
Facilities
A4.a
Posting and Labeling
C-III-2
A4.a.1
Areas in which radiation producing equipment are located or are being used shall be posted with a
standard "CAUTION – X-RAY RADIATION" sign.
A4.a.2
The controls of each radiation producing device shall bear a label or decal with the statement:
"CAUTION RADIATION - THIS EQUIPMENT PRODUCES RADIATION WHEN ENERGIZED."
Signs, labels and decals are available from the Radiation Safety Office.
A4.b
Record of Operation
A log book and a copy of the operating procedures for that particular instrument or area shall be
attached to each instrument or near the control panel.
A5
Radiation Surveys and Record Keeping Requirements
A5.a
Sub-licensee Requirements
A5.a.1
Radiation surveys
A5.a.1.a
Radiation surveys will be conducted after every change that might increase radiation exposure
hazard.
A5.a.1.b
Radiation surveys shall be conducted at least once a month.
A5.a.1.c
The results of each radiation survey shall be recorded in the log book.
A5.a.1.d
Radiation surveys shall be performed using only the appropriate instrument.
A5.a.1.d.1
Interlocks, visual and audible warning devices, and shutter mechanism checks shall be conducted
at the same time as the radiation surveys and the results shall be recorded in the log book.
A5.a.2
Log book
Each log book (record) shall contain the following information:
C-III-3
A5.a.2.a
Users log (user, date, start, finish, power settings);
A5.a.2.b
Survey Records (date, surveyor, instrument used, drawing or photograph of instrument/area,
particular area surveyed, and results of the survey recorded in proper units); and
A5.a.2.c
Safety device records (date, surveyor, drawing or detailed photograph of the instrument - indicating
the location of the safety devices, results of the checks as to whether the devices were Operative
(O) or Inoperative (IO)).
A5.a.3
Written Safety Procedures
Safety and Operating Procedures shall be written and updated as changes in that particular
instrument or area warrant the need for revision.
A5.a.3.a
The written safety and operating procedures shall be available to all users.
A5.b
Radiation Safety Office Requirements
A5.b.1
A radiation survey of all radiation producing devices shall be conducted on a 6 month interval by
the Radiation Safety Office.
A5.b.2
All interlocks, visual and audible warning devices, and shutter mechanisms shall be inspected for
proper operation on a 6-month interval by the Radiation Safety Office.
A5.c
Additional Rules and Requirements
A5.c.1
The RSC, upon recommendation of the RSO, may require additional safety devices or procedures
(beyond the minimum TAC requirements) to ensure conformance with ALARA.
The following criteria will be used to determine the need for additional safety devices or procedures:
(a) The number of persons involved with the use of the x-ray producing devices.
(b) The need to reduce the chance of any unneeded exposures.
(c) The amount of personnel traffic in and out of the lab.
(d) The age of the x-ray producing devices.
C-III-4
(e) The current safety devices in use.
(f) Number of x-ray producing devices located in a single area.
(g) Previous compliance during local and state inspections.
(h) Previous exposure reports.
A5.c.2
The structural shielding requirements of any new installation, or an existing one in which changes
are contemplated, shall be reviewed with the RSO.
A5.c.3
No person shall be permitted to operate radiation producing equipment in any manner other than
specified in the procedures unless such person has obtained written permission from the RSO and
the RSC.
A5.c.4
No person shall bypass a safety device unless such person has obtained written permission from
the RSO and the RSC.
A5.c.5
All log books and current Operating Procedures shall be readily available to each radiation
producing device or near the control panel.
A5.c.6
Each sub-licensee must maintain portable radiation monitoring device(s) capable and calibrated
for the measurement of X-ray radiation in beams of a small cross-section.
A5.c.7
The local components of any radiation producing equipment system shall be located and arranged
and shall include sufficient shielding or access control such that no radiation levels exist in any area
surrounding the local component group which could result in a dose to any individual present
therein in excess of the dose limits given in this manual. These levels shall be met at any power
rating.
A5.c.8
The RSO must be notified in advance of the procurement, transfer, or donation (received or given)
of ALL radiation producing equipment, whether ionizing or non-ionizing: X-ray units, accelerators,
or lasers.
A5.c.9
All radiation producing equipment shall be shipped to the following address:
ATTN: RSO
Central Receiving
Texas Tech University
Lubbock, Texas 79409
C-III-5
A5.c.10
Radiation producing equipment or lasers transferred within TTU must be coordinated with the RSO.
A5.c.11
The RSO shall be notified of any instrument taken out of use and placed into storage or to be
disposed of.
B RADIOFREQUENCY AND MICROWAVE DEVICES
B1
Protection from Microwave Oven Radiation
B1.a
Non-public use (i.e. departmental, laboratory/research)
B1.a.1
Registration
Person(s) responsible for each microwave oven at TTU should notify the Radiation Safety Office
of its presence.
B1.a.2
Surveys
The Radiation Safety Office will perform surveys of microwave ovens at TTU that are used for
non-public use on a request only basis. In the event that the microwave oven is found to be leaking
microwave radiation in excess of the limits specified in TRCR Part 90.9 (a)(1), the RSO (RSO) shall
notify responsible person(s). Person(s) responsible for the defective oven should discontinue use
until the oven is repaired and surveyed.
B1.a.3
Repairs
All repairs to defective ovens shall be performed by qualified repair technicians that can certify
compliance with emission levels listed in TRCR 90.9 (a)(1). A completed Repair Certification label
shall appear on all microwave ovens. This label shall include the name of the person certifying the
compliance with emission limits, and signature of authorized agent and date.
B1.b
Public-Use Microwave Ovens (i.e. Commercial food vending service)
Public use microwave ovens include any microwave oven or equipment offered for public use, or
where public access to the use of the microwave oven or equipment is made available.
B1.b.1
Registration
C-III-6
The persons and/or companies responsible for each microwave oven at TTU should notify the
Radiation Safety Office of its presence, and should have available survey records performed in
accordance with TRCR 90.5 for the previous three years.
B1.b.2
Surveys
The persons and/or companies responsible for each microwave oven at TTU shall ensure that each
microwave oven meets the microwave oven standards established in TRCR Part 90.9 (a) & (b).
B1.b.2.a
Compliance surveys of the microwave oven(s) as described in TRCR Part 90 will be performed by
the Radiation Safety Office shall be performed semi-annually.
B1.b.2.b
The microwave oven(s) shall be labeled after every survey and the label shall include: the signature
of the person performing the survey, and date of the compliance survey.
B1.b.2.c
The Radiation Safety Office, upon notification or discovery of a microwave oven not in compliance
or without proper survey labeling or records, shall immediately shut down and discontinue the use
of the microwave oven until the unit is determined to be in compliance.
B1.b.3
Repairs
All repairs to defective ovens shall be performed by qualified repair technicians that can certify
compliance with emission levels listed in TRCR 90.9 (a)(1).
B1.b.3a
A completed Repair Certification label shall appear on all microwave ovens. This label shall include
the name of the person certifying the compliance with emission limits, and signature of authorized
agent and date.
B1.b.4
Other Requirements
As specified in TRCR 90.0(b) all commercial food service microwave ovens (i.e. public use) shall
meet the National Sanitation Foundation Standards or be approved by the U.S. Food and Drug
Administration or the Texas Department of Health.
B1.b.4.a
Microwave ovens or equipment brought on TTU property by outside vendors, food brokers, etc.
shall meet all requirements of the TRCR Parts 80 and 90.
B1.b.4.b
The outside vendor, food brokers, etc. shall be responsible for repair, cleaning, and notification to
the TTU Radiation Safety Office of relocation or new locations of microwave ovens for public use.
C-III-7
B1.b.4.c
The food contact and RF radiation sealing surfaces of the cavities of microwave ovens shall be
cleaned at least once a day and shall be kept free of encrusted grease deposits and other
accumulated soil (TRCR 90.9 (b)(2)).
B1.b.4.d
Where microwave equipment and utensils are used for food preparation of potentially hazardous
foods on a continuous or production-line basis, utensils and sealing surfaces of equipment, shall
be cleaned and SANITIZED at intervals throughout the day on a schedule approved by the
regulating health authority. This schedule shall be based on food temperature, type of food, and
amount of food particle accumulation (TRCR 90.9 (b)(3)). For information concerning TTU cleaning
and sanitization policies contact the TTU Department of Environmental Health and Safety at 742-
3876.
B1.b.5
Contact
Any questions concerning standards for RF or microwave radiation not being produced in
microwave ovens or exempt equipment should be addressed to the TTU Radiation Safety Office.
B2
Safety Tips for Microwave Oven Users
(published by the U.S. Govt. Bureau of Radiological Health)
B2.a
Follow the manufacturer's instruction manual for recommended operating procedures.
B2.b
Examine the oven for evidence of shipping damage.
B2.c
Never insert objects (for example, a wire) through the door grill or around the door seal.
B2.d
Never tamper with or inactivate the oven safety interlocks.
B2.e
Never operate an EMPTY oven.
B2.f
Clean oven cavity, door, and seals frequently with water and mild detergent. DO NOT use scouring
pads, steel wool, or other abrasives.
B2.g
Have oven serviced regularly by a qualified serviceperson and inspected for signs of wear, damage,
or tampering.
C-III-8
B2.h
Additionally, users of microwave ovens manufactured prior to the new standards (prior to October
10, 1971) should follow these precautions:
B2.i
Switch the oven off before opening the door.
B2.j
Stay at least an arm's length away from the front of an oven while it is on.
END OF SECTION III
C-IV-1
SECTION IV - EMERGENCY PROCEDURES
Introduction
This section outlines basic emergency procedures. An emergency situation or accident can arise
from the use, storage, or transfer of radioactive material or from the misuse or abuse of equipment
that produces X-ray radiation or other forms of ionizing or non-ionizing (i.e. laser) radiation. This
section is intended to enhance each sub-licensee's and worker's ability to react properly to radiation
accidents.
Due to the broad scope of possible accidents at TTU, listing every step that must be followed for
each type of accident would be impracticable. Instead, one must use the following basic
procedures and apply them to his/her individual situation. The best advice for protection against
radiation accidents is to prepare for them.
A GENERAL INFORMATION
A radiation incident at TTU should be defined as any unintentional accident or any single exposure
or suspected exposure in excess of 45% of the maximum allowable exposure as set forth in TAC
§289.202, the ingestion of radioactive material in the form of liquid, gas, or dust in excess of limits
set forth in TAC §289.202(ggg)(2), any radioactive material spill regardless of activity and size, or
accidents involving laser radiation exposure to the eyes or skin.
If persons involved in a radiation incident are unsure as to the extent of exposure, ingestion, or
magnitude of the spill, those persons shall proceed with the assumption that an overexposure
(internally or externally) or major spill has occurred, unless otherwise noted. Users will report all
radiation incidents.
A1
Organization and Authority
A1.a
The responsibility of incident investigation shall be that of the RSO.
A1.b
The RSO will promptly report all investigation findings to the RSC and to the Agency [reference
TAC §289.202(xx)] for direction and action.
A1.c
If preliminary findings of an incident presented to the RSC indicate there is probable cause of
neglect or violation of state, federal, or local regulations or policies, the sub-licensee involved will
be asked to attend the next RSC meeting to answer questions and present his/her account of the
incident.
A1.d
In the event of a major emergency situation the RSO shall have the authority to bring the situation
under control. It should be noted that this may not follow the TTU Administration Organization
Chart. However, if this will only be used in extreme emergencies where this is immediate
radiological danger to individual(s) or possible major building contamination.
C-IV-2
A1.e
It is the responsibility of each sub-licensee to see that personnel working under their supervision
have practical and well understood plans for an emergency, and control of an emergency in their
respective laboratory. (reference TTU - Operating Procedure 78.01 Vol.III)
A1.f
The RSO has the responsibility to see that each radiation sub-licensee/worker knows how to:
• Recognize a radiation or laser emergency.
• Prevent or confine the accident.
• Exclude all personnel from possible risk of exposure.
• Immediately contact his/her supervisor, the RSO, and/or other emergency personnel for
assistance.
A1.g
Each sub-licensee will be responsible for assisting the RSO in controlling and/or investigating the
accident. Furthermore, the sub-licensee is responsible for assisting the victim(s) in getting medical
attention, if necessary, as soon as practicable.
B FIRES, EXPLOSIONS AND MAJOR EMERGENCIES
1. Notify all persons in the area to leave at once.
2. Notify the TTU Fire Marshall, Lubbock Fire Department, the RSO as well as other supervisory
personnel. Give them the address and the location of the fire.
3. If firemen arrive before the RSO, caution them that radioactive material is present in the area.
Be ready to advise them on location, isotope(s), activity(s), type of storage, and any other
information that may be needed to avoid radioactive contamination of personnel, building, or
equipment.
4. The sub-licensee and/or workers will need to be available to evaluate or help evaluate the extent
of damage to radioactive material and/or survey emergency personnel and equipment for
radioactive material contamination.
5. All sub-licensees and workers will be required to file an incident report with the RSO.
6. MINOR FIRES - If the fire is minor (individual decision) and there are no radiation or chemical
hazards involved, a sub-licensee or worker may attempt to put out the fire with approved
firefighting equipment.
C ACCIDENTS INVOLVING POSSIBLE RADIATION OVEREXPOSURE
If a radiation overexposure has occurred, or is suspected to have occurred, proceed as follows:
1. Immediately remove affected person(s) from the area and notify the RSO.
2. Secure the area.
3. Take the affected persons(s) to the nearest emergency center immediately for clinical
observation. Be sure to inform the attending medical personnel that it is a radiation accident.
Be prepared to answer any questions that may arise concerning the accident or type of radiation
involved.
4. Assist the RSO in obtaining all details of the incident.
C-IV-3
5. The RSO will obtain the dosimetry of all involved person(s). The RSO will then forward the
dosimetry for emergency processing.
6. Persons involved in the incident will not be permitted to work with radiation until exposure results
have been received and the RSO has determined that exposure limits have not been exceeded.
7. The RSO will provide reports to the RSC and regulatory agencies.
D ACCIDENTS INVOLVING SIFNIFICANT RELEASES OF RADIOACTIVE MATERIALS
1. Notify all other persons in the area of the accident.
2. If possible, hold breath and close all air vents.
3. Vacate the room and seal off the area, if possible.
4. Notify the RSO immediately.
5. Secure access to the area.
6. Monitor all involved persons for contamination.
7. Assist and/or submit to any bioassay deemed necessary by the RSO, RSC, or the BRC.
8. Assist the RSO in hazard evaluations and decontamination procedure.
E PERSONNEL INJURIES
Persons should not work with uncontained radioactive material when they have a break in the skin
(cut, scrape, etc.) below the wrist. If a person is cut by an article contaminated with radioactive
material the following should be used as a guide:
1. Cleanse the wound immediately by placing it under running water. If possible, retain any cotton
balls, paper towels, fluids, etc. for radiological analysis. Contact the RSO as soon as
practicable.
2. If necessary take the person(s) for emergency treatment. Be sure to tell the attending medical
personnel that radioactive material was involved in the accident.
3. Follow the necessary steps in Item D of this section, under the direction of the RSO and/or RSC.
4. Contact the RSO before proceeding with more severe methods of decontamination.
F POLICIES FOR RADIOACTIVE SPILLS
The following procedures are a generalized summary of procedures listed in NCRP REPORT 48
and ICRP Report 28:
1. Minor Spills (i.e. at the microcurie level)
a. Notify other persons in the laboratory and minimize radioactive material ingestion, inhalation,
etc.
b. Prevent the spread of contamination of the accident.
c. Contact the RSO.
d. Survey all persons involved, decontaminate if necessary, and release unneeded persons.
e. Begin decontamination procedures.
f. Submit incident report to the RSO.
C-IV-4
2. Major Spills
a. Notify all persons in the laboratory and minimize radioactive material ingestion, inhalation,
etc.
b. Prevent the spread of contamination of the accident.
c. Contact the RSO.
d. If possible, block all air vents to avoid creation of airborne contamination.
e. Vacate the laboratory, avoid spreading the contamination.
f. Survey all persons involved, and decontaminate if necessary. Do not release persons
directly involved, except for emergency medical treatment. Wait for the RSO and/or the
RSC to authorize release.
g. If deemed necessary by the RSO and/or RSC specific steps in Items D. E., or F. of this
section may need to be initiated.
G LOSS OR THEFT OF READIATION EQUIPMENT
1. Any loss or theft of radioactive material, a device containing radioactive material, or a radiation
producing device, shall be immediately reported to the RSO.
2. The RSO will provide required notification to the Bureau of Radiation Control.
3. The RSO will determine the extent of damage and analyze the recovery plan.
NOTE: Repair of any encapsulated radioactive material source IS PROHIBITED. Radiation
sources involved in an accident, fire, flood, etc. MAY NOT BE USED until tested by the RSO
and found to be in proper and safe operating condition.
H MALFUNCTION OF RADIATION PRODUCING EQUIPMENT
1. Any radiation device (X-ray, PMDG, Laser, etc.) believed to be defective shall be locked into a
safe position and made inoperative immediately. In emergency situations the individual user,
authorized user, and/or the RSO can take such action as to shield the source, deactivate the
equipment, or retrieve the source.
2. The responsible user must restrict access to the area until the RSO arrives.
3. The RSO will evaluate the incident thoroughly, notify the RSC in writing within 10 days and if
necessary report the incident to the BRC within 30 days.
I VEHICLE ACCIDENT DURING PMDG OR RAM TRANSPORTATION
If a vehicle accident occurs during the transportation of a PMDG or radioactive material and there
are no fires or injuries the following procedure should be used:
1. If a minor accident and it can be visually determined that the source is safely stored in its DOT
container then no restricted area is required, otherwise establish a safe perimeter around the
source assuming the source is in an exposed position.
2. If a survey meter is available, and no radiation hazard exits, and the vehicle is movable proceed
to destination.
3. If the source cannot be found, does not appear to be safe, vehicle is not moveable, etc. have a
responsible person notify the RSO and/or the BRC. Then proceed to isolate the vehicle and
area.
C-IV-5
4. Other areas of the Emergency Procedures may need to be instituted before the RSO or
emergency personnel arrive.
J REPORTING OF RADIATION INCIDENTS
J1
IT IS THE RESPONSIBILITY OF THE SUB-LICENSEE to report all accidents incidents involving
radioactive materials or radiation producing equipment in his/her approved facilities to the RSO, by
telephone, as soon as practicable. In addition, he/she must also report all incidents involving
his/her radioactive materials or radiation producing equipment that may occur outside his/her
approved facilities.
J2
The sub-licensee initiates this report (in writing) by completing the standard report form ("Report of
Accidents Involving ionizing Radiation" Form RS-29) and filing it with the RSO as soon as possible.
IN NO CASE should the delay exceed one work day. If any required signatories are absent, their
designees should sign in their absence. Any questions on the proper completion of this form should
be directed to the RSO.
K DECONTAMINATION PROCEDURES
There are many different methods of decontamination depending on the isotope, activity involved,
items or material contaminated, and other influencing circumstances. One must also consider the
amount of waste to be generated in decontamination and whether the decontamination is cost
effective.
K1
Preoperational Decontamination Procedure
a. Contact the RSO.
b. Plan the decontamination operation thoroughly and obtain adequate supplies.
c. Provide adequate protection for all personnel involved in the decontamination process. If
necessary be prepared to allow for replacement personnel.
d. Provide for storage of all radioactive wastes and decontamination supplies.
K2
Operational Decontamination Procedure
a. Always work toward center of contaminated area.
b. Monitor frequently.
c. Cover clean areas to avoid recontaminating the area.
d. Monitor all personnel involved before allowing them to proceed to clean areas or leave the
laboratory.
K3
Post-Operational Decontamination Procedure
a. Monitor all cleaning supplies and equipment before release.
b. Use proper disposal procedures for all radioactive wastes.
C-IV-6
K4
General Procedures for Handling Minor Spills
a. Put on extra gloves and protective clothing to prevent unneeded personnel contamination.
b. Monitor all persons first to ensure he/she is not contaminated as a result of the accident.
c. Drop absorbent paper, cloth or other suitable containment material on or around spill to limit the
spread of contamination.
d. Monitor and mark off the contaminated area. DO NOT let any person out of the laboratory
without being monitored. It is a good idea to assign monitoring responsibilities to one person.
e. Using normal cleaning agents, proceed from the outermost edges of the contained area
inwards, systematically reducing the contaminated area.
f. Keep cleaning supplies to a minimum needed to do the job and place into sealed bags after
use.
g. Put all contaminated objects and material into proper waste containers. If the above method
does not work after 3 or 4 tries, contact the RSO before proceeding to more extreme methods
of decontamination.
K5
Personnel contamination
K5.a
Identify areas(s) with a survey meter (swipe test of area may be needed if very low energy beta
emitters are involved). DO NOT use decontamination methods, which will spread localized material
or increase penetration of the radioactive material into the body (e.g. by abrasion of the skin).
K5.b
Decontamination of an open wound shall only be accomplished by a physician.
CAUTION - AVOID THE USE OF HIGHLY ALKALINE SOAPS (may result in the fixation of
radioactive material) or ORGANIC SOLVENTS (may increase skin penetration of radioactive
material).
K5.c
The following procedure should be used on intact skin:
(1) Wet hands and apply detergent.
(2) Work up good lather, keep lather wet.
(3) Work lather into the contaminated area by rubbing gently for at least 3 minutes. Apply fresh
water frequently.
(4) Rinse thoroughly using lukewarm water, limiting water to contaminated area.
(5) Repeat above procedures several times, if necessary gently scrub residually contaminated
areas with a VERY SOFT bristle brush.
(6) Additional decontamination methods can be obtained from the RSO, however DO NOT proceed
with more severe methods until consultation with the RSO.
C-IV-7
NOTE: If contamination is at a wound site, medical personnel should monitor or perform the
cleansing of the wound area. REMEMBER - If your initial efforts at decontamination DO NOT
produce encouraging results; cover the contaminated area and seek the proper assistance.
L EMERGENCY PHONE NUMBERS
TTU RADIATION SAFETY OFFICE ................................................................................. 742-3876
RSO (Cell) ........................................................................................................................ 773-1645
TTU POLICE SERVICES ................................................................................................. 742-3931
CAMPUS EMERGENCY ................................................................................................ DIAL 9911
TEXAS BUREAU OF RADIATION CONTROL (BRC) .......................................... ( 512) 835-7000
IF TTU RADIATION EMERGENCY PERSONNELCANNOT BE CONTACTED CALL:
BRC 24 HOUR EMERGENCY PHONE NUMBER ................................................. (512) 458-7460
END OF SECTION IV
C-V-1
SECTION V – RADIATION SURVEYS
A GUIDELINES FOR SURVEYS OF RADIATION LEVELS
A1
Radiation Detection Equipment
There are several types of radiation detection equipment for monitoring areas that are subjected
to radioactive contamination, monitoring radiation producing equipment, and sealed sources of
radioactive material. Each type is best suited for a particular application and should be used in
conjunction with one another.
The most common type is the G-M survey-rate meter, which is used for monitoring low-level
radiation areas (most common in radioactive material labs). The G-M tube type meter may
saturate and read zero when exposed to high radiation levels; thus, personnel could be
subjected to dangerously high radiation levels in belief that no radiation hazard existed.
For high-level areas, accelerators, analytical x-ray instruments, etc. an ion-chamber type (i.e.
Cutie Pie) is recommended over the G-M survey rate meter type. It has two basic, yet important
advantages: higher radiation levels can be measured (up to 5,000 mR/hr or more) and it will not
saturate in high radiation fields.
A1.a
Survey rate-meters are required in all installations using radioactive material or Radiation
Producing Equipment.
A2
Survey Information
Because a direct radiation survey is time consuming if properly done; a preliminary evaluation
should be performed. A properly calibrated survey meter (G-M or scintillator as appropriate)
with audible signal should be used. Be sure the survey meter has a range capable reading the
radiation fields that are most commonly encountered in that particular area. In other words,
make sure the meter will not zero out as described above in A1.
A3
Performing a Survey
A3.a
First find a radiation free area or make sure that all radiation producing equipment is turned off
or not generating x-rays; then with the meter on its lowest scale take a general or average
background reading (usually 0.01 - 0.05 mR/hr or 0 - 150 cpm in clean areas); this reading
should be recorded on the survey map or in the log book.
A3.b
While listening for changes in the audible output signal, the individual conducting the survey will
perform a thorough scan of all areas within the area covered by the survey map and/or
equipment involved. Any area indicating an average reading of more than 3 times the recorded
average background reading will be marked on the survey map. If there are no areas where
C-V-2
direct radiation levels exceed 3 times background, direct radiation levels may be recorded as
"0.1 mR/hr" unless this level (0.1) exceeds recorded background. Then the actual levels should
be recorded.
A3.c
The surveyor will immediately re-measure areas where readings were greater than 3 times
recorded background to identify excessive radiation levels. This survey should be conducted
with an ion-chamber type instrument; the reading properly recorded on the map or in the log
book (i.e. mR/hr, cpm, etc.).
A3.c.1
Survey meters are required to be calibrated annually. Contact the RSO if your meter has
not been calibrated within the past year. There should be a calibration sticker attached
to the meter indicating the last calibration and the due date for the next one.
A4
Results/Reporting
A4.1
Record all results in the proper units (mR/hr and/or cpm) in your log book or on the survey map.
A4.2
Contact the RSO if:
(a) surveys show areas that are greater than 2 mR/hr for radioactive material laboratories,
and/or
(b) surveys show more than 3 times the normal recorded reading for radiation producing
equipment.
NOTE - In general it is very hard to put exact numbers on excessive levels (readings)
since much of the older analytical x-ray equipment will have radiation levels that are
relatively high compared to most radioactive material use areas or the newer closed beam
analytical x-ray equipment. However, if there is ever a question concerning the radiation
levels around a particular instrument or area call the RSO immediately.
B SURFACE CONTAMINATION SURVEYS (i.e. SMEAR/SWIPE SURVEY)
B1
General Information
The routine monitoring for radioactive contamination in radioactive material laboratories is a
necessary and required part of the radiation safety program at TTU. Failure to control surface
contamination may cause unnecessary internal or external radiation exposure to individuals,
costly decontamination of equipment, laboratories or buildings and/or the loss of equipment,
laboratories or building, if gross contamination were found and could not be decontaminated to
acceptable levels.
Generally, the primary concern is to avoid internal exposure resulting from the intake of loose
radioactive material via inhalation, ingestion, or skin absorption. However, external radiation
C-V-3
levels from radioactive contamination may at times be hazardous. Another major concern is
limiting contamination to areas of equipment where it can be controlled or properly disposed
and/or maintaining levels of contamination at/or below acceptable levels listed in TAC
§289.202(ggg)(6).
B1.a
Removable Contamination
Removable contamination is that fraction of contamination present on a surface that can be
transferred to a smear test paper by rubbing with moderate pressure.
B1.b
Fixed Contamination
Fixed contamination is generally defined as radioactivity remaining on a surface after repeated
decontamination efforts have failed to significantly reduce the contamination level.
B1.c
Equipment
Instrument(s) used in surface contamination surveys should be sufficiently sensitive to detect
the nuclides being monitored. Uniform methods of collecting and analyzing these smears should
be used over extended periods of time in order to evaluate trends.
B1.c.1
The equipment used to count (analyze) the smear samples shall be properly calibrated,
maintained, and shall be capable of detecting the radiation from the smears.
EXAMPLE - Smears of
3
H,
14
C,
35
S, or other beta emitters should be analyzed with a liquid
scintillation counter or internal proportional counters.
B1.d
Method
The methodology in conducting smear tests varies greatly from institution to institution, from
researcher to researcher, and from individual to individual. Keeping this in mind the following is
a general guideline for smear testing.
B1.d.1
The purpose is to find ANY contamination that might be present. Continual, aggressive
monitoring will almost always give the surveyor confidence in certifying his/her area is CLEAN.
B1.d.2
Prepare for the survey by; looking over previous survey records; find out what radiation sources
are in the lab; identify problem areas (fume hoods, radiological sinks) ; identify previous problem
areas.
C-V-4
B1.d.3
The next step in the smear process is to obtain a map (diagram) of the area or sketch it out on
a piece of paper.
NOTE -This should only have to be done on a first survey only: after that a good diagram
should be kept on file, unless the physical layout of the area significantly changes.
Current copies of most laboratory diagrams are available from the RSO.
B1.d.4
When needed the diagram may be replaced or written on to include a detailed list of specialized
items or equipment surveyed. In addition to this the surveyor might find it beneficial to specify
key areas on the diagram that are smear tested at each survey.
B1.d.5
Before beginning the surveyor should prepare him/herself with the proper equipment to conduct
a routine survey: smear paper (Whatman 4.25 cm #1 or equivalent), rubber gloves, diagram,
writing instruments, vials or some other apparatus to prevent cross-contamination of the smears.
B1.d.6
CAUTION - The surveyor should mentally and physically go about his/her survey in a method
that would prevent the unnecessary spread of contamination. What this means is to start in the
"coldest" area (least area of probable contamination) and progressively proceed to areas of
greater probable contamination.
B1.d.7
If the surveyor is conducting a survey in his/her own area or in another the following questions
might be asked of him/herself or the lab workers to get a better idea of where to smear and how
many smears should be taken:
• What isotopes have been used since the last survey?
• Where are/were they used?
• Where are they stored?
• Where is the waste stored?
• Have there been any contamination problems in surveys conducted by the lab personnel?
B1.d.8
The surveyor then decides on a representative sampling of the area (i.e. where and how many)
usually based on three areas of input: individual idiosyncrasies, materials and processing, and
traffic patterns.
B1.d.8.a
Idiosyncrasies: Look for information regarding habits and misplaced items around the lab; feet
on the desks, misplaced books and equipment, etc.
C-V-5
B1.d.8.b
Materials: Look for changes in work areas, changes in previously recorded storage location, or
waste storage areas, non-radioactive use of storage containers, etc.
B1.d.8.c
Traffic: Look for high traffic areas. Particularly worn areas on the floor, high use equipment,
floors near a desk, phone, sink, hood, etc, etc.
B1.d.9
Where to Smear; Where Not to Smear
Probably the biggest problem associated with smear surveys is "what is proper to smear and
what is not". Many manuals and institutions are very vague about this, but few good points to
remember are:
(a) Areas of known contamination need not be smeared. This does not mean anything can be
treated as contaminated. It is for certain hood trays, absorbent paper, or other equipment
which is frequently used for radioactive material work and which is CLEARLY marked with
standard caution signs, and stickers.
NOTE - These items SHALL be decontaminated or disposed of after the experiment or use
and BEFORE deactivation or termination of the sub-license.
(b) Some DO'S and DON’TS
• DON'T smear the inside of a working or holding tray.
• DO smear: the counter around the tray, the floor around and/or below the tray, and the
walls around the tray.
• DON'T smear used vials or labware containing radioactive material.
• DO smear: surfaces where the vials were placed, rings on surfaces where the containers
may have been located.
• DON'T smear the inside of rad-waste containers.
• DO smear: the exterior of the container and any suspicious looking streaks of areas, the
floor or countertop around the container, and walls or vertical areas near the container.
(c) Other Items and Special Areas to Pay Attention to:
• Telephone
• Door knobs
• Refrigerators/freezers (inside; shelves, bottom, shelf guards. outside; flat tops,
suspicious streaks, handles, locks).
• Base cabinet doors (inside and outside)
• Drawers - inside (where contaminated equipment may have been placed).
• Instruments - knobs, on-off switches, keyboards, etc.
• Floors - entrances, near hoods, refrigerators/freezers, sinks, work stations, worn areas.
• Any area where equipment has been moved from -walls, floors, etc.
C-V-6
B1.d.10
Taking the Smear
(1) Here is the second problem associated with the smear surveys: What constitutes a smear
or swipe? Fundamentally, the surveyor applies (using rubber gloves) moderate pressure to
the back of the smear and rubs it over the surface to be surveyed (some surveyors like to
use a No. 8 or No. 10 rubber stopper) usually no more than 100 cm
2
or 16 square inches.
(2) Most institutions allow and "S" motion of about 12-16 inches on a large, open surfaces (eg,
walls, floors, countertops, etc). The smear is then placed either in separate vials or
something to prevent cross-contamination. It is a good idea to change gloves periodically to
prevent cross-contamination from the gloves.
(3) The smears are then transported to a counter capable of monitoring the radiation surveyed.
B2
Frequency of Surveys
B2.a
General Information
The frequency of surveys depends on the nature, quantity, and use of radioactive material as
well as equipment and procedures that are designed to protect the workers from unnecessary
exposure.
Routine surveys are necessary to control the containment of radioactive material within specified
areas and to ensure the reliability of protective equipment, containers and procedures. For any
process involving any type of "loose" radioactive material (i.e. gas, liquid, finely divided form) the
surveys shall be designed to monitor the containment and control of radioactive material
involved.
B2.a.1
Frequency
Surveys should be performed in direct proportion to isotope use.
EXAMPLE - If a person uses radioactive material once or twice a month then 1 or 2 surveys a
month should be conducted.
B2.a.2
If there is no use of radioactive material, a survey is still required at least ONCE a month, to
ensure containment control. Surveys shall be continual as long as there is radioactive material
or rad-waste in the laboratory.
B3
Records of Surveys
B3.a
Records shall be maintained in logbooks or on special forms as long as they are clear, legible,
understandable, and reviewed by authorized individuals.
C-V-7
B3.b
Maintain the following information in the logbook or on a special form:
1. date of survey
2. counts per minute
3. diagram of laboratory
4. smear location
5. machine copy of results
6. dpm or standard reference source count
B3.c
Each batch of survey samples should include a standard reference source and a background
sample count.
B3.d
Refer to TAC §289.202(ggg)(6) for contamination action levels and release limits.
END OF SECTION V
C-VI-1
SECTION VI – FORMS AND RECORDS
A. Radioactive Material Use Forms
B. Radiation Producing Equipment Forms
C. Additional Forms
Contact the Radiation Safety Office for forms.
END OF SECTION VI
SECTION VII – APPENDICES
RADIATION SAFETY INFORMATION
AND
RESOURCES
C-VII-1
APPENDIX A – REFERENCE INFORMATION
A GLOSSARY OF TERMS
Introduction
This section lists information pertinent to radiation safety and is considered to be a part of this
manual. The definitions in this glossary will not cover every term associated with radiation but does
cover a majority of the terms. If a term should be encountered in your work with radiation and is
not in this glossary, consult your supervisor or call the TTU Department of Environmental Health
and Safety.
Radiation Terms
Absorbed Dose - The amount of energy imparted to matter by ionizing radiation per unit mass of
irradiated material.
Absorption - The phenomenon by which radiation imparts some or all of its energy to any material
through which it passes.
Activity - The number of nuclear disintegrations occurring in a given quantity of material per unit
time.
Administrative Penalties - A monetary penalty assessed by the Bureau of Radiation Control for
violations of the TRCR (TAC) and/or local policies and procedures, to deter future violations and to
assure continued compliance.
Airborne Radioactive Material - Any radioactive material dispersed in the air in the form of dusts,
fumes, mists, vapors, or gases.
Alpha Particle - A strongly ionizing particle emitted from the nucleus during radioactive decay
having a mass and charge equal in magnitude to a helium nucleus.
Alpha Ray - A stream of fast-moving helium nuclei (alpha particles), a strongly ionizing and weakly
penetrating radiation.
Analytical X-Ray Equipment - X-ray equipment used for x-ray diffraction, florescence, or
spectroscopy.
Analytical X-Ray System - A group of local and remote components utilizing x-rays to determine
the elemental composition or to examine the microstructure of materials. Local components include
those that are struck by x-rays such as radiation source housing, port and shutter assemblies,
collimators, sample holders, cameras, goniometers, detectors, and shielding. Remote components
include power supplies, transformers, amplifiers, readout devices, and control panels.
Annihilation - An interaction between a positive and negative electron; their energy, including rest
energy, being converted into electromagnetic radiation (annihilation radiation).
Annual Limit on Intake (ALI) - Derived limit for the amount of radioactive material taken into the
body of an adult worker by inhalation or ingestion in a year.
Atom - Smallest particle of an element which is capable of entering into a chemical reaction.
Autoradiograph - Record of radiation from radioactive material in an object made by placing the
object in close proximity to a photographic emulsion.
C-VII-2
Background Radiation - Ionizing radiation arising from radioactive material other than the source
directly under consideration.
Beta Particle - Charged particle emitted from the nucleus of an atom, having a mass and charge
equal in magnitude to an electron.
Beta Ray - A stream of high-speed electrons or positrons of nuclear origin. Higher penetration but
less ionization than alpha rays.
BRC - Bureau of Radiation Control a division of the Texas Department of Health.
Bremsstrahlung - Electromagnetic (x-ray) radiation associated with deceleration of charged
particles passing through matter.
Committed Dose Equivalent (HT,50) - Dose equivalent to organs or tissues of reference (T) that
will be received from an intake of radioactive material by an individual during the 50-year period
following the intake.
Committed Effective Dose Equivalent - Sum of the products of the weighting factors applicable to
each of the body organs or tissues that are irradiated and the committed dose equivalent to these
organs or tissues (HE, 50 = SwTHT,50).
Contamination, Radioactive - The deposit of radioactive material in any place where it is not
desired, and particularly where its presence can cause harm.
Carrier Free - An adjective applied to one or more radionuclides in minute quantity, essentially
undiluted with a stable carrier.
CFR: Code of Federal Regulations.
Critical Organ - Organ or tissue in which the irradiation of will result in the greatest hazard to the
health or the individual or his/her descendants.
Decay, Radioactive - Disintegrations of the nucleus of an unstable isotope by the spontaneous
emission of charged particles and/or photons.
Deep Dose Equivalent (Hd) - Applies to external whole-body exposure, is the dose equivalent
at a tissue dept of 1 cm (1000 mg/cm
2
.) but internal organ(s) still considered to be irradiated.
Derived Air Concentration (DAC) - Concentration of a given radionuclide in air which, if breathed
by the reference man for working year of 2,000 hours under conditions of light work (inhalation rate
1.2 cubic meters of air per hour), results in an intake of one ALI.
Dose - A general term denoting the quantity of radiation or energy absorbed in a specified mass.
