The University of Alabama, Division of Finance and Operations

Maintenance and Decommissioning Policy for Laboratory Ventilation Equipment

Unit:  Environmental Health and Safety
Contact: Juliette Commodore Botoklo, Ph.D.
Title:  Chemical Laboratory Safety Manager, RSO
Effective Date: 03/27/2023
Revision Date: 03/27/2023
 
 
 

Purpose

The purpose of this policy is to establish requirements for maintenance and decommissioning of laboratory ventilation equipment, including, but not limited to: chemical fume hoods, biological safety cabinets, clean benches, laminar air flow equipment, glove boxes, snorkels, and canopy hoods.  This policy governs the change in service status whether it is a temporary or a permanent adjustment.  Compliance with the policy is necessary to: 1) ensure the safety of students, faculty, and staff while engaging in teaching and research operations within the University of Alabama ("UA") laboratories, 2) ensure compliance with federal, state and local laws and regulations, and 3) reduce energy usage associated with laboratory ventilation equipment.

Policy

This policy
  • Defines the scope, application, roles and responsibilities, labeling, maintenance and repairs, and decommissioning process of laboratory ventilation equipment; and
  • Incorporates the Fume Hood Management Plan, which details procedures for fume hood surveys, inspections, and energy conservation requirements related to fume hood usage.
The following requirements apply to any UA laboratory ventilation equipment monitored by Environmental Health & Safety (EHS) or a University approved third-party vendor or external contractor employed by UA to service laboratory ventilation equipment on campus.

Inspection Requirements

Chemical fume hoods must be tested in accordance with the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 110-2016 (or most recent edition), Method of Testing Performance of Laboratory Fume Hood consensus standard. Initial ASHRAE testing is performed at the time of installation by a third-party vendor. EHS conducts inspections to ensure that the equipment is performing within initial certification parameters.

Biological safety cabinets and clean benches must be tested in accordance with the National Science Foundation Biosafety Cabinetry Certification (NSF/ANSI 49 most recent edition) consensus standard on an annual basis. Inspections for biological safety cabinets and clean benches are coordinated by EHS and performed by a University approved third-party vendor/external contractor.

Glove boxes must be inspected at time of installation by a University approved certified provider. Principal investigators and departments must perform maintenance inspections of glove boxes.  The User must perform daily inspections of glove boxes. Procedural details for daily inspections are outlined in Guidelines and Procedures for Maintenance and Decommissioning of Laboratory Ventilation Equipment.

Circumstances Requiring Decommissioning of Fume Hood Equipment

Circumstances that may necessitate the decommissioning of fume hood equipment include: 
  • Determination that laboratory space is vacant and the fume hood is not being utilized.
  • User notifies EHS that the fume hood will not be in use.
  • Fume hood is out of service and requires repair.
  • Maintenance of fume hood.
  • Researcher or Principal Investigator ("PI") is terminating employment with the University.
  • Researcher or PI is relocating to another laboratory space.
  • Laboratory renovation.

Decommissioning of Laboratory Ventilation Equipment

Users must notify EHS prior to any upcoming vacancy from a laboratory space and indicate the presence of laboratory ventilation equipment. The User must decontaminate the equipment according to guidelines outlined in Guidelines and Procedures for Decommissioning of Laboratory Ventilation Equipment. If a shutdown is deemed necessary by EHS, the following will occur:

EHS will send a notification to the following:
  • Researcher or PI assigned to the space;
  • Facilities representatives;
  • Construction Administration representatives;
  • Designated Building Representative; and
  • Department Chair.
The notification shall include the following:
  • Date and time of shut down;
  • Anticipated length of outage (if temporary hibernation);
  • Reason for shut down;
  • Warning not to use the fume hood equipment; and
  • Contact person within EHS.
EHS staff will post signage on the sash of the fume hood equipment with the above noted information. Decommissioned fume hoods must not be reactivated without prior approval from EHS.

Unexpected loss of exhaust ventilation for chemical fume hoods may create significant safety or health hazards in a laboratory or building. Chemical fume hood equipment users must report any failure to EHS. For assistance with fume hood equipment, users may complete the online fume hood service request or contact EHS at 205-348-5905.

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 involved parties. Involved parties may also be billed for necessary repairs to damaged components.

Definitions

  • Biological safety cabinet:  Also known as a biosafety cabinet, this is an enclosed, ventilated device used as a primary means of containment for working safely with infectious micro-organisms. All exhaust air is HEPA-filtered as it exits the biosafety cabinet, removing bacteria and viruses. The filtered cabinets are designed to provide laboratory personnel, product, and/or environmental protection when appropriate practices and procedures are followed.
  • Canopy hood: A system used primarily for exhaust of non-toxic materials such as steam, odors, and heat.
  • Clean benches: Laminar flow work cabinets, or similar enclosures that provides filtered air across the work surface to protect against contamination. Clean benches should only be used to conduct work that requires sterile conditions but that does not involve manipulation of biohazards, chemical hazards, or radioactivity. Unpurified air is filtered through HEPA purifiers before contact with users and surrounding environment.
  • Fume hood:  A device designed to provide adequate ventilation and to control exposure to potentially volatile hazardous substances. Fume hoods are installed into the ventilation system of a building, and as such, affect the ventilation of the entire building and the exhaust at the stack.
  • Fume hood hibernation: The temporary decommissioning of a fume hood, including rebalancing of the laboratory room.
  • Fume hood decommission: The mechanical shutdown of a fume hood with the intent of permanent removal.
  • Glove box: A sealed container used to manipulate materials where a separate atmosphere is desired. Glove boxes are commonly used to protect workers from hazardous materials or to protect chemicals and materials that may be sensitive to air or water vapor.
  • Snorkel: Exhaust systems that can be mounted to the wall or ceiling to allow targeted ventilation for eliminating static electricity and sparks, and aggressive or corrosive materials.
  • User: Researcher or Principal Investigator.

Scope

This policy applies to faculty, staff, and students who work in laboratory environments that employ laboratory ventilation equipment.		 
 

Office of the Vice President of Finance and Operations

Approved by Cheryl Mowdy, Assistant Vice President for Finance and Operations, 03/27/2023