DEFINITIONS: HEALTH THREATENING VS. NON-HEALTH THREATENING EMERGENCIES
An unforeseen event that calls for immediate action to protect individuals, the environment, or property.
--HEALTH THREATENING EMERGENCY
An emergency in which there is a clear potential for serious injury to a person if immediate action is not taken. (If in doubt, consider the emergency health-threatening.)
--NON-HEALTH THREATENING EMERGENCY
An emergency in which there is not a clear potential for serious injury to any person.
UNIVERSITY HEALTH AND SAFETY POLICIES
NOTE: The School of Medicine maintains a Policy on Emergency and Hazardous Material Release Response that is virtually identical to this one, except that any references to 9-911 are replaced by 286 (Medical Center Emergency Page Operators). Dial 286 in the event of a health threatening emergency in the School of Medicine.
--POLICY ON EMERGENCY AND HAZARDOUS
MATERIAL RELEASE RESPONSE
Promulgated in a June 29, 1988, memorandum to Deans, Department Chairs and Laboratory Directors by Vice Provost and Dean of Research Robert L. Byer, and Vice President for Business and Finance William F. Massey. These policies apply to all faculty, students, staff and visitors at Stanford University. Please note that two different versions of this policy are set forth below. One is applicable to the Medical School and the other is to all non-Medical School areas. These statements are virtually identical, reflecting differences only with respect to telephone numbers, emergency contact personnel and some procedures for the units involved.
Various federal, state and local regulations require employers to develop and implement a Hazardous Materials Release Response Policy to provide a consistent and adequate means of handling an emergency involving a hazardous material. As part of Stanford's continuing commitment to develop and implement policies and procedures consistent with these regulations, the policy below has been established. The policy has been designed to assure that Principal Investigators are fully informed of and included in the response strategy.
CONTACT FIRE DEPARTMENT
In the case of an "emergency'" involving a "hazardous materials release" that is "health threatening" or "released to the environment" as defined in Section II(A) of the policy document, the Palo Alto Fire Department (PAFD) is to be notified immediately by calling 9-911 or pulling a fire alarm. Once involved, the PAFD is in command until the hazard has been fully abated and they relinquish command. In the case of a release that is "non-health threatening" and "contained" as defined, the Department of Environmental Health and Safety's Emergency Response Team should be contacted immediately and will assume command until relinquishing it to the PAFD or the hazard has been fully abated.
SUPERVISORS' RESPONSIBILITIES FOR TRAINING
As can be seen in the Responsibility section of the policy, the participation of all members of the Stanford community is required for its successful implementation. Department Chairs, Laboratory Directors, Principal Investigators, and Supervisors have the specific responsibility to see that individuals for whom they are responsible are trained in proper emergency response procedures and that the work areas for which they are responsible are posted conspicuously with emergency response procedures. (Please refer to the Definitions section and the Activating Procedures for a summary of required responses in an emergency involving hazardous materials.) EH&S is working with academic departments and can provide information for a department in establishing emergency response procedures for a specific area. An "IN CASE OF EMERGENCY" poster is available for posting from EH&S. Please call EH&S (723-0448) with any questions you may have.
REPERCUSSIONS OF NON-COMPLIANCE
Non-compliance with this policy may result in a building's Hazardous Materials Storage Permit being revoked. Civil and criminal penalties may also be sought by the enforcing agency.
--POLICY STATEMENT AND RESPONSIBILITIES FOR
ALL AREAS OUTSIDE THE SCHOOL OF MEDICINE
POLICY ON EMERGENCY RESPONSE PROCEDURES
It is the policy of Stanford University to establish and maintain emergency response procedures and capabilities to:
* respond to incidents involving hazardous materials;
* assist the Fire Department with hazardous materials expertise;
* clean up modest hazardous materials releases;
* maintain records of all hazardous materials releases and accidents;
* report incidents to outside agencies as required;
* review causes of incidents to reduce recurrence; and,
* review responses to incidents in order to improve service.
