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Laboratory Decommissioning Program

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A number of laboratories vacated by University personnel were found to contain abandoned equipment, chemicals, biological specimens, sharps, radioactive materials, and a variety of waste materials. Those entering these spaces (cleaning staff, contractors, new occupants, etc.) were placed at risk. It became necessary to implement a Laboratory Decommissioning Program t maintain safety for these individuals. This plan has been in effect since 2000.

Historically, the Laboratory Decommissioning Program began as “guidelines” for laboratory personnel. In 2003, the “guidelines” were incorporated into the “Laboratory Decommissioning Program”. Periodic changes/updates are made to this program as needed. Department personnel must take the appropriate actions listed in this program. EH&S will administer the program.

Initial Date:  August 2002

Revision Date:   October 28, 2003

Minor Revisions: August 2004

Revisions: October 2008

1. GENERAL PRINCIPLES
   
   
   1. The program is applicable for all laboratories and auxiliary spaces serving laboratories. This program provides requirements for the removal of hazards from laboratory spaces when the user is to vacate laboratory space. These moves can include:
      
      
      1. Leaving the University of Rochester;
      2. Moving to another building on campus;
      3. Relocating to another laboratory within the same building; or
      4. Moving out of an off-campus location.
      
      
      
   2. When laboratories are vacated, all chemical, radioactive and biological materials, sharps and other wastes must be removed and disposed of properly.
      
      
   3. When laboratories are vacated, all non-fixed pieces of laboratory equipment must be decontaminated, then removed from the location and appropriately placed back into service, stored in another location, or disposed of.
      
      
   4. Working surfaces and storage locations can present potential sources of exposures. These areas must be properly decontaminated.
   5. If a vacated lab does not undergo decommissioning and becomes occupied by a new PI/supervisor, all materials found within the lab become the responsibility of the new PI/supervisor.
   
   
   
2. DEFINITIONS
   
   
   1. Decommissioning:  The formal deactivation of a laboratory, assuring the safety of the space for further cleaning, renovation, or occupancy. The decommissioning process involves a survey by Environmental Health & Safety (EH&S) for those locations where chemicals and biologicals were used.  Radiation Safety will check those locations where radioactive materials were used.
      
      
   2. Laboratory: A laboratory is defined as a facility where relatively small quantities of hazardous chemicals, biologicals, and/or radiological agents are used on a non-production basis. Laboratories are to include research labs, student teaching labs and clinical labs. Facilities that include but are not limited to music labs, sound labs and computer labs are not considered labs under this program
   
   
   
   3.  Principal Investigator (PI):  Consistent with usage in federal grants and contracts, an individual who receives funding to perform a study.  The term PI, used in the context of lab decommissioning, can include co-Principal Investigator (co-PI)  and/or Radioactive Material Permit Holders.  These individuals may also receive funding under the auspices of a non-government funding source. This program impacts only those PIs who have laboratories under their direction.
      
      
   4. If a vacated lab does not undergo decommissioning and becomes occupied by a new PI/supervisor, all materials found within the lab become the responsibility of the new PI/supervisor.
   
   
   
   5. Supervisors: Clinical laboratories are structured differently than research labs. Rather than PIs heading a lab, these labs are under the direction of supervisors and managers reporting to a director. Under this program, the supervisor/manager's responsibilities shall be the same as that of a PI.
   
   
   
3.   RESPONSIBILITIES
   
   
   1. Deans, Directors, Department Heads:
      Ensure that Pl using biological, hazardous and/or radioactive materials are aware of and follow the procedures contained in this program.
      
