2015 annual report department of environment, health and … · 2015 annual report department of...

2015 Annual Report

Department of Environment, Health and Safety

University of North Carolina at Chapel Hill

Welcome to the eighth annual report of the Department of

Environment, Health, and Safety. This report is our mecha-

nism for communicating the safety culture of campus and the

activities of the EHS Department. As a service organization,

the importance of communications, collaboration, and cus-

tomer service is an everyday value, which drives the safety

culture and supports the mission of the University.

As a department, we are committed to continuous improve-

ment. This means we must go from a bureaucratic culture

(heavily rule-oriented) to a generative culture (performance-

oriented & information welcomed). Our University safety

committees are instrumental in this effort. Please see pages

56 through 63 for their activities.

To ensure that we will fulfill all our regulatory requirements,

we utilize the Plan Do - Check - Act (PDCA) management

system. Why do we use a management system? It is a

framework of policies, processes, and procedures. It helps

From the Director provide the structure of how the people, the information, and

the technology are integrated while providing a mechanism

of accountability and a process of continuous improvement.

Every program we implement has these components, as well

as clear expectations of individual requirements and responsi-

bilities.

Providing a safe work environment continues to be the main

driver of our departments work and without the collabora-

tion and communication with all of the members of our cam-

pus community it would not be possible. Throughout this

report you will see specific examples that demonstrate the

diversity of our operations.

In 2015, the department unexpectedly lost a special team

member. On pages 34 and 35 you will see a tribute and cele-

bration of his life. This experience emphasizes the importance

of every day and the value each of us brings to that day.

2

From the Director Each of us has an individual responsible to increasing the

safety culture of the campus. It can be through education,

hazard recognition or by just lending a hand to a co-worker.

The employees of EHS are committed to helping every indi-

vidual on campus understand their role and responsibility

for safety.

I invite every individual to utilize the process of hazard

evaluation in all of their activities, whether personal or

work related. Approaching every task with self-awareness,

deliberateness and caution are elements of accident preven-

tion that can provide all of us with safer and healthier lives.

I hope you will take the time to review this report and learn

something new about our department. This report would

not be possible without our staffs dedication to excellence

and collaboration.

As a team, we take great pride in our accomplishments and

in contributing to the health and safety of one of the worlds

leading academic and research institutions.

We also recognize and commend our fellow Tar Heels. It is

their commitment to health and safety, their collaborative

spirit, and their pride in being part of a great University

that makes UNC-CH a safe and healthy place to teach, learn

and serve.