For special purposes it must be appropriately qualified, e.g. absorbed dose.
Dose Equivalent - A quantity used in radiation protection expressing all radiation on a common
scale for calculating the effective absorbed dose. The unit for the dose equivalent is the rem, which
is numerically equal to the absorbed does in rads multiplied by a quality factor.
Electron - Negatively charged elementary particle which is a constituent of every neutral atom.
Electron Volt - A unit of energy equivalent to the amount of energy gained by an electron in passing
through a potential of 1 volt.
C-VII-3
Exposure - A measure of the ionizing that is produced in air by x or gamma rays. It is the sum of
the electrical charges on all the ions of one sign produced in air when all electrons liberated by
photons in a volume element of air car completely stopped in air, divided by the mass of air in the
volume element. Note: The unit for exposure is the roentgen.
Fail-Safe Characteristics - A design feature which causes beam port shutters to close, or otherwise
prevents emergence of the primary beam, upon failure of a safety or warning device.
Gamma Ray - Very penetrating electromagnetic radiation of nuclear origin. Except for origin,
identical to x-rays.
Geiger-Mueller (G-M) Counter - Highly sensitive gas-filled detector and associated circuitry used
for radiation detection and measurement.
Genetic Effect of Radiation - Inheritable changes, chiefly mutations, produced by the absorption of
ionizing radiation. On the basis of present knowledge these effects are purely additive, and there
is no recovery.
Half-life, Biological - The time required for the body to eliminate one-half of an administered dose
of any substance by the regular processes of elimination. This time is approximately the same for
the stable and radionuclides of a particular element.
Half-life, Effective - Time required for a radionuclide in a system to be diminished 50 percent as a
result of the combined actin of radioactive decay and biological elimination.
Half-life, Radioactive - Time required for a radioactive substance to lose 50 percent of its activity by
decay. Each radionuclide has its own unique half-life.
Half-value Layer (half-thickness) - The thickness of any specified material necessary to reduce the
intensity of an x-ray or gamma ray bean to one-half it original value.
Inspection - Means on examination and/or observation including but not limited to records, tests,
surveys, safety check, and monitoring to determine compliance with state and local rules,
regulations and requirements.
Inverse Square Law - The intensity of radiation at any distance from a point source varies inversely
as the square of the distance.
Ion - Atomic particle, atom, or chemical radical bearing an electrical charge, either negative or
positive.
Ionization - The process by which a neutral atom or molecule acquires either a positive or negative
charge.
Ionization Chamber - An instrument designed to measure the quantity of ionizing radiation in terms
of the charge of electricity associated with ions produced within a defined volume.
Ionization, Specific - The number of ion pairs per unit length of path of ionizing radiation in a
medium.
Ionizing Radiation - Any electromagnetic or particulate radiation capable of producing ions, directly
or indirectly in it passage through matter.
Isotope - Nuclide that has the same number of protons in their nucleus, and hence having the same
atomic number but differing in the number of neutrons, and therefore in the mass number.
C-VII-4
Labeled Compound - A compound consisting, in part, of labeled molecules.
Maximum Permissible Dose - Maximum dose of radiation which may be received by persons
working with ionizing radiation, which will produce no detectable damage over the normal life span.
Millirotogen (mR) - A submultiple of the roentgen equal of one-thousandth of a roentgen.
Neutron - Elementary particle with a mass approximately the same as that of a hydrogen atom and
electrically neutral. It has a half-life in minutes and decays in free state into a proton and an
electron.
Normal Operating Procedure - Operating procedure for conditions suitable for analytical purposes
with shielding and barriers in place. These do not include maintenance but do include routine
alignment procedures. Routine and emergency radiation safety considerations are part of these
procedures (reference TRCR 32.2(d)).
Nuclide - A species of atom characterized by its mass number, atomic number, and energy state
of its nucleus, provided that the atom is capable for a measurable time.
Open Beam Configuration - An analytical X-ray system in which an individual could accidentally
place some part of his body into the primary beam path during normal operation.
Primary Beam - Ionizing radiation which passes through an aperture of the source housing by a
direct path from the x-ray tube located in the radiation source housing.
Radiation - 1) The emission and propagation of energy through space or through a material medium
in the form of waves. 2) The energy propagated through a material medium as waves; for example,
energy in the form of elastic waves. Such as Hertzian, infrared, visible (light), etc. 3) By extension,
corpuscular emissions, such as alpha and beta radiation, or ray of mixed or unknown type, as
cosmic radiation.
Radiological Survey - Evaluation of the radiation hazards incident to the production, use or
existence of radioactive materials or other sources of radiation under a specific set of conditions.
Such evaluation customarily includes a physical survey of the disposition of materials and
equipment, measurements or estimates of the levels of radiation that may be involved, and a
sufficient knowledge of processes using or affecting these materials to predict hazards resulting
from expected or possible change sin materials or equipment.
Radionuclide - A nuclide with an unstable ratio of neutrons to protons placing the nucleus in a
state of stress. In any attempt to reorganize to a more stable state, it may undergo various types
of rearrangement that involve the release of radiation.
Radiotoxicity - Term referring to the potential of an isotope to cause damage to living tissue by
absorption of energy from the disintegration of the radioactive material introduced into the body.
RAM - Radioactive material.
Relative Biological Effectiveness - For a particular living organism, the ratio of absorbed dose of a
reference radiation that produces a specified biological effect to the absorbed dose of the radiation
of interest that produces the same biological effect.
REM - The special unit of dose equivalent. The dose equivalent in rems in numerically equal to
the absorbed does in rads multiplied by the quality factor, distribution factor, and any other
necessary modifying factors.
C-VII-5
RSC - Radiation Safety Committee; interchangeable with ILSC.
Roentgen - The quantity of x or gamma radiation such that the associated corpuscular emission
per 0.001293 grams of dry air produces, in air, ions carrying one electrostatic unit of quantity of
electricity of either sign. The roentgen is the special unit of exposure.
RSO - Radiation Safety Officer of TTU.
Shielding Material - Any material which is used to absorb radiation and thus effectively reduce the
intensity of radiation, and in some cases eliminate it.
Smear (smear or swipe test) - A procedure in which a swab (e.g., a circle of filter paper) is rubbed
on a surface and the radioactivity measured to determine if the surface is contaminated with loose
radioactive material.
Specific Activity - Total radioactivity of a given nuclide per gram of compound, element or
radioactive nuclide.
Total Effective Dose Equivalent (TEDE) - Sum of the deep dose equivalent (for external exposures)
and CEDE (for internal exposures).
Tracer, Isotopic - The isotope or non-natural mixture of isotopes of an element which may be
incorporated into a sample to make possible observation to the course of that element, alone or in
combination, through a chemical, biological, or physical process. The observations may be made
by measurement of radioactivity or of isotopic abundance.
Thermoluminescent Dosimeter (TLD) - A dosimeter made of certain crystalline material which is
capable of both storing a fraction of absorbed ionizing radiation and releasing this energy in the
form of visible photons when heated. The amount of light released can be used as a measure of
radiation exposure to these crystals.
X-Rays - Penetrating electromagnetic radiation having wavelength shorter than those of visible light
they are usually produces by bombarding a metallic target with fast electrons in a high vacuum. In
nuclear reactions it is customary to refer to photons originating in the nucleus as gamma rays, and
those originating in the extranuclear part of the atom as x-rays.
C-VII-6
B INDEX OF ABBREVIATIONS AND ACRONYMS
ALARA
As
Low As Reasonably Achievable
BRC Bureau of Radiation Control
CFR Code of Federal Regulations
DOH Department of Health
DOT US Department of Transportation
FDA Federal Drug Administration
FRC Federal Radiation Council
GC Gas Chromatograph .
ICRP International Commission on Radiation Protection
MPD Maximum Permissible Dose
NCRP National Council on Radiation Protection and Measurements
NRC Nuclear Regulatory Commission
OP Operating Procedure
PO Purchase Order
RAM Radioactive Material
RIA Radioimmunoassay
RPG Radiation Protection Guide
RSC Radiation Safety Committee
RSO Radiation Safety Officer
TDH Texas Department of Health
TLD Thermoluminescent Dosimetry
TRCR Texas Regulations for Control of Radiation
TTU Texas Tech University
C-VII-7
C List Of Symbols for Radiation Units and Terms
Measurements /Units
Ci Curie
m milli (onethousandth)
u micron (onemillionth)
k kilo (thousand)
R roentgen
rem radiation equivalent man
dpm disintegrations per minute
dps disintegrations per second
cpm counts per minute
MeV Million electron volt
LET Linear Energy Transfer
QF Quality Factor
C-VII-8
Appendix B - Texas Regulations for Control of Radiation References
Introduction
The following section will briefly describe specific parts of the Texas Regulations for Control of
Radiation (TRCR) and the Texas Regulations for Control of Laser Radiation Hazards
(TRCLRH). TTU is subject to the rules of the TRCR, TRCLRH, and other state, federal, and local
regulations when using radiation. These specific parts have been extracted because of overall
benefit to all radiation users at TTU. More specific information can be obtained from the Radiation
Safety Office
1. 25 TAC §289.201 (TRCR Part 11) - General Provisions, Texas Regulations for Control of
Radiation: contains general information concerning recordkeeping, testing of sealed sources,
violation information, and transport grouping of radionuclides.
2. TRCR Part 13 contains rules and regulations pertaining to amending licenses, annulment of
licenses, administrative penalties (i.e., fines), impoundment of sources of radiation, etc.
3. 25 TAC §289.202 (TRCR Part 21), Standards for Protection Against Radiation -
establishes standards for protection against ionizing radiation hazards. It is the purpose of the
rules in this part to control the possession, use, and transfer of sources of radiation by any
licensee so as to ensure that the dose to any individual does not exceed the standards
established in this part. Areas covered include exposure limits, concentration of radioactive
material in effluents, personnel monitoring, storage, disposal, records, limits of concentrations,
etc.. This part is the basis for ALARA, "As Low As Reasonably Achievable", which means that
each user should make every effort to keep exposures and releases as low as reasonably
achievable.
4. 25 TAC §289.203 (TRCR Part 22), Notices, Instructions, and Reports to Workers;
Inspections - establishes requirements for notices, instructions, and reports by licensees or
registrants to individual engaged in work under a license or registration, and options available
to such individuals in connection with the State Bureau of Radiation Control (BRC) inspections
regarding radiological conditions. Areas of particular interest are requirements for Posting of
Notices, Instructions to Workers, Requests by Workers for Inspections, etc.
5. TRCR Part 34, Radiation Safety Requirements for Analytical X-Ray Equipment - This
part provides special requirements for analytical X-ray equipment. Areas covered are
equipment requirements, area requirements, operating requirements, and personnel
requirements.
6. PARTS 50, 60, & 70 - TEXAS REGULATIONS FOR THE CONTROL OF LASER
RADIATION HAZARDS - The objective of these regulations is to provide guidance for safe
use of laser products and laser installations. Areas of particular interest include supervision,
controls, safety requirements, regulations, and requirements for safe operation, signs,
surveys, records, and registrations.
C-VII-9
Appendix C - Instrument Calibration Procedures
(12/01/99)
Note:
Only persons specifically authorized by the RSO may participate in the procedures
set out in Appendix C.
C-VII-10
APPENDIX C - INSTRUMENT CALIBRATION PROCEDURES
A General Procedure for Calibration of Radiation Detection and Measurement
Instruments
1. Alpha Measuring Instruments: will be calibrated annually by using a standard alpha
source.
2. Beta Measuring Instruments: will be calibrated annually by using a standard beta source.
3. Ionization Chamber Instruments: will be calibrated annually by an authorized instrument
service company or by the procedure in Part B.
4. Well Counters: will be calibrated annually by an authorized instrument service company.
5. MCA’s: will be calibrated, using standard sources, each time they are turned on for operation
and as necessary during analytical procedures.
6. GM Radiation Survey Instruments: will be calibrated annually using the procedure in Part
B of this procedure or by an authorized instrument service company
Periodic Calibration of Instruments
1. Purpose
This procedure will be used by TTU to perform its own annual radiation survey instrument
calibrations for GM and, in some cases, ionization chamber instruments. In the event that TTU
cannot perform the calibration of a needed instrument, an authorized service company will be
used.
2. Scope
Each instrument will be calibrated to verify that it correctly measures the intensity of a radiation
field (mR/hr). The procedure involves using a Ludlum Pulser to adjust the electronics of the
instrument and then placing the instrument in a radiation field of known intensity and making
necessary adjustments or calculations to verify the accuracy or determine correction factors.
3. Objective
To verify that each instrument is capable of measuring radiation levels over its multiple ranges
to within plus or minus 20 percent of the true radiation level for the appropriate energies of the
radiation.
4. Method
A known radiation field for the calibration procedure is provided through the use of a known
source in a calibrator/shield. The beam calibrator is a manually operated device which
incorporates a Cesium-137 source with an initial activity of 100 millicuries. The shield of the
calibrator provides for full shielding in all directions at all times except when the unit is in the
"ON” position. In the “ON” position, a radiation beam is emitted out of the port.
5. Applicability
This procedure applies only to GM and ionization chamber type instruments
6. Precautions and Safety
C-VII-11
a. Personnel Monitoring: The person(s) performing the calibration procedures MUST
wear his/her assigned personnel monitoring device and pocket dosimeter.
b. Area Access: ONLY persons properly trained in instrument calibration procedures AND
authorized by the RSO may conduct instrument calibrations.
c. Area Control: The area(s) where the calibrations are to be performed will cleared of
unauthorized/non-essential persons prior to initiating calibration procedures. “Caution -
Radiation Area” signs will be posted at the entrance(s) to the area. Should any
unauthorized/unmonitored person enter the area, the calibrator will immediately be turned
to the OFF position.
d. Emergencies and Malfunctions:
(1) Calibrator Malfunction: if the ON/OFF shutter mechanism fails such that the
beam cannot be shut off, immediately clear and secure the area and notify the
RSO. DO NOT leave the area unattended!
(2) Improper Calibrator Operation: should the operation of the source rod become
difficult, the calibrator shall be removed from service and returned to the
manufacturer for repair.
7. Instrument Inspection
A thorough inspection of the instrument must be performed prior to the calibration procedure, as
follows:
a. Visual Inspection: Visually check the outer meter face, adjustment knob, handle and
meter case. Certain components, when damaged (such as the meter face, needle and
adjustment knob), may affect the ability to calibrate.
b. Battery Condition Check: Inspect the batteries for damage and test for charge. Replace
if necessary. Weak batteries can cause erratic behavior.
c. Electrical Inspection: Remove the case and visually inspect the electrical/electronic
components. Inspect the internal probe, if present. If any component appears to be
burned, broken, or loose, or there appears to be internal corrosion or moisture, do not
proceed with calibration. Minor problems may be correctable, such as re-soldering a wire
or removing corrosion or moisture. If repairs are satisfactorily performed, replace the
cover and proceed with calibration. Otherwise, the instrument must be sent to an
instrument repair service.
d. Electronics Test: Perform the electronics test using the Pulser as stated in the
applicable Ludlum Instruction Manual.
e. Mechanical Inspection: Inspect and/or test all mechanical hardware, such as nuts,
screws, etc., to ensure that they are secure. Check the retaining screw that holds the
selector knob on, the retaining screw for the handle, screws that hold the circuit board to
the meter body, screws on the meter movement, etc. If necessary, all loose hardware
must be tightened. Check the proper operation of switches to assure that they “lock in”
on the selected positions.
f. Probe and Connecting Cable Inspection: Inspect the cable and connectors for signs
of damage or wear. Kinks in the cable may cause erratic behavior. The connectors must
C-VII-12
be of tight fit and the pins intact and firm. The connectors should attach to the instrument
and probe connections firmly. Repair or replace the cable before proceeding with
calibration.
8. Instrument Calibration (GM and ionization chamber instruments):
Only persons authorized by the RSO shall be allowed to calibrate radiation survey
instruments.
a. Prepare Calibration Record/Certificate: Prepare a calibration record/certificate for
each instrument to be calibrated.
b. Determine Calibration Points:
(1) Calculate and record the current source strength.
(2) Determine the points (distances from calibrator) at which the instrument (probe) must
be placed to produce the necessary radiation levels which allow calibration at two
points on each range. Enter the field intensities on the calibration record(s) for each
instrument.
c. Establish Calibration Range: Mark the calibration range for the determined points
(distances).
d. Calibrate at Each Point:
(1) Place the instrument at the desired point to checked
(2) Unlock the device and expose the source.
(3) Observe the reading on the instrument face at each predetermined point.
(4) If the instrument reading does not agree with the field intensity (within plus or minus
20%), the calibration potentiometer for that range must be adjusted until the
instrument indicates the correct response. Caution: a small amount of adjustment
produces a relatively large change in the instrument reading.
Note: For instruments that have only one calibration potentiometer, all ranges must be checked
before adjusting the potentiometer. The potentiometer affects all ranges.
(5) Once the adjustments have been made, place the instrument back at the same
location and verify the reading.
(6) Repeat steps 6.d.1 through 6.d.5 for each point to be calibrated. It may be
necessary to use attenuation blocks to obtain the lower range readings.
e. Turn Calibrator Off: Return the source to the "OFF" position. Lock the calibrator.
9. Calibration Records
a. Calibration Record and Certificate: For each instrument calibrated, complete the
following sections of the instrument calibration record (Attachment E.2 – Certificate of
Calibration, Form RS-32):
• Sublicensee name and identifying information
C-VII-13
• Instrument/detector manufacturer and information
• Calibration results
• Calibration method information
b. Certification: The person performing the calibration must sign the “Calibrated by” space
and enter the date of calibration. Indicate the next due date based on the calibration
interval for the type of use of the instrument.
c. Calibration Sticker: A “calibration sticker”, should be placed on the instrument (obscure
or remove previous ones) to indicate who calibrated the instrument; authorization (license
number); date of calibration; next due date; instrument make, model and serial number;
and the identity of the person performing the calibration.
10. Serviceability of Instruments:
a. Successful Calibration: If the instrument was successfully calibrated, submit the
completed “Survey Instrument Calibration Certificate” to the RSO for review and filing.
Return the instrument to its proper storage location.
b. Unsuccessful Calibration: If unable to calibrate an instrument, or the instrument
requires repair, tag it as unusable and needing repair. Submit the instrument with notes
of problem(s) to the RSO.
Sample: “SURVEY METER CALIBRATION LABELS” (stickers)
TEXAS TECH UNIVERSITY
MFG Model Ser.#
Cal.Date Due
Date
Cal.Source High Voltage
Tube I D Cal By
C-VII-14
TEXAS TECH UNIVERSITY CERTIFICATE OF CALIBRATION
ENVIRONMENTAL HEALTH AND SAFETY
State of Texas Broad License #L01536
Sublicensee ___________________________
Dept. ___________________
Account # _________________________
Instrument Manufacturer _________________
Model # ________________
Serial # __________________________
Detector Manufacturer ___________________
Model # ________________
Serial # __________________________
Last Calibration Date
___________________
Today’s Calibration Date
_____________________
Calibration Due Date
_____________________
Battery Meter Zeroed F/S Response Zero Reset Audio Meter Face Number ____________
Detector Tube Voltage
_____________ Volts
HV “As Found” Reading
_______________Volts
Meter HV Adjusted Reading
__________________Volts
Input Sensitivity
________mVolts
Maximum Reading
Per Scale
(mR/hr or CPM)
Calibration Point
(mR/hr or CPM)
Meter Reading
“As Found”
(mR/hr or CPM)
Meter Reading
“After Adjustment”
(mR/hr or CPM)
% Error
Method of Calibration:
Cs-137 Source Model 500 Pulser 0.1 1 10 100 1000 Ranges Calibrated Electronically
Meter Within ± 10% Within ± 10 – 20% Tolerance
Meter out of Tolerance > ± 20% Meter Requires Repair
Comments : ____________________________________________________________________________________________
Calibrated by : ______________________________________ Date: _____________________________________
i
TABLE OF CONTENTS
SECTION I MANAGEMENT OF LASER LICENSE D-1
D1 LASER SAFETY PROGRAM ....................................................................................D-1
D2 RADIATION AND LASER SAFETY COMMITTEE ....................................................D-2
D3 LASER SAFETY OFFICER ......................................................................................D-4
D4 INSPECTIONS .........................................................................................................D-6
SECTION II SUBLICENSE PROGRAM D-9
D5 DEFINITIONS ...........................................................................................................D-9
D6 SUBLICENSE APPLICATION PROCEDURES ......................................................D-10
D7 ABSENCE OF SUBLICENSEE FROM CAMPUS ...................................................D-12
D8 TERMINATION OF SUBLICENSE ..........................................................................D-12
D9 DEACTIVATION / REACTIVATION OF SUBLICENSE ..........................................D-13
D10 DEACTIVATION / REACTIVATION OF EQUIPMENT ............................................D-15
D11 RESPONSIBILITIES OF SUBLICENSEE ...............................................................D-16
D12 RESPONSIBILITIES OF USERS & OPERATORS .................................................D-18
D13 PROGRAM REQUIREMENTS ...............................................................................D-18
D14 LAB PERSONNEL ..................................................................................................D-26
SECTION III LASERS D-27
D15 BASIC LASER CHARACTERISTICS ......................................................................D-27
D16 SPECIFIC LASER REQUIREMENTS ......................................................................D-32
SECTION IV EMERGENCY PROCEDURES D-34
D17 GENERAL INFORMATION ......................................................................................D-34
D18 ORGANIZATION AND AUTHORITY .......................................................................D-34
D19 FIRES, EXPLOSIONS OR MAJOR EMERGENCIES ..............................................D-35
D20 INCIDENTS: POSSIBLE EXPOSURE OR INJURY ................................................D-35
D21 LOSS OR THEFT ....................................................................................................D-36
D22 EMERGENCY PHONE NUMBERS .........................................................................D-36
D-1
SECTION I: MANAGEMENT OF LASER LICENSE
D1 LASER SAFETY PROGRAM
Introduction
The purpose of this manual is to inform users and non-users of laser equipment about the
policies and procedures concerning laser use at Texas Tech University and state regulations,
25 Texas Administrative Code (TAC) §289.301 are covered. Policies and procedures set forth
in this guide have a primary goal to protect Texas Tech University faculty, staff, students, and
visitors against unnecessary and potentially harmful laser radiation exposure. This manual
includes the procedure for permitting lasers at TTU and the requirements to obtain a
sublicense permit for laser usage from the Radiation and Laser Safety Committee.
D1.1
Objective
This program is designed to protect the faculty, staff, employees, and students of Texas Tech
University (TTU); to protect members of the general public; and to comply with 25 TAC
§289.301 [Texas Regulations for Control of Laser Radiation Hazards (TRCLRH)].
D1.2
Method
Texas Tech University (TTU) has established this Laser Safety Manual (LrSM) to provide
safety guidance to its faculty, staff, and students when working with lasers. The Radiation
Laser Safety Committee (RLSC) and Laser Safety Officer (LSO) are also, available for
additional assistance.
D1.3
Date of Implementation
September 1, 2002, upon approval by the RLSC.
D1.4
Review
This program will be reviewed on an annual basis no later than the anniversary month of its
inception.
D1.5
Program Elements
D1.5.1
Purchase, Transfer, Shipping, and Delivery Notification: Laser purchase, transfer, shipping,
and delivery procedures are specified in D.13.1.
D1.5.2
Access Controls for Laser Areas: Access to the laser areas is controlled by D.13.4 of the
LrSM. In addition, certain elements of administrative and engineering controls regarding
D-2
storage, use, and maintenance/service procedures contain steps which specifically address
access controls.
D1.5.3
Posting of Areas and Rooms: D.13.3 of the LrSM provides for posting of the appropriate
signage respective of the class(s) of the laser.
D1.5.4
Training: D.13.5 of the LrSM addresses the required training for laboratory personnel.
D1.5.5
Management of Required Records: Records management procedures are addressed in
D.13.11 of the LrSM.
D1.5.6
Personal Protective Equipment: D.13.6 provides procedures for providing for the necessary
protection respective of the class(s) of the laser.
D1.5.7
Reports of Incidents and Accidents: All TTU personnel are responsible for reporting incidents
and accidents to the LSO - immediately. The specific procedures are found in Section IV of
the LrSM.
D2 RADIATION LASER SAFETY COMMITTEE
D2.1
Purpose and Structure
The RLSC is composed of a group of administrators, faculty, and staff appointed by the
Executive Vice President and Provost to establish policies and regulations governing the use
of ionizing and non-ionizing radiation. The RLSC is primarily responsible for the
administration, implementation, and enforcement of the laser radiation safety program at TTU.
D2.2
Duties (RLSC Authority)
The RLSC will:
D2.2.1
establish policies and procedures, as well as provide administrative advice regarding laser
radiation safety;
D2.2.2
approve or disapprove all applications, amendments, and renewals relating to the use of laser
equipment;
D2.2.3
receive and review reports from the LSO on monitoring, surveillance, and exposure;
D-3
D2.2.4
monitor procurement, use, and transfer procedures;
D2.2.5
take appropriate corrective action on laser incidents, including administrative guidance and
license suspension or revocation;
D2.2.6
provide a representative to the University Safety Committee; and
D2.2.7
serve as an avenue of appeal in cases of dispute and exception to actions by the LSO.
D2.3
Membership
The members of the committee will be appointed by the Executive Vice President and Provost.
Members of the committee, other than those specified by virtue of their position, will be
nominated by the committee chairperson and the Associate Vice President for Operations.
Each member will serve a term of three years except when lesser terms may be required to
maintain balanced membership and continuity of committee operations. Re-appointments are
permissible. The RLSC shall be composed of:
D2.3.1
three faculty members who regularly use radioactive materials;
D2.3.2
two faculty members who regularly use lasers;
D2.3.3
at least one faculty member who regularly uses radiation producing equipment;
D2.3.4
at least two faculty/staff members who are non-users of radioactive materials, lasers, or
radiation producing equipment;
D2.3.5
RSO (Ex-Officio);
D2.3.6
LSO (Ex-Officio);
D2.3.7
Associate Vice President for Operations, (Ex-Officio)
D2.4
D-4
Operating Procedures
The RLSC shall observe the following:
D2.4.1
the RLSC shall schedule a regular meeting for each month of the year. Additional meetings
may be called as necessary. The LSO will prepare and distribute a written agenda to
committee members at least one day before each scheduled meeting;
D2.4.2
a quorum, at least one-half of the voting members, is required to conduct official business;
D2.4.3
sub or ad hoc committees may be appointed by the Chairperson as needed;
D2.4.4
if a committee member is unable to continue serving on the committee for any reason, the
member shall notify the Chairperson so that a replacement may be appointed promptly; and
D2.4.5
if a committee member fails to attend three consecutive meetings or one-half of the called
meetings in a twelve-month period, without just cause, the Chairperson will contact that
member to determine if that person should be replaced. If so, the Chairperson will ask the
Associate Vice President for Operations to arrange for a replacement under the appointment
procedures of the committee.
D2.5
RLSC Responsibilities
The RLSC shall:
D2.5.1
establish policies regarding laser radiation and laser safety;
D2.5.2
provide administrative advice to the LSO on matters regarding laser radiation and laser safety;
D2.5.3
regulate type of training needed by laser users to meet applicable statutory and administrative
requirements;
D2.5.4
receive, review, and act on all applications and any amendments for the use of laser
equipment in any areas used by TTU personnel;
D2.5.5
receive and review periodic reports from the LSO on records, surveys, and inspections and
require compliance with applicable record keeping standards;
D-5
D2.5.6
periodically review the overall use of laser equipment at TTU from the standpoint of operational
hazards and potential secondary hazards;
D2.5.7
receive and review all reports from the LSO concerning laser radiation and laser incidents at
TTU;
D2.5.8
conduct necessary investigations, hearings, and/or appropriate corrective action to be taken if
a sublicensee or authorized laser personnel fail to operate the licensed laser equipment
according to the criteria specified in this policies and procedures manual at TTU;
D2.5.9
meet regularly during the academic year;
D2.5.10
perform an annual audit of the Laser Safety Program; and
D2.5.11
upon committee action, issue sublicenses which will be duly signed and approved by the
Chairperson of the RLSC.
D3 LASER SAFETY OFFICER
D3.1
Duties
D3.1.1
The LSO is a member of the Radiation Safety Office who is trained in the areas of laser
operation and laser safety and registered with the Bureau of Radiation Control. The LSO is
the University official primarily responsible for compliance with applicable safety policies and
regulations. The LSO also provides various technical services necessary for achieving such
compliance.
D3.2
Responsibilities
The LSO shall:
D3.2.1
suspend immediately or restrict operation of a laser system when, in the view of LSO, the
sublicensee or authorized laser personnel working with laser system or other personnel in the
vicinity of the laser are in danger;
D3.2.2
D-6
instruct laser users and others affected in proper procedures and policies concerning laser
equipment use, including teaching laser safety training classes. The LSO shall also provide
consulting services to TTU personnel for aspects concerning laser safety;
D3.2.3
assure that appropriate primary control measures are in effect and to recommend alternate
control measures as back up if primary measures become infeasible or inappropriate;
D3.2.4
generate reports, receive and review records from sublicensees, and maintain all material
concerning laser equipment, personnel working in laser areas, and any other information
required by the Texas Regulations for the Control of Laser Radiation Hazards (TRCLRH). This
shall include, but not be limited to: laser eye protection inspections, incident/accident reports,
LSO laser lab inspections, registration, inventory forms, and medical surveillance records;
D3.2.5
periodically inspect laser sublicensees to ensure proper record keeping, verify inventories,
inspect appropriate laser control measures, and ensure compliance with other laser safety
aspects as detailed in this manual. The LSO shall also inspect all new and existing laser
facilities and laser equipment prior to their installation or modification to ensure proper
compliance. The results of these inspections shall be periodically presented to the RLSC;
D3.2.6
investigate all actual and suspected incidents resulting from operation of a laser system by
personnel at TTU. The LSO shall prepare reports to applicable agencies and the RLSC shall
approve such reports and initiate appropriate action concerning the incident;
D3.2.7
provide each sublicensee with a copy (and updates) of the TTU Policies and Procedures
Manual for Laser Safety.
D4 INSPECTIONS
D4.1
The LSO performs routine monitoring and inspections of all laser sublicensees and the results
are then presented to the RLSC for their evaluation. Through this process, the Laser Safety
Program at TTU can keep abreast of past, present, and future concerns with laser safety.
D4.2
The entire laser safety program is periodically inspected by a Regional Inspector from the
Bureau of Radiation Control for compliance with the Texas Regulations for the Control of Laser
Radiation Hazards. The results of these inspections are presented to the Director of
Environmental Health and Safety, the Laser Safety Officer, the Radiation Safety Manager, and
the Radiation Laser Safety Committee.
D4.3
General Monitoring
D-7
D4.3.1
The LSO may visit laboratories to ensure laser operations are according to procedures set forth in
this manual and sublicensee’s SOPs.
D4.3.2
The LSO will immediately report any major violation to the sublicensee and RLSC.
D4.3.3
The LSO will report minor violations to the sublicensee and RLSC.
D4.4
Formal Inspections
D4.4.1
Laser inspections will be performed semiannually by the LSO.
D4.4.2
Inspection results will be presented to the RLSC.
D4.4.3
Violations found will be brought to the attention of the sublicensee.
D4.4.4
Inspections results and reports will be sent to the sublicensee.
D4.5
Violation Levels
D4.5.1
Violations by a sublicensee are classified as either major or minor. All violations will be
presented to the RLSC at the next regularly scheduled meeting. A copy of the most current
monitoring and inspection criteria and the type of violation may be obtained from the LSO
D4.5.2
Major Violations
Include but are not limited to:
D4.5.2.1
Unauthorized personnel in laser area when laser is in use (authorized personnel are listed on
the laser sublicense);
D4.5.2.2
Operation of laser equipment in a manner which could cause injury to personnel outside the
laser area;
D4.5.2.3
D-8
Operation of laser equipment in a manner other than that specified in the approved standard
operating procedures;
D4.5.2.4
Personnel in a laser area not utilizing proper personal protective equipment when the laser is
in use;
D4.5.2.5
Operation of laser equipment without prior authorization from the RLSC and LSO; or
D4.5.2.6
Any combination of D4.5.2.1 to D4.5.2.5.
D4.5.2.7
Any major violation may warrant the immediate deactivation of laser operation, and will remain
so until safety concerns are addressed.
D4.5.3
Minor Violations
Include but are not limited to:
D4.5.3.1
Improper posting of a laser area;
D4.5.3.2
Improper labeling of laser equipment;
D4.5.3.3
Usage log books not filled out as required;
D4.5.3.4
Monthly surveys and interlock checks not performed;
D4.5.3.5
Standard operating procedures and laser equipment manuals not in vicinity of laser equipment;
D4.5.3.6
Expiration of a laser sublicense; or
D4.5.3.7
Information on laser sublicense out of date.
D4.5.3.8
D-9
Any minor violation will be reported to the Sublicensee for correction and results discussed in
the RLSC meeting.
D4.6
Inspection Procedures
D4.6.1
The LSO shall inspect all laser usage facilities for compliance with all applicable regulations -
state, federal, and local.
D4.6.2
The LSO shall make a record of each inspection and keep those on file in the Radiation Safety
office.
D4.6.3
The LSO will forward a formal report of inspection (Form LS-1) to each sublicensee within two
weeks of final evaluation of his/her inspection results, noting corrective action needed.
D4.6.4
Each sublicensee will revise or correct his/her individual program as noted in the report under
"Corrective Actions". Questions or problems should be addressed to the LSO or the RLSC.
D4.6.5
The LSO will request a written response to some of the “Corrective Actions” from the sublicensee
within 30 days.
D4.6.6
The LSO will report all major violations as well as any instance of non-compliance for a
sublicensee to the RLSC.
D4.6.7
The LSO shall make follow-up inspections of all sublicensees having deficiencies deemed serious
by the RLSC within 15 days of report.
D4.6.8
All inspection statistics should be evaluated by the RLSC.
D4.6.
Sublicensees having repeated violations (same violation during two consecutive inspections) will
be reported to the RLSC and the RLSC for appropriate action.
D4.6.10
A Sublicensee who commits the same violation during three consecutive inspections will be
reported to the RLSC. The RLSC will issue a written notice and require the sublicensee to meet
with the committee during the next scheduled RLSC meeting to explain their violation.
D4.6.11
D-10
The RLSC may terminate a sublicense if major violations are continued.
D-11
SECTION II: SUBLICENSE PROGRAM
This section details the procedures and requirements for obtaining a sublicense for laser
equipment. Also included, will be procedures for renewals and amendments.
D5 DEFINITIONS
D5.1
Laser License – the specific laser license issued to TTU by the Bureau of Radiation Control
of the Texas Department of Health. This license authorizes all laser use programs to be
conducted at the discretion of the RLSC.
D5.2
Sublicense – an authorization issued by the RLSC to use laser equipment.
D5.3
Sublicensees – authorized laser personnel, full-time faculty members, whose training and
experience are such that they have been sublicensed by the RLSC to use lasers in their
research and educational activities. The RLSC will determine the extent of required training
respective of the laser classification involved.
D5.4
Authorized Laser Personnel – faculty, students and other professionals, usually research or
laboratory assistants or workers which may be engaged in education, laboratory research,
and research support activities. These personnel may work with lasers but only after
completing the required safety training programs and the Sublicensee amending his/her
Sublicense to include them on it.
D5.5
Non-Authorized Personnel – faculty, students, and other professionals and non-TTU
personnel which have not had TTU Laser Safety Training nor listed on the researcher’s
Sublicense.
D5.6
Operation – the normal mode of the laser or laser system over the full range of its intended
functions. It does not include maintenance.
D5.7
Maintenance – tasks specified in the maintenance instructions provided by the manufacturer
which are to be performed by the user to ensure the intended performance of the product. It
does not include operation.
D5.8
Service – procedures or adjustments described in the manufacturer’s service instruction
which are to be performed by a “licensed” manufacturer serviceman which is performed
infrequently. It does not include maintenance or operation.
D6 SUBLICENSE APPLICATION PROCEDURES
D-12
D6.1
Qualifications for a Sublicense
D6.1.1
The applicant must have sufficient training and experience in the use of the laser(s) requested to
ensure that proposed work is conducted and/or supervised in a safe manner.
D6.1.2
The applicant must be a TTU faculty member.
D6.1.3
The applicant must submit a completed application form for a laser usage sublicense, and a
resume of use and experience within the area of interest shown by the application. This resume
may include papers referencing the use of an instrument, and/or any formal training courses or
continued education.
D6.1.4
The applicant must specify on the application all types and numbers of lasers to be licensed as
well as the procedures involved.
D6.1.5
The RLSC will authorize issuance of the sublicense if it determines that all requirements have
been met.
D6.1.6
The RLSC will require all applicants to attend the TTU Laser Safety Training and/or obtain
experience by working under an active sublicensee for a specified period.
D6.1.7
The RLSC will require additional, “specific” training for individuals utilizing any class IIIB and IV
laser users.
D6.2
Requirements for Individuals Working Under a Sublicense
D6.2.1
All workers must document, prior to approval, completion of computer-based Laser Safety
Training.
D6.2.2
All workers will document, prior to approval, completion of required training for class IIIB and IV
lasers.
D6.3
Procedures for Obtaining a Sublicense
D-13
D6.3.1
The LSO will first review all applications.
D6.3.2
If an licensing amendment is properly completed by an authorized laser Sublicensee and a
qualifying inspection or a recent inspection of the laboratory by the TTU LSO shows that the
laboratory is in compliance with state and local regulations, interim approval not to exceed 30
days may be granted by the LSO.
D6.3.3
A diagram of the proposed work area in the laboratory must accompany the application,
indicating laser work areas, and non-laser work areas, and equipment location(s).
D6.3.4
Final approval is required of all applications by the TTU RLSC.
D6.3.5
To be considered for final approval all applications, amendments and renewals must be
submitted at least two working days before a regularly scheduled RLSC meeting.
D6.3.6
All applications must be completed and signed by the applicant. Incomplete applications will
be returned to the applicant for re-submission.
D6.4
Sublicense Renewal and Amendment
D6.4.1
Term
Texas Tech University sublicenses remain in effect for two years from date of issue.