PURPOSE OF POLICY
This policy and associated procedures are intended to provide tiered response to incidents involving hazardous materials appropriate to their magnitude and risk. If the appraisal of magnitude and risk is uncertain, the response strategy will address the worst case scenario. Extreme care should be taken that these procedures are followed explicitly and consistently and that the reporting party provides accurate and complete information to the responding entity. The purpose of this statement is to set forth procedures to be followed in the event of an emergency involving the accidental release of hazardous materials, in order to:
* protect research personnel, the general public, and the environment;
* protect property and research assets;
* comply with the regulatory response reporting, recording and abatement requirements;
* encourage safe practices and requests for assistance when personnel are in doubt about hazardous materials; and
* standardize response procedures throughout the University.
Refer to the "Definitions" section for a summary of required responses and actions. Conditions and releases involving asbestos are excluded from this policy (call 723-0448 for attention to asbestos concerns).
[Environmental Health and Safety's responsibilities]
Environmental Health and Safety is responsible for:
* maintaining a trained emergency response team and equipment capable of addressing modest Hazardous Materials Releases;
* maintaining working knowledge of applicable laws and regulations;
* maintaining records of Hazardous Materials Releases and incidents;
* informing the campus community of the Emergency and Hazardous Material Release Response Policy.
[Faculty and staff supervisors' responsibilities]
Department Chairs, Principal Investigators, and Supervisors are responsible for:
* ensuring the safety of those working under their direction;
* assisting the Health and Safety Emergency Response Team or Palo Alto Fire Department in any hazard evaluation in areas under their direction;
* training those under their direction in correct emergency response procedures;
* ensuring that emergency response procedures are posted conspicuously in each work area.
Faculty, Students, Staff and Visitors are responsible for:
* following sound health and safety practices;
* reporting any emergency or hazardous situation immediately according to these procedures;
* cooperating and assisting with any emergency response personnel;
* complying with all applicable University policies and practices.
--DEFINITIONS, PROCEDURES, AND REFERENCES
NOTE: The first three definitions have been revised and simplified since this policy was promulgated in 1988. See the beginning of the Appendices for the most current revisions.
An unforeseen combination of circumstances or the resulting state that increases the threat to health, life, or property and calls for immediate action.
Any emergency in which a person or people are seriously injured or could potentially be seriously injured if immediate action is not taken. For example (not meaning to exclude any other circumstances), any fire, explosion, toxic gas release, or serious injury should be considered "Health Threatening." (Reporting party call Central Communications at 9-911 or pull fire alarm and contact Principal Investigator (PI), the laboratory director, or other responsible party in the department.)
Any emergency in which there is no immediate threat of injury to people. This allows for more complete hazard evaluation to be undertaken before initiating corrective action. (Reporting party call EH&S at 3-0448 during work hours or 3-2281 at all other times and contact Principal Investigator (PI), the laboratory director, or other responsible party in the department. Call Health Physics at 3-3201 if radioactive materials are involved.)
Hazardous Materials Release
A Health Threatening or Non-Health Threatening spill, unauthorized, or unexpected release of a hazardous material from primary containment, as defined in any of the referenced laws or regulations. If Health Threatening, the Health and Safety Department Emergency Response Team (ERT) will assist the Palo Alto Fire Department or other responding agency in cleanup and report of incident to Santa Clara County. If Non-Health Threatening, EH&S will call the Central Communications if assistance is needed. Conditions and releases involving asbestos are excluded from this policy (call 5-7530 for attention to asbestos concerns).
Indicates a Hazardous Material Release that is within secondary containment, i.e. a floor, tray, or engineered containment system. (EH&S' Emergency Response Team will clean-up and record the release.)
