2012 Annual Review - UCLA - Environment, Health & Safety

News & Notes
Volume 6 No 2 501 Westwood Plaza 4th Floor, Los Angeles, CA 90095 Since 1978
2012 EH&S Highlights
• Expanded SOP template library
resources to over 1,200 chemicals
• 100% completion of 4-year project
to implement departmental Injury
and Illness Prevention Plans in all
campus departments
• Obtained 100% compliance in
Laboratory Safety for Principal
Investigators training program
• Recipient of three awards from the College Safety
Health and Environmental Management Association
(CSHEMA):
• Programmatic excellence in laboratory
safety
• Programmatic excellence in shop
safety
• Newsletter Award of Excellence for
News & Notes
Director’s Note
2012 EH&S Annual Review
We are pleased to distribute the 2012 EH&S Annual Report, which highlights the accomplishments of EH&S’ core
programs and provides a snapshot of the safety resources developed over the past year.
It was another busy and productive year at EH&S. Numerous
programs, notably laboratory safety, continue to make significant gains
in performance. Highlighted above, our laboratory safety and training
programs worked closely with PIs to achieve 100% compliance with
laboratory safety training for PIs/laboratory supervisors. Also, three
of our divisions received recognition from CSHEMA for programmatic
excellence. The Injury and Illness Prevention program reached an
important milestone in 2012 with the completion of individual IIPPs
for every department on campus. While we made progress during
2012, we are always looking for ways to improve and welcome your
input. If you have suggestions or concerns, please contact the EH&S
Hotline, 310-825-9797 or email us at EHSInfo@ehs.ucla.edu. Thank
you again for your continued commitment to protecting the health and
safety of our campus community.
- James Gibson, Assistant Vice Chancellor
www.ehs.ucla.edu
Expanded Outreach Materials
• Increased effectiveness of Laboratory
Hazard Assessment Tool (LHAT)
• Completed update of
Radiation Safety Manual
• Expanded Chemical
Hygiene Plan to clarify
existing regulations and
include new information
• Biohazardous Waste
Accumulation Area poster
• Addition of over a dozen
fact sheets, including:
• PPE
• SOP Templates
• Chemical Fume
Hoods
• Radioactive Materials
Outreach Events
• School of Medicine
Safety Fair
• Housing Safety Fairs
to promote back safety
• Coordinated Center
for Laboratory Safety
Workshop
Website Improvements
• Expansion of Laboratory Hazard
Assessment Tool
• Creation of SOP
Template library to
assist laboratories
in creating and
maintaining
applicable
resources
2012
Radiation Safety
Manual
ENVIRONMENT,
HEALTH & SAFETY
1

Laboratory Safety
The Laboratory Safety Program continues to focus on
laboratory inspections, allowing EH&S to:
• Better assess levels of safety and regulatory
compliance
• Provide information and services to the UCLA
research community
Lab Groups Inspected
LAB GROUPS INSPECTED
5000
4000
3000
2000
1000
0
102
555
365
On-Time Reporting
Initial Inspection
Reports
165
545
451
418
627
954
255
320
784
2123
Critical 48-Hour
Re-Inspection
Reports
Non-Critical 30-Day
Re-Inspection
Reports
100% 99% 97%
SOP Template Library*
19,195 total visits
7,668 unique visitors
114 countries of origin
63 languages spoken
2 www.ehs.ucla.edu
220
493
695
2424
898
338
723
2458
2007 2008 2009 2010 2011 2012
Laboratory Radiation Biosafety
PPE
757
Lab Groups
on campus
* cumulative through 2012
Unannounced PPE Inspection
Findings
PPE Inspection Findings
Lab Safety Training
INDIVIDUALS TRAINED
Compliant
94% of 898
Lab Coats
Eye Protection
Food/Drink
Gloves
216 (23%)
25000
20000
15000
10000
5000
0
682 (76%)
2011
2576 3112
751 2959 5708 6621 9497 8642
Accomplishments
• Conducted 2458 general laboratory safety
inspections, which included every lab group on
campus
• Issued >99% of all laboratory inspection reports
by the next business day
• Increased unannounced PPE inspections roughly
4-fold. Of the campus lab groups inspected, only
6% were found to have PPE-related deficiencies,
compared to 24% in 2011
New Resources
Non-compliant
6%
BSC
NFPA Door Card
Open Toed Shoes
7034
54 (6%)
2012
11817
• Expanded Chemical Hygiene
Plan to clarify existing
regulations and include new
information
• PPE, SOP and Chemical Fume
Hood Fact Sheets
34%
844 (94%)
13%
16%
8%
4%
11813 13147
2007 2008 2009 2010 2011 2012
Completed Online Completed Classroom
Fact Sheet
ENVIRONMENT,
HEALTH & SAFETY
Be Safe, Stay Informed
8%
18%
5%
increase in
compliance
1%
6%
Compliant
Non-compliant
EH&S Facts
How to Write an SOP Protocol
SOP Protocol or Procedure
Templates from the EH&S SOP Template Library (http://sop.ehs.ucla.edu) must be customized by lab groups using
chemicals to include lab-specific information. In particular, the lab must complete the protocol/procedure section
of the SOP detailing the use of a chemical so that it can be followed safely and consistently. It is important that this
section is written by the most experienced and knowledgable lab personnel for the various uses of the chemical and
reviewed by the PI. SOPs are required in order to work with hazardous chemicals listed as per Cal-OSHA.