D6.4.2
Renewal
Although the Radiation Safety Office will remind sublicensees of a pending expiration, it is the
sole responsibility of the sublicensee to submit a timely renewal application to avoid expiration
of a sublicense. If a sublicense expires, authorized use of laser equipment ends and may be
continued again, only after a new application is processed and approved by the RLSC.
D6.4.3
Conditions
Any one of the following changes in the conditions of the sublicense requires an amendment to
the sublicense:
D6.4.3.1
a change in personnel (additions and deletions);
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D6.4.3.2
a change in the authorized locations of laser use (addition or deletion of rooms);
D6.4.3.3
a change in the laser inventory (new laser equipment, transfer or disposal of laser equipment,
storage or reactivation of laser equipment);
D6.4.3.4
a change in the standard operation procedures;
D6.4.3.5
any change on the laser equipment.
D6.4.4
All modifications need to be reported to the LSO. Application forms for license renewal or
amendment are available from the Radiation Safety Office or may be found in this manual.
D7 ABSENCE OF SUBLICENSEE FROM CAMPUS
D7.1
If a sublicensee expects to be absent from the campus for more than 30 days, the LSO shall
be notified and the sublicensee shall:
D7.1.1
Deactivate all laser equipment on the sublicense during the absence (appropriate forms must
be filled out to deactivate and subsequently reactivate laser equipment); or notify the LSO as to
the responsible individual (another sublicensee) who will take over supervision of the use of the
laser equipment to be used. This sublicensee must be competent in the use and regulations
concerning the lasers to be used.
D7.1.2
Should arrangements as specified above in C.1 not be made, the RLSC Chairman and LSO,
shall revoke and terminate the sublicense. The LSO will terminate all laser use in the affected
laboratories.
D7.2
It is the sole responsibility of a sublicensee to notify the LSO during a period of his/her absence
and to take appropriate action as outlined above.
D8 TERMINATION OF SUBLICENSE
The following procedure shall be used to terminate a laser equipment sublicense.
D8.1
A letter of intent to terminate the sublicense will be submitted to the LSO.This letter will include:
D8.1.1
The date of termination.
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D8.1.2
The listing of the sublicensee's authorized laser inventory and laboratories, including storage
areas. A diagram of all these areas should accompany this letter of intent.
D8.1.3
A statement that all lasers active and/or stored will be transferred either to the LSO for storage or
disposal, or to another sublicensee authorized to possess the lasers under consideration.
D8.1.4
Upon receipt of the letter of intent, the LSO will conduct a visual inspection of the laboratory and
laser equipment. All signs and labels indicating laser use will be removed.
D8.1.5
The LSO will label all laser equipment with a "Security Seal" to prevent use until the laser
equipment is transferred or disposed. Laser equipment transferred to another TTU sublicensee
will continue to bear the "Security Seal" until the recipient sublicensee has his sublicense
adjusted accordingly and the laser equipment to be disposed will continue to bear the "Security
Seal" until the laser is rendered incapable of emitting laser radiation.
D8.1.6
AT THIS POINT, FURTHER USE OF LASER EQUIPMENT BY THE SUBLICENSEE AND
INDIVIDUAL WORKERS OF THAT SUBLICENSE IS STRICTLY PROHIBITED.
D8.1.7
Based on a review of the letter of intent, the results of the close-out survey, and the disposition of
the laser equipment, the LSO will make recommendations to the RLSC regarding the request to
terminate the sublicense.
D8.1.8
Until the RLSC and the LSO formally terminates the sublicense, the department chairperson will
be responsible for all laser equipment until these termination procedures are complete until such
time that the equipment is transferred to another sublicense.
D8.1.9
Once a sublicense has been terminated due to negligence, the sublicensee cannot apply for
another laser sublicense for a period of one year from the date of his/her laser sublicense
termination.
D9 DEACTIVATION/REACTIVATION OF SUBLICENSE
D9.1
Should a sublicensee foresee a period of time in which they do not plan to use laser equipment
the affected laboratory may be deactivated, by meeting the following criteria:
D9.1.1
A letter of intent to deactivate the sublicense will be submitted to the LSO. This letter will include:
D-16
D9.1.1.1
The date of deactivation.
D9.1.1.2
The listing of the sublicensee's authorized laser inventory and laboratories, including storage
areas. A diagram of all these areas should accompany this letter of intent.
D9.1.1.3
A statement that all lasers used and/or stored in the affected laboratory will be secured against
any use.
D9.1.1.4
A statement that all associated laser hazards are secure and contained to ensure compliance
with regulations.
D9.1.1.5
Upon receipt of the letter of intent, the LSO will perform an inspection of the laboratory and
laser equipment.
D9.1.1.6
Based on a review of the letter of intent, the results of the inspection, the LSO will make his
recommendations to the RLSC who, in turn, will authorize deactivation of the laboratory.
D9.1.1.7
Upon deactivation, all signs and labels, indicating where laser use was authorized for use shall
be removed.
D9.1.1.8
AT THIS POINT, FURTHER USE OF LASER EQUIPMENT BY THE SUBLICENSEE AND
INDIVIDUAL WORKERS OF THAT SUBLICENSE IS STRICTLY PROHIBITED.
D9.1.1.9
The LSO will label all laser equipment with a "Security Seal" to prevent any further use. These
security seals will only be removed at the expressed approval of the LSO.
D9.1.1.10
The term of deactivation of an authorized laser use area will be a MINIMUM OF FIFTEEN
DAYS AND A MAXIMUM OF UP TO TWO YEARS (or until the sublicense is due for renewal).
At the end of a deactivation period the sublicense may request, in writing, to renew the
deactivated status of the laboratory(s) for another term.
D9.1.1.11
During the period in which a laser use area is deactivated, the sublicense will remain in an
active status. If there are still active laboratories on the sublicense, all current rules,
regulations and policies governing that sublicense (relative to the active laboratories) remain in
D-17
effect. Since deactivated laboratories are no longer considered laser use areas, the
requirements for inspections no longer applies. However, the sublicensee is still responsible
for the retention of ALL records and files which were generated for that laboratory.
D9.1.2
A sublicensee may REACTIVATE a sublicense at any time AFTER the initial fifteen day period
if the following criteria are met:
D9.1.2.1
A TTU Form LS-2, Laser Amendment Application, must be filled out and delivered to the LSO.
D9.1.2.2
Any and all changes in work areas, storage areas, etc. must be reflected on the amendment
application and accompanied with a diagram.
D9.1.2.3
The LSO will review the request and inspect the laboratory area(s) and make his
recommendations to the Chairperson of the RLSC.
D9.1.2.4
After the Chairperson has approved the reactivation of the laser laboratory, it will, again, be
subject to the posting, required records, safety procedures, and survey/safety check
requirements as stipulated by local, state, federal, and TTU regulations and policies.
D9.1.2.5
At this time, the laser equipment may again be used and stored in that laboratory(s). However,
the laser equipment will be subject to a survey conducted by the LSO to ensure the laser(s)
meet all state and local requirements.
D10 DEACTIVATION/REACTIVATION OF EQUIPMENT
D10.1
Should a sublicensee foresee a period of time in which they do not plan to use specific laser
equipment, the laser may be deactivated, by meeting the following criteria:
D10.1.1
TTU form LS-2 Laser Amendment Application will be submitted to the LSO to deactivate and a
letter of intent that will include:
D10.1.1.1
A statement that the laser deactivated will be stored and secured against any use.
D10.1.1.2
A statement that all associated laser hazards are secure and contained to ensure compliance
with regulations.
D10.1.1.3
D-18
Upon receipt of the amendment application and letter of intent, the LSO will confirm
deactivation of the laser equipment and its storage area.
D10.1.1.4
Based on a review of the amendment application, the results of the confirmation, the LSO will
make his recommendations to the Chairperson of the RLSC who, in turn, will authorize
deactivation of the laser.
D10.1.1.5
Upon deactivation, all signs and labels, indicating where the laser was authorized for use shall
be removed.
D10.1.1.6
AT THIS POINT, FURTHER USE OF THE LASER EQUIPMENT BY THE SUBLICENSEE AND
INDIVIDUAL WORKERS OF THAT LASER EQUIPMENT IS STRICTLY PROHIBITED.
D10.1.1.7
The LSO will label the laser equipment with a "Security Seal" to prevent any further use. These
security seals will only be removed at the expressed approval of the LSO.
D10.1.1.8
The term of deactivation of authorized laser equipment will be a minimum of sixty days.
D10.1.1.9
During this period in which the laser is deactivated, the sublicense will remain in an active
status. If there are still active lasers on the sublicense, all current rules, regulations, and
policies governing that sublicense (relative to the active lasers) remain in effect. Since the
deactivated laser is no longer considered active, the requirements for inspections no longer
apply. However, the sublicensee is still responsible for the retention of ALL records and files
which were generated for that laser.
D10.2
A sublicensee may REACTIVATE a laser at any time AFTER the initial sixty-day period if the
following criteria are met:
D10.2.1
TTU Form LS-2, Laser Amendment Application, must be made to the LSO.
D10.2.2
Any changes in work areas, storage areas, etc. must be reflected on the amendment
application.
D10.2.3
The LSO will review the request and inspect the laboratory and make recommendations to the
Chairperson of the RLSC.
D10.2.4
D-19
After the Chairperson has approved the reactivation of the laser equipment, it will, again be
subject to the posting, required records, safety procedures, and survey/safety check
requirements as stipulated by federal, state, and local TTU regulations and polices.
D10.2.5
At this time, the laser equipment may be used and stored in that particular laboratory.
However, the laser will be subject to a inspection conducted by the LSO to ensure the unit(s)
meet all state and local requirements.
D11 RESPONSIBILITIES OF THE SUBLICENSEE
D11.1
The sublicensee has the following obligations:
D11.1.1
To assure the safe operation of the licensed laser(s) by authorized laser personnel and
account for any misuse, accidents, or injuries to persons or property;
D11.1.2
To submit an application for a laser sublicense or necessary amendments to update the
information in the latest sublicense before any work with lasers. There shall be no use of lasers
without first obtaining a sublicense or appropriate amendment from the RLSC and approval for
laser operation from the LSO;
D11.1.3
To ensure registration of all laser(s) under their authority, with the LSO (each laser(s)
purchased, donated, received, or otherwise constructed);
D11.1.4
To maintain records in accordance with national, state, and local regulations. This shall
include, but is not be limited to: laser eye protection inspections, incident/accident reports, LSO
laser lab inspections, registration, inventory forms, and other records concerning the laser(s)
under his/her control;
D11.1.5
To ensure that laser users have general laser safety training, specific hazard laser training,
and SOP training for class IIIB and IV lasers. The sublicensee will provide the SOP training;
D11.1.6
To receive approval for operation of a laser system before the installation of a laser and after
modifications have been made. All new or modified (i.e. installation setups that are different
from approved application) lasers must first be approved by the LSO before any operating of
the particular laser unit commences;
D11.1.7
To report any actual or suspected incidents resulting from a laser operated under his/her
authority to the LSO. If necessary, the sublicensee shall immediately obtain appropriate
medical attention for any worker involved in a laser accident;
D-20
D11.1.8
To provide to the LSO and maintain standard operating procedures (SOP) for all laser
equipment under their authority;
D11.1.9
To prohibit operation of the laser when adequate control of laser hazards are not met or when
personnel are not properly trained;
D11.1.10
To report to the LSO any inoperative lasers due to disassembly or destruction;
D11.1.11
To provide all lab personnel with the appropriate personal protection equipment (PPE)
required;
D11.1.12
To provide all lab personnel with the appropriate training and emergency procedures specific
to the laser being used;
D11.1.13
To correctly post work areas and all laser-producing equipment;
D11.1.14
To report possible incidents and actual exposures to the LSO;
D11.1.15
To report all lasers being transferred, sold, or decommissioned.
D12 RESPONSIBILITIES OF USERS AND OPERATORS
D12.1
To comply with all applicable safety rules and laser program requirements and those specified
by the RLSC/LSO and to be familiar with all standard operating procedures and emergency
procedures for the laser equipment under his/her control.
D12.2
To use and operate only those laser(s) which are listed on the sublicense.
D12.3
To maintain documentation of training with dates and signature.
D12.4
To report any departures from established SOPS to the sublicensee and LSO.
D-21
D12.5
To report all possible incidents and actual exposures to the LSO.
D13 PROGRAM REQUIREMENTS
D13.1
Purchase, Transfer, Shipping and/or Delivery
D13.1.1
Ordering lasers or laser equipment
D13.1.1.1
Requestor will contact the LSO via email.
D13.1.1.2
The Requestor will provide the following information:
a) Sublicensee
b) Description of item
c) Manufacturer/Vendor
d) Model and Serial Number
e) Quantity
f) Purpose
g) Location of intended use
D13.1.1.3
The LSO will:
a) Verify status of sublicense;
b) Document information received;
c) Contact Purchasing and grant approval.
D13.1.2
Transfer of laser equipment
D13.1.2.1
Requestor will contact the LSO and Property/Surplus Manager
D13.1.2.2
Requestor will provide the following information:
a) Laser specifications;
b) To whom the equipment will be transferred;
c) Time frame for the transfer.
D13.1.2.3
D-22
The LSO will:
a) Verify status and document information, and
b) Contact Property/Surplus Manager and grant approval
D13.1.3
Shipping and Delivery
D13.1.3.1
Requestor will contact the LSO
D13.1.3.2
The LSO will:
a) Verify status of sublicense and paperwork;
b) Document information received;
c) Contact Central Warehouse and grant approval.
D13.2
Facilities (25 TAC §289.301(v)(3))
D13.2.1
Laser work areas(s) will have restricted access from non-authorized personnel.
D13.2.2
Laboratories will have heat-chemical resistant materials in the beam paths (when applicable).
D13.2.3
Laser work areas and lab entrances will be posted with the correct warning signs. (signs
available from Laser Safety)
D13.2.4
All signage (sublicense, emergency numbers, etc.) shall be posted in prominent view.
D13.2.5
Laboratories will have all windows covered with appropriate materials.
D13.2.6
Laser dye, solvent, and gas laboratories will have ventilation, fume hoods, and gas cabinets
capable of handling and storing the chemicals being utilized in order to comply with regulatory
limits.
D13.3
Signage (25 TAC §289.301(v)(3))
D13.3.1
Laser equipment will be labeled with manufacturer and class designation.
D-23
D13.3.2
Laser equipment will have labels with warning, output, duration, medium, and wavelength.
D13.3.3
Laser protective housing and enclosures will be labeled during normal and servicing
operations.
D13.3.4
Labels will be specific to the hazards of the laser determined by the LSO.
D13.3.5
Signage must be posted during maintenance and servicing operations and as stated in the
Standard Operating Procedures, SOP’s.
D13.4
Control Area and Access
D13.4.1
Laser work areas(s) will have restricted access from non-authorized personnel.
D13.4.2
Class IIIB and Class IV laser laboratories will have safety interlocks or alternate control
methods approved by the LSO.
D13.4.3
All costs for installations and materials will be assumed by the sublicensee or their department.
D13.5
Training
D13.5.1
Training is available in 3 levels:
D13.5.1.1
Basic Level 1 – Fundamentals of laser principles;
D13.5.1.2
Administrative Level 2 – State regulations, TTU policies, and a brief review;
D13.5.1.3
Hazard Level 3 – Any additional training required by RLSC and LSO.
D13.5.2
D-24
Researchers are required to take Laser Training Levels 1 and 2 if they meet the following
stipulations:
D13.5.2.1
No training or experience;
D13.5.2.2
No documentation of training within the last five years.
D13.5.3
Researchers and Post-Doctorates are required to take Laser Training Level 2 if they meet the
follow stipulations:
D13.5.3.1
Have extensive training or experience;
D13.5.3.2
Have LSO approval.
D13.5.4
Students and Other Personnel are required to take Laser Training Level 1 if they meet the
following stipulations:
D13.5.4.1
No training or experience;
D13.5.4.2
No documentation of training within the last five years.
D13.6
Personal Protective Equipment (PPE)
D13.6.1
All laboratory personnel will be trained on the proper use of the following by Environmental
Health & Safety personnel:
D13.6.1.1
Laser eyewear
a) It will be in good condition and comfortable;
b) It will be labeled with wavelength and optical density; and
c) It will be inspected every year.
D13.6.1.2
Protective clothing
D-25
a) It will be tightly woven material.
b) It will be long sleeved.
D13.6.1.3
Chemical resistant gloves for handling of dyes and solvents.
D13.6.1.4
Various forms of shielding appropriate for the hazard.
D13.6.1.5
Hearing protection if work environment exceeds regulatory limits.
D13.7
Instrumentation
D13.7.1
Laser equipment will have protective housing.
D13.7.2
Laser safety interlocks for all class IIIB and IV.
D13.7.3
Laser equipment will have either a key switch or a computer code.
D13.7.4
Laser laboratories will have optical attenuators
D13.7.5
Laser equipment will have operational lights, alarms, and devices to notify others that the laser
is in “on.”
D13.8
Standard Operating Procedures
D13.8.1
The items listed are recommended to be included in the SOP’s for each laser. The information
can be revised in part to reflect major modifications that affect the laser’s performance and
operation.
D13.8.1.1
General Information:
a) Information of the laser owner;
b) Inventory control (TTU ID Number).
D13.8.1.2
System Information:
D-26
a) Description;
b) Location;
c) Class.
D13.8.1.3
Hazards Summary:
a) Beam information;
b) Non-Beam information.
D13.8.1.4
Required Control Measures:
a) Access Controls;
b) System Controls;
c) Personnel Controls.
D13.8.1.5
Alignment Procedures:
a) By whom;
b) Conditions;
c) Can be general for research purposes with the RLSC approval;
d) Buddy Policy required for Class IIIB and IV laser laboratories.
D13.8.1.6
Emergency Instructions
D13.8.1.7
All laser operators must sign the TTU form, LS-8 SOP Training Acknowledgement, to
document that they have been trained on the SOP of the laser.
D13.9
Modification
D13.9.1
A laser or laser system that requires modification that significantly changes the SOP and
performance shall not be operated until approved by the LSO.
D13.9.2
Modifications not reported to the LSO are in violation of the SOP approved by the RLSC and
terms of the sublicense.
D13.10
Usage Logs
D13.10.1
D-27
The usage logs must be dated and initialed by operator each time the laser equipment is
operated. This log should include notes of adjustments, operation conditions, maintenance,
servicing, and problems.
D13.11
Record Keeping
D13.11.1
The laser sublicensee should keep the following for documentation and inspection purposes in
one notebook. The records shall be available during routine monitoring of the lab by Laser
Safety personnel and/or regulatory agencies.
D13.11.1.1
Standard Operating Procedures (SOP)
D13.11.1.2
Signatures of SOP and PPE Training
D13.11.1.3
Usage Log
D13.11.1.4
Sublicensee Information
a) Sublicense – All Sublicensees should have a current copy.
b) Amendments/Renewals – All copies of personnel / laser changes.
c) Past Inspection Reports – All inspection reports sent from the LSO.
d) LSO Memos – All memos from the LSO are available to personnel.
e) Laser Inventory – All current laser inventories for inspections.
D13.12
General Services
D13.12.1
All laser activity must be suspended until these services have been performed:
D13.12.1.1
All laboratories must be surveyed (visual inspection) for any possible hazards within 24 hours
of the scheduled cleaning or other services. The lab shall remain in order until after the
services, and it is the responsibility of the sublicensee to ensure this. Records of the visual
surveys must be kept.
D13.12.1.2
Exposure of general service personnel to preventable hazards will result in the suspension of
general services and a probationary period, at which time the status of the sublicense will be
determined by the RLSC.
D-28
D13.13
Custodial Services
D13.13.1
All laser activity must be suspended until these services have been performed:
D13.13.1.1
To obtain special custodial service (i.e., scrubbing, stripping, and finishing floors), call
Custodial Services (744-1866).
D13.13.1.2
Prior to scheduling the cleaning, the following preparations must be made:
a) The floor must be cleared of all obstacles such as boxes, books, containers, and
chemical-labeled items. This must be done by authorized personnel. Visual surveys of
the lab must be performed within 24 hours;
b) Custodial Services will schedule the work and call to confirm the date with the
requestor;
c) The custodians will leave a checklist in the laboratory. The checklist must be completed
and signed by the lab personnel;
d) Laser laboratories requesting cleaning service will be furnished with a Request for
Custodial Service door card. The door card must be signed by the sublicensee or LSO,
and left on the outside of the door on the day the work is to be accomplished;
e) The sublicensee or a worker on that sublicense is required to be in the lab during the
cleaning of all Class IIIB and IV laser laboratories.
D13.13.1.3
To obtain routine custodial service, call Custodial Services (744-1866) to receive a door card.
Routine custodial service includes only sweeping floors, empty trash containers, and replace
paper in paper dispensers.
a) The Sublicensee will complete, sign and date a door card.
b) Place the card on the outside of the laboratory door before 6:00 PM on the day of the
routine cleaning. These cards are only good for one day. These cards assure the
custodians that there are no laser hazards.
c) The sublicensee or a worker IS NOT required to be in the lab during the routine
cleaning. Routine cleaning will probably be scheduled between 6:30 PM and 8:00 PM.
D13.14
Building, Maintenance, and Construction (BM&C Service)
D13.14.1
All laser activity must be suspended until these services have been performed:
D13.14.1.1
D-29
The LSO or sublicensee can give clearance for BM&C to perform work in an authorized laser
use/storage area. The laboratory must be surveyed within 24 hours of the scheduled work.
D13.14.1.2
The sublicensee or a worker IS required to be in the lab during the BM&C services of all Class
IIIB and IV laser laboratories.
D13.15
Other Services
D13.15.1
All laser activity is suspended until these services have been performed.
D13.15.1.1
Departmental technicians may enter and perform routine duties provided they have the
required laser training requirements, and are granted permission by both the sublicensee and
the LSO.
D13.15.1.2
Company technicians and servicemen servicing or checking items on any laser equipment
must have the permission of the LSO. The Sublicensee will be required to have the lab
surveyed within 24 hours prior to their visit. All laser hazards should be rechecked which
would be unfamiliar to the technicians and servicemen. Records of these surveys must be
kept.
D13.15.1.3
The sublicensee or a worker is required to be in the lab during the services.
D14 LAB PERSONNEL
D14.1
Authorized Personnel
D14.1.1
Personnel such as faculty, students and other professionals, usually research or laboratory
assistants or workers that may be engaged in education, laboratory research, and research
support activities may work with lasers but only after completing the required safety training
programs and the express approval of the RLSC.
D14.1.1.1
The names of authorized personnel will be listed on the sublicense. Individuals not listed on
the sublicense are not authorized personnel.
D14.2
Non-Authorized Personnel
D-30
D14.2.1
Faculty, students, and other professionals and non -TTU personnel which have not had TTU
Laser Safety Training nor the express approval of the RLSC or whose names do not appear
on a given laser sublicense.
D-31
SECTION C-III: LASERS
D15 BASIC LASER CHARACTERISTICS
D15.1
Lasers
D15.1.1
Laser is an acronym for Light Amplification by the Stimulated Emission of Radiation. The
major components of a laser are: the excitation mechanism, active medium, and an optical
cavity. In general, there are four major laser types: solid state, semi-conductor, gas and liquid
(dye). The laser light emits non-ionizing electromagnetic radiation that is ultraviolet, visible, or
infrared light.
D15.1.1.1
Pulsed Lasers – a laser that delivers energy in the form of a single pulse or train of pulses
which is delivered in less than .25 seconds. Pulsed Lasers are expressed as the total energy
per pulse (joules).
D15.1.1.2
Continuous Wave Lasers – a laser whose output is operated in a continuous mode for at least
a period of .25 seconds. Continuous Wave Lasers are expressed as the average power
(watts).
D15.2
Intensity Terms
These are important laser terms that describe degrees of intensity which a particular laser is
capable of and are also, used in regulatory standards.
Radiance – The laser energy per unit area of the beam.
Irradiance – The laser power per unit area of the beam
D15.3
Classification
D15.3.1
ANSI and LIA Classification
D15.3.1.1
The American National Standards Institute (ANSI 2000) has developed four categories of
hazard potential. The classification scheme is based on the ability of optical emissions from a
laser system to produce injury to personnel. The higher the classification number, the greater
the hazard potential.
The Laser Institute of American (LIA) Laser Safety Guide describes each class as follows:
D-32
D15.3.2
Class I – Lasers or laser systems that do not, under normal operating conditions, pose a
hazard.
D15.3.3
Class II – Low-power visible light lasers or laser systems that, because of the normal human
aversion response (i.e. blinking, eye movement, etc.), do not normally present a hazard, but
may present some potential for hazard if viewed directly for extended periods of time (similar to
many conventional light sources).
D15.3.4
Class IIIA – Lasers or laser systems that normally would not injure the eye if viewed for only
momentary periods (within the aversion response period) with the unaided eye, but may
present a greater hazard if viewed using collection optics.
D15.3.4.1
Class IIIA lasers must carry a caution label. Another group of Class IIIA lasers have DANGER
labels and are capable of exceeding permissible exposure levels for the eye in 0.25 seconds
and still pose a low risk of injury.
D15.3.5
Class IIIB – Lasers or laser systems that will produce eye damage if viewed directly. This
includes intrabeam viewing of specular reflections. Normally, Class IIIB lasers will not produce
a hazardous diffuse reflection.
D15.3.6
Class IV – Lasers or laser systems that produce retinal damage from direct or specular
reflections, but may also produce hazardous diffuse reflections. Such lasers may produce
significant eye and skin radiation hazards as well as fire hazards.
D15.4
Hazards
D15.4.1
Beam Hazards
D15.4.1.1
Beam
Direct beam viewing is dependent on the laser classification. The hazard increases beginning
with Class II as minimal to Class IV as very dangerous.
D15.4.1.2
Beam Reflections
D-33
These types of reflections can sometimes occur when modifications are made to Class I
through Class III; however it is highly dependent on the laser environment. For this reason,
the LSO should always be consulted. Class IIIB and IV hazards include specular and diffuse
reflections which are dependent on the materials, objects, and lenses in the laser area as well
as the wavelengths of the beam. The determinations of these are:
a) Specular Reflection – The reflection is mirror-like due to smooth surfaces being less
than the incident wavelength.
b) Diffuse Reflection – This type of reflection is much more scattered due to the
irregularities of the surface.
D15.4.2
Non-Beam Hazards
These hazards vary widely and are specific to the materials and the experiments involved with
the laser system.
D15.4.2.1
Physical – Factors that contribute to injury are: fire, explosions and electrocutions from arc and
filament lamps, capacitors, wiring, power supply’s, circuits, solvents, and gases.
D15.4.2.2
Chemical – Various chemical agents include dyes, solvents, gases, and laser-generated
airborne contaminants (dusts, mists, fumes, and smokes).
D15.4.2.3
Radiation – The types of radiation’s vary from infrared, ultraviolet, x-ray, and visible which the
laser produces. The radiation is dependent on the wavelength of the laser in the
electromagnetic spectrum.
D15.5
Biological Effects
Biological effects are dependent on the laser beam properties and vary with duration,
wavelength, photon energy, target tissue, and tissue condition. Therefore, all effects have to
be weighed on a case by case basis. Safety and prevention are the best protection against
personal injury.
D15.5.1
Eye
D15.5.1.1
Injuries to the eye are primarily due to two main types of biological effects which may or may
not occur separately. Biological effects to the eye are dependent on exposure conditions,
wavelength, and irradiation levels. The main tissue types of the eye which suffer these
biological effects are the cornea, lens and retina.
D-34
Figure 1: Diagram of Eye Structure
D15.5.1.2
Photochemical – High energy laser light photons may interact with molecules in the eye tissue
causing chemical bonds to be broken. The injury depends on the tissue of the eye affected.
D15.5.1.3
Thermal – Heat dissipation is a major factor in causing to the eye. Heat flow could travel
horizontally along the same tissue or vertically through different depths of underlying tissues.
D15.5.1.4
Summary – Types of eye damage from laser radiation are
• Cornea >>> Corneal Burn
• Lens >>> Cataracts
• Retina >>> Decreased Vision/ Vision Loss
• Optic Nerve >>> Blindness
D15.5.1.5
Electromagnetic Radiation to the Eye
Visible & Near Infrared
Cornea
Lens
Optic Nerve
Retina
Microwaves and Gamma
Rays
Near Ultraviolet
Far Ultraviolet &
Far Infrared
D-35
D15.5.2
Skin
Skin tissue is at risk from laser exposure. The effects to the skin are considered secondary;
the higher the power of the laser - the greater the risk to the skin.
D15.5.2.1
Thermal – It is an actual burn to the skin; the severity of the burn is dependent upon the
penetration of the skin tissue.
D15.5.2.2
Ultraviolet – Due to the intense ultraviolet beam exposure, the skin will be affected. Typically,
this affect is equivalent to a sunburn.
D15.5.2.3
Photosensitivity – This effect may occur when laser personnel are currently on medications
that would cause sensitivity to light. If medications warn against avoiding sunlight, then laser
use should also be avoided.
D15.5.2.4
Summary – Types of skin damage from laser radiation are
• Sunburn
• skin burns
• skin cancer, and
• skin aging
D15.5.3
Eye vs Skin Exposures
CIE Band
Visible
UV-C
UV-B
UV-A
IR-A
IR-B
IR-C
100
280
315
400
760
1400
3000
10
6
Photokeratitis
Retinal Burns
Corneal Burns
Cataracts
Cataracts
Erythema
Vision
Degradation
Skin Burns
B
i
o
E
f
f
e
c
t
s
D-36
D16 SPECIFIC LASER REQUIREMENTS
D16.1
Class IIIB and IV Lasers
D16.1.1
All Class IIIB and IV lasers require the following five items to be in full compliance of 25 TAC
§289.301. Exemptions will be determined by substituting engineering and administrative
controls reviewed by the RLSC and the LSO.
D16.1.1.1
Maximum Permissible Exposure (MPE) – The level of laser radiation to which a person may be
exposed without hazardous effect or adverse biological changes in the eye or skin.
Parameters that determine the MPE are wavelength, duration, exposure conditions (point or
extended source, cw or pulsed, pulse width, pulse repetition frequency). MPE are given in
units of radiant exposure (J/cm
2
).
D16.1.1.2
Nominal Hazards Zone (NHZ) – The space within which the level of direct, reflected, or
scattered radiation during operation exceeds the applicable MPE. Exposure levels beyond the
boundary of the NHZ are below the applicable MPE level.
NHZ = 1 4P
(MPE)
D16.1.1.3
Accessible Emission Limits (AEL) – The maximum accessible emission level permitted within a
particular laser class. AEL is in units of uW’s.
AEL = MPE x (area of limiting aperture)
D16.1.1.4
Optical Density (OD) – The logarithm to the base ten of the reciprocal of the transmittance.
The OD will be labeled on the eyewear for each laser.
OD = log E
i
E
i
= incident beam irradiance in W cm
2
D16.1.1.5
Interlock – A switch that, when activated, will interrupt normal operation of a laser by closing a
shutter or de-energizing the system.
D16.2
Infrared Lasers
= Divergence in radians
P = Power in watts
= 3.1415
a = aperture in cm
MPE
a
2
1/2
D-37
D16.2.1
Fire resistant materials are to be used in and around the laser work area.
D16.3
Fiber Optic Lasers
D16.3.1
The use of a tool shall be required for the disconnection of a connector of the laser fiber optic
cable for servicing and maintenance purposes, if the connector is not within a secured
enclosure. All connectors shall bear the appropriate label.
D16.4
Constructed Lasers
D16.4.1
All “constructed lasers” built from separate components must comply with the 21 Code of
Federal Regulations (CFR) Part 1040, Federal Laser Product Performance Standard. Contact
the LSO for more specific information.
SECTION IV: EMERGENCY PROCEDURES
INTRODUCTION
This section outlines basic emergency procedures. An emergency situation or accident can arise
from the use, the misuse, or abuse of laser equipment. This section is intended to enhance a
sublicensee’s and worker's ability to react properly to laser accidents.
Due to the broad scope of possible accidents at TTU, a comprehensive listing of all steps to be
followed for each type of accident is impracticable. Instead, a researcher must use the
following basic procedures and apply them to his/her individual situation. The best advice for
protection against laser accidents is to prepare for them.
It is the responsibility of each sublicensee to develop and ensure that personnel working under
their supervision have reviewed a practical emergency plan. This plan is to include all required
telephone numbers and is to be posted in each laser work area. (Reference TTU - Operating
Procedure 78.01 Vol.III)
D17 GENERAL INFORMATION
D17.1
A laser incident* at TTU is defined as any accident, single exposure, or suspected exposure as
set forth in 25 TAC §289.301.
D17.1.1
Users will report all laser incidents.
D18 ORGANIZATION AND AUTHORITY
D-38
D18.1
The LSO is responsible for investigating any laser incident at TTU.
D18.1.1
The LSO will promptly report all investigation findings to the RLSC and to the Texas Bureau of
Radiation [reference 25 TAC §289.301(xx)] for direction and action.
D18.1.2
If preliminary findings of an incident presented to the RLSC indicate there is probable cause of
neglect or violation of state, federal, or local regulations or policies, the sublicensee involved will
attend the next RLSC meeting to present his/her account of the incident.
D18.1.3
In the event of a major emergency situation the LSO shall have the authority to bring the situation
under control.
D18.5
The LSO has the responsibility to see that each laser sublicensee/worker:
• Recognizes a laser emergency;
• Has the training to prevent or confine a laser accident;
• Has the training to recognize possible risks of exposure.
D18.6
Each sublicensee is responsible to assist the LSO in controlling and/or investigating a laser
accident. Furthermore, the sublicensee is responsible to assist the laser exposure victim(s) in
getting timely medical attention.
D19 FIRES, EXPLOSIONS, OR MAJOR EMERGENCIES
D19.1
The laser sublicensee should:
• Notify all persons in the area to leave at once and turn off all electrical laser equipment.
• Notify the Lubbock Fire Department, UPD, TTU Fire Marshall, the LSO and other
supervisory personnel. Give them the address and the location of the fire.
• Caution firemen about the current situation in the area. Be ready to advise them on the
location of laser(s) and other equipment or chemicals, and provide any other information
that may be needed to avoid hazardous exposure of personnel
• Be available to evaluate or help evaluate the extent of damage to materials and
equipment.
D19.1.2
All sublicensees and workers will be required to file an incident report with the LSO.
D-39
D19.1.3
If the fire is minor (individual decision) and there are no chemical hazards involved, a sublicensee
or worker may attempt to put out the fire with approved firefighting equipment.
D20 INCIDENTS: POSSIBLE EXPOSURE OR INJURY
D20.1
The laser sublicensee should:
• Immediately remove affected person(s) from the area and notify the LSO.
• Secure the area.
• Accompany the affected persons(s) to the nearest emergency center immediately for
clinical observation. Inform the attending medical personnel that injuries occurred as the
result of a laser accident. Be prepared to answer any questions concerning the accident
or type of laser involved.
D20.1.1
Assist the LSO in obtaining all details of the incident.
D20.2
Persons involved in the incident will not be permitted to work with the laser equipment until
exposure results have been received and the LSO has determined that exposure limits are not
exceeded.
D20.3
The LSO will provide reports to the RLSC and regulatory agencies.
D21 LOSS OR THEFT
D21.1
Any loss or theft of laser(s) equipment shall be immediately reported to the LSO and TTU police.
D21.2
The LSO will provide required notification to the Bureau of Radiation Control.
D21.3
Laser equipment involved in an accident, fire, flood, etc. MAY NOT BE USED until tested
by the LSO and found to be in proper and safe operating condition. The LSO will
determine the extent of damage and analyze the recovery plan.
D22 EMERGENCY PHONE NUMBERS
TTU RADIATION SAFETY OFFICE ................................................................................. 742-3876
LSO (HOME) .................................................................................................................... 298-4621
CHAIRMAN, RADIATION LASER SAFETY COMMITTEE (HOME) ............................... 828-5787
D-40
LUBBOCK FIRE DEPARTMENT ..................................................................................... 765-5757
TTU FIRE MARSHAL (HOME) ........................................................................................ 799-1701
TTU POLICE DEPARTMENT .......................................................................................... 742-3931
CAMPUS EMERGENCY ................................................................................................ DIAL 9911
TEXAS BUREAU OF RADIATION CONTROL (BRC) ........................................... ( 512) 835-7000
IF TTU RADIATION EMERGENCY PERSONNELCANNOT BE CONTACTED CALL:
BRC 24 HOUR EMERGENCY PHONE NUMBER ................................................. (512) 458-7460
BRC-REGION II RADIATION CONTROL (CANYON) .......................................... (806) 655-7151
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FOREWORD
Texas Tech University is dedicated to the safety of all members of its community regardless of
location. The Field Safety Manual is constructed under the remit of the Department of
Environmental Health and Safety and provides a guide to the planning and execution of safe
research and education experiences in field locations (e.g., non-traditional, off-campus
locations).
When working in an off-campus location all rules, regulations, guidelines, and safety protocols
established by agency responsible for the work area (Federal, State, County of City
Government, or private entity) must be followed and accounted for during the hazard and risk
assessment process.
Title IX at Texas Tech
Texas Tech is committed to providing its students, faculty, and staff with an educational and
workplace environment free from any form of unlawful discrimination. The Texas Tech
community is dedicated to fostering and supporting a culture of mutual respect and
communication. Texas Tech University does not tolerate discrimination or harassment of
students based on or related to sex, race, national origin, religion, age, disability, protected
veteran status, or other protected categories, classes, or characteristics. While sexual
orientation and gender identity are not protected categories under state or federal law, it is
Texas Tech University policy not to discriminate on this basis. Actions related to admission,
discipline, housing, extracurricular and academic opportunities shall not be made based on a
student's protected status. Discriminatory behavior is prohibited regardless of the way it is
exhibited, whether verbally, in writing, or electronically displayed or conveyed. Individuals who
violate these policies and laws are subject to disciplinary action, up to and including expulsion.
Examples of the types of discrimination and violence that are strictly prohibited by Texas Tech
include but are not limited to: sexual harassment, the failure to provide equal opportunity in
athletics, discrimination in a school's science, technology, engineering, and math (STEM)
courses and programs, discrimination based on pregnancy.
