Laboratory Decommissioning Policy
Unit: Environmental Health and SafetyContact: Juliette Commodore-Botoklo, PhD
Title: Chemical Laboratory Safety Manager and Radiation Safety Officer
Effective Date: 03/27/2023
Revision Date: 06/23/2023
Purpose
The purpose of this policy is to ensure safe and compliant transitions in laboratory occupancy at The University of Alabama (UA) based on the recommendations of ANSI/ASSE Z9.11-2016 or most recent edition.Policy
Laboratories encompass any space and equipment, being utilized for experiments supporting or involving research, teaching, or the manufacture of drugs or chemical products; including without limitation areas with hazards, such as chemical, biological, radiological, physical, and electrical. This policy establishes the proper decommissioning process for laboratory closures, with oversight by Environmental Health and Safety (EHS), and ensures that:- Users adhere to proper laboratory decommissioning processes;
- A vacated space is in a stable condition and is safe for future use by any UA member;
- Costs associated with unwanted, unknown, and extra hazardous material disposal are minimized; and
- Sustainability is encouraged through the redistribution of unwanted but useable laboratory equipment and supplies.
General Requirements
Detailed general decommissioning guidelines and procedures are available in the Guidelines and Procedures for Decommissioning of a Laboratory. EHS provides supplemental support such as guidance applicable to chemical packing, transport, and shipping. This is evaluated and provided based on the needs of the laboratory.During decommissioning, Users are responsible for:
- Notifying EHS of the planned vacancy of the laboratory due to relocation or closure. This may be due to any reason, including but not limited to retirement, renovation of the space, resignation from UA, etc.
- Performing all duties involved in the proper decommissioning of a laboratory including, but not limited to:
- Closure of protocols.
- Preparation of hazardous waste materials for disposal.
- Submission of waste disposal request(s) to EHS for collection of all hazardous waste materials.
- Completing all necessary decommissioning documentation including equipment hazard tags for all applicable equipment, regardless of whether or not the items are to be relocated or not.
- Contacting EHS to review and sign applicable decommissioning tags and forms.
In the event of a laboratory emergency, employee exposure, or a spill (chemical, biological, or radiological spill), please contact the following:
- During normal business hours: (8:00 a.m. - 4:30 p.m., Monday - Friday) call EHS at 205-348-5905
- After hours: call UAPD Dispatch at 205-348-5454 and EHS Laboratory Safety Manager at 205-534-6550
Housekeeping and Decontamination
Users are responsible for:- Performing all necessary housekeeping and decontamination of laboratories.
- Coordinating with UA custodial services, UA logistics, and any third-party vendor(s) to perform additional housekeeping, as needed, once the laboratory has been decontaminated. Any unique or special decontamination services necessary in the space will require further review by EHS.
- Contacting the Laboratory Safety Manager to complete laboratory closure and sign the Decommissioning Safe and Compliant Certification Room Tag documenting that all necessary items related to decommissioning have been completed.
Laboratory Ventilation Equipment
Refer to the Maintenance and Decommissioning Policy for Laboratory Ventilation Equipment for proper inspection and decommissioning of laboratory ventilation equipment. Users are responsible for contacting EHS at least thirty (30) days in advance for decommissioning of any laboratory ventilation equipment, as some equipment (i.e., chemical fume hoods) may require decontamination by certified third-party vendors. Laboratory ventilation equipment includes without limitation, chemical fume hoods, biological safety cabinets, laminar air flow equipment, glove boxes, snorkels, and canopies.Hazardous Materials and Items
Chemical Reagents
Users are responsible for:- All costs associated with disposal of large quantities of expired hazardous chemicals. The American Chemical Society (ACS) recommends the disposal of any hazardous chemicals after five (5) years as large stockpiles of expired chemicals pose a safety risk.
- Coordinating all waste disposal requests and transfer of usable chemical reagents.
- Coordinating removal of all hazardous materials from laboratories and the chemical inventory system. Hazardous materials, including without limitation, Freon, lead paint, mercury, and polychlorinated biphenyl compounds (PCBs), can exist within laboratory equipment.
- Contacting EHS for removal of all controlled substances and drugs from laboratories. UA and the State of Alabama adhere to the regulations of the U.S. Drug Enforcement Agency (DEA) (Title 21 Code of Federal Regulations; PART 1317) for disposal of all controlled substances. Users are strictly prohibited from leaving controlled substances unsecured.
- Providing notice of any change of address for controlled substances as required by the DEA and Alabama Board of Pharmacy. Refer to the following websites for more information:
For additional information on the handling and removal of chemical reagents during the laboratory decommissioning process, refer to the Guidelines and Procedures for Decommissioning of a Laboratory.
Radioactive Materials
Users are responsible for:- Notifying the University’s Radiation Safety Officer (RSO) at least 30 business days in advance of plans for vacating or closure of laboratories that utilize radioactive materials.
- Contacting EHS to dispose of radioactive waste.