Released to the Environment
Indicates a Hazardous Material Release that is discharged to the surface, soil, sewer, surface water or air outside of a building at a hazardous level as defined by applicable regulations. This also refers to a Contained Hazardous Material Release that takes more than eight hours to clean up, as is specified in the Santa Clara County Hazardous Material Storage Permit Ordinance. (EH&S' Emergency Response Team(ERT) will call Central Communications at 9-911 and proceed to clean up the release, obtaining assistance as necessary and reporting to regulatory and other cognizant agencies as required).
These procedures are intended to provide tiered response to incidents involving hazardous materials appropriate to their magnitude and risk. The evaluation of the hazard, of what to report or record, and of how to respond will be made by the EH&S' Emergency Response Team (ERT) Command Staff in consultation with the Principal Investigator (PI) (or other knowledgeable or responsible parties and the Palo Alto Fire Department (PAFD) when they are involved). In the event that there is no time for a full hazard evaluation, or there are many chemicals or other complexities involved, or there is insufficient information available about the materials or situation involved, then precautions based on the worst case scenario for the incident will be applied to the response to protect the ERT, the public, and the environment. These precautions will be taken by the ERT and any other agency responding to a call for assistance. Extreme care should be taken that these procedures are followed explicitly and consistently and that the reporting party provides accurate and complete information to the responding entity.
EXTREMELY IMPORTANT: FOLLOW THESE STEPS EXPLICITLY
In all cases, when any person becomes aware of an emergency, regardless of its location:
* If Health Threatening call 9-911 and/or pull the nearest fire alarm.
* If Non-Health Threatening call EH&S at 3-0448 during working hours or 5-9999 at all other times.
* If involving radiation or radioactive materials call Health Physics at 3-3201.
* If the reporting party is unclear of the Health Threatening nature of the emergency call 9-911 and/or pull the nearest fire alarm.
* If the release is in a laboratory, in addition notify the Principal Investigator responsible for that area. If the Principal Investigator is unknown or unavailable then notify the Department or Building Administrator, Safety Committee Chairperson, or Department Chairperson. When possible, leave appropriate messages in each case. (The work and home phone numbers of these people shall be posted throughout every building.) When 9-911 (Central Communications) receives a report of an emergency involving hazardous materials during working hours they will notify EH&S immediately. During non-working hours 9-911 will notify EH&S at 3-0448 and at all other times they will contact the ERT directly. 9-911 will notify the Health Physics Office at 3-3201 in the event of an emergency involving radiation or radioactive materials.
General Responding Procedures
(more specific actions will be followed depending on the incident)
DURING WORKING HOURS: When the Health and Safety Office receives a callfrom the reporting party or Central Communications the following will occur:
a) The report receiver will acquire all pertinent information regarding the emergency (time, date, nature and location of the incident, name and phone number of reporting party and type and quantity of hazardous materials involved) and record that on a Request and Response (R&R) form. If the incident is in a laboratory, obtain if possible, the name and phone number of the PI and determine if the PI has been contacted and record this on the R&R form. If the PI has not been contacted the reporting party should be told to contact the PI immediately.
b) The R&R form will be given to a designated ERT Leader who will establish the Incident Command System (ICS) to the extent necessary to respond to the incident.
c) The ERT is in command of the affected area until further notice or command is transferred to the PAFD.
d) The ICS will consist of a Team Leader, an Operations Staff and a Command Staff. The Command Staff will include at minimum a Safety Officer and if needed a Public Information Officer. The Team Leader may function in any or all of these roles.
e) The ERT Leader will contact the reporting party to gather more information about the incident, if necessary.
f) The ERT Leader will see that the PI (or other responsible party in the order previously stated if PI is not available) has been called.
g) The ERT Leader will call for assistance such as the PAFD or cleanup contractor if the release is either Health Threatening or Released to the Environment or is otherwise necessary.
h) If the PAFD is called to the scene, Command will be transferred to the PAFD by the ERT Leader.
i) The ERT will respond to the site of the incident.
j) The ERT Leader, in consultation with the Operations Staff, Command Staff, the PI or other responsible party, and others if needed, should establish the response strategy (compliant with all requirements of the OSHA regulations in 29 CFR part 1910.120 and the SCCHMSO and other relevant laws and regulations).
k) The Operations Staff will then initiate the response strategy to abate the hazard accordingly.
