I. Purpose:
In order to maintain a safe working environment, teaching and research laboratories must be developed in conjunction with a comprehensive plan to reduce, prevent, or effectively handle safety issues that may arise. This management plan has been developed and implemented to safely manage the operation of the laboratories including the materials and equipment used, wastes generated or disposed of by the university, and to train and protect students, employees, and visitors.

II. Goal:
The mission of this plan is consistent with the university's commitment to environmental health and safety, which is communicated throughout the organization. The success of this plan is achieved through the development, training and implementation of specific hazardous materials and waste policies, procedures & guidelines. The overall goal is to maintain a process whereby laboratory safety is not compromised during the maintenance and use of the laboratories. Additionally, the goal is to provide students, faculty and staff the necessary tools and safety training to conduct undergraduate and graduate laboratory experiments and faculty research in a safe manner, to provide the training for and means of handling the hazardous materials in the laboratory, to identify safety issues relevant to the equipment used in the labs, and to provide a comprehensive plan for the management and disposal of waste materials. The goal for 2005/2006 is to provide education on the Lab Safety/Chemical Hygiene Plan to each of the Laboratory faculty and staff by June, 2006.

III. Objective:
The objective of this plan is to establish the foundation for a comprehensive laboratory safety management plan (LSM). This plan and subsequent policies, procedure & guidelines have been established to safely control those hazards associated with the operation of teaching and research labs. In addition, the plan identifies organizational structure to ensure the achievement of goals. The short term goal will be accomplished by establishing a Chemical Hygiene Policy and providing subsequent training to department faculty and staff.

IV. Scope:
This LSM plan applies to all Robert Morris University personnel including, but not limited to, those located at the Moon Campus and other RMU facilities where laboratory activities are conducted. In addition, students, volunteers, visitors, contractors and outside service providers are also included within the general scope of the plan.

V. Codes, Standards & Regulatory Requirements:

1. The LSM plan has been designed to ensure compliance with all federal, state and local hazardous materials and waste requirements. The regulatory and accrediting agencies include, but are not limited to:
   1. United States Environmental Protection Agency (EPA)
   2. Occupational Safety & Health Administration (OSHA)
   3. PA Department of Environmental Protection (DEP)
   4. PA Department of Labor & Industry
   5. Allegheny County Health Department
   6. Local City Ordinances
   7. Nuclear Regulatory Commission (NRC)

VI. Roles & Responsibilities:

1. Develop a process for identifying and assess the responsibilities of Laboratory Supervisors;
   The Laboratory Safety Committee will identify a laboratory supervisor responsible for overseeing the safety operations of the laboratory. The laboratory supervisor is usually defined as the faculty or staff member per school, unit, or department responsible for any particular laboratory area. Each laboratory area must have a laboratory supervisor.
2. Develop a Chemical Hygiene Policy;
   The Laboratory Safety Committee will work in conjunction with the Hazardous Materials and Waste Committee to develop and maintain a University Chemical Hygiene Policy. The Laboratory Safety Committee will oversee the implementation of Chemical Hygiene Policy as it pertains to the laboratory environment.
3. Collaborate to Oversee Chemical Procurement, Distribution and Storage;
   The Laboratory Safety Committee will:
   • Work with laboratory supervisors and principle investigators to ensure that all chemicals will be procured through the University Purchasing Department in the smallest quantity consistent with the intended use. If chemicals are to be transferred to the University from another individual or institution, prior approval must be obtained from the Laboratory Safety Committee and the University Safety Officer. The receiver of transferred chemicals is responsible for securing appropriate MSDS.
   • Develop procedures to address the safety requirements of chemicals stored within the laboratories.
   • Maintain a comprehensive inventory of chemicals stored within the laboratories (see Chemical Hygiene Policy).
4. Identify and Manage Biosafety Hazards;
   The Laboratory Safety Committee will work in conjunction with the Hazardous Materials and Waste Committee and with laboratory supervisors and principle investigators to oversee the procurement, use, and disposal of biohazardous material and/or biological agents (except recombinant DNA work) and to ascertain if precautions are adequate to protect personnel and the environment, and recommend measures necessary for safely working with such materials. This includes to performance of annual reviews and/or the proposal of policies and procedures for maintaining safe work environments and for compliance with federal, state, and local regulations involving the procurement, use, containment, decontamination, disinfection, and/or disposal of biological agents or biohazardous materials.
   • Review medical surveillance programs aimed at preventing laboratory-acquired infections.
   • Review incident reports involving biohazardous materials or biological agents, and recommend corrective actions to prevent recurrence, eliminate hazards or provide appropriate follow-up for exposed individuals.
   • Provide consultation on emergency response planning involving the proper handling, disinfection and disposal of biohazardous agents.
   • Mediate disputes over the proper handling, use, or disposal of biohazardous materials, and/or the proper containment of biological agents.
5. Maintain Laboratory Equipment and Accessories;
   The Laboratory Safety Committee will work with laboratory supervisors and principle investigators to oversee the maintenance of laboratory equipment to ensure that all equipment remains in good working order and to address the safety requirements of laboratory equipment
6. Maintain Laboratory Rooms, Preparation Rooms, Research Rooms, and Restricted Access Areas;
   The Laboratory Safety Committee will work with laboratory supervisors and principle investigators to oversee the maintenance of laboratory rooms, preparation rooms, research rooms, and all restricted access areas to ensure that all areas remain free of hazardous conditions and to address the access requirements of all faculty and staff personnel to ensure that these areas are accessed exclusively by personnel who are properly trained in the operation of the rooms and the equipment therein. Details for access will be found in the Operational Laboratory Safety Procedures (LS 1.1)
7. Manage the use of Compressed Gases;
   The Laboratory Safety Committee will work with laboratory supervisors and principle investigators to oversee the use of compressed gasses. The "Guidelines for Safe Use of Compressed Gases" details the procedures for the handling of Compressed Gases at the University
8. Defining the responsibilities of Laboratory Workers;
   Faculty and staff working in laboratories are subject to the requirements of the Chemical Hygiene Policy as directed by a laboratory supervisor. All laboratory workers must:
   • Consult with the lab supervisor before initiating unfamiliar, non-standard, or hazardous laboratory procedures;
   • Understand the function and use of protective equipment;
   • Use safety devices and engineering controls as appropriate;
   • Consult the MSDS before handling a chemical with which they are not familiar;
   • Immediately report to their supervisors any problems, accidents or observations regarding chemical health and safety;
   • Develop good personal chemical hygiene habits.