      
   2. PI:
      1. The PI is to notify the respective department, Radiation Safety, EH&S, and Hazardous Waste Management Unit (HWMU) when he/she will be leaving the university or relocating within the university (See Attachment 1).
      2. The PI is to take specific safety measures before leaving/relocating for the transfer of chemicals to another laboratory and/or disposing of chemicals that are no longer needed.
         1. The Hazardous Waste Management Unit (HWMU) (x52056) should be contacted for specific chemical disposal questions.
         2. HWMU strongly recommends arranging for the disposal  of all unwanted chemicals at least 14 days prior to the actual move date.
         3. All chemical shipments to off-site locations must sent in accordance with US Department of Transportation requirements.
         4. The University’s Chemical Safety Officer can be contacted for information appropriate disposal or shipping regulations.
      3. The PI is to take specific measures before leaving/relocating for the transfer of biological agents and/or animal tissues.
         1. All biologically active materials being transported to off-site locations must abide with US Department of Transportation requirements.
         2. The University’s Biological Safety Officer can be contacted for information appropriate disposal or shipping regulations.
      4. The PI shall take specific measures before leaving the laboratory/department for the transfer or disposal of radioactive materials. These measures include:
         1. Notify Radiation Safety (ext 5-3781).
         2. Survey and decontaminate all areas where radioactive materials were used or stored. Equipment in which radioactive materials were used/stored shall also be surveyed and decontaminated as necessary. The surveys shall be documented in the laboratory logbook.
         3. Transfer remaining radioactive materials to another permit holder or to Radiation Safety for disposal. Arrangements can be made, through Radiation Safety, to ship radioactive materials and radioactive equipment off site.
         4. Remove and destroy all labels indicating the presence of radioactivity.
         5. Reconcile the radioactive materials inventory in the logbook.
         6. Cancel Dosimetry badges, if appropriate.
      5. All labs and storage areas are to be completely cleaned before vacating the space(s). All working surfaces are to be cleaned with an appropriate decontamination agent based on those agents used in the lab.
      6. Chemical and/or biological storage equipment (corrosive cabinets, flammable liquid storage cabinets, incubators, refrigerators, freezers, centrifuges, cryostats, laminar flow cabinets (blow out hoods), etc.) is to be emptied and decontaminated prior to moving or disposal.
      7. Clean out all fume hoods. All chemicals, equipment, wastes, etc. must be removed from the fume hood, including the support cabinet, and the counter top decontaminated. EH&S recommends personnel to schedule current fume hood research projects to allow adequate time to disassemble active chemical research apparatus before the moving process.
      8. Clean out all biological safety cabinets and laminar flow cabinets. Biological safety cabinets are to be decontaminated by an outside contractor unless a special waver is given by EH&S. After the appropriate decontamination activity is completed, attach a copy of the “Equipment Decontamination Form” (Attachment 2) to the piece of equipment/apparatus. If the form is not completed, it may be assumed that the equipment was not decontaminated and this will delay moving, repairing, renovation, and disposal activities.
      9. All laboratory specific research apparatus must be dismantled, correctly packaged, and removed from the laboratory prior to decommissioning.
      10. All compressed gas cylinders are to be removed prior to the closing of the laboratory. Compressed gas cylinders must be properly secured and capped when they are transported. Compressed gas cylinders must be transported in an approved cylinder cart.
      11. All papers, rags, empty bottles, boxes etc. are to be properly disposed of prior to vacating the laboratory.  Maintaining good general housekeeping is the objective.
      12. Contact the following groups for information on the removal of chemical, biological and radiological equipment:
          1. EH&S (x5-3241):  For contractors to decontaminate biological safety cabinets, for information on biological, chemical, and physical hazard issues, and to schedule a decommissioning survey.
          2. HWMU (x5-2056):  For issues relating to the disposal of chemical waste (hazardous waste) disposal
          3. Radiation Safety (x5-3781):  For any issue involving radiological site evaluations and radioactive materials disposal.
      13. The PI will be responsible for all problems remaining after a decommissioning survey.  Quick corrective action is required.
      