In addition to Title IX, certain Clery specific crimes are also considered to be Title IX violations
and will be handled by the university as mandated under both statutory requirements. These
include but are not limited to sexual misconduct, domestic violence, dating violence, and
stalking.
Title IX website
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TABLE OF CONTENTS
Foreword and Title IX Information………………………………………………........... E-i
Helpful Telephone Numbers and Links………………………………………………... E-iii
E1 PURPOSE………………………………………………………………………… E-1
E2 ACRONYMS AND DEFINITIONS……………………………………………… E-1
E3 PRE-PLANNING…………………………………………………………………. E-3
Risk and Hazard Assessment………………………………………………………….. E-3
Field Safety Plan…………………………………………………………………………. E-3
Equipment………………………………………………………………………………… E-4
Field Safety Briefing……………………………………………………………………… E-6
Medical Treatment and/or Evaluation………………………………………………….. E-7
E4 FIELD HAZARDS………………………………………………………………... E-7
Vehicles…………………………………………………………………………............... E-8
Vehicle Maintenance…………………………………………………………………….. E-8
ATVs and Related Vehicles…………………………………………………………….. E-9
Machinery and Equipment………………………………………………………………. E-10
Boats and Other Watercraft……………………………………………………………. E-11
Terrain…………………………………………………………………………………….. E-12
Weather and Climate…………………………………………………………………….. E-14
Severe Weather………………………………………………………………………….. E-15
Fauna and Flora………………………………………………………………………….. E-16
Disease and Pathogens…………………………………………………………………. E-17
Remote / Overseas Locations………………………………………………………….. E-18
Chemicals and Biological Materials……………………………………………………. E-19
The Public………………………………………………………………………………… E-20
E5 PERSONAL SAFETY…………………………………………………………… E-22
E6 ESTABLISHING CAMPSITES…………………………………………………. E-23
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HELPFUL TELEPHONE NUMBERS AND LINKS
Emergency: In the event of an emergency call 911.
National Park Service Camping Information
General Outdoor Safety: For more information on outdoor and recreational safety including
North America Hunting Season and regulations, contact the U.S Forest Service. 800-832-1355
General Health: The Centers for Disease Control and Prevention (CDC) offers a website that
describes many topics related to travel, both domestic and international
U.S. Department of Labor – Occupational Safety & Health Administration: Assists with design,
implementation and evaluation of health and safety programs in the workplace
Disease: The Centers for Disease Control and Prevention (CDC) provides detailed information
about many diseases that may occur in the U.S. and internationally and risks of disease in
general, and specific to the field location and its environment may be researched.
State Departments of Health Services and Infection Disease Control: All states in the U.S.
have departments dedicated to providing information and guidance on state level (general and
specific) health and disease risks. The Texas Department of State Health Services Infectious
Disease Control Unit provides information in Texas, Tel: 512-458-7676; Toll Free: 1-888-963-
7111.
Travel Health & Outbreaks: Information on international and global health and disease risks,
including outbreaks of infectious diseases and international travel health recommendations are
provided by the World Health Organization (WHO).
Travel Advisories: Travel advisories are announced through the U.S. Department of State.
Current travel warnings, public announcements, and consular information sheets
National Weather Service
National Weather Service forecasting
National Weather Service Flood Safety
CDC Lightning Safety
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E1 PURPOSE
To set forth policies, procedures and practices of informing employees and students at Texas
Tech University about the health hazards associated with activities conducted in field sites.
d
The traditional campus resources such as Environmental Health and Safety, Texas Tech
Police, Office of Emergency Management, and Office of Risk Management are typically not
available at remote field sites. Field work should be carefully planned prior to departure to the
field site(s)
d
.
Due to the constantly changing conditions of field research, the emphasis on proper training
and preparedness is of utmost importance for all people entering the field. All fieldwork
warrants a pre-trip training regarding foreseen hazards, appropriate precautions,
communication options, and emergency procedures.
It is the policy of Texas Tech University to conduct all institutionally sponsored activities safely
and in a manner that protects the health and well-being of all participants. All participants in
field-based activities have a responsibility to promote a safe working environment, and all
activities will be designed, conducted, and operated in a manner that reasonably protects
human health and safety. Adherence to these principles is necessary for the University to
achieve its mission.
E2 ACRONYMS AND DEFINITIONS
E2.1
Acronyms
ANSI- American National Standards Institute
cc – engine capacity in cubic centimeters
DOT- Department of Transportation
GPS- Global Positioning System
DEFRA- Department for Environment, Food and Rural Affairs
PPE- Personal Protective Equipment
SPF- Sun Protection Factor
TTU- Texas Tech University
E2.2
Definitions
Benchmark - something that serves as a standard by which others may be measured or
judged, or a point of reference from which measurements may be made.
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Designated Contact – An individual not accompanying the field excursion supplied with all
Field Safety Plan information. This individual will conduct the established check-in
communications with the field group and act on the field group’s behalf should an emergency
arise. Individual must have 24 hour / 7 days a week availability and be able to execute
emergency procedures if needed.
Fauna - animal life especially the animals characteristic of a region, period, or special
environment
Field Group – group of individuals actively engaged in research activities at the field site
Field Safety Briefing – must occur prior to departure when students are participating and
should include a review of the hazard and risk assessment, provision of emergency contact
information, emergency procedures, and the schedule of work.
Field Site – Any site where field work or research is being conducted in an outdoor
environment and may include (but is not limited to) field stations, natural reserves, private
lands, public lands or parks, wilderness areas, coastline, or waterways, including those owned
and managed by Texas Tech University System, and more controlled sites such as
construction areas, excavations, green houses, agricultural fields, commercial facilities and
mines.
Field-Site Kit - a collection of materials appropriate to the location and nature of field-activities
Field Trip Leader – designated individual responsible for the safety of all field group
personnel,
as well as the safety of all equipment, vehicles and structures involved
Flora - plant, bacterial, or fungal life especially such life characteristic of a region, period, or
special environment
Fording Points - a place where a river or other body of water is shallow enough to be crossed
by wading.
Go / No Go Criteria - an individual group determination based on possible risks to the field
group
during the planned research time.
Hazard Assessment - a process of identifying hazards, evaluating the risks presented by those
hazards, and managing the risks of the hazards to be performed by incorporating appropriate
hazard controls into the experimental design process.
Trekking poles - common hiking accessory that function to assist walkers with their rhythm, to
provide stability, and reduce strain on joints on rough terrain
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E3 PRE-PLANNING
E3.1
Risk and Hazard Assessments
d
E3.1.1
Field Trip Leader(s)
d
of the field-activity are responsible for conducting a risk and hazard
assessment
d
for each field-based activity that will establish the viability for members of the
Texas Tech University community to safely participate in the proposed activity.
The assessment will establish criteria for participation in the activity and identify hazards, and
their risks, for participants. The assessment will also establish “go/no go” criteria
d
and
benchmarks
d
for continuation or withdrawal from a field environment. The assessment will
identify risks and hazards that must be addressed in the Field Safety Plan.
Appendix EA contains a Field Research Risk Assessment Tool.
E3.2
Field Safety Plan
E3.2.1
Leaders of the field-activity are responsible for creating a Field Safety Plan that must include:
E3.2.1.1
A clear definition of field site(s)
d
to be visited, defined on maps included in the document
and/or by providing GPS coordinates.
E3.2.1.2
Routes to, from and in between field sites
d
.
E3.2.1.3
Timeline of proposed work.
E3.2.1.4
Local emergency contact information, including Police/Sherriff Departments and appropriate
State and Federal Offices (National Forest Service, National Park Service offices, State Park
Headquarters).
E3.2.1.5
Assessment of potential field hazards.
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E3.2.1.6
Establishment of Go / No Go Criteria
d
and benchmarks
d
.
E3.2.1.7
Identification of required protective and emergency equipment.
E3.2.1.8
Standard operating procedures for all field activities being conducted.
E3.2.1.9
A list of all field participants and emergency contact information.
E3.2.2
Field Safety Plan must be read and signed by all field participants. The plan shall be sent to
EHS for additional review and routing to the cognizant committee/department, as needed.
E3.2.3
A copy of the Field Safety Plan must be given to the Designated Contact
d
(e.g., Department
Chair) prior to the field group
d
departing for the field site
d
.
E3.3
Equipment
E3.3.1
Field researchers must assemble a field-site kit
d
with materials appropriate to the location and
nature of field activities. A list of items in the kit should be part of the Field Safety Plan, and the
contents of the kit must be checked for completeness, functionality, and compliance prior to
departure on every trip. A list of kit items is included in Appendix EB.
E3.3.2
Items required for inclusion in the kit are:
E3.3.2.1
The Field Safety Plan with emergency procedures and protocols
E3.3.2.2
Information on Institutional Insurance Policies
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E3.3.2.3
Insurance information for vehicles and personnel,
E3.3.2.4
Any required permits including TTU permits and permits from local enforcement agencies,
E3.3.2.5
Appropriate communication equipment (e.g., radio, cell, or satellite phone),
E3.3.2.6
Appropriate PPE (safety glasses/goggles, gloves, hard hat, sturdy work boots, etc.),
E3.3.2.7
First aid kit of adequate size for the group and location of field site(s)
d
,
E3.3.2.7(a)
Repack first aid kits prior to each field excursion.
E3.3.2.7(b)
Replace any used or expired items.
E3.3.2.7(c)
Customize your kit for your destination, tasks, group size and level of training.
E3.3.2.7(d)
Pack extra gloves.
E3.3.2.7(e)
At least two field participants must be trained in first aid and CPR.
E3.3.3
Items that should be considered for inclusion dependent on field-site
d
:
E3.3.3.1
Insect repellent (DEET 30-50%)
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E3.3.3.2
Sunscreen (at least SPF 30), sun hat (three to seven-inch brim), long sleeves, and\or other
SPF blockers
E3.3.3.3
Spare clothes, including jackets, hats, and blankets for cold climates.
E3.3.3.4
Flashlight or headlamp
E3.3.3.5
Map, compass, GPS
E3.3.3.6
Extra food/snacks
E3.3.3.7
Matches or fire starter
E3.3.3.8
Signal/mirror, whistle
E3.3.3.9
Knife or multi-tool; duct tape for basic repairs
E3.3.3.10
Extra batteries
E3.3.3.11
Other equipment specific to the educational and/or research mission of the trip.
E3.4
Field Safety Briefing
d
E3.4.1
Each department and/or instructor is responsible for conducting appropriate Field Safety
Briefing
d
/ Training prior to the field excursion. The briefing must discuss the Field Safety Plan,
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all field operations, potential hazards, use of protective and emergency equipment and
emergency procedures.
E3.4.2
All participants in research-oriented field activities should complete a risk and hazard
assessment
d
as part of their on-going professional development and engagement with the
responsible conduct of research requirements.
E3.4.3
Attendance and participation in the Field Safety Briefing
d
must be documented.
E3.5
Medical Treatment and/or Evaluation
E3.5.1
Field activity participants must obtain any recommended vaccinations and make medical
preparations appropriate for the location of the field site
d
.
Contact TTU Student Wellness Center, the Health Sciences Center or appropriate travel health
clinic to learn about the required and recommended vaccinations for your intended location.
E.5.1.1.1
Preparations for handling animals that are recognized carriers of infectious diseases or being
in location(s) that are known to be hazardous must be described in the Field Safety Plan.
Consult with IACUC if needed.
E3.5.1.2
All participants with chronic ailments (e.g., diabetes, asthma) or are susceptible to acute
reactions to particular situations (e.g., allergies) or take daily medications are recommended to
share their potential health concerns with a trusted partner in the group (this may include the
Field trip leader
d
).
E4 FIELD HAZARDS
Animal use or handling falls under the purview of the Institutional Animal Care and Use
Committee (IACUC). See TTU OP 74.11.
This document identifies common field hazards, describes common risks for each type and
possible mitigation and emergency responses. The hazards listed are not comprehensive and
other risks may arise. Field trip leaders
d
are expected to identify and list all risks during the
pre-planning process.
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E4.1
Vehicles
E4.1.1
Vehicle Storage
E4.1.1.1
Do not allow non-employees or children into storage structures.
E4.1.1.2
Vehicles must be stored away from structures housing livestock.
E4.1.1.3
Vehicles must not be stored with fuel storage tanks.
E4.1.1.4
Vehicles must be parked/stored to allow easy entrance and exit from storage structure.
E4.1.1.5
Maintain clear, well-lit working spaces in and around vehicle and machinery storage buildings.
Eliminate slips, trips, and falls.
E4.1.1.6
Vehicle keys must be secured if the vehicle is to be left unattended or unsupervised.
E4.1.1.7
Check that all structures, including windows, doors, and gates are secured and locked upon
departure.
E4.1.2
Vehicle Maintenance
E4.1.2.1
The vehicle selected for each field activity should be appropriate for the terrain, road conditions
and other predicted hazards to be encountered during fieldwork.
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E4.1.2.2
It is recommended that departmental or TTU motor pool vehicles are used for all field
excursions.
E4.1.2.3
The vehicle should be current on oil changes and manufacturer service schedule.
E4.1.2.4
The vehicle should be equipped with a fully pressurized spare tire, jack, tire-lever, functioning
flashlight, and appropriate safety signage.
E4.1.3
Use of All-Terrain Vehicles (ATVs) and Related Vehicles / Equipment
E4.1.3.1
The National Safety Council has developed recommendations for using ATVs. The
recommendations include:
E4.1.3.1(a)
All personnel using small vehicles in the field must take training courses prior to use and
demonstrate competency on the vehicle type under similar conditions that will be present in the
field.
E4.1.3.1(b)
ATVs with an engine size of 70cc to 90cc should be operated by people at least 12 years of
age. ATVs with an engine size of greater than 90cc should only be operated by people at least
16 years of age.
E4.1.3.1(c)
Wear appropriate riding gear: DOT-, Snell ANSI-approved helmet, goggles, gloves, over-the-
ankle boots, long-sleeve shirt, and long pants.
E4.1.3.1(d)
Read owners' manuals carefully.
E4.1.3.1(e)
Never carry a passenger on a single-rider ATV, and no more than one passenger on an ATV
specifically designed for two people.
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E4.1.3.1(f)
Any added attachments affect the stability, operating and braking of the ATV.
E4.1.3.1(g)
Vehicle attachments should be evaluated for safe usage prior to installation.
E4.1.3.1(h)
Do not operate the ATV on streets, highways, or paved roads.
E4.1.4
Vehicle Handling
E4.1.4.1
Reduce vehicle speeds to meet the safety hazards of rock conditions, and monitor speed and
vehicle distancing to avoid sudden breaking and aquaplaning
E4.1.4.2
Reduce vehicle speed when entering standing water, streams, and rivers to avoid mechanical
damage and becoming stranded (e.g., engine flooding, loss of control).
E4.1.4.3
Unless appropriately equipped (e.g., 4- or all-wheel drive) avoid water-saturated off-road
terrain to minimize risk of being stranded.
E4.2
Machinery and Equipment
E4.2.1
All tools, equipment, and machinery must be checked for proper functioning as described by
the manufacturer before and after each use.
E4.2.2
Machinery and equipment should be serviced and maintained according to the manufacturer
recommended schedule.
E4.2.3
All electrical (power) tools must be properly grounded or double insulated and all guards or
shields must be in place.
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E4.2.4
All users of machinery and equipment must wear the necessary personal protective equipment
(PPE) and make sure that clothing has no strings or loose ends that could be caught by
machinery. Long hair must be tied back to prevent entanglement.
E4.2.5
The field site
d
must be checked for hazards prior to use of equipment and vehicles, with
particular emphasis on checking for presence and height of electrical lines, aerial impediments
(e.g., tree limbs, overhangs, etc.), ensuring unobstructed working space and that other
fieldworkers are outside the minimum recommendations and/or maintaining safe distances
from field operations.
E4.2.6
Field participants must be trained on specific equipment use prior to using equipment
independently.
E4.2.7
Do not operate any equipment that is damaged, loose, missing parts, etc. Notify the Field Trip
Leader
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immediately.
E4.2.8
Loading and Unloading Vehicles and Moving Equipment to Field Site
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E4.2.8.1
Ensure that all loads are secured using straps, chains, or lines prior to putting a vehicle in
motion.
E4.2.8.2
Ensure that appropriate equipment for unloading and necessary safety equipment to avoid
injury is available at the field site
d
.
E4.2.8.3
Mark equipment as “too heavy” if manual loading/off-loading is not possible.
E4.2.8.4
Apply appropriate control measures when lifting, moving, and carrying equipment.
E4.3
Boats and Other Watercraft
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E4.3.1
One member of the field team must hold all appropriate certificates and credentials for
assuming responsibility of the boat (watercraft) to be used. This includes tickets appropriate to
the size of the craft, its navigation and safe use.
E4.3.2
Ensure boat is sound before setting out and that no damage has occurred in transit.
E4.3.3
Life jacket/buoyancy aid must be worn by all persons when using a boat, kayak, canoe, or
other aquatic vessel.
E4.3.4
Ensure safe anchoring prior to cutting the engine.
E4.3.5
Ensure the fuel tank is horizontal and stable. Open pressure release valve when the motor is
running.
E4.3.6
Never smoke near inflatable boats or engines.
E4.3.7
If the boat length exceeds the wavelength, the boat cannot ride the waves during inclement
weather. Shelter should be sought.
E4.4
Terrain
E4.4.1
Identify the terrain types prior to departure and prepare accordingly.
E4.4.2
Mountains
E4.4.2.1
When preparing for work at a different altitude, follow these general precautions:
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a) Organize your trip ahead of time. Plan for an extra day for participants to acclimate to
the elevation change.
b) It is best practice to have a medical evaluation prior to leaving for a field excursion at
high altitudes.
c) Stay well-hydrated, rested, and educate yourself on the sign of altitude illnesses.
d) Travel with a group if you are able. The use of a buddy system is very effective in
recognizing HAI early.
e) Gradual Initial Exposure: Graded ascent to high altitude is preferred over rapid
exposure to high altitude.
f) Ongoing Exposure: After 2-3 days spent at altitudes around 3500 m, travelers should
increase their sleeping elevation no more than 600 m per day. Gaining more elevation
during the day is acceptable so long as overexertion is avoided, and the sleeping
elevation does not exceed 600m gained. In addition, an extra night of acclimatization is
recommended every 300-900m gain in sleeping elevation.
E4.4.2.2
Slope
When ascending a steep slope, follow these general precautions:
a) Shorten trekking poles
d
.
b) Take small steps.
c) Ensure secure footing prior to placing weight on the next step.
d) Walk in switchbacks, slightly weaving to the left and right.
e) Step on flat surfaces.
f) Sturdy footwear that provides ankle support should be worn to minimize the risk of
falling.
When descending a steep slope, follow these general precautions:
a) Keep your knee joints loose.
b) Sturdy footwear that provides ankle support should be worn to minimize the risk of
falling.
c) Don’t arrest your descent speed.
d) Use trekking poles.
e) Place your heel down first then your toes to ease pressure on your feet.
f) Lean back slightly so your center of gravity shifts backward (i.e., toward the mountain
top).
g) Walk in switchbacks, slightly weaving to the left and right.
h) Use side steps to descend by turning your feet perpendicular to the slope and taking
small steps sideways.
i) Step on flat surfaces.
E4.4.3
Waterbodies (lakes, oceans, rivers)
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E4.4.3.1
Life jacket/buoyancy aid should be worn by all persons whenever the waterbody presents a fall
hazard (e.g., unknown underwater terrain, quick moving water).
E4.4.3.2
The temperature of the waterbody must be considered when selecting appropriate PPE.
E4.4.4
Deserts
E4.4.4.1
The weather pattern and temperature fluctuations of the desert being visited must be
documented in the Field Safety Plan. Deserts typically have extreme temperature changes
during a day.
E4.4.4.2
Additional preventative measures to prevent dehydration and sun overexposure must be
employed.
E4.5
Weather and Climate
E4.5.1
Be prudent and check the weather forecast prior to leaving for a field site
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. Prevention of
climate induced health risk is always better than treatment.
E4.5.2
Heat-Related Danger
E4.5.2.1
See Appendix EC for Heat Stress Related Illness information from the CDC. This one-page
reference document can be included in your Field Safety Plan.
E4.5.3
Cold-Related Danger
E4.5.3.1
See Appendix ED for Cold Stress Related Illness information from OSHA. This one-page
reference document can be included in your Field Safety Plan.
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E4.5.4
Severe Weather
E4.5.4.1
The use of weather alarms (stand-alone radios, or Apps on smart devices) is recommended.
E4.5.4.2
Field personnel shall use the 30-30 rule when you see lightning. After you see lightning, start
counting to 30. If you hear thunder before you reach 30, the thunderstorm is within six miles
and there is a need to seek shelter and wait 30 minutes until the storm passes.
E4.5.4.2(a)
If lightning is present within six miles while working at higher elevations or in exposed regions,
move to lower elevations, forested areas or depressions and stay clear of tall, isolated trees.
E4.5.4.2(b)
If caught in an electrical storm lie flat face down on the ground and cover your head if in an
open area. Do not sit on ground.
E4.5.4.3
In the event of a hail-warning seek shelter to minimize risk of personal injury.
E4.5.4.4
Unless pursuing severe-weather surveillance and monitoring activities in the case of severe
weather warnings seek appropriate shelter, or if time permits, identify a safe route to leave the
area of the warning.
E4.5.5
Rain and Flooding Hazards
E4.5.5.1
Do not enter creeks or fording points
d
unless the water depth can be verified against a flood
gauge.
E4.5.5.2
Do not enter water when the depth gauge meets or exceeds vehicle clearance.
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E4.5.5.3
Do not walk through moving water. Six inches of moving water can make you fall. If you must
walk in water for field activities, walk where the water is calmest. A walking stick can be used
to check the firmness of the ground in front of you.
E4.5.5.4
Unless necessary for environmental safety (toxicity) the use of long-water boots is
discouraged.
E4.5.5.5
Do not wade into streams, rivers, ponds, or lakes unless there is a buddy present on the shore.
E4.6
Fauna and Flora
E4.6.1
All field workers must recognize that they are entering the natural habitat of the native flora
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and fauna
d
; you are their guests. It is every workers responsibility to minimize the impact of
their presence and to leave minimal evidence of their visit.
E4.6.2
Fauna
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E4.6.2.1
Carefully look for insects or hazardous animals (e.g., snakes, scorpions, spiders) before
placing your hands, feet, or body in areas where these creatures may live or hide (wood piles,
crevices, etc.).
E4.6.2.2
Wear insect repellent (30-50% DEET), but only if it will not endanger any susceptible animals
being handled, especially birds.
E4.6.2.3
Carry a first aid kit with you on any excursion so you can treat bites or stings. If the pest is
poisonous or if the bite appears inflamed, seek medical attention immediately.
E4.6.2.4
Thoroughly shake all clothing and bedding before use.
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E4.6.2.5
Avoid contact with sick or dead animals.
E4.6.2.6
Minimize the amount of time you use lights after dark as they may attract pests and animals.
E4.6.2.7
Location-specific animal hazards should be addressed in the Field Safety Plan and during the
Field Safety Briefing
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.
E4.6.3
Flora
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E4.6.3.1
Do not eat any wild plants as they may be poisonous or carry parasites.
E4.6.3.2
Wear gloves while handling plant materials.
E4.6.3.3
Plants may be coated with any airborne pollutant present in the area - avoid brushing against
plants with bare arms/legs.
E4.6.3.4
Be aware of any plants with thorns, spines etc.
E4.6.3.5
Be aware of low, over-hanging branches.
E4.6.3.6
Be aware of tree roots and creepers that may cause you to trip.
E4.7
Disease and Pathogens
E4.7.1
Field participants must decontaminate field materials prior to field trip and before departure
from the field site
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.
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E4.7.2
Potential Diseases
E4.7.2.1
Hantavirus: The CDC has detailed information about hantavirus.
E4.7.2.2
Lyme Disease: The American Lyme Disease Foundation provides information about the
disease.
E4.7.3
More information about poisonous plants, visit the FDA’s Poisonous Plant Database.
E4.7.4
Impure water
E4.7.4.1
Be aware of health risks from water borne pathogens (e.g., Hepatitis 'A', Weil's Disease, Polio,
and toxic cyano-bacteria. The CDC provides information waterborne diseases.
E4.7.4.2
Wear waterproof gloves.
E4.7.4.3
Avoid drinking contaminated water
E4.7.5
Remote/Overseas Locations
E4.7.5.1
In remote/overseas locations be careful of eating food prepared by other people - particularly
meats or fish and salads.
E4.7.5.2
In remote/overseas locations - Be wary of accepting ice in drinks.
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E4.7.5.3
Be aware that some fields are cordoned off due to soil borne pathogens. These are easily
spread from field to field if you walk or drive through them.
E4.7.5.4
Do not enter fields with DEFRA notices on them, even if the landowner gives permission.
Consult DEFRA for further information.
E4.7.5.5
Researchers travelling internationally for field work are encouraged to notify EHS prior to
departure to address safety concerns.
E4.8
Chemicals and Biological Materials
E4.8.1
Chemicals
E4.8.1.1
Handle chemicals as described in the Chemical Hygiene Plan. This includes following proper
transportation procedures for hazardous materials as outlined in CHP Section A20.1.
E4.8.1.2
Any researcher using laboratory chemicals at a field site
d
must submit a Waste Determination
Form to EHS prior to departure to the field site to ensure appropriate segregation, collection,
and transportation back to campus, if required.
E4.8.1.3
Additional measures including extra secondary containment, absorbent pads, and waste
containers should be outlined in the Field Safety Plan.
E4.8.1.4
If gas cylinders are required for field activities, proper cylinder transportation must be followed.
Regulators must be removed, valve closed, and cylinder cap firmly in place prior to transport.
Students or faculty should not transport toxic, highly toxic, reactive, pyrophoric, or corrosive
gases in vehicles. Cylinders moved in vehicles cannot be inside the passenger compartment
and must be secured in cargo bed or trunk so they cannot move during transport. Do not allow
cylinders to be exposed to high temperatures.
E4.8.2
Biological Materials
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E4.8.2.1
Handle biological materials as described in the Biosafety Manual.
E4.8.3
Agro Chemicals
E4.8.3.1
Seek information from landowner as to when crop spraying is likely and when entry to field will
be safe. Do not enter fields until safe to do so. Be aware that any skin contact is hazardous.
E4.8.3.2
Avoid pools and puddles in freshly sprayed fields which may contain chemicals.
E4.8.3.3
Keep arms and legs covered. Ensure waterproof protective gloves or gauntlets and long pants
and closed-toed shoes are worn.
E4.9
The Public
E4.9.1
Private Property
E4.9.1.1
Try to contact property owners or those responsible for the property management before
arriving. Be honest about the reasons you seek access and how much time you will need.
E4.9.1.2
Do not enter private land, property, or buildings unaccompanied or without expressed,
preferably written permission, from the appropriate person of authority. Ensure landowners and
their employees know who you are and what you are doing.
E4.9.1.3
If accompanied, acknowledge that it is their territory; let them lead the way.
E4.9.1.4
Take special care when documenting findings, particularly of sensitive information.
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E4.9.1.5
Try not to react to dirty or smelly surroundings. Do not underestimate the importance of body
language.
E4.9.1.6
Maintain an orderly work site. Keep your materials confined to the work site. You are a visitor
to another’s property.
E4.9.2
Unexpected Behavior
E4.9.2.1
Be aware of local cultures pertaining to land use and access. Be honest and transparent when
justifying your request for access or when seeking information.
E4.9.2.2
If persons on property show signs of drug or alcohol impairment or are aggressive, do not
enter.
E4.9.2.3
Do not turn your back on someone who is behaving aggressively and keep your distance. Stay
calm, speak gently and slowly, and avoid aggressive body language and stances.
E4.9.2.3(a)
Do not be enticed into an argument. Talk yourself out of problems; placate rather than
provoke.
E4.9.2.3(b)
Identify potential escape routes. Try to get away as quickly as possible. Move towards a place
where you know there will be other people.
E4.9.2.3(c)
Consider carrying a personal alarm.
E4.9.3
Strangers and Public Places
E4.9.3.1
Research and vet individuals you may meet and work with or interview.
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E4.9.3.2
Schedule meetings at neutral locations or where neither party could be at risk.
E4.9.3.3
Where possible conduct any interviews with an observer.
E5 PERSONAL SAFETY
E5.1
It is the responsibility of each field participant to uphold the safety rules outlined by the Field
Trip Leader
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.
E5.1.1
Behavior
E5.1.1.1
Consider cultural sensitivities and norms when preparing for field work, including selection of
field clothing and display of signs, identifiers etc.
E5.1.1.2
Carry documents providing permission to work in a particular locality and personal
identification.
E5.1.1.3
Field participants should always act in a professional manner. Horseplay shall not be tolerated.
E5.1.1.4
Field participants should carry a Personal first-aid kit.
E5.1.1.5
Clean hands frequently. Always wash hands prior to eating, taking medications, applying first
aid treatment, etc.
E5.1.2
Attire and Personal Protective Equipment
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E5.1.2.1
Appropriate clothing must be worn. Wear clothes made of tightly woven materials. Long pants
and long sleeves should be worn with sturdy, solid, closed-toe footwear that provides ankle
support are required. Confine long hair and loose clothing.
E5.1.2.2
Hearing protection (noise attenuating earmuffs or ear plugs) are required for personnel using
loud equipment (e.g., chainsaws, tractors, etc.).
E5.1.2.3
Safety glasses must be worn when using any equipment that may produce flying debris (e.g.,
rock chisel, chainsaw, etc.)
E5.1.2.4
Hard hats and protective footwear (hard toed boots/slip-on protection a.k.a. “clackers”) must be
worn as directed or needed.
E5.1.2.5
Rain gear is recommended during inclement weather
E5.1.2.6
Work gloves are recommended for field activities, especially when it involves rock or soil
sampling.
E5.1.2.7
Additional PPE items may include hearing protection, respirators/self-rescuers, high-
visibility/reflective safety vest, safety belts and lanyards, harnesses, gloves and chemical- or
fire-resistant clothing (coveralls).
E6 ESTABLISHING CAMPSITES
E6.1
Campsites
E6.1.1
All sites used for camps must be adequately drained. They must not be subject to periodic
flooding.
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E6.1.2
The camp must be located so the drainage from and through the camp will not endanger any
domestic or public water supply.
E6.1.3
All sites must be adequate in size to prevent overcrowding of necessary structures. The
principal camp area where food is prepared and served and where sleeping quarters are
located must be at least 200 feet apart.
E6.1.4
The grounds and open areas surrounding the shelters must be maintained in a clean and
sanitary condition free from rubbish, debris, wastepaper, garbage, or other refuse.
E6.1.5
Do not camp or sleep near obvious animal nests or burrows.
E6.2
Refuse Disposal
E6.2.1
When working at a field site where garbage bins are not available, use fly-tight, rodent-tight,
impervious, cleanable, or single service containers for the storage of garbage.
E6.2.1.1
Keep garbage containers stored away from your campsite or work area. Food crumbs and
debris may attract insects and animals.
E6.2.1.2
Garbage containers must be kept clean.
TABLE OF CONTENTS
AA Chemical Segregation ..................................................................................... AA-1
AB Chemical Hygiene Checklist ......................................................................... AB-1
AC Chemical Spill Response ................................................................................ AC-1
AD Handling and Operating Gas Cylinders ......................................................... AD-1
AE Traps for Vacuum Lines ................................................................................. AE-1
AF Hazardous Waste Disposal ............................................................................ AF-1
AG Carcinogen, Mutagen and Teratogen Procedures ....................................... AG-1
AH Peroxide Forming Compounds ...................................................................... AH-1
AI Exposure Assessment Worksheet.................................................................. AI-1
AJ Equipment Decontamination Form ................................................................ AJ-1
AK Laboratory Decommissioning Checklist ....................................................... AK-1
AL Reporting ......................................................................................................... AL-1
SCAN and Incident Reporting ................................................................................. AL-1
Initial Investigation of Overexposure Form ............................................................ AL-2
BA Biosafety Checklists ……………………………………………………………….BA-1
BB Characteristics of Common Disinfectants .................................................... BB1
BC Select Agent Links ......................................................................................... BC-1
BD Biological Safety Cabinets ............................................................................ BD-1
Class I ........................................................................................................................ BD-1
Class II ....................................................................................................................... BD-2
Class III ...................................................................................................................... BD-5
BE Autoclave Testing Program ........................................................................... BE-1
Procedure .................................................................................................................. BE-1
EHS Report Form ...................................................................................................... BE-5
BF Biowaste Treatment Logs .............................................................................. BF-1
Solid Biowaste Log – Chemical Disinfection................................................................ BF-1
Solid Biowaste Log – Autoclave .................................................................................. BF-2
Liquid Biowaste Log .................................................................................................... BF-3
BG Biobarrel Use .................................................................................................. BG-1
BH Biosafety Links ............................................................................................... BH-1
CA Radiation Reference Information .................................................................. CA-1
Glossary of Terms ...................................................................................................... CA-1
Index of Abbreviations and Acronyms ....................................................................... CA-8
List of Symbols for Units and Terms .......................................................................... CA-9
CB Texas Radiation Regulations ........................................................................ CB-1
CC Instrument Calibration .................................................................................. CC-1
Procedures ............................................................................................................... CC-1
Sample Survey Meter Calibration Label .................................................................... CC-5
Sample Certificate of Calibration ............................................................................... CC-6
DA Laser Forms ................................................................................................... DA-1
Laser Application (LS-1) ......................................................................................... DA-1
Application Amendment (LS-2) .............................................................................. DA-7
Amendment Attachment (LS-2A) ........................................................................... DA-8
Laser SOP Outline (LS-7) ....................................................................................... DA-9
SOP Training Acknowledgement Form (LS-8) ................................................... DA-10
Laser Usage Log (LS-11) ..................................................................................... DA-11
Short-Term Laser Application (LS-17) ................................................................ DA-12
DB Laser Reference Information ........................................................................ DB-1
Glossary of Terms ...................................................................................................... DB-1
Index of Abbreviations and Acronyms ........................................................................ DB-8
Texas Laser Regulations ........................................................................................... DB-9
References .............................................................................................................. DB-10
EA Field Activity Planning Checklist and Risk Assessment ............................. EA-1
EB Field Site Kit Checklist ................................................................................... EB-1
EC First Aid for Heat Illness ................................................................................. EC-1
ED First Aid for Cold Illness ................................................................................. ED-1
Appendix AA
AA-1
Chemicals are segregated into 11 different categories depending on the compatibility of that chemical with
other chemicals. If you feel a chemical is misclassified or have other questions regarding chemical storage
and classification, please contact EHS by email at
ehs.lab.safety@ttu.edu
or call 806-742-3876.
SOURCE: Adapted from Stanford University’s ChemTracker Storage System. Used with permission from R. Kevin Creed,
Stanford University.
All Storage Group 8 chemicals must
have separate containment.
AA-2
CHEMICAL SEGREGATION
Chemicals are to be segregated into 11 different categories depending on the compatibility of that
chemical with other chemicals.
The Storage Groups are as follows:
Group 1 – Compatible Organic Acids
Group 2 – Compatible Organic Bases
Group 3 – Non-Reactive Flammable and Combustible, including solvents
Group 4 – Not intrinsically Reactive or Flammable or Combustible
Group 5 – Compatible Oxidizers including Peroxide
Group 6 – Compatible Inorganic Bases
Group 7 – Compatible Inorganic Acids not including Oxidizers or Combustible
Group 8 – Incompatible with ALL other storage groups
Group 9 – Compatible Pyrophoric & Water Reactive Materials
Group 10 – Poison Compressed Gases
Group 11 – Compatible Explosive or other highly Unstable Material
The following link will take you to the chemical classification list. This is not a complete list of
chemicals, but is provided to give examples of each storage group:
CHEMICAL CLASSIFICATION LIST
Appendix AB
Appendix AC
AC-1
DOES YOUR SPILL REQUIRE EHS RESPONSE?
Follow the flow chart to determine if EHS should respond to your spill.
Lab personnel may clean up the spill themselves using
the guidance provided in Appendix AC of the Lab Safety
Manual and the chemical Safety Data Sheet. Submit a
SCAN report to EHS after cleanup is complete.
Are personnel comfortable responding to
the spill?
Do the hazards presented by the spill
exceed those of routinely working with
the chemical?
Are the hazards of the spill known?
Do personnel have access to adequate
spill response materials and equipment,
including appropriate PPE?
Is the spill greater than 4 liters?
Is the spill a manageable volume and
state?
Is the material toxic, flammable,
corrosive or reactive?
Was mercury spilled?
Is the spill likely to escalate to an
emergency (e.g. fire, oxygen deprivation,
IDLH, LEL, etc.)?
NO
Was material released into the
environment (e.g. into a drain, waterway,
grass or dirt)?
YES
YES
Evacuate the work area and immediately
call EHS
742-3876 – Daytime M-F 8AM-5PM
742-3328 – Non-daytime (24hr/day)
Personnel may perform Limited Actions on their
way out of the work area, such as:
• closing the fume hood sash if the spill is
contained in the hood;
• opening the fume hood sash if the spill is
located outside of the hood;
• shutting off heated equipment or gas
lines; or
• stabilizing reactions.
Only perform such actions if no immediate
danger is present.
Personnel should notify others in the area of the
spill and be available to relay spill and/or work
area details to EHS.
Personnel are also required to submit a SCAN or
Incident Report as it applies to the situation.
NO
Have personnel been trained on proper
spill response?
NO
YES
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
NO
YES
NO
NO
AC-2
Basic Spill Response Equipment
Spill kits in work areas should be appropriate to the hazards present. Some potential
components of spill kits are listed below:
• Absorbents
o Paper towels
o Pig pads
o Dams for large spills
o Commercial absorbent powders
o Clay kitty litter
• Neutralizers
o Acid Neutralizer (included in EHS provided spill kit)
o Alkali Neutralizer
o Solvent Neutralizer
• Disinfectants (see Section B7.2 of the University Laboratory Safety Manual)
o Freshly prepared 10% bleach solution
o Alcohols (ethanol or isopropanol)
o Quaternary ammonium salts
• Personal Protective Equipment
o Household rubber gloves
o Splash goggles or face shield
o Lab apron or coat
• Tools for Clean-up
o Forceps, tongs or other tools to pick up and collect broken glass
o Broom and dust pan
o Plastic bags
o Rigid container with lid to collect broken glass
NOTE: Use disposable clean up supplies when possible because contaminated tools will be
considered hazardous waste.
