Laboratory Decommissioning Policy

Supplement, expand, or consolidate these procedures, as required, to address the specific decommissioning efforts. All work areas that generate, handle, or manage biological, hazardous, or radioactive materials and/or waste adhere to the requirements stated in this policy and all related programs as indicated.

The laboratory decommissioning process begins 90 days in advance and is organized in three stages: 1.) 90 days before vacating; 2.) 30 days before vacating; and 3.) moving day. The PI notifies their department, Tulane’s Office of Environmental Health and Safety (OEHS), and any other applicable Tulane entities of any planned moves as early as possible. It is the responsibility of the PI to orchestrate the move. The PI, OEHS, and the Departmental Safety Representative (DSR) will work together to prepare a systematic plan and to set target dates to execute a safe decommissioning process. OEHS assists in the disposal of hazardous waste. If the laboratory worked with radioactive materials, OEHS’s Radiation Safety Officer participates in the decommissioning planning. If the laboratory housed biological agents, it is the responsibility of the PI to notify Tulane’s Office of Biosafety.

The PI or the department responsible for the laboratory being vacated assumes the costs associated with decommissioning the space which includes the cost of waste disposal, cleanup, and decontamination. If the PI and other laboratory personnel fail to properly decommission the laboratory as required, the department assumes the cost(s) of any fines imposed, if violations of closeout procedures are discovered by regulatory agencies. Decommissioning requirements must be met before the vacated laboratory can be re-occupied.

8.1 Responsibilities

In order to properly decommission laboratory spaces at Tulane, personnel act jointly with the OEHS. Specific responsibilities are identified for each appointment below:

8.1.1. Responsibilities of OEHS

• OEHS verifies that the space is free of hazardous materials and contamination. OEHS completes this verification in a timely manner and provides a written approval to the department (for new occupancy) or Campus Services (for space to undergo construction/renovation).
• OEHS provides instructions and guidance to PIs and their staff on all laboratory moves, closures, and decontamination, including requirements for labeling and identification of research materials.
• OEHS evaluates and provides guidance for the movement of research materials (only if the materials are moved to another location on Tulane’s campus).
• OEHS provides technical assistance and support regarding occupational health and safety matters relating to hazardous chemical waste management.
• OEHS assists in scheduling hazardous waste pickups with qualified vendors who properly dispose of waste at an offsite location in accordance with federal, state, and local regulations.

8.1.2. Responsibilities of PIs

• PIs contact OEHS 90 days (or as soon as possible) prior to vacating the laboratory. Notification is required even if only a single room is to be vacated, and even if the space is to be used by another PI.
• PIs are responsible for the safety of materials and equipment, including the safety and compliance of materials and equipment left behind in a vacated laboratory, even if the laboratory is to be used by another PI.
• PIs adhere to established health and safety procedures for safe and compliant disposal and decontamination of research materials. If these procedures are not followed, OEHS will arrange for the proper disposal and decontamination, as it deems necessary. The costs of these activities, including labor charges to properly segregate and label hazardous materials, will be charged directly to the PI. If the PI is unable to pay for these charges, costs will be assumed by the department under which the PI worked.
• PIs ensure that laboratory decommissioning is performed by staff who are knowledgeable of hazards and who are trained in all required safety disciplines.
• PIs inform OEHS prior to the shipment or movement of any hazardous materials or equipment that are transferred to another location on Tulane’s campus.
• PIs assume costs for identification of characteristics of unknown chemicals. 
•  PIs assume costs associated with disposing of abandoned, unknown, or mismanaged chemicals.
• PIs remove hazardous materials from research spaces

8.1.3. Responsibilities of Department

• The PI is responsible for the complete decommissioning of the laboratory space prior to vacating the laboratory. However, in cases where an abandoned laboratory or abandoned materials are identified, the department that the PI reported to is responsible for the decommissioning and all costs associated with the process (including the removal of all wastes) and the recertification (requires an environmental cleaning company to come in and clean all surfaces and equipment).
• The department will assume the costs of decontamination and disposal of research materials in situations where there has been a failure to meet the requirements listed in the PI Responsibilities section and those costs cannot be recovered from the PI.
• The department secures written approval from OEHS before reassigning vacated laboratory space.
• The department secures written approval from OEHS before initiating construction or renovation in vacated laboratory space.