      
      
   3. Department / Unit
      1. The department/unit is responsible for verifying that Radiation Safety, EH&S and HWMU has been notified when an investigator will be vacating a laboratory.  This can be accomplished by memorandum, e-mail, or by completion of the Room Decommissioning Form (Attachment 1).
      2. The department/unit is responsible for any deficiencies not corrected by the PI.   Should the laboratory not be appropriately decommissioned and departmental personnel are not available, the department / unit will be held accountable for fees resulting from decommissioning activities.  
         1. These activities may include but not limited to: decontamination of equipment, disposal of chemicals and cleaning lab spaces of old samples or other safety hazards.
         2. The department/unit is responsible for verifying that materials in the departmental common spaces that belong to the PI have been removed. This includes locations where chemicals, biologicals, and radiologicals may be stored in freezers remote from the laboratory.
         3. Departmental administrators should contact other lab technicians in their department to assist in decommissioning activities. EH&S can be contacted for other possible solutions to lab decommissioning issues.
          
      
      
      
   4. Radiation Safety
      1. Prior to relocating to the new facility, new radioactive material laboratory locations must be approved by the Radiation Safety Office. Notification must be given at least 4 weeks before relocation. Radiation Safety will notify PI of approval.
      2. The PI will be advised on precautions to be taken during transfer of radioactive materials. Use of radioactive materials should be discontinued approximately one week prior to relocation.
      3. Radiation Safety will collect all radioactive waste containers not being transferred to the new facility.
      4. Upon completion of the survey and decontamination by the PI or the department as stated above, Radiation Safety will conduct a final confirmatory radiological survey of the facility. Radiation Safety will verify that the equipment used to store or analyze radioactive materials is decontaminated. The PI will be notified of the radiological survey results. If contamination is identified, lab personnel will be responsible for decontamination. The laboratory will be reevaluated upon completion of decontamination efforts. For information on equipment decontamination, contact Radiation Safety or refer to the Radiation Safety Manual.
      
      
      
   5. Environmental Health & Safety
      1. The PI or the department must notify EH&S four weeks in advance of moving. Upon notification by the PI or the department, EH&S will schedule an appointment to verify the following activities have occurred:
         1. All chemical and biological materials have been properly removed, disposed and/or stored;
         2. All special in-house equipment has been removed; drawers and cabinets emptied, and fume hoods cleaned;
         3. All needles, razor blades and other sharps are to be removed from cabinets, drawers and other surfaces and placed into sharps containers;; and,
         4. All counter tops have been properly cleaned/decontaminated.
      2. EH&S will complete a Laboratory Decommissioning Clearance for Laboratory Areas Form (Attachment 3).
      3. PI and Facilities Management will be notified of the survey results. Laboratory personnel will be responsible for any additional corrective actions.  Upon completion of decommissioning activities and a successful evaluation by EH&S, the area will be released for renovation or general clean up by Housekeeping for reuse.
      
      
      
   6. Hazardous Waste Management Unit
      1. The PI or the department must notify HWMU at least four weeks in advance of moving. Upon notification, HWMU will schedule removal of hazardous waste materials.  The lab staff must complete the following actions prior to the removal of any hazardous waste:
         1. A Hazardous Waste tag must be completed for each container to be removed from the lab. The Hazardous Waste tag is required in order for HWMU to track both waste and reissued chemicals.
         2. Waste containers must be suitable for transport (container compatible with waste, tight fitting caps, outside of containers clean).
      2. Waste tags and additional information regarding disposal of chemicals is available upon request. Note: Prior to discarding unwanted chemical(s) that have not reached the expiration date, please work with your department and/or other departments to arrange for reuse/recycling.  HWMU operates a chemical reissue program.
      
      
      