AC-3
Basic Chemical Spill Response Steps
1. Notify other personnel in the laboratory to stay clear of the spill area.
2. Decontaminate any victim at the nearest safety shower or eyewash unit for a minimum
of 15 minutes. Take other appropriate action as described in the SDS.
3. Notify your supervisor or appropriate personnel to the spill.
4. Limit or restrict access to the area as necessary.
5. Wear clean PPE appropriate to the degree of hazard presented by the spill. This may
include a dust mask, lab apron, additional gloves, face shield, etc.
6. Gather all spill kit materials.
7. Surround the spill with an appropriate neutralizer or absorbent to keep the material from
spreading.
8. Do not neglect furniture, equipment and vertical surfaces (i.e., cabinets, walls, doors)
when cleaning a spill.
9. Cover the spill area completely with absorbent. Follow manufacturer instructions if using
a commercial absorbent.
10. If the spill contains a biohazard, cover the spill with absorbent pads or paper towels then
saturate with an appropriate disinfectant and allow adequate contact time for disinfection
before cleaning. Disinfect the area a second time after the absorbent material has been
removed.
11. Gather the contaminated clean-up materials (including broken glass and contaminated
tools and PPE) into a closeable bin and label as hazardous waste. Broken glass
disposed of in a broken glassware bin must be decontaminated before disposal.
12. It is prudent to mop the spill area after cleaning the spill.
13. Submit a Waste Pick Up request for the container in a timely manner.
14. Submit a SCAN report
http://www.depts.ttu.edu/ehs/about/scan.php to EHS detailing
the incident.
15. Request a new spill kit from EHS at 806-742-3876 or ehs.lab.safety@ttu.edu if the
EHS-provided spill kit was used for clean-up.
Appendix AD
AD-6
Use and storage of compressed, liquified, or cryogenic gases
Background
TTU laboratory operations may require the use of compressed, liquified, or cryogenic gases.
While all gases contain substantial potential energy in their containers, depending on the
particular gas, there is also a potential for exposure to toxic, corrosive, flammable, reactive, or
oxygen depleting materials. Anyone using a gas must be familiar with its hazards; reading the
Safety Data Sheet (SDS) is an excellent introduction to the safe handling, use, and storage of a
compressed, liquified, or cryogenic gas. Additionally, all laboratories and research projects
employing gases must comply with the provisions of this Appendix.
The language in this Appendix is intended to set out current minimum standards for the safe use
of compressed gases and provide additional provisions to implement in the future. Basic
compliance is the bare minimum required for laboratory operations and is indicated by terms
such as will, shall, must. Better compliance represents a step up in safety procedures, policies,
and practices. Best compliance is the highest standard and ensures that lab operations fully
align with requirements set out by National Fire Protection Association (NFPA) and
Occupational Safety and Health Association (OSHA). Both better and best compliance elements
will identified with arrow bullet points ( ).
All laboratories will be required to meet the standards of better compliance within two years of
the implementation of this Appendix.
Building and experimental design proposing the use of compressed, liquified, or cryogenic gases
shall involve representatives from EHS and the Fire Marshals to ensure that (1) building and floor
limitations on compressed gas quantities are followed and (2) the laboratory space is
appropriately sized and equipped to accommodate these materials.
Prohibited activities
The following activities are prohibited:
• Dispensing of any type of gas into another container (apart from cryogenic materials).
• Leaving experiments using toxic, extremely toxic, flammable, oxidizing, corrosive, or
reactive/ pyrophoric, gases unattended. This does not apply to gas systems that supply
analytical devices, gas systems used in exhausted cabinets and hoods, or gas systems
used in laboratories with gas monitoring sensors that can alert an individual outside the
lab of a release.
Ordering
• All compressed, liquified, or cryogenic gases are considered hazardous materials and
must be identified as such when ordered through TechBuy.
• Labs wishing to order flammable, oxidizing, toxic, extremely toxic, reactive/pyrophoric,
unstable, or corrosive gases must consult with EHS prior to placing an initial order.
AD-6
Gas Inventory
Laboratories will maintain an inventory of the following gas types stored or in use in the lab
space. The inventory will include the gas type, number of containers, date of expiry for
container certification, and container size. This information will be provided to EHS on January
1 and July 1 of each year.
• Flammable
• Toxic and extremely toxic
• Reactive/ pyrophoric
• Oxidizing
• Corrosive
• Unstable
• Cryogenic gases in quantities greater than 5 liters
1
Training
All individuals using gases in the laboratory will complete the following training prior to working
with or moving a gas container:
• Laboratory safety
• Compressed gas safety
• Liquid nitrogen safety (if using or transferring liquid nitrogen)
Individuals using any type of gas container or manifold system must be able to demonstrate that
they can turn on and off gases that they intend to use. All individuals using hazardous gas
types (flammable, corrosive, oxidizing, reactive/ pyrophoric, unstable, and toxic/ highly toxic)
must be specifically trained on the hazards of these gases, means to detect releases, methods
employed to mitigate the hazards, and emergency procedures in the event of a release.
Transport
Moving cylinders and gas containers presents several risks; containers can be heavy, bulky,
and difficult to move by hand and the valve assembly can become damaged if the cylinder is
dropped or struck. The following provisions address transportation of gas containers.
3
rd
Party transport
Compressed, liquified, and cryogenic gases are considered hazardous materials for purposes of
transportation by freight carriers (by air, rail, marine, or over the road). All freight transportation
of these materials must be cleared through EHS Materials Shipping
.
Vehicle transport
• Texas Tech University vehicles, not personal vehicles, will be used to transport gas
containers.
• Gas containers may not be transported in the same compartment of the vehicle as the
driver or passengers.
1
This refers to total quantity of cryogenic gases in the work area, not just the amount in one container.
AD-6
• Gas containers will be secured to prevent movement during transport.
• Containers must be transported with valves closed and protected.
• Gas containers shall not be allowed to be exposed to high temperatures during
transport.
• Incompatible gases shall be segregated during transportation (see segregation
information below).
Hand transport
• Large gas containers must be transported using dollies or carts that allow the container
to be secured during movement.
• Containers must be transported with valves closed and protected.
• Gas containers shall not be allowed to be exposed to high temperatures during
transport.
• Incompatible gases shall be segregated during transportation (see segregation
information below).
• Freight elevators are preferred for moving gases between floors; gas containers shall not
be transported with the non-laboratory personnel in elevators.
Better: Flammable, corrosive, toxic, and cryogenic gases shall be transported in
an empty elevator.
2
Better: a portable oxygen meter may be used when gases are being transported
in confined spaces such as elevators as a means of detecting potential leaks.
Best: a portable multi-gas meter that can measure O
2
and flammability and
specific gases may be used when gases are being transported in confined
spaces such as elevators as a means of detecting potential leaks.
Storage of gases
As gases represent a larger hazard in smaller spaces, the amount of gas containers in a
laboratory space shall be kept to a minimum. As long as the quantity limitations set out below
are not exceeded, labs should keep no more than two spare containers of each gas type in the
lab space.
Better: One spare cylinder for each gas type may be kept in the lab space.
3
Gas containers that are not regularly used must not be stored in occupied laboratory spaces.
General
• Store gases in cool, dry, well ventilated, and secure area.
• Gases must not be stored where they would impede exit from the space or building (i.e.,
away from emergency exits, not under stairs, etc.).
• Hazard warnings indicating gas use shall be posted at entrances to laboratory or storage
space.
2
NFPA 45 A 8.3.3.1
3
NFPA 45 10.1.6.3 & 10.1.6.4
AD-6
Quantities
The National Fire Protection Association (NFPA) sets limits on quantities of gases that can be
stored or used inside a building.
4
These limits are difficult to translate to individual lab spaces
since they are based on the construction features of the building like firewalls, fire doors, and
fire suppression systems. To simplify the application of gas storage guidelines to laboratories,
TTU has adopted the following storage limitations for laboratory spaces of 750 square feet or
greater.
The table below, and accompanying adjustments, represent the maximum allowable quantity
(MAQ) of a particular gas type that may be stored and used in a laboratory space. For example,
the maximum quantity of an oxidizing gas for storage or use in a third floor, 700 sf lab that was
stored in vented cabinets would be 1,500 scf x 0.5 [for third floor location] x 0.5 [for <750 sf of
lab space] x 2 [for vented cabinets] = 750 scf.
Gas Type
Class (DOT codes)
MAQ for storage room
or lab space >750 sf
Notes
Cryogenic
Inert (2.2)
5 liters
5
Flammable
Gas (2.1)
1,000 scf
Liquified (2.1)
150 lb
LP (2.1)
300 lb
Inert
Gas (2.2)
NL
Liquified (2.2)
NL
Oxidizing
Gas (2.2, 5.1)
1,500 scf
Liquified (2.2 5.1)
150 lb
Corrosive
Gas (2.2, 8)
810 scf
Liquified (2.2 8)
150 lb
Pyrophoric
Gas
50 scf
Liquified
4 lb
Toxic
Gas (2.3)
810 scf
Liquified (2.3)
150 lb
Highly Toxic
Gas (2.3)
20 scf
Liquified (2.3)
4 lb
Unstable
Gas, 3 or 4 detonable
10 scf
Gas, 3 non-detonable
50 scf
Gas, 2
750 scf
Liquified, 3 or 4 detonable
1 lb
Liquified, 3 non-detonable
2 lb
Liquified, 2
150 lb
Table notes and adjustments to MAQ.
• NL- no limits on quantities to be used or stored
• MAQ- maximum allowable quantity
4
NFPA 55, Table 6.3.1.1.
5
This is not a maximum limit of cryogenic gas that can be used or stored in this space. It is the threshold that
triggers the need for an oxygen sensor.
AD-6
Adjustment to MAQ
Multiplier
Storage: materials are stored in a dedicated gas storage room or approved gas cabinet.
2.0
Lab use: lab space is in basement or second floor
0.75
Lab use: lab space is in sub-basement or third floor
0.50
Lab use: lab space is on fourth floor or above
0.125
Lab use/ storage: lab space or non-dedicated gas storage room <750 square feet
0.50
Lab use: gas being used is in an approved cabinet, gas cabinet, or exhausted enclosure
2.0
Lab use: lab is an instructional (teaching) lab
6
0.10
Rooms devoted to gas storage should not exceed the quantity limitations outlined above.
Best: Gas storage rooms shall meet all requirements set out by NFPA.
Security
• The contents and hazards of a gas container shall be readily apparent to lab personnel
through labeling or signage. Cylinders must be labeled as to contents and DOT hazard
class.
7
• Gas containers must be secured upright for storage or use. Straps, chains attached to a
solid object, or a cylinder stand are appropriate for securing cylinders. Multiple cylinders
of compatible gases may be tightly nested and secured with a single chain or strap.
Best: Gas cylinders are individually secured and not nested.
Best: Where multiple gas types are aggregated, the location for each gas type is
identified with signage.
• Cylinders in storage must be closed and capped.
Segregation
Flammable, corrosive, oxidizing, reactive/ pyrophoric, unstable, and toxic/ highly toxic gas types
are considered hazardous gas types. Each cylinder or container of a hazardous gas type must
be separated from any other cylinder or container of a hazardous gas type by at least 20 feet or
by a container-height fire barrier with ½ hour fire resistance.
8
For gases with separation
restrictions, that restriction may be reduced to 5 feet if one gas is in a gas cabinet and reduced
to zero if both gases are in a gas cabinet.
9
Use of gases
Note that all provisions for safe storage of gases apply, as appropriate, to the use of gases as
well.
Setup
• Researchers should set up experiments to minimize the amount of gas needed.
6
NFPA 55, 10.1.6.7
7
NFPA 55 7.1.7
8
NFPA 55 Table 7.1.10.2 & 7.1.10.2.2
9
NFPA 55 7.1.10.2.3
AD-6
• Regulators for cylinders will be selected in accordance
with the type of gas being used. An experienced
individual or the gas vendor must be consulted to
provide information on the appropriate regulators for
each gas type employed and how to set up and attach
the regulator.
• Grease, Teflon tape, oil, soapy water, or other
materials shall not be used on regulator threads.
• Pressure regulators must have two gauges (inlet and
outlet side).
10
• Gas cylinders shall be located so they may not obstruct
egress from the lab space. If a gas cylinder or cryogenic container is located adjacent to
an egress point, the lab space must have a second egress point.
11
• Gas systems will be checked for leaks prior to use. The method of leak detection
employed, the date conducted, and the individual conducting it will be documented.
Flames may not be used for leak detection.
• Manifolds and piping used to distribute gases will be selected with the gas type and
pressure in mind and be assembled and installed by a competent person in accordance
with NFPA 54 and 55 and manufacturer’s specifications.
• Piping used to distribute gases shall be labeled as to the gas type at the supply and
discharge point.
12
• Manual shut valves for gases will be within 6 feet of the point of use.
13
• Flow control or excess flow valves should be incorporated in gas delivery design in a
way that minimizes the potential volume of releases from the experimental apparatus.
• Exhaust from gas-fed experimental apparatus must be considered as having the same
hazard of the supply gas and be appropriately monitored and/or vented.
Better: Exhaust gas composition is monitored and categorized to determine
actual hazard.
Use
• Cylinder valves, not regulator valves, will be used to turn gas on and off. Cylinder valves
shall be operated by hand- do not use wrenches or other tools.
• Users will wear safety glasses when pressurizing regulators and lines. Turn gas on
slowly and ensure gauge faces are facing away from individuals.
• Gas container valves will be off, unless in use.
• Gas containers and associated equipment shall be regularly inspected for damage or
loose connections.
Emergency procedures
• Laboratories will develop emergency procedures to address releases of gases used in
the laboratory. These procedures will contain information on the hazards of the gases
10
NFPA 45 10.1.5.2
11
NFPA 45 5.3.1 (5) & 5.3.1 (6)
12
NFPA 45 10.2.5
13
NFPA 45 10.2.3
AD-6
used, means of detecting releases, procedures to shut down experimental apparatus,
and notification requirements.
• TTU Fire Marshal will be provided an inventory of hazardous gas types found in each
building.
• In the event of a release of a hazardous gas type, lab personnel must call 9-911 from a
campus phone or 911 from a cell phone. Shut off sources of energy and ignition and
evacuate the lab promptly. If it is safe to do so, attempt to close the cylinder valve.
Notify the DSO and building manager of the issue and do not re-enter the lab space until
it has been cleared by emergency responders or EHS personnel.
• All incidents and near-misses associated with gas use will be reported to EHS within 24
hours.
Security
Storage areas and laboratories using hazardous gas types must take measures to secure gas
containers, prevent unauthorized use, and ensure that all containers are accounted for.
Gas specific requirements
General
Gas containers must be regularly recertified to be refilled or used for transportation. Cylinders
have the date of their last testing embossed in the steel or aluminum, generally around the neck
of the bottle. Some cylinders have multiple dates displayed as they have been recertified
multiple times.
The following example explains
how to read the testing dates.
Cylinder test dates are stamped in
a month_INSPECTOR CODE_year
format. The photo to the left
shows several date stamps- the
initial stamp at the top is dated
12/91 with a B842 inspector code
between the month and the year.
The next date stamp is 03/05 and
final stamp is 08/14. Some dates
will have stars or + signs stamped
behind them. Hydrostatic tests are
valid for 5 years; if the test date has a star behind it, the test is valid for 10 years.
• Laboratories may not accept cylinder deliveries of cylinders with invalid test dates.
• Laboratories may not store cylinders with test dates that have expired more than 7 years
ago.
Better: Laboratories may not store cylinders with test dates that have expired
more than 3 years ago.
AD-6
Flammable gases
Flammable gases will have a flashback arrestor as part of the regulator to ensure that
flame cannot propagate back into the tank. For piping longer than 50 feet, a second
flashback arrester must be installed at the point of use.
• Labs employing flammable gases will regularly inspect piping and manifolds and perform
leak testing annually. The method of leak detection employed, the date conducted, and
the individual conducting it will be documented. Flames may not be used for leak
detection.
Better: Labs employing flammable gases will regularly inspect piping and
manifolds and perform leak testing quarterly. The method of leak detection
employed, the date conducted, and the individual conducting it will be
documented.
Better: Laboratories employing flammable gases will install a % LEL monitor that
will provide a local alarm of gas releases.
Better: Laboratories employing flammable gases will employ local ventilation at
locations in the gas delivery system where leaks are more likely (regulator,
manifolds, etc).
Best: Laboratories employing flammable gases will install a flammable gas
monitor that will provide a local alarm of gas releases and notify outside
personnel.
Flammable gas cylinder valves should only be opened ½ to ¾ turn.
Acetylene gas will be used at less than 15 pounds of pressure.
Corrosive gases
Better: Corrosive gases should be used in fume hoods where possible.
Best: Corrosive gases are stored and used in vented cabinets.
Better: Where possible, gas-specific monitors will be employed to provide a local alarm
of gas releases.
Best: Laboratories employing corrosive gases will install a gas monitor that will
provide a local alarm of gas releases and notify outside personnel.
Better: Laboratories employing corrosive gases will employ local ventilation at locations
in the gas delivery system where leaks are more likely (regulator, manifolds, etc).
• Non-empty corrosive gas containers will be returned to the supplier no later than the
expiration of their hydrostatic test date. Labs using these gases will implement tracking
to ensure this occurs.
Best: Non-empty corrosive gas containers will be returned to the supplier within 3
years of shipping date.
14
• Labs employing corrosive gases will regularly inspect piping and manifolds and perform
leak testing twice per year. The method of leak detection employed, the date conducted,
and the individual conducting it will be documented. Flames may not be used for leak
detection.
Better: Labs employing corrosive gases will regularly inspect piping and
manifolds and perform leak testing quarterly. The method of leak detection
14
NFPA 45 A10.1.2
AD-6
employed, the date conducted, and the individual conducting it will be
documented.
• Hydrofluoric acid and hydrogen bromide gases must be returned to the supplier within 2
years of shipping date.
15
Labs using these gases will implement tracking to ensure this
occurs.
Toxic and extremely toxic gases
These gases present an extreme hazard to laboratory personnel, particularly for gases like
carbon monoxide or hydrogen sulfide that have poor warning properties. Toxic and extremely
toxic gases should be used in lab spaces equipped with appropriate safety features to limit the
hazards.
Laboratories employing toxic and extremely toxic gases will employ local ventilation at
locations in the gas delivery system where leaks are more likely (regulator, manifolds,
etc).
Better: Toxic and extremely toxic gases should be used in fume hoods where
possible.
Best: Toxic and extremely toxic gases are stored in an NFPA 55 compliant gas room
or used from approved gas cabinets, or exhausted enclosures.
16
• For gases with poor warning properties, gas-specific monitors will be employed to
provide a local alarm of gas releases.
Best: Laboratories employing toxic and extremely toxic gases will install a gas
monitor that will provide a local alarm of gas releases and notify outside
personnel.
• Non-empty toxic and extremely toxic gas containers will be returned to the supplier no
later than the expiration of their hydrostatic test date. Labs using these gases will
implement tracking to ensure this occurs.
Best: Non-empty toxic and extremely toxic gas containers will be returned to the
supplier within 3 years of shipping date.
17
• Labs employing toxic and extremely toxic gases will regularly inspect piping and
manifolds and perform leak testing twice per year. The method of leak detection
employed, the date conducted, and the individual conducting it will be documented.
Flames may not be used for leak detection.
Better: Labs employing toxic and extremely toxic gases will regularly inspect
piping and manifolds and perform leak testing quarterly. The method of leak
detection employed, the date conducted, and the individual conducting it will be
documented.
Oxidizing gases
• No oils or greases will be used on oxidizing gas fittings.
Better: Laboratories employing oxidizing gases will employ local ventilation at locations
in the gas delivery system where leaks are more likely (regulator, manifolds, etc).
15
NFPA 45 A10.1.2
16
NFPA 45 10.1.4.1
17
NFPA 45 A10.1.2
AD-6
• Labs employing oxidizing gases will regularly inspect piping and manifolds and perform
leak testing annually. The method of leak detection employed, the date conducted, and
the individual conducting it will be documented. Flames may not be used for leak
detection.
Better: Labs employing oxidizing gases will regularly inspect piping and manifolds and
perform leak testing quarterly. The method of leak detection employed, the date
conducted, and the individual conducting it will be documented.
Better: Labs using oxygen will install an oxygen sensor that will provide a local alarm of
gas releases.
Best: Laboratories using oxygen will install a gas monitor that will provide a local alarm
of gas releases and notify outside personnel.
Reactive and pyrophoric gases
These gases present an extreme hazard to laboratory personnel; they should be used in lab
spaces equipped with appropriate safety features to limit personnel exposure to the hazards.
• Pyrophoric and reactive gases should be used in fume hoods and away from
combustible materials.
Best: Pyrophoric and reactive gases larger than lecture size must be used from
sprinklered safety cabinets.
18
Best: These gases must be stored in an NFPA 55 compliant gas room or used from
approved gas cabinets, or exhausted enclosures.
19
• Where possible, gas-specific monitors will be employed to provide a local alarm of gas
releases.
Best: Laboratories employing pyrophoric and reactive gases will install a flammable gas
monitor that will provide a local alarm of gas releases and notify outside personnel.
• Non-empty pyrophoric and reactive gas containers will be returned to the supplier no
later than the expiration of their hydrostatic test date. Labs using these gases will
implement tracking to ensure this occurs.
Best: Non-empty pyrophoric gas containers will be returned to the supplier within
3 years of shipping date.
20
• Labs employing pyrophoric and reactive gases will regularly inspect piping and
manifolds and perform leak testing twice per year. The method of leak detection
employed, the date conducted, and the individual conducting it will be documented.
Flames may not be used for leak detection.
Better: Labs employing pyrophoric and reactive gases will regularly inspect
piping and manifolds and perform leak testing quarterly. The method of leak
detection employed, the date conducted, and the individual conducting it will be
documented.
Unstable gases
The laboratory use of these gases will be evaluated by EHS on a case-by-case basis.
18
NFPA 45 10.1.4.3
19
NFPA 45 10.1.4.1
20
NFPA 45 A10.1.2
AD-6
Inert gases (both compressed and cryogenic)
Inert gases do not present the hazards of the gases listed above, but they often have poor
warning properties and can displace available oxygen in laboratory spaces if they are released.
This is particularly true of cryogenic gases which expand to fill a volume 600 to 800 times that of
the container if released.
• Individuals working with cryogenic gases must have insulated gloves and face shields as
part of their PPE ensemble.
• Laboratories with more than 10 full-sized inert gas cylinders in use or storage will install
an oxygen sensor that will provide a local alarm of gas releases.
• Areas where cryogenic gases are dispensed will have an oxygen sensor installed.
• Laboratories using or storing cryogenic gases will install an oxygen sensor that will
provide a local alarm of gas release based on the size of the cryogenic gas container
and the square footage of the room. For each 150 square feet of laboratory space, 1
liter of cryogenic gas may be stored or used without the installation of an oxygen sensor.
Better: Laboratories employing oxygen sensors as noted above will install a gas monitor
that will provide a local alarm of gas releases and notify outside personnel.
• Labs employing inert gases will regularly inspect piping and manifolds and perform leak
testing annually. The method of leak detection employed, the date conducted, and the
individual conducting it will be documented. Flames may not be used for leak detection.
Better: Labs employing inert gases will regularly inspect piping and manifolds
and perform leak testing quarterly. The method of leak detection employed, the
date conducted, and the individual conducting it will be documented.
Better: Laboratories employing inert gases will employ local ventilation at locations in the
gas delivery system where leaks are more likely (regulator, manifolds, etc).
Cylinder disposal
Gas cylinders are likely to be regulated as both hazardous waste and hazardous materials for
transportation. Coordinate with the gas vendor to remove surplus or unneeded gas containers.
• Damaged cylinders must be removed from the laboratory promptly. Contact EHS to
coordinate removal and appropriate disposal.
• Empty gas containers will be marked as such and removed from the lab as soon as
possible.
• Handle and store empty gas cylinders as if they are full.
Appendix and lab practices review
A Chemical Hygiene Plan and associated laboratory SOPs are not static documents; they
should gradually improve over time as regulations change, new best practices come online, and
labs gain familiarity with experimental tools.
21
The contents of this appendix will be reviewed
annually by the ILSC and updated to (1) reflect changes in regulation or best practices and (2)
lab practices in place across TTU. As better and best practices become the norm across
21 29 CFR 1910.1450(e)(4)
AD-6
campus, those standards will become the new baseline safety standard for use of compressed,
liquified, and cryogenic gases.
Laboratories will annually review experimental practices associated with gas use, review
lessons learned from incidents and near misses, and identify areas where lab practices could
change to meet the better or best practices in this Appendix.
Appendix AE
AE-1
TRAPS FOR VACUUM LINES
Always place an appropriate trap between experimental apparatus and the vacuum source. The
vacuum trap:
• Protects the pump, pump oil, and piping from the potentially damaging effects of the
material;
• Protects personnel from materials in the apparatus; and
• Prevents vapors and related odors from being emitted back into the work area or vacuum
system exhaust.
Improper trapping can allow vapor to be emitted from the exhaust of the vacuum system resulting
in potential personnel exposure and/or entry into the work environment.
Proper Trapping Techniques
All lines leading from the equipment to the vacuum source must be equipped with a trap or filter
as appropriate.
Particulates
• Vacuum lines should be fitted with filtration capable of efficiently trapping the particulates
in the size range being generated.
Aqueous or Non-Volatile Liquids
• A filter flask at room temperature is sufficient for vacuum lines using aqueous or other
non-volatile liquids.
• An in-line hydrophobic filter may be added for additional protection to the vacuum system.
Solvents and Other Volatile Liquids
• A cold trap (see Figure 2) of sufficient size and cold enough to condense vapors generated
followed by a filter flask capable of collecting fluid that could be aspirated out of the cold
trap should be used.
• A cold trap using a cooling bath of dry ice and isopropanol or ethanol is sufficient for most
volatile liquids (temperatures as low as -78 °C). Glycols may also be used as the bath
liquid.
• Avoid using an acetone-dry ice cooling bath. The alternatives mentioned above are less
flammable, less prone to foaming and splattering and less likely to degrade trap
components (i.e. O-rings, plastic).
• Use caution when handling dry ice and preparing cooling baths. Wear splash goggles,
cryogenic gloves, and a lab apron when handling cryogenic liquids to avoid any skin
exposure.
AE-2
• Dry ice and liquified gases used in cooling baths should always be open to the
atmosphere. Never use them in closed systems where they may develop uncontrolled
pressures.
• Perform procedures in a well-ventilated area. Never lower
the head into a dry ice chest as asphyxiation can occur.
• Add dry ice slowly to the bath liquid to avoid foaming.
• Check cold traps frequently to make sure they do not
become plugged with frozen material.
• A cold trap using liquid nitrogen may only be used with
sealed or evacuated equipment. If the system is opened
while the cooling bath is in contact with the trap, oxygen
may condense from the atmosphere and react explosively
with any organic material present.
• Wrap Dewar flasks and cold traps with screens, friction
tape, or a metal jacket.
• Select equipment used at low temperatures carefully
because temperature can dramatically change the
characteristics of materials.
• After completion of a procedure using a cold trap under
pressure, isolate the trap from the vacuum source, remove
from the cooling bath and vent to atmospheric pressure in
a safe and environmentally acceptable manner.
Highly Reactive, Corrosive or Toxic Gases
• A sorbent canister or scrubbing device capable of trapping the gas should be used.
• Chemical traps for specified chemicals are available from laboratory supply vendors.
These traps contain neutralizers that mitigate the hazards of the chemical being collected.
Glassware
• Glassware under vacuum should be kept behind a shield or closed hood sash, taped or
resin (plastic) coated.
• Check glass vessels for star cracks, scratching and etching marks each time a vacuum
apparatus is used.
• Use only round-bottom or thick-walled (e.g. Pyrex) evacuated reaction vessels specifically
designed for operations at reduced pressures.
• Do not use glass vessels with angled or squared edges in vacuum applications unless
specifically designed for that purpose (e.g. extra thick glass).
• Repaired glassware should be inspected under polarized light before use in vacuum or
thermal operations.
• Never evacuate thin-walled, Erlenmeyer or round-bottom flasks larger than one liter.
Figure 2: An example of a cold
trap in a vacuum line immersed
in a cooling bath.
AE-3
• Glass components of rotary evaporators should be made of Pyrex or similar glass.
Enclose apparatus in a shield. Gradually increase rotation speed and vacuum to the flask
whose solvent is to be evaporated.
• Glass vacuum desiccators should be made of Pyrex or similar glass and be completely
enclosed in a shield or wrapped with friction tape in a grid pattern so as not to conceal the
contents. Never carry or move an evacuated desiccator.
Dewar Flasks
• Dewar flasks are under high pressure and can collapse from thermal or mechanical shock.
Shield Dewar flasks using a layer of fiber-reinforced friction tape or by enclosure in a
wooden or metal jacket. This reduces the risk of flying glass should the container collapse.
• Use metal Dewar flasks when there is a possibility of breakage.
• Styrofoam buckets with lids are a safer alternative for short-term storage and transport of
cryogenic liquids.
Other Vacuum Considerations
• An in-line hydrophobic filter may be added to any vacuum line for additional protection to
the vacuum system.
• Assemble vacuum apparatus to avoid strain. Joints should allow various sections to be
moved without transmitting strain to the flask neck(s).
• Support heavy apparatus by the bottom as well as by the neck.
• Equipment or apparatus under pressure should be located behind a blast shield or inside
a closed fume hood.
• If solvents or corrosive substances are drawn into the pump, change the oil before further
use to prevent damage to the vacuum. Oil contaminated with solvents and corrosive
substances must be handled as hazardous waste.
• Oil and pumps contaminated with mercury must be handled as hazardous waste. Contact
EHS immediately at 742-3876 for disposal.
• Keeping a log of pump usage may be desirable to guide length of oil use and potential
contaminants in the pump oil.
References
CDC/NIH. Biosafety in Microbiology and Biomedical Laboratories. 5
th
ed. (2009). Appendix A.
https://www.cdc.gov/biosafety/publications/bmbl5/
.
National Research Council. Prudent Practices in the Laboratory: Handling and Management of
Chemical Hazards, Updated Version. (2011).
https://www.nap.edu/catalog/12654/prudent-
practices-in-the-laboratory-handling-and-management-of-chemical.
Appendix AF
AF-1
HAZARDOUS WASTE DISPOSAL
A. In any discussion of hazardous waste, addressing the concept of waste minimization is a
must. Minimizing the amount of waste generated can be accomplished in a number of ways.
Some are described below.
1. Surplus chemicals can be exchanged among labs, sections, or departments. This
applies not only to 'virgin' materials, but to the end products of processes or
experiments which could be of use to someone else.
2. Materials may be distilled to recover them to a point of usability, if not to the original
user, to another user on campus. This is greatly facilitated by segregating potential
wastes to the extent practical at the point of generation.
3. Substitution of a less hazardous material for one requiring special handling will not only
cut disposal costs, but reduce hazards in the laboratory as well.
4. Microscale operations reduce the waste volume by proportionately reducing the
amount of chemicals input for the reaction.
5. Steps must be taken to ensure faculty and staff members do not depart until all
substances in their work areas are clearly marked as to contents. Compliance with the
Texas Hazard Communication Act (TAC § 502) will eliminate most problems of this
type, however, the cost of analysis for the identification and hazard classification of
unknowns is high enough to make this a cost effective endeavor.
B. Once it has been determined that the substance can't be exchanged, recycled, or
neutralized, contact EHS to arrange for it to be picked up for entry into the waste stream.
Waste pickups are made on Tuesday and Thursday of each week. Wastes should not be
allowed to accumulate as this presents health and environmental hazards. When requesting
EHS to arrange for a waste pick up, you will need to enter in your request online at
www.ehs.ttu.edu and have the following information available:
1. Name and telephone number of person requesting pick up
2. Department and room number where waste is located
3. Department and room number of requestor, if different than above
4. A TTU email account
5. Type of waste
6. Size of container
7. Are the containers properly labeled with an orange EHS “Waste” sticker
8. Has the Transfer of Chemical, Bio Waste, and/or Universal Waste form been completed
9. Any other information that you feel the person picking up the waste should know.
AF-2
C. EHS has developed labels in various sizes to be affixed to each container of hazardous
waste once collection has begun. These labels are available from EHS at no cost. The
following areas of the label shall be filled out by the generator.
Contents - List all wastes in the container. (Has to be the full name. Abbreviations and
formulas are not acceptable)
Building - Your facility.
Room # - Self-explanatory.
Accumulation Start Date - The date you first placed any waste in the container.
Hazard - Check the appropriate block for the hazard(s) associated with the waste.
D. When filling out the Request for Transfer of Chemicals form, ensure that the names used in
the 'Chemical Description ' block match those on the waste container labels and that there
is an appropriate entry in each column with the possible exception of 'Remarks‘ and
‘Transaction Number’. The information for the 'Hazardous Characteristics ' column can
usually be obtained from the original container or the MSDS; however, if the required
information cannot be obtained from either of those sources or from a reference, contact
EHS for assistance. All other entries are self-explanatory.
Appendix AG
AG-1
GUIDANCE FOR WRITING CARCINOGEN, MUTAGEN, AND
TERATOGEN PROCEDURES
Written procedures for work with carcinogens, mutagens, and teratogens shall include the
following information as a minimum:
1. Chemical of concern.
a. What chemical will be used?
b. Identify whether it is a carcinogen, a mutagen, or a teratogen.
c. Are there other hazards associated with the chemical? i.e., corrosive, reactive, flammable,
toxic, irritant.
2. Physical form of chemical.
a. Solid, liquid, or gas?
b. Will the form change during the process? i.e., solid placed in solution or liquid phasing
into a vapor.
3. Quantity on-hand in the laboratory and the amount used in each procedure.
a. How much is present and how is it stored?
b. How much will be used for each repetition of the process?
4. Laboratory and specific location(s) in the lab where the chemical will be handled or used.
a. Where will it be measured, mixed, etc.?
b. Where will the process in which it is used take place?
c. Are these areas clearly marked?
d. Is the laboratory posted?
5. Administrative controls employed to limit exposure.
a. Will all lab workers be using/handling it?
b. Will all lab workers be present when it is used/handled?
6. Engineering controls employed to limit exposure.
a. Will the use/handling be done in a hood?
b. Will the process take place in a hood?
7. Personal protective equipment (PPE) employed to limit exposure.
a. Will lab workers be wearing gloves, goggles, face shield, etc.?
b. Is the PPE on hand appropriate for this chemical?
AG-2
8. Laboratory security measures.
a. Are non-essential personnel barred from the lab when operations with this
chemical take place?
b. Is the storage location for the chemical secure?
9. Medical surveillance.
a. Does an OSHA substance-specific standard regarding this chemical exist?
b. Has EHS performed exposure monitoring that indicates surveillance is necessary?
10. Informed consent.
a. Has every worker in the laboratory been made aware of all the hazards associated with
this chemical?
b. Have all been trained regarding the necessity of the exposure control portions of this
procedure and the potential consequences of failure to comply?
c. Is the training documented and acknowledged by signatures of the lab workers?
Include any other information or procedures specific to this chemical or laboratory that may
have a bearing on the safety and health of lab workers.
AG-3
PROCEDURES FOR WORK WITH CARCINOGENS, MUTAGENS, AND
TERATOGENS
• It is the responsibility of the lab workers to be aware of hazards associated with any
chemical they use. Information is available from Material Safety Data Sheets found in
_____________.
• All new workers in the laboratory who will work with carcinogens, mutagens, and teratogens
will be trained by one of the following
people_______________________________________.
• For any chemical used in the laboratory, the lab worker is responsible for being aware of
known or suspected hazards. For each known carcinogenic, mutagenic, or teratogenic
chemical to be used, the lab worker should identify these and other hazards (i.e. corrosive,
reactive, flammable, toxic, irritant) based on available MSDS recommendations available in
the laboratory.
• The lab worker should be aware of the physical form of the chemical and any potential
phase changes during the experiment.
• The lab worker should be aware of the quantity on hand to be used.
• Opened containers of carcinogens, mutagens, and teratogens should be stored in the
labeled area under the hood and used in the hood as indicated in the laboratory.
• Sealed containers of carcinogens, mutagens, and teratogens should be stored according to
their hazards.
• Usage of these compounds should be limited to lab workers trained in their safe usage.
• Lab workers should wear Personal Protective Equipment (PPE) including, but not limited to
gloves, lab coat, hair restraints, goggles, and any other PPE recommended by the MSDS
that is deemed appropriate.
• When working with hazardous chemicals, only group members should be in the lab. To
prevent unauthorized usage of chemicals, access must be limited. Access to this lab can be
acquired through ______________________.
• If OSHA monitoring is required, it should be performed by EHS.
• Every lab worker is to receive training in the safe handling of hazardous chemicals and is to
document this by signing an informed consent document.
• If you have any questions, please ask ________________________________.
Appendix AH
AH-1
PEROXIDE FORMING COMPOUNDS
It is recommended that peroxide forming chemicals be checked for the formation of peroxides or
disposed of one year after opening. If peroxides are present, remove the peroxides or dispose of
the chemical. These recommendations are from Stephen R. Rayburn, The Foundations of
Laboratory Safety, 1990 and Jay A. Young, Improving Safety in the Chemical Laboratory, 1991.
List of Peroxide Forming Compounds
1
This is not an all inclusive list. It is the responsibility of the laboratory to identify peroxide
forming chemicals.