VII. Implementation Policies, Procedures and Guidelines:
The policies, procedure and guidelines which provide the basis for the LSM Plan were developed and implemented to comply with applicable federal, state, and local requirements. The independent policies or components thereof provide the written documentation as required by regulations and also establish written procedures necessary to address the potential concerns associated with the selection, inventory, handling, storage, use, and disposal of hazardous materials and waste. The LSM Plan establishes processes for:

1. Establishing written criteria consistent with applicable law and regulation to identify, evaluate and inventory safety concerns with the laboratory environment;
   A chemical inventory will be maintained in each department for the hazardous materials located in that department. A master chemical inventory of all hazardous materials will be maintained by Safety Services and kept in the Master MSDS binders in the Operations Center. Safety Services will be responsible for updating the master list annually. Department Heads will update the department's hazardous materials inventory when new hazardous materials are introduced into the workplace and will forward a copy to Safety Services.

   See "Chemical Hygiene Policy" (LS 1.2)

2. Process for identifying a laboratory manager/supervisor;
   A laboratory supervisor will be assigned by the Laboratory Safety Committee for each operational laboratory. This manager/supervisor is responsible for the enforcement of the policies and procedures that pertain to the laboratory.

   The laboratory manager/supervisor must:

   • Ensure implementation of the Laboratory Safety Management Plan and the Chemical Hygiene Policy in compliance with the OSHA Lab Standard;
   • Determine what hazardous chemicals or regulated substances are in use in his or her laboratory.
   • Maintain a close liaison with the unit or departmental Safety Officer and report to him/her any incidents which may lead to unsafe working conditions;
   • Advise lab workers in the conduct of "non-standard" lab procedures and in the handling of hazardous substances;
   • Ensure that appropriate and required personal protective equipment is available and in working order;
   • Ensure that available engineering controls such as laboratory hoods are used properly and are in good working order;
   • Arrange for workplace air sampling, wipe sampling or other sampling to document potential exposures as required;
   • Conduct periodic laboratory inspections to ensure compliance with the Chemical Hygiene Policy and Standard Operating Procedures;
   • Assist lab personnel in the proper collection and segregation of unwanted hazardous chemicals or waste for disposal;
   • Maintain laboratory-specific documents such as laboratory hood ventilation inspection stickers and laboratory chemical inventories;
   • Provide lab workers ready access to MSDS. When hazardous materials are ordered, it is the responsibility of the laboratory supervisor to obtain an MSDS. When the new MSDS is obtained, the laboratory supervisor will forward a copy to the user department and one to Safety Services for the master chemical inventory.
   • Notify the Safety Officer of any internal or external transfer of material that is defined as extremely hazardous (see Chemical Hygiene Policy - LS 1.3).
   • Notify the appropriate receiving department or unit(s) if an order is placed for a chemical which requires special handling precautions upon receipt (e.g., cold storage, shock sensitive, etc.).
3. Managing hazardous chemical waste, radioactive waste, universal waste, and the collection of specific waste streams;
   The Hazardous Waste Management and Disposal Policies detail the procedures for the handling and disposing of various types of waste at the University (Hazardous Waste Management and Disposal HM 1.1). A laboratory specific policy will define the specific types of wastes generally produced during the operation of the laboratory and detail methods for the collection and storage of these wastes at these satellite locations.
4. Developing a written policy for the use of Personal Protective Equipment in the laboratory;
   Exposure to some hazards may not be controlled by using engineering or administrative controls and may require the use of personal protective equipment (PPE). Policies and procedures for general PPE will be found in the Safety Management section of this manual. Where it has been determined that laboratory specific requirements exist or additional/specific PPE is needed, it will be utilizes in accordance with a detailed PPE Hazard Assessments for the subject lab work.
5. Operational Laboratory Safety Procedures (See Appendix - LS 1.1);
   This document will detail Robert Morris University's uniform procedures and work practices to ensure that all laboratory personnel who work or teach in a laboratory area are properly informed about the safety procedures enforced during work activities in the laboratory and the procedures or precautions which will be distributed to all students and personnel who conduct research in all Robert Morris University laboratories. The Operational Laboratory Safety Procedures (OLSP) also define the various Laboratory Rooms, Preparation Rooms, Research Rooms, Shops, Studios, and Restricted Access Areas. The OLSP's will also include guidelines for employee and student access to these areas.
6. Procedures that describe precaution and protective measures used during the Disposal of Broken Glassware and for the Disposal and Handling of Sharps;
