Environmental health and safety programs for companies that house laboratories are complex and not easily maintained.

Drawing on the results of countless laboratory inspections, Environment Health & Engineering, a health and safety engineering consultant, says one of the best ways to keep current is to perform periodic self-audits, and has made available a white paper that offers practical insights into the most
common errors and omissions encountered.

Available for download at www.eheinc.com/labaudit.htm,  the paper, entitled “Environmental Health and Safety Compliance in Laboratory Operations: Common Deficiencies Encountered During Audits,” can help companies and institutions that house laboratories avoid the common mistakes that can lead to worker injury or fines.

“We’ve found that one of the best ways to keep the program current is to perform a periodic self-audit, and a good checklist is important,” said Jack McCarthy, president and co-founder of EH&E. “This list of
commonly encountered deficiencies is a great place to start.”

EH&E reviews the most common deficiencies encountered within seven compliance categories, and provides a short list of some simple actions that can help maintain the program at a high level.
For small and mid-size companies that may not have a full time safety officer charged with keeping the program current, maintaining compliance is especially difficult. Even the most basic plan involves keeping a variety of permits up to date, performing chemical storage and handling requirements,
and keeping a number of contingency plans current and complete.

Recordkeeping is a constant battle, whether for tracking hazardous chemical waste manifests or for performing regular employee monitoring (formaldehyde, radiation etc.).

Environmental Compliance
Compliance in this category involves managing air emissions, controlled substances, the discharge of wastewater and the management of wastes of all types. The majority of compliance deficiencies found are in the area of waste management and practices, particularly relating to improper storage and labeling of chemicals, and in related paperwork.

State and federal Environmental Protection Agency regulations mainly apply, specifically the Resource Conservation and Recovery Act (RCRA), but OSHA regulations also apply.
The specific violation most commonly encountered in this category includes:
• Improper chemical container labeling/storage – Common storage of incompatible chemicals is a typical issue, as is the improper labeling of secondary chemical containers such as breakers and flasks.

Worker education and the availability of proper labels is the best solution.
• Improper hazardous waste labeling – Common violations seen during walkthroughs
include chemical labels with abbreviation, no hazard listed, no dates.
• Outdated, unused chemicals still on the shelf – This is a very common violation. The best solution is to install a chemical inventory tracking mechanism, even as simple as a spreadsheet, and assign upkeep to a single person in each laboratory. Update the inventory (and review expiration dates) quarterly.
• Improperly labeled and maintained Satellite accumulation Areas (SAA) and Main Accumulation area (MAA) – The most commonly encountered deficiencies are: non-hazardous waste stored with hazardous waste and a lack of regular inspections, which usually results in overdue transfers of chemical wastes. Large signs designating each area, with printed instructions/policies next to each SAA will help to minimize these violations.

Permitting and Plans
Federal, state and local requirements all apply when obtaining the proper permits and maintaining required plans. Because the required permits vary based on the size and nature of activities on the site and because some are based on local ordinances, it is not surprising that many companies lack one or more of the permits they are required to obtain, and plans they are required to develop
and maintain. In many cases, permits and plans that were not required when the company was only half its current size are now required but are not in place.

The following permits/plans are overlooked most frequently:
• Spill Prevention Control and Countermeasures (SPCC) Plan – Every facility storing or using oils in significant quantities (including vegetable oil and hydraulic elevator fluid) must develop a plan. The
quantity triggering the need for this plan is only 1,320 gallons in containers 55 gallons
or greater.
• Air Permitting for facilities with emergency power generators and boilers – Generators and boilers are often subject to various compliance requirements and may also need a permit from the state
Dept. of Environmental Protection and/or the EPA.
• Plan Approvals for air emissions associated with operations, not emergency generators.
• EPA hazardous waste generator registration (improper status is common).
• Flammable materials storage permit –from the local fire department.
• Industrial Alcohol Users Permit – from the ATF.
• Sewer Use wastewater discharge permit.
• Tier II reporting under the Emergency

Planning and Community Right-to-Know Act (usually tripped by fuel storage for boilers and emergency generators or occasionally by use of extremely hazardous substances which have lower thresholds).
Controlled substance license(s) from Drug Enforcement Administration (DEA) for manufacturing with a controlled substance or using a controlled substance as part of research.
• Controlled Substance Standard Operating Procedure(s) – Facilities using controlled substances are required to have certain documented procedures in place.
• Department of Transportation Security Plan – Facilities that offer hazardous wastes requiring a placard for transportation in commerce are required to develop and adhere to a security plan for
hazardous materials, which include:
• Biological Safety Manual – Often out of date;
• Chemical Hygiene Plan – Often out of date;
• Lockout/Tag Out Procedures – Inadequate;
• Confined Space Program – Inadequate;
• Hazard Communication Program –
Inadequate; and
• Select Agent or Toxin Standard Operating Procedure(s) – Facilities using select agents or toxins are required to have certain documented procedures in place.