Acetal
Acrylic acid
Butadiene
Chlorobutadiene (chloroprene)
Chlorotrifluroethylene
Cumene
Cyclohexene
Cyclooctene
Cyclopentene
Diaactylene
Dicyclopentadiene
Diethyl ether
Diethylene glycol dimethyl ether (diglyme)
Dioxane (p-dioxane)
Divinyl acetylene
Ethyl acrylate
Ethylene glycol dimethyl ether (glyme)
Furan
Isopropanol
Isopropyl ether
Methyl acetylene
Methyl cyclopentane
Methyl methacrylate
Methyl-isobutyl ketone
Potassium amide
Potassium metal
Sodium amide (Sodamide)
Styrene
Tetrafluoroethylene
Tetrahydrofuran
Tetrahydronaphthalene
Vinyl acetate
Vinyl chloride
Vinyl ethers
Vinyl pyridine
Vinylidene chloride
AH-2
Detection and Inhibition of Peroxides
2
Peroxide Test Strips
Commercially purchased test strips can be used for the detection of peroxide formation (follow
the manufacturer’s instructions).
Please note that these methods are BASIC protocols. Should a researcher perform one of these
methods, all safety precautions should be thoroughly researched.
Ferrous Thiocyanate Detection Method
Ferrous thiocyanate will detect hydro peroxides with the following test:
1. Mix a solution of 5 ml of 1 % ferrous ammonium sulfate, 0.5 ml of 1 N sulfuric acid and 0.5
ml of 0.1 N ammonium thiocyanate (if necessary decolorize with a trace of zinc dust)
2. Shake with an equal quantity of the solvent to be tested.
3. If peroxides are present, a red color will develop.
Potassium Iodide Detection Method
1. Add 1 ml of a freshly prepared 10% solution of potassium iodide to 10 ml of ethyl ether in a
25 ml glass-stoppered cylinder of colorless glass protected from light (both components are
clear).
2. A resulting yellow color indicates the presence of 0.005% peroxides.
Inhibition of Peroxides
1. Storage and handling under an inert atmosphere is a useful precaution.
2. Addition of 0.001 % hydroquinone, diphenylamine, polyhydroxyphenols, amino phenols or
aryl amines may stabilize ethers and inhibit formation of peroxides.
3. Dowex-1© has been reported effective for inhibiting peroxide formation in ethyl ether.
4. 100 ppm of 1-naphthol is effective for peroxide inhibition in isopropyl ether.
5. Hydroquinone is effective for peroxide inhibition in Tetrahydrofuran.
6. Stannous chloride or ferrous sulfate are effective for peroxide inhibition in dioxane.
AH-3
References
1 Copied from Prudent Practices in the Laboratory.
2 Copied from the CRC Handbook of Lab Safety, 2
nd
Ed.
Appendix AI
AI-1
EXPOSURE ASSESSMENT
1. Assessment versus Monitoring –
Exposure assessment is that portion of the exposure evaluation performed by the laboratory
supervisor which involves a judgment based on materials being used, the manner of their use, and
personal knowledge of the procedures being performed. Exposure monitoring is that portion of
exposure evaluation performed by the CHO, or other persons trained in industrial hygiene
sampling techniques, which involves gathering data with direct or indirect reading instruments or
equipment. Both methods evaluate employee exposure to some contaminant, with assessment
being used as the screening method to determine if monitoring is necessary.
2. Assessment Procedures –
An initial assessment of all laboratory procedures should be performed using the attached
checklist. It may include such factors as the amounts and characteristics of the materials used, the
frequency and duration of use, and the effectiveness of engineering controls and protective
equipment. No exposure monitoring is indicated if laboratory employee exposures to substance(s)
regulated by OSHA do not exceed the action level or PEL specified in 29 CFR 1910 subpart Z.
Exposure monitoring would be indicated when there is reason to believe exposure levels for the
substance(s) used in the areas indicated routinely exceed the action level or PEL.
EXPOSURE ASSESSMENT CHECKLIST
YES NO
1. Is the procedure performed in a closed system?
2. Can the procedure be performed inside a lab hood or other containment?
3. Is the lab hood performing to established standards?
4. If the substance is highly toxic, is it handled fewer than three times per week, for less than
an hour per occurrence?
5. Have all employees remained free of any of the signs or symptoms associated with
overexposure to the substance?
6. Does historical monitoring data indicate acceptable exposure levels?
7. Does the written procedure address required personal protective equipment, emergency
equipment and actions, work practices, and housekeeping?
8. Is personal protective equipment appropriate to the hazard?
If you answered 'NO' to any of these questions, contact the CHO for further
evaluation to be performed.
Appendix AJ
AJ-1
EQUIPMENT DECONTAMINATION FORM
Equipment from laboratories where hazardous materials, recombinant DNA and/or potentially infectious materials are
stored and/or manipulated must be decontaminated before repair, maintenance or removal from the laboratory. It is the
responsibility of the PI to ensure that all equipment is properly and adequately decontaminated before it is removed from
the work area for surplus or repair. Leave the completed form with the equipment after decontamination for EHS
approval. Call EHS at 742-3876 to schedule inspection and clearance of your equipment. (Click here for a fillable PDF
version of this form).
EQUIPMENT LOCATION AND DESCRIPTION
Department: Building: Room:
Equipment Description: TTU Inventory Number:
Serial Number: Make & Model:
EQUIPMENT DESTINATION AND USAGE
This equipment is to be:
☐Repaird or Maintenanced ☐Relocated ☐Surplus ☐Discarded
☐Other – Please specify:
If the equipment is being discarded, please indication the manner in which it will be disposed of below.
This equipment:
☐ Has never been used with hazardous materials and was last cleaned:
Note: The equipment is required to be cleaned with warm soapy water regardless of use.
☐ Has been used with the following type(s) of material:
Please list details regarding nature of hazard where applicable.
☐Chemical(s):
☐Biological Agent(s):
☐Radioactive Material(s):
EQUIPMENT DECONTAMINATION PROCESS
☐ This equipment was decontaminated by a third party.
Attach proof of decontamination provided by the company and P0 used for payment to this form.
☐ This equipment was decontaminated by laboratory personnel.
Attach decontamination procedure to this form.
Name and Title of Personnel Signature Date
EHS Review and Approval To be filled out by EHS
Comments:
Reviewer: Title:
Signature Date
Appendix AK
AK-1
LABORATORY DECOMMISSIONING CHECKLIST
BUILDING:
ROOM:
PI:
SURVEY
DATE:
VACATE
DATE:
Section Area of Interest
Requires
completion
A General Lab Hazards Y N N/A
1
Remove absorbent material and tape from lab surfaces; dispose of according to
hazards in area. Disinfect/decontaminate the lab surface.
2 Dispose of unwanted paperwork - shred confidential documents.
3
Empty all drawers and cabinets. Dispose of unusable materials, decontaminate
everything else. Divide as give/keep and label boxes.
4 Dispose of broken glass accordingly.
5 All extra boxes, trash, packing materials are to be disposed of.
6 Sweep and mop laboratory with appropriate disinfectant.
7
Wide down all laboratory benches, shelves, storage areas, etc. with appropriate
disinfectant.
8
Empty and decontaminate all axillary storage areas, cold rooms, alcoves, walk-in
freezers, etc.
9
Carefully evaluate shared storage areas, refrigerators, freezers, cold rooms for
materials. Properly arrange transport, transfer or disposal of materials.
AK-2
B Equipment Y N N/A
1
Disinfect and decontaminate ALL equipment for EHS inspection and clearance. Refer
to section 9 of the Biosafety Manual for more information.
2
Remove all thermometers and loose items from equipment. Decontaminate and
prepare the equipment according to final destination.
3
Empty all items from freezers and refrigerators; disinfect and decontaminate inside
and outside of unit.
4 Submit Equipment decontamination forms to EHS for inspection and clearance.
C
Chemical Hazards
Y
N
N/A
1 Check all cabinets, hoods, drawers, etc. for chemical storage.
2 Prepare all chemical waste for EHS waste pick up.
3
Label secondary containers of chemicals to be moved according to the storage group
the container is for. Include any pertinent hazard information.
4 Contact EHS regarding transport of the chemicals to be moved to a new location.
5
Contact EHS regarding the transfer of any unopened/opened chemicals to a different
PI.
6 Dispose of all mercury thermometers as hazardous waste.
7
Return empty gas cylinders to the vendor. Contact EHS for disposal of non-returnable
gas cylinders.
8
Cap and secure tanks containing gas. Contact EHS regarding transfer to new campus
location or return to the vendor.
9 Contact EHS for destruction of DEA Controlled Substances.
10 Contact EHS to discuss chain of custody for keys to lockable storage cabinets.
AK-3
D Biological Hazards Y N N/A
1
Decontaminate all work surfaces, door knobs, draw handles, etc. with an effective
antimicrobial cleaner.
2 Disinfect of all biological waste by autoclaving or schedule a waste pick up with EHS.
3 Dispose of sharps in appropriate container and a scheduled a waste pick up with EHS.
4
Disinfect all equipment. Laminar hoods and biosafety cabinets require fumigation by a
third party. See section 9 of the Biosafety Manual for details.
5
Empty and disinfect all refrigerators, freezers, cold rooms, incubators, etc. Wipe down
all interior/exterior surfaces and components with disinfectant.
6
Contact EHS for transfer of biological materials. The recipient may need to obtain IBC
approval.
7
Contact EHS regarding the transport of biological materials. If the materials are under
an IBC protocol, a new protocol is needed for on-campus transfers.
8 Contact EHS for destruction of Select Agents
E Radiation Hazards Y N N/A
1
Notify the Radiation Safety Officer of the move. The RSO will direct decommissioning
of the laboratory.
AK-4
F Laboratory - Specific Considerations in Decommissioning Y N N/A
1
2
3
4
5
6
7
8
9
10
If you have any questions or require assistance at any point in time during the move, do not hesitate to
contact EHS at 806-742-3876. Please do not work with chemical, biological or radioactive hazards during
non-business hours so that EHS can quickly address any issues/emergencies which may arise.
Appendix AL
AL-1
FORMS
The following forms are included in this section as printable documents for your convenience. These
forms are also available on the EHS website. The Near-Miss Form (SCAN) and the Hazardous Waste
Pick-Up Form are only available on-line through the EHS website. Please contact EHS with any
questions at 806-742-3876.
Link for Near-Miss reporting (SCAN):
http://www.depts.ttu.edu/ehs/about/scan.php
SCAN QR-Code
Link for Incident Reporting (damage to property or person, exposure):
https://www.texastech.edu/offices/risk-management/
Risk Management QR-Code
Link for Hazardous Waste Pick-Up request:
https://www.depts.ttu.edu/ehs/forms/waste-request.php
Waste Request QR-Code
Forms included in Appendix AL:
• Initial Investigation of Overexposure Form
AL-2
Submit form via fax to 806-742-3895 or scan and email to [email protected].
For questions, call 806-742-3876, Environmental Health & Safety, Administrative Support Center, Rm 122.
INITIAL INVESTIGATION OF POSSIBLE OVEREXPOSURE
(To be completed by PI/Lab Supervisor/Departmental Representative)
Date of incident: Date of interview:
Name of Person:_____________________________________________ Telephone No.:
Department:______________________________ Immediate Supervisor
Name of Chemical(s) in use:
If available, attach relevant MSDS to this report.
Time and Date of Incident :
Length of exposure (hour/minutes):______________ Amount of Chemical involved in ounces:
Control measures used at time of incident:
Laboratory Hood or Splash Shield:
Personal Protective Equipment: ____Gloves ____Goggles ____Face Shield ____Lab coat ____Other
Description of Incident
AL-3
Witnesses:
Location of injuries or sites of contact, e.g. eyes, skin:
Additional Information:
AL-4
Signs and symptoms developed:
Eye irritation Taste Breath odor Nausea Vomiting
Headache Dizziness Shortness of breath Chest pain
Pale skin Skin irritation Rash Blistering Tingling
Other_______________________________________________________________________________
____________________________________________________________________________________
Elapsed time for signs and symptoms to develop:_____________________________________________
_______________________________________________________________________________________
Are signs and symptoms same as indicated on MSDS? Yes No If No, specify below.
________________________________________________________________________________________
________________________________________________________________________________________
Monitoring Equipment Used: ____PID ____Detector tubes ____Mercury Meter ____Miran 1BX
Additional Comments:
Name of Investigator Signature Date
NOTE: This information will be provided to the examining physician.
AL-5
PHYSICIAN'S WRITTEN OPINION FOR MEDICAL CONSULTATION
(To be completed by Attending Physician)
Physician’s Name: ___________________________ Employee Name: ______________________________
Company: __________________________________________ Date of Visit: ________________________
Description of incident: _____________________________________________________________________
________________________________________________________________________________________
Result of medical examination*: ______________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
* This written opinion shall not reveal specific findings of diagnosis unrelated to occupational exposure.
Medical examination revealed employee to be at an increased risk as a result of exposure to a hazardous chemical in the
workplace: _________________________________________________________________
Recommended medical follow up: ____________________________________________________________
________________________________________________________________________________________
Comments: ______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
The above referenced employee has been informed by me of the results of this consultation and related medical condition
that may require further examination or treatment.
Physicians Signature Date
Appendix BA
AL-2
Biological Laboratory Requirements
The checklists below will be referenced as needed by the IBC to evaluate a space for special research.
Other references as mentioned in B5.2, B5.3, and B5.4 will also be referenced to properly evaluate
containment needs. EHS and the IBC will also reference these checklists during certification of lab
spaces and annual inspections.
Biosafety Level 1 (BSL1) see B9.2.2.1
Biosafety Level 2 (BSL2) see B9.2.2.2
Animal Biosafety Level 1(ABSL1) see B9.2.3.1
Animal Biosafety Level 2 (ABSL2) see B9.2.3.2
Arthropod Containment Level 1 (ACL1) see B9.2.3.3
Arthropod Containment Level 2 (ACL2) see B9.2.3.4
Plant Containment Level 1 (PCL1) see B9.2.3.5
Plant Containment Level 2 (PCL2) see B9.2.3.6
The checklists can be found on the EHS Tools, Templates, & Posters page:
https://www.depts.ttu.edu/ehs/academicsafety/lab/tools-templates.php
CDC Import Permit Program
BSL2
https://www.cdc.gov/cpr/ipp/inspection/docs/Import_Permit_Checklist_BSL-2.pdf
BSL3
https://www.cdc.gov/cpr/ipp/inspection/docs/Import_Permit_Checklist_BSL-3.pdf
ABSL2
https://www.cdc.gov/cpr/ipp/inspection/docs/Import_Permit_Checklist_ABSL-2.pdf
ABSL3
https://www.cdc.gov/cpr/ipp/inspection/docs/Import_Permit_Checklist_ABSL-3.pdf
ACL2
https://www.cdc.gov/cpr/ipp/inspection/docs/Import_Permit_Checklist_ACL-2.pdf
ACL3
https://www.cdc.gov/cpr/ipp/inspection/docs/Import_Permit_Checklist_ACL-3.pdf
AL-3
Appendix BB
BB-1
CHARACTERISTICS OF COMMON DISINFECTANTS
Sodium Hypochlorite
(Bleach) 5.25%
Phenols
Quaternary
Ammonium
Compounds
(Quats)
Hydrogen Peroxide Alcohols Iodophors
Usable
Concentration
1% to 20% As directed As directed 3%-8% 60-80% As directed
Shelf Life
Unmixed
: Expiration on
container
Mixed: 24hours
Check expiration on
container
Check expiration on
container
Check expiration on
container
Check expiration on
container
When solution is pale
yellow to colorless
Inactivated by
Organic Matter
YES YES
YES
Except 4th-
generation
quats
YES NO YES
Irritant
YES
YES
YES
YES, >6%
YES
YES
Other Health
Concerns &
Hazards
REFER TO SDSs
Corrosive YES
YES, >10%
Not appropriate for use
with certain metals.
NO YES
Residue
YES
YES
YES
NO
NO
YES
Protective
Controls
PPE and ventilation.
Toxicity
Toxic to aquatic
organisms.
Toxic to all animals
including aquatic
organisms. Remains
persistent in the
environment. Subject to
disposal restrictions.
Toxic to aquatic
organisms.
Toxic to aquatic
organisms.
Disinfection chart adapted from Cleaning for Health. http://www.cleaning-for-health.org/disinfectant-chart/ and the CDC Guideline
for Disinfection and Sterilization in Healthcare Facilities. 2008.
Appendix BC
BC-1
SELECT AGENT LINKS
Center for Disease Control & United States Department of Agriculture Select Agent Information
https://www.selectagents.gov/
Bureau of Industry & Security - Export Administration Regulations (EAR)
https://www.bis.doc.gov/index.php/regulations/export-administration-regulations-ear
Microorganism & Biological Toxin location - Chapter 1 Sections 1C351-1C354
Appendix BD
BC-1
BIOLOGICAL SAFETY CABINETS
Placement:
https://absa.org/wp-content/uploads/2019/05/NIH-BSC-Placement_Dos_and_Donts.pdf
Additional information can be found in Appendix A of the BMBL, pg. 370-395.
Figures have been taken from Appendix A of the BMBL.
Class I
• Protect personnel and the environment but not research materials.
o Provide an inward flow of unfiltered air, similar to a chemical fume hood, which protects the
worker from the material in the cabinet. The environment is protected from biological
contamination by HEPA filtration of the exhaust air before it is discharged into the laboratory.
Cabinet can also be ducted to the outside via the building exhaust. See Figure 1.
• Can be used for handling BSL 1, 2 and 3 materials.
• Cannot be used with volatile or toxic chemicals unless ducted to the outside with proper
environmental protection measures in place.
FIGURE 1. Class I BSC: A) Front opening; B) Sash; C) Exhaust HEPA filter; D) Exhaust plenum
BD-2
Class II
The National Sanitation Foundation and American National Standards Institute have set forth a standard
for certification of Class II BSCs. This standard, NSF/ANSI 49, covers the basic requirements for design,
construction and performance parameters to provide protection and a variety of other standards, such as
electrical safety and noise level, in addition to evaluation and decontamination procedures.
• 4 types of Class II BSC: A1, A2, B1, B2 and C1
• Provide personnel, environment, and product protection.
o Air is drawn around the operator into the front grille of the cabinet, which provides
personnel protection. In addition, the downward laminar flow of HEPA-filtered air within the
cabinet provides product protection by minimizing the chance of cross-contamination along
the work surface of the cabinet. Because cabinet air passes through the exhaust HEPA
filter, it is contaminant-free (environmental protection).
• Can be used for handling BSL 1, 2 and 3 materials.
Type A: Figures 2 and 3.
• 70% air is recirculated in cabinet; 30% air is exhausted into the laboratory
• A1: 75 FPM air intake; biologically contaminated ducts/plenums are positively pressured to room;
not for use with toxic or volatile chemicals or gases regardless of ducting
• A2: 100 FPM air intake, biologically contaminated ducts/plenums are negatively pressured to
room; not for use with toxic or volatile chemicals or gases if exhausted to room – if chemicals are
to be used, additional measures to protect the environment may be needed.
o Previously, there had been a Type B3 cabinet; this cabinet type has been eliminated by the National
Sanitation Foundation and units which are listed as B3 are categorized as type A2; new A2 units are not
equivalent to B3 unless connected the building exhaust.
Type B: Figures 4, 5 and 6.
• 100 FPM air intake
• Exhausted air must be ducted to the outside of the building
o offers protection to the environment from biologicals
o environmental protection from chemicals requires additional measures
• B1: 40% of air is recirculated and 60% is exhausted; biologically contaminated plenums are
negative to the room or surrounded by negative pressure plenums; chemical use is restricted,
contact EHS.
• B2: 0% of air is recirculated and 100% is exhausted; biologically contaminated ducts are under
negative pressure or surrounded by negative pressure ducts or plenums; chemical use is allowed
so long as additional measures are in place to protect the environment.
Type C1: Figure 7
• 100 FPM air intake
• 30% recirculated, 70% exhausted. Exhaust cabinet air must pass through a dedicated, internal
cabinet duct to the outside through a blower and HEPA filter; may be ducted to switch from A2
equivalent to mimic function of B1 cabinet.
BD-3
Left: FIGURE 2. Class II, Type A1 BSC: A) Front opening; B) Sash; C) Exhaust HEPA filter; D) Supply
HEPA filter; E) Common plenum; F) Blower/fan.
Right: FIGURE 3. Class II, Type A2 BSC: A) Front opening; B) Sash; C) Exhaust HEPA filter; D) Supply
HEPA filter; E) Positive pressure common plenum; F) Negative pressure plenum
Left: FIGURE 4. Class II, Type B1 BSC: A) Front opening; B) Sash; C) Exhaust HEPA filter; D) Supply
plenum; E) Supply HEPA filter ; F) Blower/fan; G) Negative pressure exhaust plenum (ducted to building)
Right: FIGURE 5. Class II, Type B1 BSC Classic style: A) Front opening; B) Sash; C) Exhaust HEPA filter;
D) Supply HEPA filter; E) Negative pressure exhaust plenum (ducted to building exhaust); F) Blower/fan; G)
additional HEPA filter for supply air
BD-4
FIGURE 6. Class II, Type B2 BSC: A) Front opening; B) Sash; C) Exhaust HEPA filter; D) Supply HEPA filter; E)
Negative pressure exhaust plenum (ducted to building exhaust with additional filters for chemical use).
FIGURE 7. Class II, Type C1 BSC A) Front opening; B) Sash; C) Exhaust HEPA filter; D) Supply HEPA filter;
E) Supply Blower, F) Exhaust Blower.
BD-5
Class III
• Also called a glove box or total containment cabinet
• Designed for work with highly infectious agents that require BSL4 containment
• Provides the highest level of personal, environmental, and product protection
o The cabinet is gas-tight with a non-opening view window, and has rubber gloves attached to
ports in the cabinet that allow for manipulation of materials in the cabinet. Air is filtered through
one HEPA filter as it enters the cabinet, and through two HEPA filters before it is exhausted to
the outdoors.
FIGURE 8. Class III: A) Glove ports; B) Sash; C) Exhaust HEPA filter (double HEPA or HEPA then incinerated
and exhausted outside the building; D) Supply HEPA filter; E) autoclave or pass-through box
Appendix BE
.
Periodic Autoclave Testing & Reporting
Environmental Health & Safety
BE-1
SOP No. 5.4
Print Name
Initial
Title
Date
Author
Rebecca Maloney
Biosafety Mngr.
Reviewed by
Heather Coats
Training & Outreach Mngr.
Authorized by
Matt Roe
Director, EHS
DATE CREATED: NOV 2016 LAST REVISED: 16JUN2021 REVISION NO.: 2
Purpose
Materials that may be considered biohazardous, including contaminated equipment and lab ware, must
be rendered non-infectious prior to washing, storage, or disposal. To ensure health and safety, it is a
matter of Texas law that all biohazardous materials, items potentially contaminated with such materials,
items that could be mistaken for medical or biohazardous waste (e.g., agar plates used to grow non-
pathogenic microbes) or items that have come in contact with biological materials must be
decontaminated prior to disposal.
“Moist heat in the form of saturated steam under pressure is the most widely used and the most
dependable means to destroy microorganisms
1
.” Operational standards require that the autoclave
reach a temperature of not less than 121° C (250° F) for 30 minutes at 15 pounds per square inch
pressure to effectively sterilize the load contents. A variety of factors can affect the efficiency of an
autoclave; therefore, regular testing of autoclaves to ensure sterilization conditions for temperature,
time, and pressure are reached is crucial to insure sterilization and regulatory compliance. Information
regarding autoclave use and testing can be found in detail in section B.8.4 of the Texas Tech University
Biosafety Manual.
Responsibilities
It is the responsibility of the principal investigator for each lab that uses an autoclave to develop lab-
specific internal standard operating procedures for each autoclave/steam sterilizer for which they are
responsible. The procedure must address each of the following cycle parameters:
• Time
• Temperature
• Pressure
• Type of waste
• Type of container(s)
• Closure on container(s)
• Pattern of loading
• Water content
• Maximum load quantity
• Internal periodic testing to insure the equipment is in working condition
BE-2
This standard operating procedure (SOP) outlines the elements that should be considered and included
as appropriate in lab-specific autoclave procedures. This lab procedure should also include a means to
ensure that training, recordkeeping, and testing is conducted for each autoclave in a lab or used by
their lab personnel. All personnel using autoclaves must be adequately trained by their PI or lab
supervisor. Never allow untrained personnel to operate an autoclave. Please refer to section B.8.4 of
the Texas Tech University Biosafety Manual for more details regarding autoclave use and regulations
prior to drafting a laboratory-specific SOP. The EHS-provided Autoclave Training is required for all
autoclave users.
Summary of Recommended Standard Practices
• Review the operator’s manual for instructions prior to operating the unit. Different makes and
models have unique characteristics. Never exceed the maximum operating temperature, pressure
and load volume of the autoclave.
• Wear the appropriate personal protective equipment (safety glasses, lab coat and heat- resistant
gloves) when loading and unloading the autoclave. Often a pulse of hot steam escapes when the
hatch is opened. Stand on the back side of the hatch and not too close when opening an
autoclave.
• Place autoclavable bags on their side in a secondary containment to retain any leakage that might
occur - never place autoclave bags directly in the autoclave chamber. The secondary containment
vessel must be constructed of material that will not melt or distort during the autoclave process.
o Polypropylene is a plastic used for such secondary containers. It is capable of withstanding
autoclaving but is resistant to heat transfer. Materials contained in a polypropylene pan will
take longer to autoclave than the same material in a stainless-steel pan.)
o Autoclave bags shall be loosely secured with autoclave tape or a twist tie. Knotting or
twisting closed the top of the bag will interfere with proper autoclaving of the contents.
• Lab personnel must use heat-sensitive tape or other device to visually check that optimal
temperatures have been achieved on each container in a load that is processed.
• Load parameters for every load or biohazardous waste must be recorded by personnel on the
record sheet. Please see attached log sheet.
• Autoclaves will be evaluated at least annually with a biological indicator by EHS. A laboratory may
voluntarily self-test more frequently if desired at their own expense.
• Autoclaves which process biowaste shall be evaluated by laboratory personnel monthly or at the
follow applicable frequency:
o for laboratories of more than 50 pounds but less than or equal to 100 pounds per month,
testing shall be conducted at least once per month;
o for laboratories of more than 100 pounds but less than or equal to 200 pounds per month,
testing shall be conducted at least biweekly; and
o for laboratories of more than 200 pounds per month and persons that treat medical wastes
off-site, testing shall be conducted at least weekly.
• EHS will supply the biological indicators for required state testing.
• It is recommended that testing be performed on a Friday so that the weekend can be used for
required incubation time. This minimizes the number of potentially failed autoclave runs in the
event of a positive test.
BE-3
• A report form must accompany all vials.
• Autoclaves require testing after installation and any service.
• Testing of units on main campus should coordinate the test date with the biological safety officer.
Please submit questions, comments, or other assistance to EHS at safety@ttu.edu or call EHS at
806-742-3876.
Use of Biological Indicators
EHS will be assisting in monitoring autoclave performance by providing bioindicators for state-required
testing. In most cases, EHS will incubate the BI after the cycle and provide results to the users. Certain
remote campuses will incubate their BI and provide the test results to EHS. Biological indicators (BIs)
contain G. stearothermophilis spores and a nutrient broth and are supplied in a serializable pouch
bearing chemical indicators.
• Do not open or adjust the pouch closure. The pouch serves as a “challenge pack” and will help
contain the bio-indicator material in case of accidental breakage.
• Currently, EHS provides Steris Dual Species Self-Contained BIs that can be used to assess a
variety of autoclave settings including 121C/30min gravity steam sterilization cycles for packaged
items (i.e., biowaste). Please inquire about other cycles as needed.
• More than one BI may be required to test an autoclave depending on capacity.
• Avoid running BIs on Fridays or the day before a scheduled university closure to allow for
incubation during the work week.
Instructions for indicator use are outlined below.
1. Do not open the pouch. Place the pouch in the most challenging location for sterilization (refer
to your model’s instruction manual). Run a biowaste cycle. Other cycle options for testing are
as follows: pre-vac, gravity 30, wrapped, or other cycle recommended by manufacturer for
testing.
2. After completion of the cycle:
a. For on campus locations, remove the pouch from the load and notify EHS for vial pick-
up.
b. For those on remote campuses that incubate their own BIs, remove the BI from the
pouch. Observe the chemical process indicator for color change (blue to brown) on
both the vial and the pouch.
c. Seal the BI by using the activator set to close the lid to the vial. Label the vial with the
autoclave tested. The BI is properly activated when the culture media is released from
the crushed media ampoule and the spore disc contacts the media. Repeat step ‘c’ for
the positive control BI (unautoclaved BI from same lot). Transfer test BIs and control BI
to an incubator set between 55C-59C.
d. Evaluate vials after 24hrs. A color change from blue/purple o yellow or presence of
turbidity are indicative of a failed test. If the control BI does not turn yellow, should be
considered invalid and repeated. Heat exposure outside the manufacturer’s guidelines
can result in damage to the media components that results in a tan appearance to the
media ampoule; this is an invalid result.
e. Document results on the report form.
BE-4
Failed Tests
In the event a test fails or is otherwise invalid proceed as follows:
1. Post an “Out of Service” sign on the autoclave. Contact the service contract personnel to
initiate a service call.
2. Do not use the autoclave until it has been inspected, repaired and successfully challenged with
a biological indicator.
Testing Components and Results
References
1. Rutala, W.A., Weber, D.J., Healthcare Infection Control Practices Advisory Committee. CDC.
Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.
2. Texas Tech University Biosafety Manual.
VIAL
ACTIVATOR
BE-5
Periodic Autoclave Testing Report Form
If using EHS assistance for incubation, please complete this form and submit with the test vial.
If you have questions, comments or need assistance in incubation, please contact ehs.lab.safety@ttu.edu
STERILIZER TEST DATA
Please fill in all information requested for complete and accurate results.
Principle Investigator Name:
Office Phone: Office Fax:
Operator Name (in CAPS):
Operator Signature:
Building Name: Room No.:
Sterikon Vial ID: Date of Test:
Make: Asset Tag No.:
Model: Serial No.:
Temperature: degree C/F Exposure time: minutes Pressure: psi
Autoclave is used to sterilize the following items:
Lab Process involves: BSL Level:
FOR EHS USE ONLY – DO NOT WRITE BELOW THIS LINE
Date Received:
Test Results:
: ⃝ Positive ⃝ Negative (No Growth) ⃝ Invalid (No growth in Control)
⃝ Autoclave Passed ⃝ Autoclave Failed ⃝ Retest required
Evaluated by (PRINT): Date:
Signature:
Appendix BF
Solid Biowaste Treatment Log – Chemical Disinfection
BF-1 PAGE ___ of ___
PI:
The waste in the log below was treated
according to SOP:
Chemical agent used was prepared
according to SOP:
BLDG:
ROOM:
DATE
MM/DD/YYYY
PRINTED NAME INITIALS
QTY (g) OF
WASTE
COMMENTS
Solid Biowaste Treatment Log - Autoclave
BF-2 PAGE ___ of ___
PI:
The waste in the log below was prepared
according to SOP:
The autoclave in room ______ was used
according to SOP:
BLDG:
ROOM:
Biowaste is autoclaved at a minimum of 121°C and 15psi for no less than 30 minutes.
DATE
MM/DD/YYYY
PRINTED NAME INITIALS
QTY
(lbs. or L)
OF WASTE
COMMENTS
Liquid Biowaste Treatment Log
BF-3 PAGE ___ of ___
PI:
The waste in the log below was treated
according to SOP:
Chemical agent used was prepared
according to SOP:
BLDG:
ROOM:
DATE
MM/DD/YYYY
PRINTED NAME INITIALS
QTY (ML)
OF WASTE
COMMENTS
Appendix BG
Use of EHS-provided Biobarrels
Environmental Health & Safety
SOP No. 6.5
BG-1
Print Name
Initial
Title
Date
Author
Rebecca Maloney
Biosafety Manager
18FEB2021
Reviewed
by
Eric Quintela
Environ. Protection
Manager
26MAR2021
Authorized
by
Matt Roe
Director, EHS
29MAR2021
DATE CREATED: 08FEB2021 LAST REVISED: REVISION NO.:
PURPOSE
This SOP describes the proper use and preparation of EHS-provided biological waste
barrels (biobarrels) for biowaste management at Texas Tech University. Biobarrels are
generally used in areas that lack autoclaves for biowaste treatment. Waste disposed of
in biobarrels is transferred to a third-party vendor for treatment and final disposal.
NOTES
Biobarrels are not the primary or singular means of biowaste containment in an area in
most instances. Biobarrels are supplied with biohazard liner; this liner is required for
use and to be used as a liner only. Proper waste segregation is required for use of EHS
biobarrels. Improper use endangers biobarrel users, downstream biobarrel handlers,
and costs the university money when biobarrels are overweight and/or used for non-
biohazardous items.
Failure to comply with biobarrel use requirements use may result in issuance of
corrective actions and/or delayed pick-up. Serial non-compliance may result in
revocation of biobarrel services in areas of elective biobarrel use when other approved
methods of biowaste management are accessible.
PROTECTIVE EQUIPMENT
Campus area will dictate PPE (i.e. clinic vs lab). Standard PPE applies when utilizing
biobarrels:
laboratory coat or other outer protective garment as required by the area-specific
requirements
eye protection (goggles or safety glasses) as required by the area-specific requirements
latex or nitrile gloves
PROCEDURE
I. ACCUMULATION OF BIOWASTE – IMMEDIATE AREA OF GENERATION
1. Waste items are disposed of in the immediate area of generation into smaller biowaste-
labeled receptacles lined with biohazard-labeled polypropylene bags or Keeper™ boxes.
a. Solid biowaste disposal is the primary purpose for biobarrels. Liquids should be
kept to a minimum in biobarrels. If you need advice on options for disposing of
BG-2
you liquid biowaste, contact EHS at 806.742.3876 to speak with the Biological
Safety Officer.
b. Chemicals, other hazardous waste, and non-biohazardous waste are not
disposed of in biobarrels. Disposal of these materials in the biobarrels will result
is revocation of biobarrel services.
2. When area accumulation reaches ¾ full, secure the top of the bag; transfer the bag to a
leak-proof container to transport the waste to the biobarrel.
a. DO NOT compress biological waste in the bags. This causes contamination to the
worker, often compromises the bag, and can result in unnecessary exposure.
b. Transport bags with containment to prevent spills and unintentional exposure
(It’s also required by the BMBL.).
c. Disinfect the inside of the transfer container and area biowaste receptacles
regularly and anytime a spill is evident.
II. ACCUMULATION OF BIOWASTE – BIOBARRELS
1. Remove the lid to the biobarrel, add your bag, then secure the lid back in place.
a. Biobarrels shall remain closed except when waste is actively being added to the
biobarrel.
2. You may continue using the same biobarrel until the bag is ¾ full or it weighs 40 lbs.
You can use a simple home scale to estimate weight of the biobarrel; weighing is best
completed with 2 people.
a. There is no minimum weight requirement to request a biobarrel pick up.
b. Biobarrel weights cannot exceed 40lbs. This is a requirement of the waste
management vendor and exceeding the limit results in fines that can be passed
on to the generator (i.e., biobarrel user).
c. Biobarrel cannot be filled beyond ¾ full. The head space in the biobarrel allows
the user to safely tie off the biobarrel liner for pick-up and prevents excessive
weight.
d. Do not compress biological waste in the biobarrel. This practice can cause
unnecessary contamination to the worker, often compromises the individual
biobags or biobarrel liner, and can result in exposure.
e. If you accidently overfill your biobarrel, simply remove a bag or two and transfer
to another biobarrel. Containing your waste in the smaller bags allows this to be
done safely.
III. PREPARING YOUR BIOBARREL FOR EHS PICKUP
Plan ahead – there is no minimum required weight in the biobarrel to request a waste
pickup. When your biobarrel has reached the conditions outlined in Section II.2 above
or you are otherwise ready for EHS pickup, follow the steps below.
BG-3
1. Place a waste request online through the EHS website:
https://www.depts.ttu.edu/EHS/. The form is located under the Quick Links > Request
Forms > Submit a Waste Request.
a. Select the Biological Waste option and complete the form. You will receive an
email regarding your request if submission was successful.
2. Before EHS arrives at your area to pick up your biobarrel, take the following steps to
make sure your barrel is ready to go.
a. Weigh your biobarrel to make sure it is not over 40lbs.
b. Tie off your biobarrel liner and secure the lid.
EMERGENCY PRE-PLANNING
• Post SOPs for managing biological spills and exposures near the location of the
biobarrel.
• Keep a biological spill kit near the biobarrel.
REFERENCES
Links to the University Laboratory Safety Manual, Posters, SOPs, and Waste Request
Form are available through the Academic Safety Resources webpage:
https://www.depts.ttu.edu/ehs/academicsafety/labsafety_resources.php
Biosafety and Microbiological and Biomedical Laboratories, 6
th
ed.
University Laboratory Safety Manual
Using EHS Biobarrels poster
EHS SOP 3.1: Transporting Biological Materials
EHS SOP 8.2: Managing Biological Spills
BG-4
ACKNOWLEDGMENT OF PROFICIENCY
The individuals below have been trained and are competent in completing the above
procedure.
Worker Name Worker Signature Date
Supervisor
Initial
Date
Appendix BH
BH-1
LINKS
Biosafety Homepage
https://www.depts.ttu.edu/ehs/academicsafety/Biosafety/index.php
Academic Safety Resources
Access to the LSM, tools & templates, Raider RAMP and more.
https://www.depts.ttu.edu/ehs/academicsafety/resources.php
IBC Committee Homepage
IBC Charge & Membership, links to application documents and information regarding review
process
https://www.depts.ttu.edu/ehs/academicsafety/icc/ibc.php
IBC Toolbox
Guides for using Cayuse and creating protocols, researcher manuals, personnel forms and
assurances.
https://www.depts.ttu.edu/ehs/forms/TTUIBC_ResearcherToolbox.php
Cayuse Homepage
https://ttu.esirius.cayuse.com/
Appendix CA
CA-1
REFERENCE INFORMATION
Glossary of Terms
This section lists information pertinent to radiation safety and is considered to be a part of
this manual. The definitions in this glossary will not cover every term associated with
radiation but does cover a majority of the terms. If a term should be encountered in your
work with radiation and is not in this glossary, consult your supervisor or call the TTU
Department of Environmental Health and Safety.