   In addition to the safety procedures and information provided through the Safety Management Plan, procedures for the Disposal of Broken Glassware (LS 1.5) and for the Disposal and Handling of Sharps (LS 2.1) will be established and found within the LSM Plan.
7. Procedures on Storage of Peroxide Forming Materials;
   In addition to the safety procedures and information provided through the HM&W Plan, procedures for Storage of Peroxide Forming Materials (LS 1.7) will be established and found within the LSM Plan.
8. Policies for use of Formaldehyde and Gluteraldehyde;
   In addition to the safety procedures and information provided through the HM&W Plan, a policy for the use of Formaldehyde and Gluteraldehyde (LS 1.8) will be established and found within the LSM Plan.
9. Procedures for Equipment Management;
   In some cases safety control features are designed into laboratory equipment these controls exist for the purpose of personal protection. In some cases, the manufacturer of laboratory equipment defines recommended maintenance routines for the safe and proper operation of their equipment. Procedures for the inspection of safety control features and for the inspection, maintenance, and recording of laboratory equipment will be outlined in the Equipment Management Procedures LS 1.3.
10. Reporting and investigating all safety incidents;
    The Incident Investigation and Reporting policy and form found in the Safety Management section will be used to document spills, material exposure, or similar incident in the lab. University personnel shall complete this form if an incident/spill occurs. The Lab Safety Subcommittee will review lab related incidents. Corrective action is implemented as necessary. A summary of performance is reported to the University Safety Committee.
11. Annual Evaluation;
    This Plan will be evaluated annually by the LSM Sub-Committee. The annual evaluation will assess the program goal(s), objective(s), scope, performance and effectiveness utilizing at least one of the following: staff knowledge and skills, monitoring and inspection activity, emergency and incident reporting, level of staff participation and inspection, preventative maintenance and testing of equipment. The necessary revisions, deletions or additions to any or all parts of the management plan, implementation procedures and guidelines will be made. A summary report will be submitted to the University Safety Committee annually.
12. Ongoing Monitoring of Performance;
    Performance measures are selected to monitor actual and/or potential risks related to one or more of the following issues:
    • Staff knowledge and skills
    • Level of staff participation
    • Monitoring and inspection activities
    • Emergency and incident reporting
    • Inspection, preventative maintenance and testing of equipment

      The LSM performance measures established for 2005 include:

    • Review the preventive maintenance records for all laboratory safety equipment to ensure proper maintenance by facilities management personnel.
    • Review laboratory accident report records to identify safety areas requiring improvement.
    • Review observed safety concerns with laboratory supervisor.
    • Conduct safety surveys with laboratory instructors to determine the effectiveness of the established policies and procedures.
13. Emergency procedures describe the specific precautions, procedures and protective equipment used during hazardous material and waste spills or exposures;
    The appendix to this plan contains specific policies with detailed procedures for types of laboratory operation and safety management. Some of the university (RMU) specific policies that address these issues include; Chemical Hygiene, Operational Guidelines, Personal Protective Equipment and Chemical Spill Response.

VIII. Orientation and Education Program:
All University personnel who lecture in the laboratory, conduct undergraduate or graduate lab courses, or utilize University laboratories for research purposes will receive education on the Lab Safety Management Plan. Training/education may be provided through multiple venues including: presentations, computer-based, self study/learning packets, hands on and similar tools.

Employees receive department specific LSM training from their department manager. This includes job specific LSM hazards.

IX. Information, Collection, and Evaluation System:
Status reports will be prepared and submitted to the University Safety Committee on a quarterly basis. The reports will include, but not be limited to, a summary of the plan effectiveness as measured by the performance measure(s) identified in this management plan. It will also include risks not anticipated in the original management plan design; the need for additional resources to accomplish the goals and objectives; and identified problems, needs, opportunities and proposed solutions for correction of identified deficiencies.

X. LSM Management Documentation:
Every operational department receives a copy of this plan and the associated implementation policies and procedures. These documents are contained in Section 4.0 of the Robert Morris University - Safety Policy Manual. The manuals are assembled, packaged and distributed by the Safety Department.

APPENDIX
Implementation Policies, Procedures & Guidelines

Associated Policies:
Personal Protective Equipment - See Section 1.0 Safety Management
Hazardous Waste Disposal - See Section 3.0 Hazardous Materials and Waste Management
Biohazard Waste Disposal - See Section 3.0 Hazardous Materials and Waste Management

Chemical Hygiene