Steps for Writing Protocols/Procedures
STEP1
STEP2
STEP3
STEP4
STEP5
Give a general range of quantities
that can be used in a safe and
consistent manner. If necessary,
provide two procedures to cover a
wider range of quantities.
Outline the conditions under which
the procedure applies.
Provide a step-by-step explanation
of a general experimental process
covered within the range of
quantities. Provide details on
engineering controls and hazards
associated with the process.
Include a specific example procedure
describing in detail the experiment.
This could be an experimental
procedure from your lab notebook.
If quantities or conditions significantly
deviate from the SOP be sure to
obtain approval from the PI, and
include any changes to an updated
SOP.
Shorts/Skirts
ES/EW
Facility Control
Protocols/Procedures must include the following components, as
illustrated in the example below:
Quantities and conditions that the SOP covers, a summary
covering each type of use, and an example of the actual use.
Protocol /Procedure
Quantities covered by this SOP:
0 - 40 g
Conditions covered by this SOP:
0 oC – 50 oC
General:
Sodium hydroxide pellets are used to make aqueous solutions that
range in concentration from 0.01M to 1M and volume of 10mL to 1L.
The sodium hydroxide pellets are weighed and then slowly added to a beaker
of water that is cooled in an ice bath. Caution: Dissolution of sodium hydroxide
is exothermic! The solution is then stirred until all the sodium hydroxide is
dissolved. It is then allowed to warm to room temperature. The final concentration
is determined by titration with potassium hydrogen phthalate. (See SOP on
Titrations).
Example:
To make 1L of a 1M sodium hydroxide solution:
40g of NaOH pellets was weighed out in a plastic weigh boat. Slowly,
only a few pellets at a time was added to 1L of water in a 2L beaker equipped
with a magnetic stir bar in an ice bath. After the last of the sodium hydroxide was
added and dissolved, the 2L beaker was removed from the ice bath and allowed
to warm to room temperature before being titrated with potassium hydrogen
phthalate. The plastic weigh boat was triple rinsed with water (the first wash
being disposed as hazardous waste) before being disposed of in the trash.
NOTE
Any deviation from this SOP requires approval from PI.
Sodium Hydroxide (pellets) 5 Date: 10/18/2012
SOP Template Library
EH&S has developed an SOP Template Library (http://sop.ehs.ucla.edu) that includes
templates for several hundred chemicals. These templates can easily be customized
for your specific operations.
Contact EH&S:
Tel: 310-825-9797
Fax: 310-825-7076
www.ehs.ucla.edu
Rev 01/13

Radiation Safety
The Radiation Safety Program:
• Ensures the safe use of radioactive materials,
radiation-producing machines and lasers
• Oversees academic and clinical compliance with
regulatory requirements governing radioactive
materials
Radiation Safety Inspections
INSPECTIONS COMPLETED
800
700
600
500
400
300
200
100
0
555 545
On-Time Reporting
Initial Inspection
Reports
Accomplishments
• Second consecutive inspection from the
California Department of Public Health
– Radiologic Health with no items of noncompliance
noted
• Oversight of radiation safety at off-site facilities
for non-research, out-patient only clinical
diagnostic scans
• Technical advisors to Ronald Reagan Medical
Center for mass-casualty radiologic emergency
drill
New Resources
627
Critical 48-Hour
Re-Inspection
Reports
784
• Revised EH&S Radiation
Safety Manual
• Generally-Licensed
Radioactive Material Fact
Sheet
• Developed e-training module:
Dosimetry
695
Non-Critical 30-Day
Re-Inspection
Reports
97% 90% 97%
723
2007 2008 2009 2010 2011 2012
Fact Sheet
ENVIRONMENT,
EH&S Facts
HEALTH & SAFETY
Generally Licensed Radioative Materials
What are classified as “generally licensed” radioactive devices or materials?