Radiation Terms
ABSORBED DOSE: The amount of energy imparted to matter by ionizing radiation
per unit mass of irradiated material.
ABSORPTION: The phenomenon by which radiation imparts some or all of its
energy to any material through which it passes.
ACTIVITY: The number of nuclear disintegrations occurring in a given quantity of
material per unit time.
ADMINISTRATIVE PENALTIES: Means a monetary penalty assessed by the
Bureau of Radiation Control for violations of the TRCR (TAC) and/or local policies
and procedures, to deter future violations and to assure continued compliance.
AIRBORNE RADIOACTIVE MATERIAL: Means any radioactive material dispersed
in the air in the form of dusts, fumes, mists, vapors, or gases.
ALPHA PARTICLE: A strongly ionizing particle emitted from the nucleus during
radioactive decay having a mass and charge equal in magnitude to a helium nucleus.
ALPHA RAY: A stream of fast moving helium nuclei (alpha particles), a strongly
ionizing and weakly penetrating radiation.
ANALYTICAL X-RAY EQUIPMENT: Means x-ray equipment used for x-ray
diffraction, florescence, or spectroscopy.
ANALYTICAL X-RAY SYSTEM: Means a group of local and remote components
utilizing x-rays to determine the elemental composition or to examine the
microstructure of materials. Local components include those that are struck by x-
rays such as radiation source housing, port and shutter assemblies, collimators,
sample holders, cameras, goniometers, detectors, and shielding. Remote
components include power supplies, transformers, amplifiers, readout devices, and
control panels.
CA-2
ANNIHILATION: An interaction between a positive and negative electron; their
energy, including rest energy, being converted into electromagnetic radiation
(annihilation radiation).
ANNUAL LIMIT ON INTAKE (ALI): Derived limit for the amount of radioactive
material taken into the body of an adult worker by inhalation or ingestion in a year.
ATOM: Smallest particle of an element which is capable of entering into a chemical
reaction.
AUTORADIOGRAPH: Record of radiation from radioactive material in an object
made by placing the object in close proximity to a photographic emulsion.
BACKGROUND RADIATION: Ionizing radiation arising from radioactive material
other than the source directly under consideration.
BETA PARTICLE: Charged particle emitted from the nucleus of an atom, having a
mass and charge equal in magnitude to an electron.
BETA RAY: A stream of high speed electrons or positrons of nuclear origin. Higher
penetration but less ionization than alpha rays.
BRC: Means Bureau of Radiation Control a division of the Texas Department of
Health.
BREMSSTRAHLUNG: Electromagnetic (x-ray) radiation associated with
deceleration of charged particles passing through matter.
COMMITTED DOSE EQUIVALENT (HT,50): Dose equivalent to organs or tissues
of reference (T) that will be received from an intake of radioactive material by an
individual during the 50-year period following the intake.
COMMITTED EFFECTIVE DOSE EQUIVALENT (HE, 50): Sum of the products of
the weighting factors applicable to each of the body organs or tissues that are
irradiated and the committed dose equivalent to these organs or tissues (HE, 50 =
SwTHT,50).
CONTAMINATION, RADIOACTIVE: The deposit of radioactive material in any place
where it is not desired, and particularly where its presence can cause harm.
CARRIER FREE: An adjective applied to one or more radionuclides in minute
quantity, essentially undiluted with a stable carrier.
CFR: Means Code of Federal Regulations.
CA-3
CRITICAL ORGAN: That organ or tissue, the irradiation of which will result in the
greatest hazard to the health or the individual or his descendants.
DECAY, RADIOACTIVE: Disintegrations of the nucleus of an unstable isotope by
the spontaneous emission of charged particles and/or photons.
DEEP DOSE EQUIVALENT (Hd): Applies to external whole body exposure, is the
dose equivalent at a tissue dept of 1 cm (1000 mg/cm
2
.) but internal organ(s) still
considered to be irradiated.
DERIVED AIR CONCENTRATION (DAC): Concentration of a given radionuclide in
air which, if breathed by the reference man for working year of 2,000 hours under
conditions of light work (inhalation rate 1.2 cubic meters of air per hour), results in an
intake of one ALI.
DOSE: A general term denoting the quantity of radiation or energy absorbed in a
specified mass. For special purposes it must be appropriately qualified, e.g.
absorbed dose.
DOSE EQUIVALENT: A quantity used in radiation protection expressing all radiation
on a common scale for calculating the effective absorbed dose. The unit for the dose
equivalent is the rem, which is numerically equal to the absorbed does in rads
multiplied by a quality factor.
ELECTRON: Negatively charged elementary particle which is a constituent of every
neutral atom.
ELECTRON VOLT: A unit of energy equivalent to the amount of energy gained by
an electron in passing through a potential of 1 volt.
EXPOSURE: A measure of the ionizing that is produced in air by x or gamma rays.
It is the sum of the electrical charges on all the ions of one sign produced in air when
all electrons liberated by photons in a volume element of air car completely stopped
in air, divided by the mass of air in the volume element.
Note: The unit for exposure is the roentgen.
FAIL SAFE CHARACTERISTICS: Means a design feature which causes beam port
shutters to close, or otherwise prevents emergence of the primary beam, upon failure
of a safety or warning device.
GAMMA RAY: Very penetrating electromagnetic radiation of nuclear origin. Except
for origin, identical to x-rays.
GEIGER-MUELLER (G-M) COUNTER: Highly sensitive gas-filled detector and
associated circuitry used for radiation detection and measurement.
CA-4
GENETIC EFFECT OF RADIATION: Inheritable changes, chiefly mutations,
produced by the absorption of ionizing radiation. On the basis of present knowledge
these effects are purely additive, and there is no recovery.
HALF-LIFE BIOLOGICAL: The time required for the body to eliminate one-half of an
administered dose of any substance by the regular processes of elimination. This
time is approximately the same for the stable and radionuclides of a particular
element.
HALF-LIFE EFFECTIVE: Time required for a radionuclide in a system to be
diminished 50 percent as a result of the combined actin of radioactive decay and
biological elimination.
HALF-LIFE RADIOACTIVE: Time required for a radioactive substance to lose 50
percent of its activity by decay. Each radionuclide has its own unique half-life.
HALF VALUE LAYER (half thickness): The thickness of any specified material
necessary to reduce the intensity of an x-ray or gamma ray bean to one-half it original
value.
INSPECTION: Means on examination and/or observation including but not limited
to records, tests, surveys, safety check, and monitoring to determine compliance with
state and local rules, regulations and requirements.
INVERSE SQUARE LAW: The intensity of radiation at any distance from a point
source varies inversely as the square of the distance.
ION: Atomic particle, atom, or chemical radical bearing an electrical charge, either
negative or positive.
IONIZATION: The process by which a neutral atom or molecule acquires either a
positive or negative charge.
IONIZATION CHAMBER: An instrument designed to measure the quantity of
ionizing radiation in terms of the charge of electricity associated with ions produced
within a defined volume.
IONIZATION, SPECIFIC: The number of ion pairs per unit length of path of ionizing
radiation in a medium.
IONIZING RADIATION: Any electromagnetic or particulate radiation capable of
producing ions, directly or indirectly in it passage through matter.
CA-5
ISOTOPES: Nuclides having the same number of protons in their nuclei, and hence
having the same atomic number but differing in the number of neutrons, and therefore
in the mass number.
LABELED COMPOUND: A compound consisting, in part, of labeled molecules.
MAXIMUM PERMISSIBLE DOSE: Maximum dose of radiation which may be
received by persons working with ionizing radiation, which will produce no detectable
damage over the normal life span.
MILLIROENTGEN (mR): A submultiple of the roentgen equal of one-thousandth of
a roentgen.
NEUTRON: Elementary particle with a mass approximately the same as that of a
hydrogen atom and electrically neutral. It has a half-life in minutes and decays in
free state into a proton and an electron.
NORMAL OPERATING PROCEDURES: Operating procedure for conditions
suitable for analytical purposes with shielding and barriers in place. These do not
include maintenance but do include routine alignment procedures. Routine and
emergency radiation safety considerations are part of these procedures (reference
TRCR 32.2(d)).
NUCLIDE: A species of atom characterized by its mass number, atomic number,
and energy state of its nucleus, provided that the atom is capable for a measurable
time.
OPEN BEAM CONFIGURATION: An analytical X-ray system in which an individual
could accidentally place some part of his body into the primary beam path during
normal operation.
PRIMARY BEAM: Ionizing radiation which passes through an aperture of the source
housing by a direct path from the x-ray tube located in the radiation source housing.
RADIATION: 1. The emission and propagation of energy through space or through
a material medium in the form of waves. 2. The energy propagated through a
material medium as waves; for example, energy in the form of elastic waves. Such
as Hertzian, infrared, visible (light), etc. 3. By extension, corpuscular emissions, such
as alpha and beta radiation, or ray of mixed or unknown type, as cosmic radiation.
RADIOLOGICAL SURVEY: Evaluation of the radiation hazards incident to the
production, use or existence of radioactive materials or other sources of radiation
under a specific set of conditions. Such evaluation customarily includes a physical
CA-6
survey of the disposition of materials and equipment, measurements or estimates of
the levels of radiation that may be involved, and a sufficient knowledge of processes
using or affecting these materials to predict hazards resulting from expected or
possible change sin materials or equipment.
RADIONUCLIDE: A nuclide with an unstable ratio of neutrons to protons placing the
nucleus in a state of stress. In any attempt to reorganize to a more stable state, it
may undergo various types of rearrangement that involve the release of radiation.
RADIOTOXICITY: Term referring to the potential of an isotope to cause damage to
living tissue by absorption of energy from the disintegration of the radioactive material
introduced into the body.
RAM: means radioactive material.
RELATIVE BIOLOGICAL EFFECTIVENESS: For a particular living organism, the
ratio of absorbed dose of a reference radiation that produces a specified biological
effect to the absorbed dose of the radiation of interest that produces the same
biological effect.
REM: The special unit of dose equivalent. The dose equivalent in rems in
numerically equal to the absorbed does in rads multiplied by the quality factor,
distribution factor, and any other necessary modifying factors.
RSC: means Radiation Safety Committee.
ROENTGEN: The quantity of x or gamma radiation such that the associated
corpuscular emission per 0.001293 grams of dry air produces, in air, ions carrying
one electrostatic unit of quantity of electricity of either sign. The roentgen is the
special unit of exposure.
RSO: means Radiation Safety Officer of TTU.
SHIELDING MATERIAL: Any material which is used to absorb radiation and thus
effectively reduce the intensity of radiation, and in some cases eliminate it.
SMEAR (smear or swipe test): A procedure in which a swab, e.g., a circle of filter
paper, is rubbed on a surface and it radioactivity measured to determine if the surface
is contaminated with loose radioactive material.
SPECIFIC ACTIVITY: Total radioactivity of a given nuclide per gram of compound,
element or radioactive nuclide.
TOTAL EFFECTIVE DOSE EQUIVALENT (TEDE): Sum of the deep dose
equivalent (for external exposures) and CEDE (for internal exposures).
CA-7
TRACER, ISOTOPIC: The isotope or non-natural mixture of isotopes of an element
which may be incorporated into a sample to make possible observation to the course
of that element, alone or in combination, through a chemical, biological, or physical
process. The observations may be made by measurement of radioactivity or of
isotopic abundance.
THERMOLUMINESCENT DOSIMETER (TLD): A dosimeter made of certain
crystalline material which is capable of both storing a fraction of absorbed ionizing
radiation and releasing this energy in the form of visible photons when heated. The
amount of light released can be used as a measure of radiation exposure to these
crystals.
X-RAYS: Penetrating electromagnetic radiation having wavelength shorter than
those of visible light they are usually produces by bombarding a metallic target with
fast electrons in a high vacuum. In nuclear reactions it is customary to refer to
photons originating in the nucleus as gamma rays, and those originating in the
extranuclear part of the atom as x-rays.
CA-8
INDEX OF ABBREVIATIONS AND ACRONYMS
ALARA As Low As Reasonably Achievable
BRC Bureau of Radiation Control
CFR Code of Federal Regulations
DOH Department of Health
DOT US Department of Transportation
FDA Federal Drug Administration
FRC Federal Radiation Council
GC Gas Chromatograph .
ICRP International Commission on Radiation Protection
MPD Maximum Permissible Dose
NCRP National Council on Radiation Protection and Measurements
NRC Nuclear Regulatory Commission
OP Operating Procedure
PO Purchase Order
RAM Radioactive Material
RIA Radioimmunoassay
RPG Radiation Protection Guide
RSC Radiation Safety Committee
RSO Radiation Safety Officer
TDH Texas Department of Health
TLD Thermoluminescent Dosimetry
TRCR Texas Regulations for Control of Radiation
TTU Texas Tech University
CA-9
LIST OF SYMBOLS FOR RADIATION UNITS AND TERMS
Measurement and units
Ci Curie
m milli (one thousandth)
u micron (one millionth)
k kilo (thousand)
R roentgen
rem radiation equivalent man
dpm disintegrations per minute
dps disintegrations per second
cpm counts per minute
MeV Million electron volt
LET Linear Energy Transfer
QF Quality Factor
Appendix CB
CB-1
TEXAS REGULATIONS FOR CONTROL OF RADIATION
The following section will briefly describe specific parts of the Texas Regulations for Control
of Radiation (TRCR) and the Texas Regulations for Control of Laser Radiation Hazards
(TRCLRH). TTU is subject to the rules of the TRCR, TRCLRH, and other state, federal, and
local regulations when using radiation. These specific parts of the Texas Administration
Code (TAC) have been extracted because of overall benefit to all radiation users at TTU.
More specific information can be obtained from the Radiation Safety Office
1. 25 TAC §289.201 (TRCR Part 11) - General Provisions, Texas Regulations for
Control of Radiation: contains general information concerning recordkeeping, testing of
sealed sources, violation information, and transport grouping of radionuclides.
2. TRCR Part 13 contains rules and regulations pertaining to amending licenses,
annulment of licenses, administrative penalties (i.e., fines), impoundment of sources of
radiation, etc.
3. 25 TAC §289.202 (TRCR Part 21), Standards for Protection Against Radiation -
establishes standards for protection against ionizing radiation hazards. It is the purpose
of the rules in this part to control the possession, use, and transfer of sources of radiation
by any licensee so as to ensure that the dose to any individual does not exceed the
standards established in this part. Areas covered include exposure limits, concentration
of radioactive material in effluents, personnel monitoring, storage, disposal, records,
limits of concentrations, etc.. This part is the basis for ALARA, "As Low As Reasonably
Achievable", which means that each user should make every effort to keep exposures
and releases as low as reasonably achievable.
4. 25 TAC §289.203 (TRCR Part 22), Notices, Instructions, and Reports to Workers;
Inspections - establishes requirements for notices, instructions, and reports by
licensees or registrants to individual engaged in work under a license or registration, and
options available to such individuals in connection with the State Bureau of Radiation
Control (BRC) inspections regarding radiological conditions. Areas of particular interest
are requirements for Posting of Notices, Instructions to Workers, Requests by Workers
for Inspections, etc.
5. TRCR Part 34, Radiation Safety Requirements for Analytical X-Ray
Equipment - This part provides special requirements for analytical X-ray equipment.
Areas covered are equipment requirements, area requirements, operating
requirements, and personnel requirements.
6. PARTS 50, 60, & 70 - TEXAS REGULATIONS FOR THE CONTROL OF LASER
RADIATION HAZARDS - The objective of these regulations is to provide guidance
for safe use of laser products and laser installations. Areas of particular interest
include supervision, controls, safety requirements, regulations, and requirements for
safe operation, signs, surveys, records, and registrations.
Appendix CC
CC-1
INSTRUMENT CALIBRATION PROCEDURES
12/01/99
General Procedure for Calibration of Radiation Detection and Measurement
Instruments
1. Alpha Measuring Instruments: will be calibrated annually by using a standard
alpha source.
2. Beta Measuring Instruments: will be calibrated annually by using a standard beta
source.
3. Ionization Chamber Instruments: will be calibrated annually by an authorized
instrument service company or by the procedure in Part B.
4. Well Counters: will be calibrated annually by an authorized instrument service
company.
5. MCA’s: will be calibrated, using standard sources, each time they are turned on for
operation and as necessary during analytical procedures.
6. GM Radiation Survey Instruments: will be calibrated annually using the procedure
in Part B of this procedure or by an authorized instrument service company.
Periodic Calibration of Instruments
1. Purpose: This procedure will be used by TTU to perform its own annual radiation
surveyinstrument calibrations for GM and, in some cases, ionization chamber
instruments. In the event that TTU cannot perform the calibration of a needed
instrument, an authorized service company will be used.
2. Scope: Each instrument will be calibrated to verify that it correctly measures the
intensity of a radiation field (mR/hr). The procedure involves using a Ludlum Pulser
to adjust the electronics of the instrument and then placing the instrument in a radiation
field of known intensity and making necessary adjustments or calculations to verify
the accuracy or determine correction factors.
3. Objective: To verify that each instrument is capable of measuring radiation levels
over its multiple ranges to within plus or minus 20 percent of the true radiation level
for the appropriate energies of the radiation.
4. Method: A known radiation field for the calibration procedure is provided through the
use of a known source in a calibrator/shield. The beam calibrator is a manually
operated device which incorporates a Cesium-137 source with an initial activity of 100
millicuries. The shield of the calibrator provides for full shielding in all directions at all
times except when the unit is in the "ON” position. In the “ON” position, a radiation
beam is emitted out of the port.
CC-2
5. Applicability: This procedure applies only to GM and ionization chamber type
instruments
6. Precautions and Safety:
a. Personnel Monitoring: The person(s) performing the calibration procedures
MUST wear his/her assigned personnel monitoring device and pocket dosimeter.
b. Area Access: ONLY persons properly trained in instrument calibration
procedures AND authorized by the RSO may conduct instrument calibrations.
c. Area Control: The area(s) where the calibrations are to be performed will
cleared of unauthorized/non-essential persons prior to initiating calibration
procedures. “Caution - Radiation Area” signs will be posted at the entrance(s) to
the area. Should any unauthorized/unmonitored person enter the area, the
calibrator will immediately be turned to the OFF position.
d. Emergencies and Malfunctions:
(1) Calibrator Malfunction: if the ON/OFF shutter mechanism fails such that
the beam cannot be shut off, immediately clear and secure the area and
notify the RSO. DO NOT leave the area unattended!
(2) Improper Calibrator Operation: should the operation of the source rod
become difficult, the calibrator shall be removed from service and returned
to the manufacturer for repair.
7. Instrument Inspection: A thorough inspection of the instrument must be performed
prior to the calibration procedure, as follows:
a. Visual Inspection: Visually check the outer meter face, adjustment knob,
handle and meter case. Certain components, when damaged (such as the meter
face, needle and adjustment knob), may affect the ability to calibrate.
b. Battery Condition Check: Inspect the batteries for damage and test for charge.
Replace if necessary. Weak batteries can cause erratic behavior.
c. Electrical Inspection: Remove the case and visually inspect the
electrical/electronic components. Inspect the internal probe, if present. If any
component appears to be burned, broken, or loose, or there appears to be
internal corrosion or moisture, do not proceed with calibration. Minor problems
may be correctable, such as re-soldering a wire or removing corrosion or
moisture. If repairs are satisfactorily performed, replace the cover and proceed
with calibration. Otherwise, the instrument must be sent to an instrument repair
service.
d. Electronics Test: Perform the electronics test using the Pulser as stated in the
applicable Ludlum Instruction Manual.
e. Mechanical Inspection: Inspect and/or test all mechanical hardware, such as
nuts, screws, etc., to ensure that they are secure. Check the retaining screw that
CC-3
holds the selector knob on, the retaining screw for the handle, screws that hold
the circuit board to the meter body, screws on the meter movement, etc. If
necessary, all loose hardware must be tightened. Check the proper operation of
switches to assure that they “lock in” on the selected positions.
f. Probe and Connecting Cable Inspection: Inspect the cable and connectors for
signs of damage or wear. Kinks in the cable may cause erratic behavior. The
connectors must be of tight fit and the pins intact and firm. The connectors
should attach to the instrument and probe connections firmly. Repair or replace
the cable before proceeding with calibration.
8. Instrument Calibration (GM and ionization chamber instruments):
Note: Only persons authorized by the RSO shall be allowed to calibrate radiation
survey instruments.
a. Prepare Calibration Record/Certificate: Prepare a calibration
record/certificate for each instrument to be calibrated.
b. Determine Calibration Points:
(1) Calculate and record the current source strength.
(2) Determine the points (distances from calibrator) at which the instrument
(probe) must be placed to produce the necessary radiation levels which
allow calibration at two points on each range. Enter the field intensities on
the calibration record(s) for each instrument.
c. Establish Calibration Range: Mark the calibration range for the determined
points (distances).
d. Calibrate at Each Point:
(1) Place the instrument at the desired point to checked
(2) Unlock the device and expose the source.
(3) Observe the reading on the instrument face at each predetermined point.
(4) If the instrument reading does not agree with the field intensity (within plus
or minus 20%), the calibration potentiometer for that range must be adjusted
until the instrument indicates the correct response. Caution: a small
amount of adjustment produces a relatively large change in the instrument
reading.
Note: For instruments that have only one calibration potentiometer, all ranges must be
checked before adjusting the potentiometer. The potentiometer affects all ranges.
(5) Once the adjustments have been made, place the instrument back at the
same location and verify the reading.
(6) Repeat steps 6.d.1 through 6.d.5 for each point to be calibrated. It may be
necessary to use attenuation blocks to obtain the lower range readings.
CC-4
e. Turn Calibrator Off: Return the source to the "OFF" position. Lock the
calibrator.
9. Calibration Records:
a. Calibration Record and Certificate: For each instrument calibrated, complete
the following sections of the instrument calibration record (Attachment E.2 –
Certificate of Calibration, Form RS-32):
(1) Sublicensee name and identifying information
(2) Instrument/detector manufacturer and information
(3) Calibration results
(4) Calibration method information
b. Certification: The person performing the calibration must sign the “Calibrated
by” space and enter the date of calibration. Indicate the next due date based on
the calibration interval for the type of use of the instrument.
c. Calibration Sticker: A “calibration sticker”, should be placed on the instrument
(obscure or remove previous ones) to indicate who calibrated the instrument;
authorization (license number); date of calibration; next due date; instrument
make, model and serial number; and the identity of the person performing the
calibration.
10. Serviceability of Instruments:
a. Successful Calibration: If the instrument was successfully calibrated, submit
the completed “Survey Instrument Calibration Certificate” to the RSO for review
and filing. Return the instrument to its proper storage location.
b. Unsuccessful Calibration: If unable to calibrate an instrument, or the
instrument requires repair, tag it as unusable and needing repair. Submit the
instrument with notes of problem(s) to the RSO.
CC-5
Sample: “SURVEY METER CALIBRATION LABELS” (stickers)
TEXAS TECH UNIVERSITY
MFG Model Ser.#
Cal.Date Due Date
Cal.Source High Voltage
Tube I.D.
Cal. By: Texas Tech License L01536
LS-1
9/00
CC-6
CERTIFICATE OF CALIBRATION
State of Texas Broad License #L01536
Sublicensee _______________________
Dept. _________________
Account #_____________________
Instrument Manufacturer______________
Model # _______________
Serial # _____________________
Detector Manufacturer________________
Model # _______________
Serial # _____________________
Last Calibration Date
__________________
Today’s Calibration Date
_____________________
Calibration Due Date
_____________________
Battery Meter Zeroed F/S Response Zero Reset Audio Meter Face Number ____________
Detector Tube Voltage
_____________ Volts
HV “As Found” Reading
_______________Volts
Meter HV Adjusted Reading
__________________Volts
Input Sensitivity
________mVolts
Maximum Reading
Per Scale
(mR/hr or CPM)
Calibration Point
(mR/hr or CPM)
Meter Reading
“As Found”
(mR/hr or CPM)
Meter Reading
“After Adjustment”
(mR/hr or CPM)
% Error
Method of Calibration:
Cs-137 Source Model 500 Pulser 0.1 1 10 100 1000 Ranges Calibrated Electronically
Meter With in ± 10% With in ± 10 – 20% Tolerance
Meter out of Tolerance > ± 20% Meter Requires Repair
Comments: __________________________________________________________________________________________
Calibrated by: ______________________________________ Date: ___________________________________________
Appendix DA
FORMS
• Laser Application (LS-1)
• Laser Amendment (LS-2)
• Laser Amendment Attachment (LS-2A)
• Laser Standard Operating Procedure Outline (LS-7)
• Laser SOP Training Acknowledgement (LS-8)
• Laser Use Log (LS-11)
• Short Term Application (LS-17)
LS-1
9/00
DA-1
LASER EQUIPMENT SUBLICENSE APPLICATION
(UNDER TEXAS BUREAU OF RADIATION LASER LICENSE Z00130 ISSUED TO TEXAS TECH UNIVERSITY)
PLEASE PRINT OR TYPE. USE ADDITIONAL PAPER IF NECESSARY
APPLICANT’S FULL NAME APPLICANT’S INITIALS
OFFICE DEPARTMENT & BUILDING OFFICE NUMBER
PHONE NUMBER APPLICANT’S E-MAIL ADDRESS
PLEASE COMPLETE SECTIONS I – III FOR ALL LASER EQUIPMENT UNDER YOUR CONTROL.
NOTE THAT SECTIONS E – L MUST BE COMPLETED FOR EACH LASER. USE ADDITIONAL
FORMS IF NECESSARY
SECTION I
A. HAVE YOU EVER POSSESSED A LASER EQUIPMENT LICENSE UNDER YOUR NAME?
YES NO
IF YES GIVE NUMBER AND ISSUING AGENCY:
WAS THE LICENSE OR SUBLICENSE EVER SUSPENDED? YES NO
IF YES EXPLAIN:
B. HAVE YOU EVER HAD PRACTICAL EXPERIENCE WITH LASERS? YES NO
C. HAVE YOU HAD FORMAL TRAINING IN THE SAFE USE OF LASERS FOR WHICH THIS
APPLICATION
APPLIES? YES NO
IF YES EXPLAIN:
D. IF YOUR ANSWER TO PART B OR C WAS YES, DOCUMENT YOUR USE BY INCLUDING A
COPY OF A PUBLISHED JOURNAL ARTICLE OR PROVIDE A CONFIRMATION LETTER FROM
A LASER / RADIATION SAFETY OFFICER
LS-1
9/00
DA-2
E. COMPLETE FOR EACH LASER FOR WHICH YOU WILL BE LICENSED
Manufacturer
Model
Number
Serial
Number
Building
Room
Number
Status
(Active/Stored)
1.
2.
3.
4.
5.
In, Sections F – L , the lasers will be referred to in the same order as they are listed in Section E
F. LIST INFORMATION FOR EACH LASER
Class
(I,II,III,IV)
Laser Setup *
Refer to
Illustrations
(A,B,C)
Emission
Duration Range
(seconds)
Emission Power
Range
(Watts or Joules)
Emission
Wavelength
Range
1.
2.
3.
4.
5.
Laser Setups *
A - Open Path (laser beam is accessible without defeating an interlock)
B - Fully Enclosed (laser beam accessible via an “opened” interlock)
C - Fiber Delivery (laser beam is delivered without an accessible beam path)
D - Other (Explain)
LS-1
9/00
DA-3
G. STATE THE FOLLOWING FOR EACH LASER:
Person in Charge Comments about Laser (s)
1.
2.
3.
4.
5.
LS-1
9/00
DA-4
H. LIST THE FOLLOWING PROPERTIES FOR EACH LASER
Laser
Type
(dye, gas, solid
state..)
Active Material
(Ar,HeNe,GaAs,Nd
Yag..)
Excitation
Mechanism
(optical,electrical,chemi
cal..)
Time-Dependent
Properties
(cw, pulsed, rep.
pulsed..)
1.
2.
3.
4.
5.
I. DESCRIBE LASER APPLICATION (Research Development, Welding, Scribing, Cutting, etc..)
1.
2.
3.
4.
5.
LS-1
9/00
DA-5
J. ATTACH A COPY OF NORMAL OPERATING PROCEDURES FOR EACH LASER.
[25 TAC §289.301(v)(2)(B)] “Normal operating procedures” means operating procedures for
conditions suitable for analytical purposes with shielding and barriers in place. These do not
include maintenance but do include routine alignment procedure. Routine and emergency laser
radiation considerations are part of these procedures.”
EXCEPTION: LSO MAYGRANT APPROVAL TO ACCEPT ONE COPY FOR SEVERAL LASERS WITHIN THE
SAME CLASS AND SAME OPERATION SETTING, HOWEVER THE LSO MUST REVIEW EACH
CASE, INDIVIDUALLY.
K. LIST ALL PERSONNEL WHO WILL USE THE LASER EQUIPMENT AND WHOSE NAMES
SHOULD APPEARON THE SUBLICENSE
NAME DATE TTU LASER TRAINING COMPLETED
1.
2.
3.
4.
5.
6.
L. ATTACH A SEPARATE, PAGE-LENGTH DETAILED MAP OF THE PROPOSED WORK AREA
FOR EACH LASER. INCLUDE LASER RADIATION AND NON-LASER RADIATION AREAS,
EQUIPMENT LOCATION (I.E. SINKS, HOODS), AND DOORS. (THIS ALSO PERTAINS TO
“MOBILE” LASERS. LSO WILL REVIEW AND DETERMINE EACH CASE INDIVIDUALLY)
M. CLASS I – IIIA LASER APPLICANTS PROCEED TO SECTION III.
N. CLASS IIIB AND IV LASER APPLICANTS PROCEED TO SECTION II.
LS-1
9/00
DA-6
SECTION II
TO BE COMPLETED BY CLASS IIIB AND IV LASER APPLICANTS ONLY
A. DO YOU HAVE THE “STATE-REQUIRED” [25 TAC §289.301(t)(1)] PROTECTIVE EYEWEAR
DESIGNED SPECIFICALLY FOR THE WAVELENGTH OF THE EMITTED LASER RADIATION?
YES NO
IF YES, PROVIDE THE MANUFACTURER AND THE WAVELENGTH RANGE
B. DO YOU ALREADY HAVE DOOR INTERLOCKS THAT PREVENT UNAUTHORIZED ACCESS TO THE
DESIGNATED AREA (S) OF LASER USE, WHILE THE LASER(S) ARE OPERATING?
YES NO
IF YES, PROVIDE THE MANUFACTURER IF NOT THE SAME AS THE LASER MANUFACTURER
IF YES, HAS THE TTU LSO APPROVED THE EXISTING INTERLOCK?
YES NO
IF NO, DO YOU HAVE FUNDING FOR THE INSTALLATION OF STATE-REQUIRED DOOR
INTERLOCKS FOR THE LASER AREA (S)? [25 TAC §289.301(r)(2)(B)] YES NO
SECTION III
Acknowledgement Statement
I (THE APPLICANT) WILL COMPLY WITH THE STATE OF TEXAS LASER LICENSE
REQUIREMENTS, REGULATIONS, AND ALL SPECIFIC CONDITIONS REQUIRED BY THE
RADIATION LASER SAFETY COMMITTEE.
THE APPLICANT CERTIFIES THAT ALL PERSONNEL LISTED ON THIS SUBLICNESEE
APPLICATION WILL COMPLY WILL THE STATE OF TEXAS LASER LICENSES
REQUIREMENTS, REGULATIONS, AND ALL SPECIFIC CONDITIONS REQUIRED BY THE
RADIATION SAFETY COMMITTTEE, AND THAT ALL OF THE INFORMATION CONTAINED
HEREIN AND ATTACHED HERETO IS COMPLETE AND CORRECT TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
DATE SIGNATURE OF THE APPLICANT
SIGNATURE OF THE DEPARTMENT CHAIR
LS-2
10/00
DA-7
LASER APPLICATION FOR AMENDMENT OR RENEWAL OF A SUBLICENSE
SUBLICENSEE NAME DEPARTMENT PHONE NUMBER
SUBLICENSEE ID LETTERS BUILDING & ROOM NUMBERS SUBLICENSEE EXPERIATION DATE
A. CIRCLE ONE: AMENDMENT RENEWAL AMENDMENT AND RENEWAL
B. INDICATE ALL LASERS FOR WHICH YOU ARE CURRENTLY LICENSED.
ACTIVE
OR
STORED
MANUFACTURER
MODEL
#
SERIAL
#
CLASS
(I, II,
IIIA,
IIIB, IV)
1. ________________________________________________________________________________________NC / A / D
2. ________________________________________________________________________________________ NC / A / D
3. ________________________________________________________________________________________ NC / A / D
4. ________________________________________________________________________________________ NC / A / D
C. IF THIS AMENDMENT ADDS A NEW CLASS OF LASER, HAVE YOU HAD FORMAL TRAINING IN THE SAFE USE
OF THIS LASER? (CIRCLE ONE) YES NO NA
IF YES, DOCUMENT YOUR USE FOR EACH NEW CLASS BY INCLUDING A COPY OF A PUBLISHED JOURNAL ARTICLE (ONE PER
CATEGORY) OR PROVIDE A CONFIRMATION LETTER FROM A RADIATION/LASER SAFETY OFFICER.
D. LIST ANY NEW ROOMS OR AREAS (FOR WORK OR STORAGE) THAT WILL APPEAR ON THE AMENDED
LICENSE. (INDICATE "NA" IF NOT APPLICABLE) _______________________________________________
E. LIST ALL PERSONNEL WHOSE NAMES SHOULD BE ADDED TO OR DELETED FROM THE SUBLICENSE.
INDICATE DATE THAT TTU TRAINING COURSE WAS COMPLETED. ANSWER THE QUESTIONS WHEN
DELETING PERSONNEL.
Question #1: Did person deleted act in a conscientious and safe manner while in your lab?
Question #2: Is retraining appropriate for this person?
CIRCLE TRAINING ANSWER WHEN DELETING PERSONNEL
FULL NAME ONE DATE Question #1 Question #2
1. A / D Y / N Y / N
2. A / D Y / N Y / N
3. A / D Y / N Y / N
4. A / D Y / N Y / N
THE APPLICANT CERTIFIES THAT ALL PERSONNEL LISTED ON THIS SUBLICENSE APPLICATION WILL COMPLY WITH THE STATE OF TEXAS
RAM LICENSE REQUIREMENTS, REGULATIONS, AND ALL SPECIFIC CONDITIONS REQUIRED BY THE RADIATION AND LASER SAFETY
COMMITTEE, AND THAT ALL OF THE INFORMATION CONTAINED HEREIN AND ATTACHED HERETO IS COMPLETE AND CORRECT TO THE
BEST OF THEIR KNOWLEDGE AND BELIEF.
SIGNATURE OF THE SUBLICENSEE DATE
SIGNATURE OF THE DEPARTMENT CHAIR DATE
LS-2A
10/00
DA-8
ATTACHMENT
FOR AMENDMENT OR RENEWAL OF A LASER SUBLICENSE
E. LIST ALL PERSONNEL WHOSE NAMES SHOULD BE ADDED TO OR DELETED FROM THE SUBLICENSE.
INDICATE DATE THAT TTU TRAINING COURSE WAS COMPLETED. ANSWER THE QUESTIONS BELOW
WHEN DELETING PERSONNEL.
Question #1: Did person deleted act in a conscientious and safe manner while in your lab?
Question #2: Is retraining appropriate for this person?
CIRCLE TRAINING ANSWER WHEN DELETING PERSONNEL
FULL NAME ONE DATE Question #1 Question #2
5. A / D Y / N Y / N
6. A / D Y / N Y / N
7. A / D Y / N Y / N
8. A / D Y / N Y / N
9. A / D Y / N Y / N
10. A / D Y / N Y / N
11. A / D Y / N Y / N
12. A / D Y / N Y / N
13. A / D Y / N Y / N
14. A / D Y / N Y / N
15. A / D Y / N Y / N
THE APPLICANT CERTIFIES THAT ALL PERSONNEL LISTED ON THIS SUBLICENSE APPLICATION WILL
COMPLY WITH THE STATE OF TEXAS LASER LICENSE REQUIREMENTS, REGULATIONS, AND ALL
SPECIFIC CONDITIONS REQUIRED BY THE RADIATION AND LASER SAFETY COMMITTEE, AND THAT
ALL OF THE INFORMATION CONTAINED HEREIN AND ATTACHED HERETO IS COMPLETE AND
CORRECT TO THE BEST OF THEIR
KNOWLEDGE AND BELIEF.
SIGNATURE OF THE SUBLICENSEE DATE
SIGNATURE OF THE DEPARTMENT CHAIR DATE
LS-7
12/00
DA-9
STANDARD OPERATION PROCEDURE OUTLINE
Each sublicensee will be responsible for creating SOP’s for each laser which should include the
following information.
System Information
• Description
• Location
• Classification
Hazard Summary
• Beam Information
• Non-beam Information
Control Measures
• Access Controls
• System Controls
• Personnel Controls
Procedural Information
• Adjustment and Alignment
• Maintenance and Servicing
• General Research
• Buddy Policy (if required)
Training Requirements
• Sublicensee
• SOP and PPE
• Environmental Health & Safety (if required)
Chain of Command
• Sublicensee
• Supervisory
• Research personnel
Emergency Instructions
• First Aid
• Evacuation
• Contacts: 9-911, sublicensee, LSO
NOTE: IF A LASER IS RE-ASSEMBLED OR MODIFIED, LSO APPROVAL IS REQUIRED BEFORE
ITS USE
LS-8
12-00
DA-10
SOP TRAINING ACKNOWLEDGEMENT
I CERTIFY THAT I HAVE READ AND HAVE BEEN TRAINED ON ALL THE STANDARD
OPERATING PROCEDURES AND PERSONAL PROTECTIVE EQUIPMENT. I WILL
COMPLY WITH THE SAFETY REQUIREMENTS.
NAME SIGNATURE DATE
Please Print
LS-11
12-00
DA-11
USAGE LOGS
Operator must be date and initial each time that the laser is operated: include notes of
adjustment, operation conditions, maintenance, servicing, and problems.
Modifications that significantly change SOP’s and performance shall not be operated
until approved by LSO. Modifications not reported are in violation of the terms of the
sublicense.
