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620 Environmental Health and Fire Safety

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SUBJECT: ENVIRONMENTAL HEALTH AND SAFETY
NUMBER: 620
AUTHORIZING BODY: VICE PRESIDENT FOR FINANCE AND ADMINISTRATION
RESPONSIBLE OFFICE: ENVIRONMENTAL HEALTH AND SAFETY
DATE ISSUED: MAY 1997
LAST UPDATE: SEPTEMBER 2007

RATIONALE:  To provide information to Oakland University (University) on issues related to occupational and environmental health and safety, and fire and life safety.

POLICY:  The Office of Environmental Health and Safety (EH&S) is responsible for the development, implementation and management of University policies and procedures that are designed to protect employees from occupational illness/injury, protect campus persons and buildings from fire, protect the University from fines and penalties for failure to comply with environmental health and safety rules and regulations, and protect the environment and surrounding community from injury/illness resulting from improper handling/disposal of hazardous materials on campus.

SCOPE AND APPLICABILITY:  This policy applies to all faculty, staff, students, vendors, contractors and visitors on campus.

DEFINITIONS:

Authority Having Jurisdiction:  The governmental agency, subagency or owning authority which regulates processes and compliance.

Biohazardous Materials:  Hazardous biological materials which can significantly impact the environment, agriculture, and cause disease to living organisms, including humans, animals and plants. Biohazardous Materials include recombinant DNA, infectious organisms (i.e. bacteria, fungi, parasites, prions, rickettsias, viruses, etc.), tissues containing infectious organisms, and biologically active agents (i.e. toxins, allergens and venoms).

Compliance Program:  A program which consists of any/all policies and procedures that must be implemented at the University in order to comply with a specific regulation. The program may include documentation, training programs and other educational material.

Compliance Program Guidance Manual:  A manual or guidance document that describes in detail the methods that Oakland University will employ in order to comply with relevant regulatory standards. These include, but are not limited to: Biosafety, Bloodborne Pathogens Exposure Control, Chemical Hygiene Plan, Confined Space Entry, Hazard Communication (Michigan-Right-to-Know), Hazardous Waste Management, Medical Waste, Power Lockout, Radiation Safety, Respiratory Protection Program and Tuberculosis Exposure Control.

Exit Access:  Refers to building corridors and stairwells leading up to “exits”, whereas “exits” are the doors, or other means provided, that open to areas of safety away from fire and smoke.

Hazardous Waste:  A waste with properties that make it dangerous or potentially harmful to human health or the environment and/or that exhibits at least one of the following characteristics – ignitability, corrosivity, reactivity, or toxicity. Hazardous Wastes can be liquids, solids, contained gases, or sludges and can be the by-products of manufacturing processes or simply discarded commercial products, like cleaning fluids or pesticides.

Institutional Biosafety Committee:  The use of Biohazardous Material is governed by the Institutional Biosafety Committee. All proposed use of Biohazardous Materials must be reviewed and approved by the Institutional Biosafety Committee. Once approved, users of Biohazardous Material must comply with all applicable rules and guidelines governing the use, storage, transport and disposal of all potential human pathogens. Compliance is then monitored and enforced by the Laboratory Compliance Manager who acts as the University’s Biosafety Officer, and serves as a member of the Biosafety Committee. The Biosafety Officer, under the direction of the Vice Provost for Research, will enforce all aspects of the University’s Select Agent Program per the requirements of the Animal and Plant Health Inspection Service (APHIS)/Centers for Disease Control and Prevention (CDC) rules and regulations.

Laboratory Safety Committee:  General laboratory activities, including the use of laboratory chemicals, supplies and equipment, are all addressed by the Laboratory Safety Committee. Any/all issues, problems, questions, etc. related to laboratory safety are reviewed by the Laboratory Safety Committee for guidance and consultation. Approval and enforcement authority are the responsibility of the Laboratory Compliancce Manager acting as the University’s Chemical Hygiene Officer and Laboratory Safety Committee Chair.

Occupational Safety Regulation:  A rule, ordinance, or law by which conduct related to workplace safety is regulated.

Office of Environmental Health and Safety: EH&S is organized into two primary categories of responsibility:

  1. Occupational and environmental safety which includes:
  1. Protection of the environment and public health including air, water and land.
  1. Participation on University Stormwater Pollution Prevention Committee.
  1. Hazardous Waste management.
  1. Occupational health and life safety which includes:
  1. Occupational hazards including employee training, regulatory compliance and industrial hygiene
  1. Chair University Health and Safety Committee

  2. Participation on University Pandemic Planning Taskforce
  1. Fire and life safety.

  2. Construction safety

  3. Laboratory safety which includes radiation safety, biological safety and chemical hygiene.
  1. Chair Laboratory Safety Committee

  2. Participation on Radiation Safety Committee

  3. Participation on Institutional Biosafety Committee.

 

Pandemic Planning Taskforce:  The Committee will address the University’s Business Continuity Planning and Infection Control Planning in preparation for a pandemic or other health emergency or any emergency related closure.