The United States Nuclear Regulatory Commission (NRC) defines these as “usually consisting of radioactive material
contained in a sealed source within a shielded device.” Some chemical compounds may also meet this criteria, such as
those containing naturally occurring uranium and thorium. Examples of generally licensed devices and materials include:
• Electron capture detectors (gas chromatograph units)
• Static eliminators
DO’s and DON’Ts
• Calibration standards installed in liquid scintillation counters DO’s
• Uranyl acetate
33Review labeling and SDS thoroughly
• Uranyl nitrate
before use
• Thorium nitrate
33Ensure laboratory personnel are
trained on the labeling and SDS
Are they safe?
requirements
They are produced to be safely used by individuals with no radiation 33Keep device or material secure at all
training or experience. Safety precautions should still be taken since times
these devices or materials are not without hazards.
33Complete the LHAT annually to ensure
EH&S is aware of your inventory
What are my responsibilities as the “general licensee”? 33Contact EH&S if your device requires
leak testing
An individual or organization possessing generally licensed devices 33Notify EH&S of unwanted generally
or materials is termed the “general licensee” and must follow certain licensed devices/materials
use and disposal requirements. Every generally licensed item will
DON’Ts
arrive with labeled instructions affixed prominently on the equipment
or container. For unsealed generally licensed material, a Safety Data 23Handle unsealed material without
wearing proper PPE
Sheet (SDS) will be provided. The instructions and SDS must be read
thoroughly to ensure proper use and disposal.
Some of these requirements may include but are not limited to:
• Security of the device/material
• Proper handling and use and appropriate personal protective
equipment (PPE)
• Routine maintenance of the device/material
• Semi-annual leak testing
• Return to vendor, or disposal of as radioactive waste, after the
source is no longer useful
nitrate, or thorium nitrate compounds
How can EH&S help me stay compliant?
in the regular trash
To ensure compliance, EH&S should be notified if generally licensed
material was purchased directly from a vendor and not received through the EH&S Radiation Safety Office. The most
efficient way to do this is to complete the Laboratory Hazard Assessment Tool (LHAT) on an annual basis, or whenever
inventory changes occur.
Certain generally licensed devices (e.g. static eliminators, electron capture detectors) require semi-annual leak testing to
ensure no radioactive contamination is present. EH&S will test these devices and maintain the required records for you.
Disposal Guidelines
Contact EH&S:
NEVER dispose of generally licensed material or devices as regular trash. EH&S is able to Tel: 310-825-9797
assist with the shipment of unwanted sources to the original manufacturer or may be able Fax: 310-825-7076
to collect the device for proper disposal through an approved disposal facility.
www.ehs.ucla.edu
Keep your workplace safe
23Remove the source from any generally
licensed device without prior
authorization from EH&S
23Abandon or improperly dispose the
material
23Operate damaged devices
23Dispose of any equipment containing
generally licensed devices without
contacting EH&S
23Discard of any uranyl acetate, uranyl
Rev 10/12
www.ehs.ucla.edu
The Biosafety Program:
Biosafety Inspections
Accomplishments
Biosafety
• Minimizes the risks of research involving
biohazardous materials
• Coordinates activities of the Institutional Biosafety
Committee, which reviews and approves use of
biohazardous materials in research
INSPECTIONS COMPLETED
600
500
400
300
200
100
0
102
165
On-Time Reporting
2011 Critical 48-Hour
Re-Inspection Reports
50%
2012 Critical 48-Hour
Re-Inspection Reports
80%
• Successful annual inspection of medical wastegenerating
laboratories and accumulation sites
by the California Department of Public Health,
requiring only minor corrective actions
• Surprise inspection of medical wastes
generated from high containment laboratory
operations by U.S. Department of
Transportation with no violations cited
• Successful inspection of UCLA Select Agent
Program by U.S. Centers for Disease Control
(CDC)
Policy and Document Development
418
320
493
• Registration of Genetically Modified Animals
Policy (specifies experiments requiring IBC
review/approval and exemptions)
• Post-Exposure SOP templates
338
2007 2008 2009 2010 2011 2012*
*Decrease due to a shift in focus to more critical issue
response and 48-hour re-inspections during 2012
3

4
Injury Prevention
Preventative activities of the Injury Prevention
Program include:
• Ergonomic evaluations
• Job safety analyses
• Shop safety inspections
• Accident and incident investigations
• Development of Injury & Illness Prevention Plans
Injury & Illness Prevention
Plans In Place
Accident Investigations
Annual Ergonomic Lab Visits
600
400
200
0
600
500
400
300
200
100
0
151
261
363
515
26
59
78
2007 2008 2009 2010 2011 2012
280
42
420
138
511
161
416 417
161
2007 2008 2009 2010 2011 2012
100% of
campus
IIPP’s
complete
1881%
www.ehs.ucla.edu
Hotline Injury Reports
Timely reporting of injuries to
the EH&S Injury Hotline allows
employees to receive appropriate
care, and ensures on-time
reporting to regulatory agencies.