Employee Training
Employee training and the required recordkeeping are commonly found to be deficient. New employees especially are prone to being overlooked for all-important orientation training, and required refresher training courses are also frequently overdue.

A company policy for new employee orientation training along with a good recordkeeping system for documenting courses completed by each employee will generally alleviate most issues.
The courses most frequently required are:
• OSHA Laboratory Safety Standard compliance training;
• OSHA Bloodborne Pathogen Standard training; and
• OSHA Hazards Communication training.

Biosafety
Biosafety compliance involves following guidelines set by federal (National Institute of Helath, Centers for Disease Control, EPA, OSHA) and state agencies and even local boards of health. The laboratory
practices and techniques used, the safety equipment employed, and even the facility design is determined by the biosafety level and risk group assigned to the work. The most common compliance
deficiencies found in this area include:
• Expired certifications for biosafety cabinets – Inspections are required annually;
• Improper use of biosafety cabinets – Sashes are sometimes kept too high, safety glasses are not always worn, a technician may be seen leaning into the BSC, and materials may be found stored on the grille;
• Overfilled sharps containers – Auditors frequently find sharps containers over-filled, and a common result is needles, syringes and other items found exposed nearby;
• Improper maintenance of aspirating bottles – Aspirating bottles are often found without the required secondary containment, and some with mold inside, which indicates that the laboratory has not been
disinfecting and disposing of the liquids;
• Failure of workers to use the appropriate personal protective equipment;
• Use of the wrong disinfectant for specific biological agents; and
• Improper storage of select agents or toxins, needles and syringes.

Occupational Health and Safety
Proper employee training on the dangers involved with their work and the proper use of safety equipment is the primary focus of this category. Training deficiencies have been covered separately as shared by all categories.

However, two additional items relating to safety equipment are frequently reported:
• Improperly labeled and secured gas cylinders – High pressure gas cylinders must be secured individually, but are often found with a single chain or cable securing several cylinders. A missing identification or hazard label on the bottles is also a common problem; and
• Liquid nitrogen handled without cryogenic gloves – Workers must use these special gloves when working with cryogenics, but are often seen using latex or other gloves unsuitable for this purpose.

Fire and Life Safety
Fire and life safety equipment is often maintained by a third party, and is usually found to be in working order and with current inspection dates. However, the equipment often becomes invisible to
employees and is treated as part of the building landscape.

Therefore, the most common deficiencies involve blocking or isolating the equipment by employees who forget that it’s there:
• Blocked egress routes – Boxes, chairs and equipment are often found in front of exit routes and blocking aisles;
• Storage in front of or on top of spill kits – This is a very common issue, seen in most laboratories;
• Stored materials on top of flammable cabinets – These cabinets seem to be a magnet for many items that seem to have no other place, and are often combustible materials;
and
• Storing flammables in boxes – This is more common than it should be, but auditors often find flammables in their shipping containers stacked next to the flammable cabinet.

General Documentation Deficiencies
The EH&S compliance program requires that a number of documents be kept current, including the Emergency Action Plan, Chemical Hygiene Plan, Exposure Control Plan and Biological Safety Manual. These plans should be reviewed a minimum of once per year, and a record kept of the annual
review. Auditors often find outdated or incomplete plans.

Rules change, and it is important to keep up to date on proper storage of petroleum products, as well as any regulatory changes relative to secondary or tertiary containment.

Simple Steps to Stay Current
Using the common deficiencies listed above, Environment, Health & Engineering auditors recommend taking a few basic and inexpensive steps to help maintain your compliance program at a high level:
• Focus on training – Proper training of employees is a common deficiency by itself, but it can also help to address many of the common deficiencies listed in other categories by building awareness. Web training programs can help reduce the cost and still provide valuable information.
• Keep an accurate chemical inventory – The inventory will help to prevent out-of date chemicals, and the periodic inventories required will also help prevent improper storage and handling issues.
• Keep a compliance calendar – Mark the due dates for important components of the program, such as permit renewals, plan reviews, and safety committee meetings. A visual checklist like this will be a great indicator of how well you’re doing.

Perform annual audits – An annual audit, with posted findings for each laboratory, is the best way to prevent falling behind. A third party audit can be helpful through the involvement of an experienced
auditor, but doing it yourself is also useful and instructional.

Taking the steps for program maintenance can make a substantial improvement in your EH&S compliance program. For more information on doing so, go to
www.eheinc.com.  FSM