Radiation Safety Committee:  The use of ionizing radiation, including radioisotopes and radiation-generating machines, is governed by the Radiation Safety Committee. All proposed use of ionizing radiation on the University campus must first be reviewed and approved by the Radiation Safety Committee. Once approved, users of ionizing radiation must comply with the Federal, State, University and Radiation Safety Committee rules governing the use, storage, transport and disposal of radioisotopes and radiation-generating machines. Said compliance is then monitored and enforced by the Laboratory Compliance Manager who acts as the University’s Radiation Safety Officer and who serves as a member of the Radiation Safety Committee.

Select Agent Program:  The Centers for Disease Control and Prevention (CDC) regulates the possession, use and transfer of select agents and toxins that have the potential to pose a severe threat to public health and safety. The Select Agent Program oversees these activities and registers all laboratories and other entities in the United States of America that possess, use, or transfer a select agent or toxin.

Stormwater Pollution Prevention Committee:  The Committee will address the requirements of the National Pollutants Discharge Elimination System (NPDES) including management of the University’s Stormwater Permit Application.

University Health and Safety Committee:  The Committee will work in conjunction with EH&S to develop a Health and Safety Program for the University. The Committee, through the Chair (The Manager of Environmental Health and Life Safety), will act as an advisory group to the University, will apprize the Administration and make recommendations for the correction or potentially unsafe practices and conditions. 

PROCEDURES:    

A. Ensuring Regulatory Compliance

When an Occupational Safety Regulation is deemed applicable to the University’s activities and/or conditions, the EH&S staff member shall examine the regulatory text, and generate a Compliance Program which consists of any/all policies and procedures that must be implemented at the University in order to comply with the regulation, and thereby protect University employees. [Note: Occupational Safety Regulations provide the minimum requirements toward this goal; the EH&S has the right and responsibility to add any reasonable requirements to the Compliance Program as deemed necessary. Each Compliance Program shall be described in a Compliance Program Guidance Manual (Manual), which is distributed to front-line supervisors, managers, etc., of any/all departments that are impacted by the regulation. EH&S shall also distribute updates to this Manual as often as necessary.

EH&S shall train and test supervisors (and their current employees if so desired by the supervisors) in topics explicitly required by the Compliance Program, in addition to those deemed necessary by EH&S. Supervisory training sessions and tests shall be repeated regularly (at a minimum as often as is explicitly required by the regulation).

Once a supervisor has,


1. received the Compliance Program Guidance Manual;


2. completed the training;


3. passed the associated examination; and


4. received training materials and blank exams, the following becomes his/her responsibility (or the responsibility of his/her designee):
  • Arranging for funding of any/all materials, supplies, equipment, and so forth, required by the Compliance Program.

  • Record-keeping (with copies of any/all records submitted to EH&S upon request).

  • Monitoring and enforcing employee compliance; utilizing any/all disciplinary resources allowed whenever employees fail to comply.

  • Making arrangements for training and testing of any/all employees within 10 calendar days of employment.

  • Coordination of training/ testing of existing employees at the required intervals.

  • Submitting photocopies of any/all completed tests to EH&S for grading and database entry. Note: EH&S maintains a master database of all employee training records.

  • Bringing to the attention of EH&S in a timely manner any problems, concerns, or questions, related to regulatory compliance or safety in general.

B. Emergency Procedure - Fire

Fire Alarms - When an emergency evacuation alarm is sounded in any University building, all persons will immediately leave the building in an orderly manner by means of the nearest exit. For those operations that require special consideration, special evacuation plans must be approved by the EH&S and steps immediately initiated to secure the operation and evacuate personnel as soon as is practical.

  • Evacuation - Under no circumstances are any employees to remain in, or return to, an evacuated building, unless they first secure the permission of the Oakland University Police Department (OUPD), local police or fire officials, and/or an “ALL CLEAR” is issued by the OUPD. Employees who witness unauthorized persons remaining in, or re-entering a building, should bring this to the attention of the OUPD, local police or fire officials.
  • Use of Elevators - For their own protection, faculty, staff, visitors, students and vendors will refrain from using elevators during an emergency evacuation.

  • Safe Distance - Emergency responders require all persons to remain at least 100 feet away from evacuated buildings to enable rescue/responding vehicles and personnel to enter and exit the buildings quickly and safely.