   7. Facilities/Planning Project Management
   1. Many Facilities Units are required to perform activities in active laboratories.  These activities may include, but are not limited to, repairing gas lines, adjusting fume hood controls, removing or adding cabinets, and painting.  These activities do not require EH&S to perform decommissioning of the space.  However, Facilities is to ask the occupants to identify the hazards that are present in the immediate work location, have these hazards removed/eliminated, and have work in the immediate space terminated for the duration of the work.  For example: Should a repair be needed to unclog a waste (sewer) line at a sink, the materials stored under the sink must be removed, the floor of the cabinet cleaned by the occupants, and the occupants are not to use the sink until repaired are completed.
   2. For laboratory renovations, PPM or the Facilitites manager may utilize outside construction groups/contractors or internal personnel.  If a lab has NOT completed the decommissioning process, construction work, including painting, must not proceed. Failure to notify EH&S prior to the start of the construction may delay the project.  To avoid delays, PPM or the Facilities manager is to:
      1. Ask the department if EH&S and, if isotopes were used, Radiation Safety, were contacted for Lab Decommissioning.  If not, Facilities/PPM is to instruct them to do so.
      2. Facilitites/PPM is to notify EH&S, and if isotopes were used, Radiation Safety, of the planned work.  A description of the planned work, including available drawings or blueprints, need to be provided.
      3. A change of occupancy for the lab requires the lab to update the eyewash to the current UofR Design Standard 15450, Emergency Eyewash and Shower Equipment.
      4. Failure to report could delay the planned work since the decommissioning process did not occur and hazards may still be present.

RELATED DOCUMENTS:

    Radiation Safety:

    Hazardous Waste Management:

    Environmental Health & Safety:

TECHNICAL SUPPORT:

All referenced guidelines, regulations, and other documents are available at EH&S (x5-3241).

REFERENCES:

• Hazard Communication Standard (29 CFR 1910.1200)
• The Resource Conservation and Recovery Act (RCRA)
• NRC Regulations (10 CFR 20.1404 & 10 CFR 30.4)
• Chemical Hygiene Standard  (29 CFR 1910. 1450)
• Bloodborne Pathogens Program (29 CFR 1910. 1030)
• NYSDEC 10 NYCRR Part 16 & 6NYCR370

ATTACHMENTS

1. Request for Room Laboratory Decommissioning Inspection
2. Equipment Decontamination Form
3. Decommissioning Clearance Form

Attachment 1

University of Rochester

REQUEST FOR ROOM DECOMMISSIONING INSPECTION

(Please type or print)

Radiation Safety & Environmental Health & Safety MUST verify decommissioning of all vacated laboratories. Decommissioning involves inspection by Environmental Health & Safety (EH&S) and if applicable, by Radiation Safety in locations of radioactive materials use. All special in-house equipment must be removed; drawers and cabinets emptied, and fume hoods cleaned by laboratory personnel. Radiation Safety MUST be notified prior to transferring stock materials or possible radionuclide contaminated laboratory equipment (centrifuges, glassware, refrigerators, freezers etc.) to a new location. Radiation Safety MUST conduct stock material transfers in most instances. Please indicate on this form if a final waste pick-up by the Hazardous Waste Management Unit will be required before vacating a laboratory.

PI/ Radioactive Material Permit Holder: ____________________________________

Department: ____________________________________________________________

Office Address: __________________________________________________________

Phone Number: Office: ______________ Lab: ______________

Laboratory Currently Uses Radioactive Materials:   Yes______    No_____

List Laboratories Being Decommissioned (Include Cold Rooms, Common Equipment Rooms, etc.): ___________________________________________________________

___________________________________________________________

For above locations, will the lab:

Be Vacated:  Yes_____    No_____
Be Relocated:            Yes_____ No_____
If Yes, new location:_________________________________________
Effective Date of Change:___________________________

Will A Hazardous Waste Pick-Up Be Required:    Yes_____ No_____

Principal Investigator/Authorized User:

Signature:__________________________________ Date: _________________

Attachment 2

This form is for use and completed by Radiation Safety and Environmental Health & Safety only. A copy of this document will be posted on the door of locations surveyed and will be provided to the department.

Principal Investigator______________________________

Department___________________________    Bldg_________________Room______

Phone Number__________________________ Projected Start Date_________________

First Inspection Date_____________________ Final Inspection Date________________

Approval Contingent Upon: ____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

Decommission Approved:   YES    NO    Conditional approval

Inspector Signature/Date: ___________________________

QUESTIONS? Contact EH&S at 275-3241 or e-mail EH&S Questions.

This page last updated 9/21/2009. Disclaimer.