8.1.4. Responsibilities of Campus Services

• Campus Services must ensure that vacated laboratory space is not re-occupied without prior written approval from OEHS.
• Campus Services must ensure that construction or renovation does not commence in vacated laboratory space without prior written approval from OEHS.

8.1.5. Responsibilities of Employees

• Employees complete any assigned training.
• Employees remain knowledgeable of risks associated with management of hazardous materials, associated wastes, and emergency response procedures.

8.2 Procedure

8.2.1. General Guidelines

The following are general guidelines for the PI:

• Package and move laboratory items only during normal business hours.
• Arrange for heavy equipment to be transported by a vendor or Campus Services.
• Never transport hazardous materials alone.
• Wear appropriate personal protective equipment for the material being handled.
• Remove all hazardous substances and equipment from their assigned laboratory space(s).
• Properly identify and properly dispose of all wastes and materials.

8.2.2. Decommissioning Plan

90 Days Before Vacating

The PI notifies their department, OEHS, and any other applicable Tulane entities of the PI’s plan to vacate the laboratory space. While waiting for a response from OEHS, the PI reviews the Laboratory/Studio Decommissioning Checklist (Appendix A; also see Section C below). OEHS accompanies the PI and the department’s DSR on a tour and survey of the space to be vacated. The PI, OEHS, and the DSR develop a decommissioning plan that included target dates for critical steps in the decommissioning process.

30 Days Before Vacating

The PI confirms with OEHS on the status of each item in the plan to ensure that the project is on time, to assess what has been accomplished, and to prepare for what remains to be done. The PI surveys the laboratory to ensure that no new materials have been generated during decommissioning preparations. The PI certifies that all unknown materials have been identified. If hazardous materials are transferred to another location on Tulane’s campus, the PI reviews plans for transfer with OEHS, especially highly toxic (e.g., highly reactive, or shock sensitive chemicals, toxic gases, etc.) or infectious materials. The PI procures personal protective equipment (e.g., gloves, goggles, glasses), supplies (e.g., boxes, plastic bags, containers for broken glass, spill kits), or signage needed for moving day.

Moving Day

All individuals wear the appropriate personal protective equipment for the materials being handled (safety glasses, goggles, laboratory coat, gloves, closed-toe shoes, etc.). The PI have boxes, plastic bags, containers for broken glass, spill kits, and other such supplies, ready and available. Packaging and moving laboratory items occurs during normal business hours. If the move cannot be completed within the allotted time, OEHS must be notified. 

8.2.3. Decommissioning Checklist

The PI is to complete the Laboratory/Studio Decommissioning Checklist (Appendix I). This form will be certified by OEHS upon the completion of the decommissioning process. The duties outlined in this section are the responsibility of the PI unless otherwise specifically stated

8.2.3.a. Hazardous Materials

• All chemical containers are properly and clearly labeled at all times; doing so will eliminate the cost of identifying “unknown” chemicals prior to waste disposal, one of the most costly decommissioning activities. If unknown chemicals are present, segregate them for identification.
• Keep waste streams (i.e., chemicals, radioactive materials, biologicals, sharps) separate when packaging for disposal. If there is any radioactive/biological or chemical/biological mixed waste, segregate for proper disposal according to appropriate waste disposal methods. Contact OEHS for assistance.
• Facilitate sustainability and cost savings efforts by making unopened, usable chemicals or supplies available to others in the same unit, or to other units. Remind the recipient that the chemicals received must be added to their chemical inventory and reported to OEHS as part of the annual chemicals inventory update.
• Certify that the laboratory’s chemical inventory is current. Identify those chemicals you wish to dispose, recycle, or reuse. Prepare a separate inventory of chemicals to be disposed and/or recycled and forward a copy to OEHS. Discuss disposal or recycling with OEHS during the initial decommissioning planning and as the decommissioning progresses.
• In preparing hazardous materials for transport for short or long distances, verify that the materials are placed in prescribed containers designed to prevent release and/or spillage. Labs may be allowed to move chemicals short distances (i.e. from building to building). A licensed commercial vendor will be required to transport chemicals longer distances. OEHS will not package nor assist with the movement of hazardous chemicals.
• Check shared laboratories, instrumentation rooms, under hoods, inside freezers, refrigerators, or cold rooms for remaining biological agents, chemicals, or radioisotopes.
• Consult Tulane’s policy, Management of Hazardous Waste, for proper storage, labeling, and disposal methods of hazardous waste.