C. Drills

EH&S will schedule, monitor, and maintain records of each non-dormitory fire drill as required. University Housing schedules and maintains records of dormitory fire drills as required.

  • Every alarm must be treated as an actual emergency, University faculty and staff are directed NOT to call the police dispatcher to determine whether the alarm is a drill.

D. Use of Exits and Exit Access

  • Employees must never obstruct exit-access (building corridors and stairwells leading up to exits) OR exits (i.e., with furniture, storage, displays, vending machines, etc), and should immediately report any such obstructions they may encounter to EH&S.

  • Fire doors on stairwells (unless designed, constructed and installed to close automatically in the event of a fire) are to remain closed at all times and should NEVER be propped open (e.g., with chairs, door-stops, etc.). Any/all “prop-open” devices should be immediately removed.

  • Exit signs should be properly illuminated at all times and should not be obstructed or blocked from view. Any obstructive items should be immediately removed when encountered (and/or reported to EH&S.

  • Exits or exit-access doors should never be locked (unless the doors are equipped with panic hardware or other approved means to permit emergency egress by building occupants). Violations should be immediately reported to EH&S.

E. Fire Protection Equipment

  • Tampering with, obstructing or in any way interfering with fire protection equipment, including but not limited to: smoke detectors, pull stations, fire extinguishers, sprinklers, horns and/or strobes is prohibited.

  • All fire protection equipment shall be installed in compliance with applicable codes and standards under the supervision of EH&S (or their designee), and must be approved prior to being placed in service.

  • Clear access must be maintained at all times to all fire extinguishers, fire alarms, and all other emergency fire equipment. Access should never be blocked to this equipment. Obstructions should be immediately removed and reported to EH&S.

F. Fire Prevention and Fire Safety Systems

Codes and Standards

Oakland University recognizes and hereby establishes the use of the following codes and standards related to fire safety: 

Classrooms, office buildings, dormitories and places of assembly:

The State of Michigan Department of Consumer and Industry Services, Bureau of Fire Safety and the State Fire Safety Board, through Section 3c of Act No. 207 of the Public Acts of 1941 (which establishes rules that apply to these types of buildings and references additional standards developed by the National Fire Protection Association (NFPA)).

All other buildings at the University must be constructed to the standards established by the most recently adopted edition of the Michigan Construction Code, and should be maintained to the standards established by the NFPA 101 and NFPA 1.  
  1. Plans and Specifications
  1. Departments or persons wishing to construct, add to, modify, repair, or remodel any building or portion of a building that may affect the building’s fire protection features or its fire safety systems, may do so only after review and approval by the EH&S and the Facilities Management (FM).

  2. Departments or persons wishing to install, remove, repair, or modify any fire alarm, fire detection, or fire suppression system may do so only after review and approval by EH&S.

  3. Detailed plans and specifications for any projects described in 2. a. and 2. b. above must be submitted to and approved by EH&S and FM. Submitted documents will be reviewed to ensure compliance with any/all generally accepted and/or adopted fire code guidelines.
  1. Plans and specifications must include: drawings of sufficient detail so that the extent and nature of the work is clearly identified, specifications of the material to be used, and Underwriters Laboratories listings and design numbers as appropriate.  
  1. Inspection and Occupancy Approval
  1. All projects will require a final inspection and approval from EH&S and/or the State or Local Fire Marshall, prior to occupancy and/or the closeout of the project.
  1. Projects that involve the concealment of any work will be required to be inspected by the appropriate office or agency prior to any concealment.

  2. The University Project Manager of each construction project shall either serve as, or formally designate, an individual to handle/coordinate health and safety matters; this individual will act as liaison to EH&S, and arrange for any/all required meetings, submittals, inspections, etc.

  3. Any work that is found to be in non-compliance, or has not been approved by the appropriate office or agency, must be corrected at the direction of the appropriate office or agency; any/all costs associated with the correction(s) shall be the responsibility of the department that initiated the original project.
  1. Unauthorized Activities and Equipment
  1. Cooking, grilling and the use of unapproved cooking appliances are prohibited except in areas designated for such use or with the written approval of the Authority Having Jurisdiction.

  2. Use of any unauthorized electrical equipment (i.e. space heaters, hot plates, grills) is prohibited.

  3. Open burning, flames and burning of candles or combustibles are prohibited. 
     
  1. Bonfires
  1. A bonfire may be allowed only after obtaining a permit from EH&S and in conjunction with an organized event and/or facility rental for a recognized University function.