Mary Beth Koza, Director

Environment, Health and Safety

Who We Are

Biological Safety

Dan Eisenman

Biological Safety Officer & Manager

Erika England

Biological Safety Specialist

Kara Milton

Assistant Biological Safety Officer

Terrence Rusch

Export Control Specialist

Chemical Safety

Catherine Brennan

Assistant Director, & Chemical

Safety and Emergency Response

Officer

Jim Potts

Chemical Safety Specialist

Environmental Affairs

Mal Donohue

Manager

Ray Bond

Senior Hazardous Materials Specialist

Janet Clarke

Environmental Specialist

Roger Connor

Radioactive Materials Specialist

Larry Daw

Environmental Compliance Officer

Sharon Myers

Environmental/Stormwater

Compliance Officer

Mike Novitzky

Hazardous Materials Specialist

Frank Stillo

Environmental Specialist

Steve Parker

Hazardous Materials Manager

Administration

Mary Beth Koza

Director

Amy Butler

Dosimetry Technician

John Covely

Public Communication Specialist

Nelda Hamlett

Administrative Assistant

4

Who We Are

Fire Safety &

Emergency Response

David Guynn

Fire Marshal and Manager

Kitty Lynn

Fire Safety Professional

Emily Powell

Fire Safety Professional

Adam Swift

Fire Safety Inspector

Workplace Safety

Mary Crabtree

Manager

Debra Bergman

Workers' Compensation/

Clinical Hygienist

Tommy Simmons

Workplace Safety Field Specialist

Neah Tucker

Occupational Field Hygienist

UEOHC

James Hill MD, MPH

Medical Director

Cynthia Gamble

Occupational Health Nurse

Suzanne Carr

Nurse Practitioner

Sherice Love

Administrative Support

Associate

Pam Miner

Occupational Health Nurse

Radiation Safety

Roger Sit

Cyclotron Health Physicist

Mark Brueckner

Associate Radiation Safety Officer

Montego Fearrington

Health Physics Technician

John Grachus

Health Physics Technologist

Aaron Gunsalus

Lead Health Physics Technologist

Jonathan Moore


Mike Soles

Health Physics Technologist

Bradford Taylor


Occupational &

Environmental Hygiene

David Catalano

Field Hygienist

Kim Haley

Industrial Hygienist

Janet Phillips

Industrial Hygienist,

EHS Organization Each service section within EHS has unique and

specific management duties and responsibilities

that are determined by any number of compli-

ance requirements, state and federal regulatory

agencies, university policies, industry standards,

and a commitment to going beyond compliance,

when possible, to ensure a safe and healthy cam-

pus, community and state.

Biological Safety Biological Safety provides

guidance, assistance, and

surveillance over research

activities involving bio-

hazardous agents, recom-

binant DNA, bloodborne

pathogens, and biohazard-

ous waste management.

Biological Safety monitors

and reviews the perfor-

mance and maintenance of

laboratory containment

sy s t ems and p rov i des

technical support to EHS

incident responders.

Chemical Safety The main function of the

Chemical Safety section is to

manage the process of im-

proving safety through edu-

cation, compliance, and the

constant task of identifying

and evaluating potential

safety hazards in order to

reach the destination of a

safe research laboratory

environment. Because the

breadth and depth of UNC

research is always expand-

ing, the process of safety

improvement is ongoing and

ever-changing, providing

daily challenges to support

the research process.

Environmental Affairs The Environmental Affairs

section proactively manages

the environmental permit-

ting of the campus and en-

sures compliance with the

increasing number of per-

mits required by state and

federal agencies. The section

has responsibility for over-

sight of underground/above

ground storage tank man-

agement, air quality permits

(Title V), water quality

(NPDES) permits, surface

water quality, storm water

management, wetland is-

sues, environmental assess-

ments at inactive waste

sites, collection of radioac-

tive and hazardous materi-

als/wastes from campus,

and operation of the Hazard-

ous Materials Facility (a

fully permitted Treatment-

Storage-Disposal facility),

and the storage-for-decay

program for short-lived

radioactive wastes.

What we do 6

Fire Safety &

Emergency Response Fire safety management in-

cludes six functions: inspec-

tions, enforcement, education,

engineering, fire investiga-

tion, and response. With 438

buildings on campus and a

wide range of potential fire

safety risks, EHS personnel

are constantly checking fire

related equipment, running

test alarms, and assessing

egress risks. The section

provides student and employ-

ee fire education, so that safe-

ty becomes a collaborative

effort and a fire safety culture

becomes the norm.

Occupational &

Environmental Hygiene

OEH ensures that indoor

campus environments are

conducive to good health and

wellbeing by recognizing

evaluating and controlling

health and safety hazards,

using knowledge and experi-

ence in industrial hygiene,

asbestos management, air

and water quality and safety

engineering. OEH assesses

potential safety hazards, pos-

sible instances of exposure

and suitability of protective

equipment. Working with

facilities engineering and

facilities services personnel to

keep historical buildings

functional, while protecting

employee health, and work-

ing with planning, construc-

tion and startup of new and

renovated buildings to antici-

pate building health issues.

UEOHC The University Employee

Occupational Health Clinic

provides occupational health

care services to all part-time,

full-time, and temporary em-

ployees of the University of

North Carolina at Chapel Hill.

The UEOHC directs medical

care for all workplace inju-

ries/illnesses. The Clinic pro-

vides pre-employment screen-

ing, annual immunization

reviews, and medical surveil-

lance for healthcare and non-

healthcare workers.