8.3.2.b. Radioactive Materials

• Unused, usable radioactive materials transferred to other Tulane PIs are subject to the approval of the Radiation Safety Officer. Procedures are outlined in the Tulane’s Radiation Safety Manual.
• The Radiation Safety Officer shall make arrangements for the proper disposal of all radioactive materials that are not transferred.
•  Discuss packaging and moving of radioactive sources with OEHS during the initial decommissioning planning and as the process progresses. Radioactive sources might require shielding for safe transport. 
• Ensure that equipment has no external radiation contamination present. A radiation wipe and meter survey may need to be conducted by the Radiation Safety Officer. 

8.3.2.c. Laboratory Equipment

• Biological safety cabinets must be decontaminated with appropriate disinfectants. Once this initial decontamination is completed, contact OEHS. Cabinets must be certified by Tulane’s Office of Biosafety prior to use in the new location on Tulane’s campus. If the cabinets are to remain in the original laboratory, the cabinets are properly decontaminated before the laboratory is vacated. Contact the Office of Biosafety for assistance with the decontamination and removal of biological safety cabinets.
• Chemical fume hoods are inspected by OEHS for explosive perchlorate/nitrate crystals. If perchlorate crystals/nitrate crystals are found, the hood/ducts will need to be washed by a vendor. Contact Campus Services to schedule a vendor to wash the hoods. OEHS will retest the hood until no further contamination is observed.
• Fume hoods that will remain in the original laboratory must be appropriately cleaned/decontaminated by the PI before the laboratory is vacated.
• Old and/or broken equipment is decontaminated. The PI completes the Equipment Transfer Certification (Appendix B) and submits the form to OEHS. OEHS certifies the equipment for disposal. The PI contacts Campus Services for disposal of the equipment.
• The PI decontaminates all equipment that contains radioactive, chemical, and/or biohazardous materials before the laboratory is vacated.
• Discuss any equipment that contains hazardous materials with OEHS to ensure proper disposal of the materials prior to moving the equipment.

8.3.2.d. Biological Materials

• Defer to the Office of Biosafety for proper disposal of biological materials.
• Properly dispose of biological wastes. Autoclaving may be necessary for certain agents.
• Make available any unopened, unused, usable sharps and/or biological agents to others in the unit or to other units. Select biological agents may require special precautions. Contact the Tulane Office of Biosafety for more information.
• Appropriate shipping containers, secondary containment, biohazard labeling, and personal protective equipment must be used when transporting biological materials.

8.3.2.e. Animal Handling

Defer to Tulane’s Office of Research.

8.3.2.f. Controlled Substances/Drugs.

Registrants leaving Tulane are required to notify Louisiana Board of Pharmacy (LABP) and Drug Enforcement Agency (DEA) of the change in location. Tulane will not notify the LABP and DEA on behalf of the Registrant. Disposal of a Registrant’s current inventory of Controlled Substances on hand must be completed prior to the Registrant’s departure from Tulane. Please visit the DEA website, the State Board of Pharmacy website, and the Tulane OEHS website for more information. Review Tulane’s policy, Use Of Controlled Substances In Animal Research And Bench Research Tulane University.

8.3.2.g. Sharps

Properly dispose of all needles and syringes (used or unused) in appropriate sharps containers.

