A. Compliance Issues

The health and safety of workers and building occupants is the most important factor to consider in laboratory work. In addition to these health and safety concerns, compliance with OSHA, Radiation Protection, and EPA regulations is also important because of the severe financial consequences, especially related to EPA hazardous waste regulations. Fines for seemingly minor violations, e.g., improper labeling, lids not screwed-on tight, etc., may run into the tens of thousands of dollars; therefore compliance with these regulations must receive special attention.

B. Safety Standards

Sources of health and safety standards and key compliance issues include:

Standard Key Compliance Issues
OSHA Laboratory Standard Laboratory Safety Plan, training of staff, SDSs, emergency plan, secure compressed gas cylinders, outdated peroxide-formers
EPA/State Hazardous Waste regulations Lids, labels, mixing incompatibles, secondary containment, location
Radiation Protection regulations Radiation source control, dose limits, waste, training, personnel monitoring, labeling, and hazard information signs
Fire/Life Safety Codes 10-gallon open storage flammables limit, clear laboratory egress, hallway storage
Biological Safety, Security, and rDNA Biological agents and toxins use practices, containment, facilities, management and security.
University policies Training, prevention of injuries, personnel policies, grant proposal review
Consensus standards of good laboratory practice Hazardous material inventory minimization and storage compatibility, housekeeping, appropriate attire, food and drink within designated area

C. Violation Severity Classifications

The University uses the following categories of violations:

Imminent danger
A process, action, or condition where there is reasonable certainty a hazard exists in a UNC laboratory that can be expected to cause serious physical harm.
Serious violation
A process, action, or condition in a UNC laboratory that will probably lead to physical harm or significant exposure to biological or physical agents or violates regulatory standards (e.g. hazardous waste container management).
Non-serious violation
A process, action, or condition that has a direct relationship to health and safety in a UNC laboratory but probably would not cause serious physical harm significant exposure to biological or physical agents. Related non-serious violations may result in a serious violation where in combination they present a substantial probability of exposure, injury, or physical harm.
Documentation
Required UNC laboratory EHS documentation has not been completed, updated, submitted, and/or retained.

A comprehensive list of University citations based on the key indicators is on the EHS website.

D. Enforcement Policies

Imminent danger

EHS notifies laboratory personnel to cease operations immediately and close the laboratory, then notifies the EHS Director who in turn notifies the department head of the affected PI to request assistance in abatement of the problem. The EHS Director also notifies the Associate Vice Chancellor for Energy, Environment, Health and Campus Safety to secure the area if necessary. EHS will perform follow-up inspections to ensure compliance.

Serious violation

EHS notifies laboratory personnel and PI, if available, of the violation and sets a deadline for abatement, and may recommend that the PI shut down the operation until abated. Follow-up notification, in writing, goes to the PI and safety supervisor. EHS will perform follow-up inspections to ensure compliance if appropriate.

If EHS observes instances of noncompliance with hazardous waste container management regulations, ALL laboratory personnel, including Principal Investigators, will be required to complete an online “Hazardous Waste Refresher” training course. All lab members must complete the training course within two weeks of the laboratory safety inspection report date. If not all lab personnel complete the training within two weeks, EHS will act in accordance with the University Enforcement Policy, which requires consultation with the EHS Chemical Hygiene Officer. EHS will conduct a follow-up hazardous waste inspection in three months to verify that compliance with the regulations is being maintained.

Non-serious violation

EHS notifies laboratory personnel of the violation and requests abatement as soon as practicable. EHS sends follow-up notification in writing to the PI. EHS sends a summary report of all inspected PIs to respective department heads annually.

Documentation violations

EHS notifies laboratory personnel of the violation and requests abatement as soon as practicable. EHS sends follow-up notification in writing to the PI. EHS sends a summary report of all inspected PIs to respective department heads annually.

E. Notification of Granting Agencies

For some laboratories, EHS has signed a “Certificate of Environmental and Safety Compliance”, a requirement for some granting agencies. This certification requires EHS to notify the granting agency if that laboratory is in violation of any applicable environmental or safety law or regulation.

F. Reports to Department Heads and Laboratory and Chemical Safety Committee

EHS will send annual reports to the department head summarizing inspection activities within his or her department. The reports will list the non-serious, serious, imminent danger, and documentation violations for each PI and render a general assessment of Outstanding, Good, Fair, or Unacceptable. EHS will also report these findings at meetings of the Laboratory and Chemical Safety and Radiation Safety Committees, as appropriate.