DURING NON-WORKING HOURS: When a reporting party calls the Work Information Center or Central Communications the following will occur:
a) The dispatcher for Central Communications or the person at the Work Information Center will acquire all pertinent information regarding the emergency (time, date, nature and location of incident, name and phone number of reporting party, and type and quantity of hazardous materials involved) and record that information.
b) If Central Communications has been contacted they will then dispatch the appropriate fire, police and ambulance service.
c) The PAFD is in command until further notice or command is transferred to the ERT.
d) The Work Information Center or Central Communications will then go down the emergency call list provided by the Health and Safety Office of members of the ERT. They will call each team member, in the order that they appear on the list, until they reach one of them at home.
e) The Work Information Center or Central Communications will then give the pertinent information, gathered from the reporting party to the ERT Member. Central Communications will continue to call other team members if requested to do so by the member contacted.
f) The first designated ERT Leader contacted will establish the Incident Command System (ICS) to the extent necessary to respond to the incident.
g) ICS will consist of an ERT Leader, an Operations Staff and a Command Staff. The Command Staff will include at minimum a Safety Officer and if needed a Liaison Officer and a Public Information Officer. The Team Leader may function in any or all of these roles.
h) The ERT Leader will contact the reporting party to gather more information about the incident, if necessary.
i) The ERT Leader will call for assistance such as the PAFD or cleanup contractor if the release is either Health Threatening or Released to the Environment or if otherwise necessary.
j) If the PAFD is called to the scene, Command will be transferred to the PAFD by the ERT Leader.
k) The ERT Leader will see that the PI or other responsible department member has been called.
l) The ERT will respond to the ESF to pick up the ER vehicle.
m) At ESF the Team Leader will begin an R&R form on the incident.
n) The ERT will then respond to the site of the incident.
o) The ERT Leader, in consultation with the Operations Staff, Command
Staff, the PI or other responsible party, and others if needed, will establish a response strategy that complies with all requirements of the OSHA regulations in 29 CFR part 1910.120 and the SCCHMSO and other relevant laws and regulations.
p) The Operations Staff will then initiate the response strategy to abate the hazard accordingly.
For a Non-Health Threatening, Contained incident (the PAFD or other agencies are not present) the following procedures apply:
a) On arrival at the site the ER Team will conduct an initial hazard evaluation of the incident.
b) If the ERT Leader determines that the incident is either Health Threatening or Released to the Environment, then the ERT will call for additional assistance from the PAFD and transfer Command to the PAFD at that time. If time permits this should be done after consulting with the PI or other responsible party and the Director, Associate Director, Fire Marshall, or other designated Command Staff members of the Health and Safety ERT.
c) A full hazard evaluation should then be conducted if time permits.
d) Under the command of the PAFD, the ERT Leader, in consultation with the Operations Staff, Command Staff, the PI or other responsible party, and others if needed, will establish the response strategy that complies with all requirements of the OSHA regulations in 29 CFR part 1910.120 and the SCCHMSO and other relevant laws and regulations.
e) The Operations Staff will then initiate the response strategy to abate the hazard accordingly. Whenever the PAFD or Police arrive, they designate an Incident Commander and establish their own ICS. The ERT Leader will then render any assistance that the Incident Commander may need.
All Hazardous Material Releases will be reported to the Health and Safety Office and recorded on an R&R. Only very small spills (less than 50 ml) of low hazard will be excepted. For any Health Threatening Hazardous Material Release to the Environment, Central Communications will be notified immediately to assist in the response and the Santa Clara County Health Department will also be notified immediately at (408) 299-6930.