8.3.2.h. Universal Waste

Properly segregate, store, and label universal waste. Review Tulane’s policy, Management of Universal Waste.

8.3.2.i. Gas Cylinders

Compressed gas cylinders and cryogenic gas cylinders are returned to the gas distributor. Preparation for return includes removing gas connections and replacing cylinder caps.

8.3.2.j. Asbestos Containing Materials (ACM)

Material identified as ACM are disposed of through OEHS. These materials include cementitious laboratory/tabletops, woven heat protection equipment (gloves, hot pads, etc.), older laboratory fume hoods (cementitious panels inside), and ovens. Review Tulane’s Asbestos Management Policy.

8.3.2.k. General Housekeeping

• Remove all trash from the space including empty containers, papers, and disposable materials. Remove all laboratory matting, absorbents or chucks from all benches and cabinets and empty all drawers. Non-hazardous materials are disposed of as general waste.
• Remove all hazard identification signs and labels.
• Dispose of uncontaminated broken glass or unwanted glassware in a glass waste box with a clear plastic liner. Contact Facilities Services to remove the broken glass boxes.

8.3 Regulated Areas

Ensure that regulated areas are in compliance with all federal and state regulations and Tulane policies.

8.4 Compliance Methods

Ensure proper actions are taken to remain in compliance with federal, state, and local regulatory requirements as well as with the responsibilities and regulated areas identified in this policy.

8.5 Emergencies

Accidents involving hazardous or chemical wastes require immediate action to prevent fire, explosion, injury, or death. It is imperative that all personnel handling these materials be well informed and trained on the appropriate response methods.

8.5.1 Chemical Spills

Emergency response procedures identified in Standard Operating Procedures (SOPs) or Job Hazard Analyses (JHAs) are to be carefully followed. Research/departmental leaders shall prepare SOP or JHAs for each task that occurs in a work area. These site or task-specific procedures must include methods for handling accidents or spills and ensure the following have been completed:

         o Laboratory personnel are familiar with the chemical, physical, and toxicological properties of each hazardous substance in the laboratory.

         o Safety Data Sheets have been gathered and consulted prior to the initial use of the hazardous substance.

         o Laboratory personnel are always using the minimal amount of the hazardous chemical so as to minimize generation of waste.

         o Laboratory personnel are familiar with emergency response guidelines outlined in SOP or JHA.

Employees are equipped to address incidental spills of hazardous chemical wastes in small quantities, such as a 4-liter container or smaller. Larger spills may require specific materials, personal protective equipment, and special handling to protect human health.

Responsible individuals remove unnecessary personnel from the spill area and attend to injured or contaminated persons using emergency eyewash and shower.

If possible, turn off ignition sources and confine the spill to prevent spread or further contamination (upright spilled container, close doors, pull down sash of hood, etc.).

Responsible individuals standby in an uncontaminated area to provide information and assistance to emergency responders.

Always contact Tulane Police Department and OEHS for assistance with spills. All laboratory workers must be aware of this procedure.

8.5.2 Medical Emergencies

In the event of a personal injury or illness involving a hazardous chemical, consult the SOP, JHA, and/or Safety Data Sheet (SDS). If appropriate, immediately wash the exposed area for at least 15 minutes using the nearest eyewash or emergency shower. Seek assistance and obtain medical attention. If possible, provide a list of SDSs to the attending physician. Complete a First Report of Injury and submit it to Worker’s Compensation in Human Resources (See Injury/Illness Policy).

Refer to Tulane’s Needlestick & Sharp Object Injury Report in the event of an injury involving needles or sharp objects. For emergencies related to bloodborne pathogens, refer to Tulane’s Bloodborne Pathogens Exposure Control Plan.

8.6 Records

If materials (not wastes) are moved to another facility, it is the responsibility of the PI to maintain the records. Required waste records are dependent upon the type of materials that are disposed. Consult the appropriate policy to determine which records are the responsibility of Tulane and which records are the responsibility of the PI.