Radiation Safety Radiation Safety integrates

education, oversight, compli-

ance, service and consultation

to protect students, staff, the

general public and the envi-

ronment, from the effects of

bo th i oniz ing and non -

ionizing radiation. Implicit

in all aspects of radiation

safety is security. Safety and

security are accomplished

through training, inspection,

licensing, registration and

controlled access to certain

materials.

Workplace Safety Workplace Safety provides

services in the areas of ergo-

nomics, respiratory protection,

safety training, industrial

maintenance and construction

safety, clinical safety, medical

surveillance, Workers' Com-

pensation, and the Safety

Management Information

System. The diversity of

services provided by the

Workplace Safety section

supports the Universitys

overall mission of teaching

and research for both academ-

ic and non-academic divisions.

What we do

H o w w e d o i t

With the breadth and depth of UNC research always expanding, the process of EHS compliance management is ongoing and ever

changing, requiring a robust and adaptive management system. In 2015, the department continued to utilize an integrated man-

agement system for the Universitys environment, health, and safety compliance programs. This effort was designed to ensure

continuous improvements by incorporating a process of ongoing monitoring, reviews, and revisions of procedures and policies

through the use of the Plan - Do - Check - Act (PDCA) model. Just as a circle has no end, the Plan - Do - Check - Act cycle is a

four-step process model for carrying out change, cycling through each step for continuous improvement.

PDCA Integrated Management System UNC EHS Management System

Plan Objectives

Targets

Goals

Objectives

Work plans

Program development

Do

Implementation and Operations

Training

Communications

Consultation

Outreach

Lab Safety and Hazard Management Plans

Emergency response

Check Checking

CLIP inspections

HMP inspections

Monthly reports

Annual reports

Performance reviews

Act Corrective and Preventive Actions Policy & procedure adoption

Strategic planning process

8

H o w w e d o i t

PLAN EHS Goals

Hazard Review Design Review

Lab Worker Registration Lab Safety Plan

New Regulations Training Design

ACT Safety Committees EHS Data Analysis

Incident Investigation Regulatory Impact Analysis

Responses to Regulatory Agencies

UNC CH EHS

Management System

DO Lab Surveys

Risk Assessments Hazmat Responses

Lab Waste Disposal Medical Surveillance

Environmental Permits Fact Sheets/Newsletters Service Reimbursement

& Payment

CHECK Supervisor

EHS - CLIP Self-Inspection

Grant Compliance Regulatory Inspections Lab Safety Plan Review

Chemical Inventory Reports EHS Hazard Management

Plan

The EHS organization continues to develop and implement tools and processes to proac-

tively assist the campus in the areas of regulatory compliance for biological safety, chemical safety,

radiation safety, controlled substances, export shipping controls, occupational safety, environmental permitting, fire/life safety, and emer-

gency response. Monthly reporting metrics as well as the Universitys safety committee structure support this process. A critical compo-

nent of the management system is having the staff perform compliance verification and utilize this data for planning. Understanding and

expertise in the science is essential to the development of a management compliance system.

Mission Statement The University of North Carolina at Chapel Hill Department of Environment, Health & Safety supports the University's core

mission of teaching, research, and service by providing comprehensive environmental, health, and safety services to the

University community. This includes education through training and consultation, maintaining a safe environment through

recognizing and controlling health and safety hazards, ensuring a process of regulatory compliance, and minimizing future

potential liabilities.

Mission of the Organization Provide a safe work place. Ensure a process of compliance. Minimize future potential liabilities.

Values of the EHS Organization The organization will:

Use time efficiently. Be a resource for new ideas. Connect to us relationally. Stay with us on the journey through all twists and turns. Establish state of the art safety and environmental protocols and procedures. Enable us to be all we can be.

EHS Mottos Be All You Can Be. Strive Towards Excellence.

W h y w e d o i t 10

The University will achieve and

mainta in diversi ty on the

campus through the admission

of students and employment of

faculty and staff who broadly

reflect the ways in which we

differ.