Santa Clara County Hazardous Materials Storage Ordinance (SCCHMSO) (SCC Ord. NS517.31 Sec. B11-306.01): Specifies Hazardous Materials release recording and reporting requirements and that an emergency and spill response plan be developed and implemented. Chapter 6.6 of the Health and Safety Code (Safe Drinking Water and Toxic Enforcement Act): Contains requirements for the reporting of hazardous materials releases. They do not apply, however, until a particular chemical has been listed by the Governor for more than 12 months. Even then the requirements will only apply to those chemicals that are listed. Chapter 6.95 of the Health and Safety Code (Hazardous Material Release Response Plans and Inventories): Refer to spill reporting requirements. Title 19 California Administrative Code Sections 2701 et sec. California Occupational Safety and Health Administration regulations: Require reporting industrial injury as defined on OSHA form 5020. Cal/OSHA (Hazardous Materials Information and Training Act): See OSHA 29 CFR. Superfund Amendments and Reauthorization Act of Environmental Protection Agency (EPA) part 1910.1200 Title III CERCLA Amendments.: Community right to know, reporting and cleanup of releases to the environment.
Resource Conservation and Recovery Act of Environmental Protection Agency (EPA): Defines illegal disposal.OSHA 29 CFR part 1910.120: Regulates emergency response teams.Proposed OSHA 29 CFR 1910.1450: Regulates emergency response teams. OSHA 29 CFR 1910.1200: Hazard Communications Standard, emergency information and training.
CHEMICAL HAZARD COMMUNICATION POLICY
Promulgated by Dean of Research Robert L. Street, and Director of Healthand Safety Alain Decleve, 10-1-86, in a memorandum to Deans, Department Chairs and Principal Investigators.
[Information about hazards]
Various federal, state, and local regulations require employers toinform employees about certain potential hazards with which they may come into contact in the workplace. As a part of Stanford's continuing commitment to develop and implement policies and procedures consistent with these regulations, the enclosed written policy of chemical hazards communication has been established to inform individuals about hazardsin the workplace.
This policy is consistent with recent regulations promulgated by Cal/OSHA under California's Hazardous Substance and Training Act. Although the Act and the regulations address an employer's obligations to employees, you will note that the Stanford policy includes students among those who are to be informed about chemicals in their environment. Typically, students will receive this information and training as partof their academic courses. This communication policy represents only one portion of Stanford's overall program of chemical safety, which also includes the establishment of proper procedures and facilities for the acquisition, storage, use, and disposal of chemicals, and for emergency responses.
Because the safe and appropriate handling of chemicals is "situation dependent," the implementation of the overall safety program requires the active involvement of individual faculty members and staff supervisors.
[Supervisor's obligations to understand and implement this policy]
It is the responsibility of principal investigators, lab directors, supervisors, and academic administrators to become familiar with and carry out their individual duties under the attached policy, and to articipate in the implementation of the programs that EH&S is developing in support of this policy. Those duties include responsibilities to inform students, faculty and staff of the policy's provisions.
EH&S, which is responsible for coordinating the chemical hazard communication program for the University, will be working with academic departments in the development of individualized communication programs in regard to the safe use of chemicals. Please call that office (723- 0448) with any questions you may have.
[Informing students and employees of chemical hazards]
It is Stanford University policy that all faculty, staff, and students who may come into contact with hazardous chemicals either in the workplace or in labs receive information concerning the particular hazards which may be posed, and the methods by which they may deal with such material in a safe and healthful manner. Questions concerning what substances are considered to be hazardous chemicals should be directed to the Health and Safety Department. The Health and Safety Department is responsible for the development of a comprehensive chemical hazard communication program for the University as a whole, and will also be available to assist each department in promulgating an individualized chemical hazard communication program specific to that department. The following provisions are to be included in each department's program.