- Performing all necessary decontamination and initial contamination surveys in areas exposed to radioactive material.
Biological Agents
Users are responsible for:- Informing and coordinating with EHS for the disposal of all biological agents, including without limitation, human and animal tissue. Animal parts, carcasses, excreta, bedding, etc. must be disposed of through UA Medical Waste Program in accordance with disposal guidelines from the Animal Care Facility, provided by the Institutional Animal Care and Use Committee (IACUC).
- Informing the Biological Safety Officer in the Office for Research Compliance of any planned vacancy of the laboratory in order to coordinate status updates of all biological use authorizations.
- Coordinating transportation and shipment of biological materials off-campus in compliance with federal transportation requirements. Contact EHS Lab Safety for specific shipment requirements.
- Ensuring that biological and infectious samples are transferred by a specialized moving company or package delivery company (e.g., FedEx.) certified by the U.S. Department of Transportation (DOT) to transport biological and infectious material, and capable of refrigerating the samples during transport. Person(s) responsible for packaging samples for shipment shall have successfully completed the Shipment of Infectious Agents and Biological Materials Training within the past two years. Samples shall be packaged according to DOT and International Air Transport Association (IATA) regulations. If the lab does not have personnel trained in these programs, EHS personnel can offer limited assistance with packing and shipping biological and infectious materials.
Asbestos Containing Material (ACM)
Users are responsible for contacting EHS for survey, testing, and disposal of asbestos-containing materials. Specialized procedures are required for material identified as ACM; therefore, EHS must dispose of these items. ACM material may include, without limitation, cementitious lab/table-tops, woven heat protection equipment (gloves, hot pads, etc.), older laboratory fume hoods (cementitious panels inside), ovens, etc.Gas Cylinders
Users are responsible for contacting the appropriate vendor for collection of unwanted gas cylinders. If the vendor is unknown, another vendor willing to collect the cylinder must be secured through the University’s Procurement Services Department. Compressed gas cylinders and cryogenic gas cylinders must be relocated by the gas distributor.Material Transfer Agreement
Material Transfer Agreements (MTA) facilitate transfer of materials (generally biological) from one institution to another. An MTA is a contract between the owner of a material and the intended recipient governing the transfer and subsequent use of the material. Exemplary materials include bacteria, cultures, nucleotides, proteins, plasmids, cell lines, transgenic animals, and pharmaceuticals. Since an MTA is a contract that governs the transfer of materials, the agreement also covers issues such as ownership of the transferred materials, modifications and derivatives made by the recipient, limitations on use of the materials, and confidentiality.Users are responsible for contacting the University’s Office of Research and Technology Agreements to initiate a Materials Transfer Agreement.
Enforcement
Failure to comply with the requirements specified in this policy may expose the University to fines and violations and can result in disciplinary actions for the user. Involved parties may also be billed for expenses due to resultant decontamination and repairs to damaged components.Definitions
- Contamination: Unwanted radioactive or hazardous materials disbursed on or in equipment, structures, objects, soils and or water. Contamination can be surface or incorporated within the solid (volumetric).
- Decommissioning: A general term referring to the formal process for removal of a laboratory and its components from an active status or service.
- Decommissioning Hazard Tag: A signed form attached to any decommissioned equipment located in a laboratory indicating that the item has been properly decontaminated and is safe for future use.
- Decommissioning Safe and Compliant Room Tag: A signed form attached to the entrance doors of any decommissioned laboratory indicating that the space has been properly decontaminated and is safe for future use.
- Decontaminate: The removal or reduction of residual biological, radioactive, and hazardous materials by mechanical, chemical, or other techniques to achieve a stated objective or end condition (acceptable level).
- Hazardous Materials: Any substance or material designed or reflected in Title 29 CFR 1910.120. Exposure to these materials may result in adverse effects on the worker, the public, or the environment. Hazardous materials can include but are not limited to, chemical, biological, radiological, pharmaceutical, sharps, electronics (DVDs, CDs, laptops), glassware, gas cylinders, aerosols cans, oil or lubricants, Freon, lead paint, polychlorinated biphenyl compounds (PCBs), and universal waste (batteries, pesticides, lamps, mercury-containing materials).
- User: Researcher or Principal Investigator, other laboratory occupants, and project managers.
References
- ANSI/ASSE Z9. 11- 2016 (American National Standards and American Society of Safety Engineers Laboratory Decommissioning)
- Biosafety in Microbiological and Biomedical Laboratories
- Committee on Prudent Practices for Handling, Storage, and Disposal of Chemicals in Laboratories, Board on Chemical Sciences and Technology, Commission on Physical Sciences, Mathematics, and Applications, National Research Council, 2007. Prudent Practices in the Laboratory: Handling and Disposing of Chemicals, National Academy Press: Washington, D.C.
- EPA Environmental Management System Standard - 40 CFR 262.105 (b)(8)
- OSHA Lab Standard (Occupational Exposure to Hazardous Chemicals in the Lab) - 1910.1450