The Univers i ty promotes

intellectual growth and derives

the educational benefits of

d i v e r s i t y b y c r e a t i n g

oppor tun i t i e s fo r in t en se

dialogue and rigorous analysis

and by fostering mutually

beneficial interactions among

members of the community.

The University provides an

environment that values and

respects civility and cordiality

of discourse in order that all

m e m b e r s o f a d i v e r s e

community feel welcomed and

feel free to express their ideas

without fear of reprisal.

W h y w e d o i t

T he Univ e rs i ty o f No r th

Carolina at Chapel Hill, as an

educational inst i tut ion, is

committed to the following core

values with respect to diversity:

T he Un i v e rs i ty sup p o r t s

intellectual freedom, promotes

personal integrity and justice,

and pursues values that foster

enlightened leadership devoted

to improving the conditions of

human life in the state, the

nation, and the world.

The University believes that it

can achieve its educational,

research, and service mission

only by creating and sustaining

an env i ronment in whic h

students, faculty, and staff

represent diversity, for example,

of social backgrounds, economic

c i r c u m s t a n c e s , p e r s o n a l

characteristics, philosophical

outlooks, l i fe experiences,

p e r s p e c t i v e s , b e l i e f s ,

expectations, and aspirations, to

mention some salient factors. Core Diversity Values of the University

What They Say Biological Safety

The policies for safe conduct of dual

use research at UNC have been

implemented. All BSL-3 labs have

received in person training during

their annual BSL-3 training to

comply with the new federal policy.

Online training is available for all

researchers. The department of

Homeland Security has vetted

UNCs program. Thus, we have

done a thorough job of preparing for

dual use types of research and are

fully compliant with the spirit and

the law of the national policies that

govern this work.

P. Frederick Sparling, MD

Chair Emeritus Department of Medicine UNC School of Medicine

Chemical Safety

In preparing for the upcoming

multimillion dollar renovation of the

Mary Ellen Jones building, we were

tasked with clearing out labs and

cleaning up the spaces to establish a

sa fe construct ion s i te for the

contractor. The EHS Chemical

Safety team put in the extra effort

(and even a bit of their own elbow

grease) to make sure that the labs

were decontaminated in time for

construction to start. We really

appreciate all their hard work and

that help was just a phone call

away.

Amy E. Dean, PE LEED AP PMP Facilities Planning Structural

Engineer/Project Manager Facilities Services

Fire Safety & Emergency Response

The EHS Fire Safety group works with Hous ing and Res ident i a l Education on a regular basis to ensure the safety of students living on campus. EHS conducts fire drills in student housing four times per year, and train all Resident Assistants yearly on emergency procedures. They also train students and DHRE employees on fire extinguisher usage, while maintaining over 2000 fire extinguishers located in our buildings. Most recently, Fire Safety has begun conducting regular inspections of our housing units and mechanical spaces, helping our department correct potential safety hazards before they become an issue to students or staff.

Doug Fleming

Facilities Superintendent Building Services - Housing Support

Facilities Services


We in UNC Building Services have

been thrilled with EHSs leadership

in identifying where the various

mechanical room drains go. This

will prevent water pollution by

keeping chemicals out of our creeks

and lakes, and positively impacts

U N C s r e p u t a t i o n a s a n

e n v i ro n m e n ta l ly r e sp o n s i b l e

member of the community.

Mark Obenshain

Assistant Director HVAC Operations Facilities Services

12

What They Say Workplace Safety

EHS Workplace Safety took the

initiative to participate and has been

an invaluable member of the States

Workers Compensation Core Team.

Working with OSHR and several

state agencies supporting the

Governor and General Assembly

direction in developing a standardize

state-wide workers compensation

program that will ensure continuity

of services for injured employees

while realizing cost savings for the

state of North Carolina. OSHR and

the Governors office recognizes and

appreciate the commitment and the

expertise that EHS has brought to

the state-wide program.