NAME PROCEDURE DATE
Please Print
LS-17
12/13
DA-12
LASER SAFETY SHORT-TERM APPLICATION
“SUPERVISED WORK WITH LASERS”
APPLICANT
1. FULL NAME:
2. TITLE:
3. INSTITUTION:
4. DEPARTMENT:
APPLICANT’S STATEMENT
I UNDERSTAND THAT THIS IS TEMPORARY APPROVAL ONLY FOR THE PERIOD SPECIFIED
AND GRANTED DUE TOTHE CIRCUMSTANCES STATED ABOVE WHICH IS AUTHORIZED BY THE
TTU LASER SAFETY OFFICER (LSO) OR RADIATION LASER COMMITTEE CHAIRMAN. I
RECOGNIZE THE HAZARDS OF LASERS AND UNDERSTAND THAT ALL STUDIES/WORK MUST BE
DONE UNDER THE SUPERVISION OF THE SUBLICENSEE, SUBJECT TO SUBLICENSE CONDITIONS
AS PRESCRIBED BY TTU LASER SAFETY POLICY.
APPLICANT’S SIGNATURE DATE
Approval of this application does not include transfer of Laser Equipment
LASER SAFETY USE ONLY
APPROVED BY DATE APPROVED PERIOD
Appendix DB
REFERENCE INFORMATION
• Glossary of Terms
• Index of Abbreviations and Acronyms
• 25 Texas Administrative Code §289.301
• References
DB-1
REFERENCE INFORMATION
GLOSSARY OF TERMS
This section lists information pertinent to laser safety and is considered to be a part of this
manual. The definitions in this glossary will not cover every term associated with lasers but
does cover a majority of the terms. If a term should be encountered in your work with lasers
and is not in this glossary, consult your supervisor or call the TTU Department of
Environmental Health and Safety.
ABSORPTION - means the transformation of radiant energy to a different form by
interaction with matter.
ACCESS CONTROL - Entry must be restricted to only authorized laser personnel
during the operation of laser equipment.
ACCESSIBLE EMISSION LEVEL (AEL) - means the maximum accessible emission
level permitted within a particular class as set forth in TRCR Part 70 .
AGENCY - means the Texas State Radiation Control Agency, Texas Department of
Health.
AVERAGE POWER - means the total energy imparted during exposure divided by the
exposure time.
AVERSION RESPONSE - means the movement of the eyelid or the head to avoid an
exposure to a noxious stimulant or bright light. It can occur within 0.25 seconds,
including blink reflex time.
APERTURE - means any opening in the protective housing or other enclosure of a laser
product through which laser radiation is emitted, thereby allowing human access to such
laser radiation.
ATTENUATION - means the decrease in the radiant flux as it passes through an
absorbing or scattering medium.
BEAM - means a collection of rays which may be parallel, divergent or convergent.
BEAM DIAMETER - means the distance between diametrically opposed points in the
cross-section of a beam where the power per unit is l/e times that of the peak power per
unit area.
BEAM DIVERGENCE (O) - means the full angle of the beam spread between
diametrically opposed l/e irradiance points; usually measured in milliradians (one
milliradian is approximately 3.4 minutes of arc).
BEAM EXPANDER - means any combination of optical elements which can increase
the diameter of the laser beam. Laser beam expansion is always accompanied by a
proportional decrease in laser beam divergence .
DB-2
BEAM SPLITTER - means an optical device which uses controlled reflection to produce
two beams from a single incident beam .
CLASS I - Any laser that does not permit access during the operation to levels of laser
radiation in excess of the accessible emission limits contained in subsection (cc) (1) of
this section.
CLASS II - Any laser that permits human access during operation to levels of visible laser
radiation in excess of the accessible emission limits contained in subsection (cc) (1) of
this section, but does not permit human access during operation to levels of laser radiation
in excess of the accessible emission limits contained in subsection (cc) (2) of this section.
CLASS IIIa - Any laser that permits human access during operation to levels of visible
laser radiation in excess of the accessible emission limits contained in subsection (cc) (2)
of this section, but does not permit human access during operation to levels of laser
radiation in excess of the accessible emission limits contained in subsection (cc) (3) of
this section.
CLASS IIIb - Any laser that permits human access during operation to levels of laser
radiation in excess of the accessible emission limits of subsection (cc) (3) of this
section, but does not permit human access during operation to levels of laser radiation
in excess of the accessible emission limits contained in subsection (cc) (4) of this
section.
CLASS IV - Any laser that permits human access during operation to levels of laser
radiation in excess of the accessible emission limits contained in subsection (cc) (4) of
this section.
C0-2 LASER - wave-length 10.6 micrometers (for infrared, invisible).
COLLIMATED BEAM - a “parallel” beam of light with very low divergence or
convergence.
CONTINUOUS WAVE (cw) - means the output of a laser which is operated in a
continuous rather than pulse mode for a period greater than 0.25 seconds.
CONTROLLED AREA - means an area where the occupancy and activity of those
within are subject to control and supervision for the purpose of protection from radiation
hazards.
DIFFRACTION - means the deviation of a part of a radiation beam, determine by the
wave nature of the radiation, and occurring when the radiation beam passes the edge of
an opaque obstacle.
DIFFUSE REFLECTION - means the change of the spatial distribution of a beam of
radiation when it is reflected in many directions by a surface or by a medium.
EMERGENT BEAM DIAMETER (a) - means the diameter of the laser beam at the exit
aperture of the laser product. Measured in centimeters (cm).
DB-3
ENERGY (Q) - means the capacity for doing work. Energy content is commonly used to
characterize the output from pulsed laser products and is generally expressed in
joules (Jo) .
ENERGY DENSITY - means the emittance (M) or irradiance (E) of electromagnetic
radiation, energy per unit area, e.g., joules meter^2 or joules/centimeter^2 .
EXPOSURE - means the product of an irradiance (E) and its duration .
GAS LASER - means a type of laser where the laser action takes place in a gaseous
medium .
HELIUM-NEON (HeNe) Laser - red aiming beam. Wave length 632.8 nanometers .
HERTZ (Hz) - means the unit which expresses the frequency of a periodic oscillation in
cycles per second .
HUMAN ACCESS - means access at a particular point to laser or collateral radiation by
any part of the human body or by an object. A laser product or installation shall be
considered to permit human access if radiation in excess of an accessible emission limit
is incident at a point that can be reached by a straight object 3.0 + 0.1 millimeters in
diameter and lO.O + 0.1 centimeters in useful length .
INCIDENT - means an unusual event or occurrence.
INDIVIDUAL - means a human being.
INFRARED RADIATION - the electromagnetic radiation with wavelengths that lie in the
0.7 micrometer to l millimeter range.
INSTALLATION - means any location where one or more products are used or
operated.
INTENSITY - means the amount of energy or energy per unit time passing through a
unit area perpendicular to the line of propagation at the point in question.
INTRABEAM VIEWING - means the viewing condition whereby the eye is exposed to all
or part of a laser radiation beam.
IRRADIANCE (E) - means the quotient of the radiant power incident on an element of a
surface by the area of what element, expressed in watts per square centimeter
(W/cm^2).
JOULE (J) - means a unit of energy, one J = l Watt/second .
LASER - Light Amplification by Stimulated Emission of Radiation. A device which
generates or amplifies electromagnetic oscillations in the spectral region between the
far infrared (submillimeter) and ultraviolet . The laser consists of an amplifying (active
or Casing) medium and a regenerative of feedback device (resonant cavity). The
amplifying medium can be gas, solid, or liquid. The feedback medium is generally
DB-4
bounded by two end mirrors. The laser light produced is of high intensity, high
monochromaticity, small beam divergency (collimated), and is phase coherent .
LASER CONTROLLED AREA - means any area which contains one or more lasers and
in which the activity of personnel is subject to control and supervision for the purpose of
protection from laser radiation hazards.
LASER PROTECTIVE DEVICE - means any device, the intended function of which is
the control of laser radiation with the intent of reducing or eliminating the exposure of
personnel to such radiation.
LASER RADIATION - means all electromagnetic radiation which is produced as a result
of controlled stimulation emission.
LASER SAFETY OFFICER (LSO) - means any individual, qualified by training and
experience in occupational and public health aspects of lasers, who is designated to
evaluate the radiation hazard of and to establish, administer, and be responsible for,
laser radiation protection .
LASER SYSTEM - means a laser in combination with an appropriate laser energy
source with or without additional incorporated components.
LASING MEDIUM - means a material emitting coherent radiation by virtue of stimulated
electronic or molecular transitions to lower energy levels.
LIMITING APERATURE - means the maximum circular area over which radiance or
radiant exposure can be averaged.
MAINTENANCE - means the performance of those adjustments or procedures specified
in user information provided by the manufacturer, with the laser or laser system, which
are to be performed by the user to insure the intended performance of the product. It
does not include “operation” or “service” as defined in this section.
MAXIMUM EMISSION DURATION - means the maximum duration of repeated, or
continuous operation of which the laser product is capable, whichever is greater.
MAXIMUM OUTPUT - means that maximum magnitude of energy or power, at any time
after manufacture, of total accessible laser radiation emitted by a laser product over the
full range of operational capability .
MAXIMUM PERMISSIBLE EXPOSURE (MPE) - means that integrated radiance or
irradiance which is specified for accessible emission limits of class l or collateral
radiation of TRCR Table 70-3. Exposure duration for MPE shall be that of actual or
potential personnel exposure, and not a product of classification emission duration.
MEDIACAL LASER PRODUCTS - means any laser product designed or intended for
purposes of in vivo diagnostic or therapeutic laser irradiance of any part of the human
body .
DB-5
NEODYMUM.YTTRIUM ALUMINUM GARNET (Nd.YAG) LASER - wavelength (A) 1 06
nanometers .
NOMINAL HAZARD Z _ (NHZ) - means the space within which the level of the direct,
reflected, or scattered radiation during normal operation exceeds the applicable MPE.
Exposure levels beyond the boundary of the NHZ are below the appropriate MPE level .
NOMINAL OCULAR HAZARD DISTANCE (NOHD) - means the distance along the axis
of the unobstructed beam from the laser to the human eye beyond which the irradiance
or radiant exposure during normal operation is not expected to exceed the appropriate
MPE .
OPERABLE LASER - means a laser which can produce laser radiation.
OPERATION - means the performance of the laser or laser system over the full range
of its intended functions (normal operation). It does not include “maintenance” or
“service” as defined in this section.
OPTICAL DENSITY (D) - means the logarithm to the base ten of the reciprocal of the
transmittance.
OUTPUT POWER and OUTPUT ENERGY - means the laser output power used
primarily to rate CW lasers since the energy delivered per unit time remains constant
(output measured in watts). In contrast, pulsed lasers deliver energy in pulses and their
effects can be best categorized by energy output per pulse.
POWER (P) - means the time rate at which energy is emitted, transferred, or received;
usually expressed in watts.
PROTECTIVE HOUSING - means those portions of a laser product which are designed
to prevent human access to laser and collateral radiation in excess of the prescribed
accessible emission limit under conditions specified in TRCR Part 70.
PULSE DURATION - means the time increment measured between the half-peals-
power points of the leading and trailing edges of the pulse.
PULSE REPETITION FREQUENCY (PRF) - means the number of laser pulses per unit
time (usually expressed in seconds).
PULSED LASER - means a laser which delivers its energy in the form of a single pulse
or a train of pulses, where the duration of a pulse is less than or equal to 0.25 seconds.
Q-SWITCH - means a device for producing very short (approximately 30 nanoseconds),
intense laser pulses by enhancing the storage and dumping of electronic energy in and
out of the basing medium, respectively.
Q-SWITCHED LASER - means a laser which emits short (approximately 30
nanoseconds), high-power pulses by utilizing a Q-switch.
DB-6
RADIANCE (L) - means radiant power per unit area of radiation surface per unit solid
angle of emission, expressed in watts per square centimeter per steradian (w/cm^2/Sr).
RADIANT ENERGY (Q) - means energy emitted, transferred or received in the form of
radiation, expressed in joules (J).
RADIANT EXPOSURE (H) - means the quotient of radiant energy incident on an
element of a surface by the area of that element, expressed in joules per square
centimeter ( J/cm^2 ).
RADIANT INTENSITY (I) (of a source in a given direction) - means the quotient of the
radiant flux leaving the source, propagated in an element of solid angle containing the
given direction, by the element of solid angle. Expressed in watts per steradian (w/Sr) .
RADIANT POWER means power emitted, transferred or received in the form of
radiation, expressed in watts (W).
REFLECTANCE, REFLECTIVITY (P) - means the ratio of total reflected radiant power
to total incident power .
REFLECTION - means the deviation of radiation following incidence on a surface .
REMOTE CONTROL CONNECTOR - means a two-terminal connector which permits
the connection of external controls placed apart from other components of the laser
product to prevent human access to all laser and collateral radiation in excess of limits
specified Safe Eye Exposure Distance (SEED) - means the distance from an operating
laser such that the energy that might infringe upon the eye is less than the MPE .
SAFETY INTERLOCK - means a device associated with the protective housing or
enclosure of a laser product to prevent human access to excessive radiation under
conditions specified .
SERVICE - means the performance of those procedures or adjustments described in
the manufacturer’s service instructions which may affect any aspect of the performance
of the laser or laser system. It does not include “maintenance” or “operation” as defined
in this section.
SHALL - the word “shall” is understood to mean mandatory.
SHOULD - the word “should” is understood to mean that which is advisable .
SOURCE - means the term used to describe either a laser or laser-illuminated reflecting
surface.
SPECULAR REFLECTION - means a mirror-like reflection.
TRANSMISSION - means the passage of radiation through a medium.
TRANSMITTANCE (T) - means the ratio of total transmitted radiant power to total
incident radiant power.
DB-7
ULTRAVIOLET RADIATION - means the electromagnetic radiation with wavelengths
shorter than those for visible radiation (0.2 - 0.4 micrometers). This region is often
broken down into three spectral bands by wavelength: VV-A (315 - 400 nanometers).
UV-B (280 - 315 nanometers), and UV-C (200 - 280 nanometers).
UNRESTRICTED AREA - means any area to which access is not controlled for the
purposes of protection of individuals from exposure to radiation .
VAPORIZATION - means the conversion of a solid or liquid into vapor.
VISIBILE RADIATION (Light) - means all electromagnetic radiation which can be
detected by the human eye . It is commonly used to describe wavelengths which lie in
the range between 0.4 micrometers and 0.7 micrometers .
WATT (W) - means a unit of power, or radiant flux .
WAVELENGTH - means only the propagation wavelength in air of electromagnetic
radiation.
DB-8
INDEX OF ABBREVIATION AND ACROMYMS
TAC Texas
LSM Laser Safety Manual
RLSC Radiation Laser Safety Committee
LSO Laser Safety Officer
SOP Standard Operating Procedures
OD Optical Density
PPE Personal Protective Equipment
ANSI American National Standards Institute
LIA Laser Institute of America
DB-9
REGULATIONS
The regulatory documents and licenses may be examined at Administration Support
Center Room 122, in the department of Environmental Health & Safety.
More specific information can be obtained from the Radiation Safety Office.
TEXAS DEPARTMENT OF HEALTH
The following section will briefly describe specific parts of the Texas Regulations for
Control of Radiation (TRCR) and the Texas Regulations for Control of Laser
Radiation Hazards (TRCLRH). TTU is subject to the rules of the TRCR, TRCLRH, and
other state, federal, and local regulations when using lasers
1. 25 TAC §289.301- establishes requirements for the registration of who receive,
posses, acquire, transfer, or use class IIIB and class IV lasers; requirements for
protection against laser radiation hazards; and responsibilities of the registrant and
the laser safety officer, laser hazard control methods, training requirements and
notification of injuries.
2. 25 TAC §289.201- General Provisions, contains general information concerning
record keeping, testing of sealed sources, violation information, and transport
grouping of radionuclides.
3. 25 TAC §289.203- Notices, Instructions, and Reports to Workers;
Inspections - establishes requirements for notices, instructions, and reports by
licensees or registrants to individual engaged in work under a license or
registration, and options available to such individuals in connection with the State
Bureau of Radiation Control (BRC) inspections regarding radiological conditions.
Areas of particular interest are requirements for Posting of Notices, Instructions to
Workers, Requests by Workers for Inspections, etc.
4. 25 TAC §289.204- Fees for Certificates of Registration, Radioactive Material
(s) Licenses, Emergency Planning and Implementation, and Other Regulatory
Services, establishes fees, schedules and provide for the payment of
registrations, licenses emergency planning and implementation, and other
regulatory services according to the various categories in the specified disciplines.
5. 25 TAC §289.205- Hearing and Enforcement Procedures, governs the
proceedings for the granting, denying, renewing, transferring, amending,
suspending, revoking, or annulling of license or certificate of registration;
determining compliance; assessing administrative penalties; and determining
propriety of other agency orders.
TEXAS TECH UNIVERSITY LASER LICENSE
Texas Tech University currently holds a laser license issued by the Texas Department
of Health Bureau of Radiation Control: Certificate of Laser Registration Z00130.
This license authorizes Texas Tech University to receive, possess, transfer or acquire
laser devices and to use such devices for the purpose (s) and at the place (s)
designated. Texas Tech University is subject to all applicable rules, regulations and
orders of the Texas Department of Health, and the stated conditions.
REFERENCES
1. Laser Institute of America; 2000.
2. Rockwell Laser Industries; 1994.
3. Sliney, D.; and Wolbarsht, M. Safety with Lasers and Other Optical Sources. New
York: Plenum Press; 1980.
4. Michel, R.; Michel, R.; Kerns, K.; and Zimmerman, T.; Managing a Sound Laser
Safety Program, Operational Radiation Safety, Vol. 77, No 2. S2-S8. August 1999.
5. 25 Texas Administrative Code §289.301
Appendix EA
Field Activity Planning Checklist and Risk Assessment
EA-1
Complete a separate assessment for each field site being visited. Mark NA in the left-hand column if
the activity is not applicable to the field activities being conducted.
Risk Probability Breakdown
Risk is the combination of the severity of the harm that can be inflicted by a hazard and the likelihood
of the harm happening.
Risk Level
Description / How to Determine Risk Level
A
Nuisance event, low hazard, incident can be managed by field participants, SCAN
filed
B
Moderate event, work must stop to address incident, may required Field Trip Leader
intervention, SCAN required
C
Potential emergency, immediate action required, medical attention may be required,
Designated Contact notified, incident report filed
D
Emergency action required, medical attention sought, Designated Contact notified,
incident report filed
Field Trip Leader(s): ________________________________________ Contact # ___________________
Field Trip Leader(s): ________________________________________ Contact # ___________________
Field Activity: __________________________________________________________________________
Field Site Name: _______________________________________________________________________
Estimated Dates at Site:________________________________________
Planning and Preparation Check List
Comments
NA
Pre-Trip Planning and Training
Yes
No
Has a specific field site been identified?
Is this a roving field experience?
Has the Field Safety Plan been
completed?
Is the detailed Risk and Hazard
Assessment complete?
Have you established Go/No criteria?
Do you have a Designated Contact?
Person:
Has the Designated Contact been given a
copy of the Field Safety Plan?
Do you have all insurance and permits
necessary for field work?
Have you obtained emergency contact
Field Activity Planning Checklist and Risk Assessment
EA-2
information for the facilities closest to the
field site(s)?
Have you obtained Emergency Contact
information for all field participants?
Have participants conducted pre-trip field
safety briefing?
Have all participants read the Field Safety
Plan?
Does the field safety plan include a list of
equipment for field work?
Is all appropriate PPE available for all
participants?
Are appropriate emergency
communication devices available?
Has a list of required equipment been
distributed to all participants?
Is appropriate first aid, field site kit, and
emergency equipment checked for
completeness and functionality?
Are at least two field participants trained
in First Aid?
Persons:
If vehicular travel is required to reach field
site, can a TTU vehicle be used?
Driver must be TTU approved
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Vehicles
A
B
C
D
Vehicular storage buildings/garages
Are high volume fuel-storage facilities
present?
Is secure storage for valuable/critical
equipment available at the field site?
Are appropriate vehicles for field
environment available?
Do vehicles have current service records?
Are vehicle oil and fluids at correct levels
and tires at pressure?
Is there a flashlight, spare tire, jack & tire-
lever and signage in case of breakdown?
Is a person with good driving record and
mental state for driving available?
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Machinery & Equipment
A
B
C
D
Will mechanical tools and instruments be
used?
SOP needed
Have tools and machinery been serviced
and checked for operational readiness?
Is appropriate and safe (e.g., grounded,
insulated) electrical power available?
Are tools and machines compliant with
available power supplies?
Is appropriate PPE available for use with
tools and machines?
Will tools and instruments need to be
used in confined space?
Have participants been trained on
equipment use?
Field Activity Planning Checklist and Risk Assessment
EA-3
Potential Hazard
Risk Probability
Comments & Mitigation
NA
All-Terrain Vehicles (ATVs) and
Related Vehicles
A B C D
Will ATVs or similar vehicle be used
during fieldwork?
Are engine sizes greater than 90cc?
Is appropriate Snell ANSI approved riding
gear available for use?
Is the terrain appropriate for ATV use?
Is the ATV road-approved and
appropriately certified?
Will the ATV be used in proximity to
normal highway traffic?
The ATV will not be required to carry
loads or more than 1 person.
Have riders received training on vehicle in
similar conditions as those anticipated in
the field?
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Roads and Railroads
A
B
C
D
Is any of the fieldwork near roads and
highways?
Is any of the fieldwork near railroad
tracks?
Are appropriate high-visibility clothing and
signage available?
Is any work to be conducted on or
proximal to narrow, winding
roads/highways with limited sight lines?
Will any work be on, under or close to
bridges?
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Water, Boats, and Watercraft
A
B
C
D
Will the fieldwork include proximity to, or
work upon a body of water?
Will the work require use of a watercraft?
Is there a team member with certificates
and credentials for the watercraft?
Bring copy
Does the fieldwork require the presence
of a team member with technical water-
safety certificates?
Certificate:
Are appropriate safety devices available?
(Buoyancy aids, life-vests, flares).
Are there appropriate mooring and
anchoring facilities?
Field Activity Planning Checklist and Risk Assessment
EA-4
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Loading and Unloading Vehicles and
Moving Equipment
A B C D
Will large/heavy loads be transported to
and from field site?
Mark “Too Heavy”
Is additional equipment needed for the
loading/unloading of equipment in the
field?
Is there a safe loading/unloading site
(e.g., flat, stable, traffic-free, boat-ramp)
in the field locality?
Is appropriate safety equipment available
for loading/unloading in the field?
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Terrain
A
B
C
D
Is the field site terrain typically associated
with increased physical risk? Detail
below.
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Weather and Climate
A
B
C
D
Is there a high probability of sustained
high temperature conditions?
Is there a high probability of sustained low
(sub-freezing) temperature conditions
Is there a high probability of severe
weather events?
Is there a high probability of significant
rain fall and associated flood-dangers?
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Fauna
A
B
C
D
May fieldwork participants encounter
hazardous animals, including mammals,
Field Activity Planning Checklist and Risk Assessment
EA-5
insects, arachnoids and/or reptiles?
Is field clothing appropriate for deterring
potentially hazardous fauna?
Is the first aid kit equipped with
treatments for stings, bites, and potential
fauna toxins?
Can field equipment and supplies be
safely secured and made fauna-proof?
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Flora
A
B
C
D
Clearing of the field area
Poisons, toxins
Plant risks – identify local flora that may
cause irritation
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Disease and Pathogens
A
B
C
D
Risk of water borne diseases
Hepatitis
Vaccination
Tetanus
Vaccination
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Chemical and Biological Risks
A
B
C
D
Will chemicals or reagents be
carried/used in the field?
Is appropriate PPE available?
Is secondary containment available?
What is the potential for waste
production?
Submit a Waste Determination to
EHS if you expect to generate
waste in the field
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Agro Chemicals
A
B
C
D
Field Activity Planning Checklist and Risk Assessment
EA-6
Will reagents be intentionally introduced
to the field locality?
Are appropriate licenses and permissions
available/carried in the field?
Potential Hazard
Risk Probability
Comments & Mitigation
NA
Private Property
A
B
C
D
Will fieldwork be conducted on private
property?
Have all private land/property owners
been contacted?
Potential Hazard
Risk Probability
Comments & Mitigation
NA
People – Strangers
Is the fieldwork to be conducted in an
area where other individuals may be
encountered (e.g., national parks)?
Are there cultural considerations about
the field site area to be noted?
Is international travel taking place?
Consult with EHS for research
material transport
NA
Personal Safety and Responsibilities
Comments & Mitigation
Have all field participants notified
someone of where they are going and
how long they will be gone?
Are team members that are driving
vehicles or ATVs been properly licensed
and/or trained?
If team members have a medical
condition such as diabetes or allergies, do
they have the proper items to treat
themselves?
Have all team members provided
emergency contact information?
Have all field participants undergone
appropriate medical evaluation, treatment
or vaccination?
Field Activity Planning Checklist and Risk Assessment
EA-7
Potential Hazard Considerations
Potential Hazard – Criteria, Limits, Critical Factors to consider
Comments
Issues, Mitigators, Scenarios
Natural Environment
1
Foul Weather Considerations- wind, rain, snow, lighting, flash flood: local,
upstream
Before & During activity
2
Temperature Extremes (Hot/Cold): Temperatures (>30°C, <5°C), Wind,
Humidity
Length of Exposure, Season/Day
3
Strong Sunlight (Inc. sunburn): Serious sunburn, “snow” blindness,
contributing factor to fatigue
Exposure length, surface albedo
4
Darkness/Low Light: Contributing factor to other hazards that result in injury
Visibility, Fatigue, Weather
5
Uneven/Slippery Walking Surfaces: Slip, trip, or fall that results in injury
Cumulate Fatigue, Weather
6
Sharp Objects- rocks, coral, vegetation: Contact or fall results in penetration
wound/scratched
Visibility, Fatigue, Weather
7
Heights/Drop-offs (Inc. high elevation): Fall that result in in free-fall drop of
more than 2 m
Slope/softness of “landing” zone
8
Falling Objects/Obstructions: Spontaneous/Participate-caused, capable of
causing serious injury
Time of year, freshness of outcrop
9
Tight Spaces/Narrow Openings/Overhang: Results in impact or crushing
injury, or panic/distress
Visibility, crowding
10
Toxic/Allergic Sources (Vegetation, pollen): Causes acute reaction,
contributing factor to other hazards
Time of year, EMS access
11
Animals- insects, reptiles, mammals, other: Causes trauma, envenomation,
allergic reaction
Time of year, local experience
12
Fire Hazard: Hot vehicle exhaust system/discarded cigarette causes fire,
traps group, endangers ecosystem
Access to site during burn bans
13
Water/Current: Fall results in submersion, Strenuous exertion in water
triggers pre-existing medical condition
Time of day/year, Hypothermia
14
Smoke/Dust/Fog: Causes eye/throat/nose/ injury, contributing factor to other
hazards
Time of year/date
Man-Made Environment (for Pedestrians)
15
Vehicular Traffic: -roads, railroads: Vehicle impacts participate, group activity
causes traffic hazards
Time of Day/Year
16
Road Shoulders- space restrictions, visibility: vehicle impacts participation,
group activity causes traffic hazard
17
Bridges: Vehicle impacts participate, group activity causes traffic hazards
Sidewalk/ width of shoulder
18
Fences & Gates: if gate not available, crossing results in fall, impact,
lacerations, penetrating wound
Property owner interactions
19
Utility Lines: Approach route or proportions of outcrop allow contact with
power lines, resulting in injury
Alternate Routes
20
Local Inhabitants (Inc. hunters): Group provokes hazardous reaction from
locals; distraction factor
Time of year/day
Transportation (Auto, Boat, Air)
21
Vehicle Condition: Primary or contributing factor to accident/collision
Rental company, local experience
22
Driver Qualifications/Experience for Location: Primary or contributing factor
to accident/collision
Availability of local drivers
23
Route Conditions- roughness (Inc. flat tires): Rough enough to be
contributing factor to accident/collision
Type of vehicle used, local drivers
24
Route Condition- congestions: Enough to be contributing factors to accident,
esp. around airport and major cities
Time of day, Route selection
25
Route Conditions- winding, limited sight: Enough to be contributing factor to
accident/collision
Time of day, Route selection
26
Pedestrians: Sufficiently numerous or common to be contributing factor to
accident
Time of day, Route selection
Field Activity Planning Checklist and Risk Assessment
EA-8
27
Intersections/Railroad Crossing: Hazardous/Unguarded/Confusing location
contributes to accident
Time of day, Route selection
Human Factors/Participant Activities
28
Pre-Existing Physical/Medical Needs: Contributing factor to accident, acute
episode of illness
Pre-trip participant information
29
Extended Immobility: Enough to be contributing factor to accident, trigger
pre-existing medical condition
Agenda/Travel planning
30
Lack of Rest Stops/Facilities: Contributing factor to fatigue, accident
Pre-trip planning
31
Fatigue/Dehydration: Enough to be contributing factor to accident, trigger
pre-existing medical conditions
Agenda, Time of year/day
32
Hiking/Walking: Intensity, length, duration, cumulative exertion sufficient to
trigger illness, contribute to injury
Time of day/year, weather
33
Separation of Individuals from Group: Contributing factor to accident
Safety briefing, Read backs
34
Individual Behavior/Risk Acceptance: Contributing factor to accident
Management letter, briefings
35
Lifting/Carrying: Improper technique/overloaded backpacks results in injury
Gear selection, individual fitness
36
Climbing: Requires use of both hands to ascend/descend more than 2 m
vertical, exposure to fall & injury
Weather, outcrop condition
37
Use of tools (e.g., chipping): Improper technique/equipment causes injury to
self or other participate
Required PPE
38
Digging/Trenching: Digging causes injury to self or other participant, trench
collapse causes injury
OSHA rules for deep trenches
39
Swimming/Snorkeling/SCUBA/Boating: Improper
technique/conditioning/equipment causes injury
Pre-trip Screening, PDF Policy
40
Equipment Failure: Sufficient critical and serious to be contributing factor to
accident
Pre-trip planning, inspections
41
Food Handling: Improper technique/equipment contributes to food-borne
illness
Training, Sanitation facilities
42
Language/Culture Differences: Contributing factor to accident
Pre-trip participate information
Other Factors
43
Limited/Remote Medical Services: Consequences of injury/illness escalates
due to remoteness
Pre-trip, communication
44
Limited Communications: Consequences of injury/illness escalates due to
delayed access to EMS assistance
Pre-trip planning, field checks
Appendix EB
Field Site Kit Checklist
EB-1
Field researchers must assemble a field-site kit with materials appropriate to the
location and nature of field activities. A list of items in the kit should be part of the Field
Safety Plan, and the contents of the kit must be checked for completeness,
functionality, and compliance prior to departure on every trip.
Required Items
Copy of Field Safety Plan with emergency procedures and protocols and
contact information
Institutional insurance policy information
Any required permits including TTU permits and/or permits from local
enforcement agencies
Appropriate communication equipment (e.g., radio, cell, or satellite phone)
Appropriate PPE (safety glasses/goggles, gloves, hard hat, sturdy work boots,
etc.)
First aid kit of adequate size for the group and location of field site
Drinking water or another hydration
Items for Consideration
Insect repellant (DEET 30-50%)
Sunscreen (at least SPF 30), sun hat (three to seven-inch brim), long sleeves,
and\or other SPF blockers
Spare clothes, including jackets, hats, gloves and blankets for cold climates.
Flashlight or headlamp
Map, compass, GPS
Extra food/snacks
Matches or fire starter
Signal/mirror, whistle
Knife or multi-tool; duct tape for basic repairs
Extra batteries
Other equipment specific to the educational and/or research mission of the tri
Appendix EC
heat stress
First Aid for
Heat Illness
Cooling is key. Know the symptoms and treatment of heat illness.
Things you need to know:
• Heat illness can strike quickly—learn to recognize the symptoms.
• Workers with heat illness should stop working, get cool, and
drink uids.
• Altered mental state can be a sign of heat stroke and requires
immediate attention.
•
When treating severe heat illness, cooling is the rst priority
.
OFTEN FATAL Severe Less Severe
Signs and Symptoms
Symptoms can occur in any order. For example,
a person will not always experience heat cramps
before they suer from heat exhaustion.
What to Do
Heat Rash/Prickly Heat
• Red cluster of pimples or small
blisters, usually on neck, upper
chest, groin, under breasts, and in
elbow creases
• Extensive areas of skin that do
not sweat on heat exposure, but
present gooseflesh appearance that
subsides with cool environments
• When possible, a cooler, less humid work environment is the best
treatment
• Keep rash area dry
• Powder can be applied to increase comfort
• Do not use ointments or creams, as they may impair cooling—warm,
moist skin can make the rash worse
Heat Cramps
• Muscle cramps, pain, or spasms
in the abdomen, arms, or legs
• Drink fluids every 15 to 20 minutes and eat a snack or sports drink
• Avoid salt tablets
• Get medical help if the worker has heart problems, is on a low sodium
diet, or if cramps do not subside within 1 hour
Heat Syncope (Fainting)
•
Fainting, dizziness, or light-
headedness after standing or
suddenly rising from a sitting/
lying position
•
Sit or lie down in a cool place when beginning to feel faint or dizzy
•
Slowly drink water or clear juice
Heat Exhaustion
• Headache
• Nausea
• Dizziness, weakness
• Irritability
• Thirst, heavy sweating
• Elevated body temperature
• Decreased urine output
• Call for medical help or take worker to a health facility for evaluation
and treatment
• Stay with worker until help arrives
• Remove worker from hot area and give liquids to drink
• Remove unnecessary clothing, including shoes and socks
• Cool worker with water, cold compresses, an ice bath, or fans
• Encourage frequent sips of cool water
Heat Stroke
• Confusion, altered mental
state, slurred speech, loss of
consciousness
• Hot, dry skin or profuse sweating
• Seizures
• Very high body temperatures
• Fatal if treatment delayed
• This is an emergency! Call for emergency care immediately!
• Move worker to a cool area and remove outer clothing
• Cool worker with water, cold compresses, an ice bath, or fans
• Circulate air around worker to speed cooling
• Place cold, wet cloths or ice on head, neck, armpits, and groin
• Stay with worker until emergency medical services arrive
heat stress First Aid
Case Study: Heat Stroke
A 44-year-old male worker died of heat stroke while
working on a North Carolina farm. The man had been
working in the elds for about a week. On August 1st,
the heat index was between 100 °F and 110 °F. Around
3 p.m., the worker complained to the crew leader that
he was feeling ill. He drank some water and was driven
to the employee housing and left alone. He was found
unconscious 45 minutes later. Emergency personnel took
the worker to the hospital, where he was pronounced
dead. His core body temperature was 108 °F.
Lessons Learned
• Feeling ill while working in the heat is a serious warning
sign. Any employee who reports feeling unwell during
work in hot conditions could have heat exhaustion, which can quickly progress to heat stroke
if not treated.
• Proper rst aid for someone with suspected heat exhaustion or heat stroke involves COOLING the
body as quickly as possible—not simply drinking water.
• People with severe heat illness do not always recognize the risks they face. If a worker shows
signs of heat exhaustion or heat stroke, do not leave him or her alone until he or she receives
medical attention.
Photo by ©Thinkstock
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health
DHHS (NIOSH) Publication No. 2017-128
Appendix ED
Cold temperatures and increased wind speed (wind
chill) cause heat to leave the body more quickly, putting
workers at risk of cold stress. Anyone working in the
cold may be at risk, e.g., workers in freezers, outdoor
agriculture and construction.
Common Types of Cold Stress
Hypothermia
• Normal body temperature (98.6°F) drops to 95°F or less.
• Mild Symptoms: alert but shivering.
• Moderate to Severe Symptoms: shivering stops;
confusion; slurred speech; heart rate/breathing slow;
loss of consciousness; death.
Frostbite
• Body tissues freeze, e.g., hands and feet. Can occur at
temperatures above freezing, due to wind chill. May
result in amputation.
• Symptoms: numbness, reddened skin develops gray/
white patches, feels firm/hard, and may blister.
Trench Foot (also known as Immersion Foot)
• Non-freezing injury to the foot, caused by lengthy
exposure to wet and cold environment. Can occur at air
temperature as high as 60°F, if feet are constantly wet.
• Symptoms: redness, swelling, numbness, and blisters.
Risk Factors
• Dressing improperly, wet clothing/skin, and exhaustion.
For Prevention, Your Employer Should:
• Train you on cold stress hazards and prevention.
• Provide engineering controls, e.g., radiant heaters.
• Gradually introduce workers to the cold; monitor
workers; schedule breaks in warm areas.
Protecting Workers
from Cold Stress
QUICK
CARD
TM
For more information:
U.S. Department of Labor
www.osha.gov (800) 321-OSHA (6742)
OSHA 3156-02R 2014
QUICK
CARD
TM
How to Protect Yourself and Others
• Know the symptoms; monitor yourself and co-workers.
• Drink warm, sweetened fluids (no alcohol).
• Dress properly:
– Layers of loose-fitting, insulating clothes
– Insulated jacket, gloves, and a hat (waterproof, if
necessary)
– Insulated and waterproof boots
What to Do When a Worker
Suffers from Cold Stress
For Hypothermia:
• Call 911 immediately in an emergency.
• To prevent further heat loss:
– Move the worker to a warm place.
– Change to dry clothes.
– Cover the body (including the head and neck)
with blankets, and with something to block the cold
(e.g., tarp, garbage bag). Do not cover the face.
• If medical help is more than 30 minutes away:
– Give warm, sweetened drinks if alert (no alcohol).
– Apply heat packs to the armpits, sides of chest,
neck, and groin. Call 911 for additional rewarming
instructions.
For Frostbite:
• Follow the recommendations “For Hypothermia”.
• Do not rub the frostbitten area.
• Avoid walking on frostbitten feet.
• Do not apply snow/water. Do not break blisters.
• Loosely cover and protect the area from contact.
• Do not try to rewarm the area unless directed by
medical personnel.
For Trench (Immersion) Foot:
• Remove wet shoes/socks; air dry (in warm area); keep
affected feet elevated and avoid walking. Get medical
attention.
For more information:
U.S. Department of Labor
www.osha.gov (800) 321-OSHA (6742)