Departmental The principal investigators, laboratory directors and obligations supervisors are responsible for ensuring the following: Chemical * Except as described below, all hazardous labeling substances must be stored and used with the original labels provided by the vendor.Transfer of * For chemicals transferred to new containers, chemicals each new container must be labeled with the full chemical name or other identifying information, and must, in addition to the chemical identification, include a warning sign or other appropriate safety information.
Portable containers which are intended for immediate use by the employee who performs thetransfer need not be labeled according to these specifications. Good labeling practices are not only necessary for informing the users about chemical hazards-they also allow for proper disposal of these substances.
Material Safety Data Sheets (MSDS)
Material Safety Data Sheets contain information about characteristics, health hazards, and emergency response procedures for each hazardous substance. Chemical manufacturers are mandated by law to provide MSDS's to their customers. The Health and Safety Department will maintain a master set of MSDS's covering each hazardous substance received from vendors, will coordinate the requests for MSDS's to vendors, and will report to Cal/OSHA if vendors fail to supply MSDS's. Each academic and support department must maintain current MSDS's for all hazardous substances located in that department, and ensure that they are accessible to its faculty, staff and students. Copies of MSDS's not provided with the purchased chemicals should be obtained from the master set in the Health and Safety Office.
Principal investigators, laboratory directors and supervisors are responsible for informing andtraining employees and students under their direction about hazardous substances in their work areas. This information and training must be provided to employees at the time of the initial assignment to the work area, and to students within a reasonable period after enrollment in a course or lab involving the use of chemicals. Additional instruction must also be provided whenever a new potential hazard is introduced in the work area or laboratory. Yearly refresher courses are advisable thereafter. Components of The general information and training should include chemical safety the following: training program * The existence, location and availability of the written chemical hazard communication program, the department procedures to implement that program, and the faculty, staff and students' rights under the California Hazardous Substances Information and Training Act;
* an explanation of what a MSDS is, along with an explanation of the contents of the MSDS for any hazardous substance to which employees or students have the potential to be exposed;
* the location and accessibility of MSDS's for chemicals used or in storage;
* the details of the department labeling and MSDS policies and procedures;
* the location of work areas where hazardous substances are used;
* the methods for detecting and identifying a possible release of hazardous materials in the lab or workplace;
* the general health hazards and safety precautions to be taken for each class of substances used and the proper protective equipment to be used;
* the emergency procedures to be followed in case of chemical spills, fires and other incidents.
In addition to these general training and information requirements, the principal investigators, laboratory directors and supervisors are responsible for communicating specific information to their staffs and/or students as appropriate concerning safety procedures to be followed for all routine and non-routine laboratory or maintenance tasks involving hazardous materials. Employees and students are to be informed of any new information concerning potential hazards as it becomes available.
The project managers or University employees in charge of projects involving outside contractorsare also to be informed of potentially hazardous materials present at their worksites and areresponsible for communicating that information to the outside contractors. Such information shouldalso be posted outside of all work areas containing potentially hazardous materials.EH&S has various training materials to assist departments in implementing information and trainingprograms. If laboratory work involving chemicals is part of an academic course, it is theresponsibility of the instructor to include relevant safety training as part of the curriculum.
List of Hazardous Substances
Inventory The principal investigator, laboratory director and chemical supervisor are responsible for gathering and hazards maintaining an up-to-date inventory of the hazardous substances in each laboratory or work area. The Posting inventories should be posted outside each laboratory requirements or work area. Copies of these inventories should be made available to EH&S upon request.
Resources to Questions and concerns of employees or students about resolve safety in general and the chemical hazard safety-related communication program in particular should first bequestions addressed to their principal investigator, supervisor or department chairperson. In addition, EH&S(723-0448) and the Employee Relations Department (723-4433) are available as resources. Questions about this policy and its implementation should, for research and academic departments, be directed to the Office of the Dean of Research, and for other departments, to the cognizant vice president.
Back to the contents