G. Laboratory Safety

  1. EH&S under the direction and guidance of the three (3) associated Safety committees, provides consultation and operational support to the academic and research community in an effort to maintain a safe and healthful working and learning environment 

Laboratory Audits

  • The Laboratory Compliance Manager, acting as Radiation Safety Officer, Biosafety Officer, and Chemical Hygiene Officer, will conduct regular announced and unannounced compliance audits of laboratories.

  • Failure to maintain a safe and regulatory compliant working and teaching laboratory environment will result in corrective action, up to and including the closure of the offending laboratory and the revocation of the privilege to use regulated substances at the University.

  • It is the responsibility of the Department Chairs, Principal Investigators and Laboratory Managers to ensure that research and teaching labs are free of hazards and in compliance with all applicable regulations and guidelines. 

H. Hazardous Waste Management

  • EH&S collects and disposes of Hazardous Waste in accordance with applicable laws. Hazardous Waste may not be collected, disposed of, or stored without prior approval from EH&S. Generally, EH&S will collect and dispose of Hazardous Waste at no charge to the generating department, except for the following units or waste streams:

  • Auxiliary units disposing Hazardous Wastes with the assistance of EH&S, will be charged disposal fees.

  • Disposal arrangements and disposal fees for wastes classified as liquid industrial waste by the Michigan Department of Environmental Quality (includes some off-specification commercial chemical products, industrial wastewater, used oil that is being recycled, storm sewer and sanitary sewer clean-out residue, grease trap clean-out residue, and other liquid industrial waste) will be the responsibility of the generating departments. EH&S must be notified prior to disposal.

  • Disposal arrangements and disposal fees for wastes classified as asbestos waste, including asbestos that is abated, remediated, and/or removed will be the responsibility of EH&S or FM. An Asbestos Waste Shipment Record which complies with applicable National Emissions Standards for Hazardous Air Pollutants (NESHAP) Standards and applicable Department of Transportation (DOT) Standards and which documents landfill disposal in an approved landfill must be provided to EH&S.

  • Waste generated by contractors and any waste from remodeling or new construction will be the responsibility of the contractor.

  • A copy of the associated “Hazardous Waste Manifest”, listing Oakland University’s “Generator ID Number” must be forwarded to the EH&S within five (5) business days of pick-up.

  • All employees (including graduate students and/or student employees) performing tasks in an area where Hazardous Wastes are generated or stored must receive Hazardous Waste Management training.

  • EH&S must be notified of all containers of Hazardous Waste immediately so that on-site storage and/or disposal can be arranged. Unwanted electrical equipment must be delivered to the University Property Office (Property Office) for recycling unless it is determined that the electrical equipment cannot be decontaminated. A certificate of decontamination must be affixed to any lab equipment delivered to the Property Office. Arrangement must be made for contaminated equipment to be transferred to EH&S or picked-up for disposal as a Hazardous Waste. A copy of any Hazardous Waste manifests signed at the time of Hazardous Waste disposal must be forwarded to the Laboratory Compliance Manager. All questions concerning Hazardous Waste disposal should be directed to the EH&S.

I. Authority

  • The Office of Environmental Health and Safety shall be notified immediately of the arrival of representatives and/or inspectors representing local, state or federal regulatory agencies responsible for environmental and/or occupational health and/or life safety.

  • EH&S or their designees may enter premises and other areas owned, rented or leased by the University for the purposes of conducting inspections (announced or unannounced), addressing safety hazards, testing, maintenance or repair of safety equipment, investigation of fires or occupational injuries/illnesses, and/or investigation of health or fire safety concerns, questions, complaints or violations (actual or potential).

  • Upon observing a condition or activity out of compliance with one or more University Compliance Programs, and/or one that is otherwise dangerous to persons or property, the EH&S Staff or their designees may take any/all necessary steps to 1) have the hazardous condition/activity abated/terminated, and 2) protect campus persons and property until that time. This could include, but is not limited to, the following:

  • Bringing the matter (verbally or in writing) to the attention of any/all responsible parties (including, but not limited to, the employees immediately involved/impacted, their supervisors, the Deans, Directors or Department Heads).

  • Allowing a reasonable period of time to correct the situation; perhaps requesting that any/all abatement activities/strategies be provided to EH&S following completion.

  • Upon observing a condition or activity deemed “immediately dangerous to life or health” (often referred to as an “IDLH situation”) EH&S Staff or their designees have the right and responsibility to shut down whatever operations are impacted/implicated by the hazardous act/condition, and deny access (up to and including padlocking the equipment, area, etc.) to any/all individuals until the situation has been corrected.

  • This authority also applies unequivocally to ANY/ALL outside contractors performing work on the University’s campus.

RELATED POLICIES AND FORMS:

OU AP&P #310 Building Alterations, Renovations and/or Modifications

APPENDIX:    

 

2012