Safety Recommendations
Implemented
Accomplishments
3 2
• Completed a four-year initiative to implement
customized Injury & Illness Prevention Plans
for all campus departments, reaching 100%
completion
• Recipient of the Campus Safety Health and
Environmental Management (CSHEMA)
2012 Safety Excellence Award for the Hazard
Assessment Tool for Shops (HATS)
• Twenty-fold increase (1,881%) in accident
investigations between 2007 and 2012
• Collaborated to create UC Ergonomic
Guidelines for Dining Service workers

Environmental Programs
Environmental Programs support the University’s
policies to minimize the environmental impact of
its activities through regulatory oversight, training
and inspections. The responsibilities of the division
include:
• Monitoring for the presence of toxic substances
• Providing respirator training and fit-testing
• Ensuring food safety
• Ensuring recreational water safety
• Managing the hazardous waste program
• Implementing integrated pest management
Hazardous Waste Generated
(in tons)
300
200
100
Annual Pool Inspections
0
7
74
229
2007 2008 2009 2010 2011 2012
Pools are tested for:
• Chlorine levels
• Pathogens such as:
• Coliforms
• Legionella
pneumophila
• Pseudomonas
aeruginosa
221
236
293
4085%
20
Number of
pools/spas
on campus
www.ehs.ucla.edu
Annual Pest Control Inspections*
1200
900
600
300
0
2007** 2008** 2009 2010 2011 2012
Decrease in inspections due to proactive repairs by Facilities
Management, education and targeted applications.
*Inspections are conducted by outside vendor and supplemented by
EH&S staff
**2007 & 2008 data provided by Facilities Management
Exposure Assessments
100
80
60
40
20
0
18
55
29
General Completed by Vendor Laboratory
Accomplishments
31
39
63 61
2009 2010 2011 2012
Asbestos Training
600
500
400
300
200
100
0
1101
65
46
780
118
880
128
642
187
783 766
511
2007 2008 2009 2010 2011 2012
Non-Lab
• Prepared Hazardous Materials Management
Program for Fleet Services
• Successful completion of the 3-Year AHERA
Re-inspection of the University Elementary
School by Asbestos and Lead Program
• Performed targeted lab clean outs in the
Department of Chemistry and Biochemistry
686%
5

Fire Safety
The Fire and Life Safety Program addresses fire code
compliance, fire and life safety training needs, fire
suppression systems and fire hazard abatement.
Plan Reviews Completed (Title 24)
800
600
400
200
0
Annual Title 24 requires the review of construction
plans at various stages in project development.
Building Inspections Completed (Title 24)
300
250
200
150
100
50
0
2009 2010 2011 2012
Annual Title 24 also requires the review fire
suppression systems prior to the official opening of
new construction.
Hands-on Fire Extinguisher Training
Accomplishments
111%
A key component to fire prevention is the education
of the campus community on the proper use of fire
extinguishers and fire prevention education.
• Conducted fire suppression and fire/life safety
systems inspections of trash chutes in Housing
and Hospitality Services
• Implemented annual fire pump certification, which
includes testing of all campus fire pumps
• Obtained proper licensing to permit the installation,
repair, inspection, testing and maintenance of
campus fire suppression systems
www.ehs.ucla.edu
New Training Modules
LABORATORY SAFETY ONLINE
REFRESHER
Training
The EH&S Training & Outreach Program continues
to support campus safety efforts in the areas of
classroom and online training, participation in
outreach events, and the development of materials
to support safety in laboratory and non-laboratory
settings.
Safety Training
INDIVIDUALS TRAINED
40000
30000
20000
10000
0
2576
2494
4141
9121
9963
14718
14523
18202
16695
19403
Completed Online Completed Classroom
RADIATION SAFETY E-TRAINING
MODULE: DOSIMETRY
20794
16719
EMPLOYEE SAFETY HANDBOOK ONLINE
RESOURCE
UC Center for Laboratory Safety
CLS awarded four seed grants in 2012 to support
laboratory-safety related research:
• Identifying chemical and procedural hazards
associated with pharmaceutical compounding
tasks at health teaching science laboratories
and formulating risk mitigation strategies.
(Manchester University College of Pharmacy)
• Tracking signs and consequences of a
changing lab safety culture by performing
statistical analysis of existing inspection and
incident data. (MIT)
• Investigating the efficacy of selected disinfectants
as alternative to chlorine bleach for use in
laboratory and animal facilities. (UCLA)
• Assessing the health risk of researchers
working with mice treated with the toxins/
carcinogens
tamoxifen and
BrdU. (UCLA)