John Bogner, Director

Safety, Health & Workers Compensation Division

Office of State Human Resources

Radiation Safety

During the design planning,

construction, and opening of the

new UNC Hospitals Hillsborough

Campus, Radiation Safety provided

invaluable input and guidance in

support of our radiation services. It

is a comfort to know that I can rely

on the staff to provide the necessary

design guidelines, site testing, and

licenses to ensure the safe operations

of our facilities. The staff is always

readily available and responsive to

the needs of our patients and they

are a pleasure with which to work. I

have managed UNC Hospitals

contract with EHS for 20 years and

have always found the staff to be

experienced and knowledgeable, a

dedicated team of professionals.

Cindy Taylor

Director Environment, Health & Safety/

Workers Compensation UNC Health Care

UEOHC

T h e U E O H C p r o v i d e s t h e

Universi ty with rap id medica l

a s s e s s m e n t o f o u r a c c i d e n t a l

occupational exposures, which allows

us to quickly assist the injured

e m p l o y e e , e s t a b l i s h m e d i c a l

surve i l lance an d communica te

prompt ly with our sponsoring

organizations.

Daniel Eisenman, PhD, CBSP

Biological Safety Officer & Manager UNC Environment, Health and Safety

Occupational & Environmental Hygiene

At the request of UNC Horizons,

OEH inspected their apartments for

indoor quality concerns. OEH made

serval recommendations, which

a l l o w e d t h e U N C P r o p e r t y

Management office to work with the

building management implement

corrective actions. It was a great

value to the program and we enjoyed

working with them.

Crystal Royal

Director of Operations UNC Horizons Program

Obstetrics and Gyneocology School of Medicine

2015 Performance

Intrapreneurship*

Education

Compliance

Growth

Develop clinical laboratory inspection program to identify and inspect campus clinical labs and ensure safe work environment for employees working in clinical laboratory areas.

Develop mechanical room inspection process to identify and eliminate hazards to ensure safe work environment for Facilities Services and Energy Services employees.

Work with NCDENR on development and implementation of remedial action plan for Town of Chapel Hill Old Sanitary Landfill at Carolina North.

Renew University Resource Conservation and Recovery Act Part B Operating Permit for Hazardous Materials Facility.

Renew radioactive materials licenses: UNCH Medical broad-scope and UNC academic accelerator licenses.

Develop and implement system for dual use research of concern compliance for the research community.

Develop and implement new training delivery platform for EHS on-line self-study units, the first pilot to be Respiratory N95.

Update biological use registration process and provide training across campus.

Develop/implement required training for Principal Investigators for dual use research of concern.

Implement States Hazard Hero program and actively use theme of June is Safety Month as a communication vehicle to enhance campus safety culture.

Continue to utilize customer-feedback mechanism of Collaborative Laboratory Inspection and hazardous waste programs to drive early identification of safety risks, hazards, commu-nications, training need, and improve service and customer feedback.

Develop and implement EHS cross functional team to analyze the reason(s) for generation of high hazard and unknown chemical waste from University laboratories. Develop action plan which drives education and ultimate reduction of high hazard and unknown laboratory chemical waste generation.

Finalize chemical inventory tracking process for on-line HMP program. Train and implement 5S Management Process for Environmental Affairs waste handling group pertaining to all vehicles, storage and office areas.

Continue to support move-in and commissioning of Marsico Hall. Support Mary Ellen Jones renovation project including permitting, design review and demo-lition activities.

Develop and implement on-line Permitting program for Hot Work, Confined Space, and Energized Work.

Develop comprehensive chemical fume hood alarm manual that notes types used on campus, building locations, specifications and calibration information.

Develop, identify and implement new clinical location classification mechanism in HASMIS for SOM personnel located off campus.

Conduct risk assessment of vibration exposure for campus departments to determine at-risk work tasks and monitoring needs.

*The word intrapreneurship, a relatively new word as cited in the American Heritage Dictionary, is used here instead of the word productivity because it suggests a broader and more positive concept of integrating innovative approaches into the measurable activities of change and improvement.

14

2015 Performance

Environment, Health and Safety - Division of Finance and Administration - University of North Carolina at Chapel Hill - 1120 Estes Drive Extension, Chapel Hill, NC 27599 - 919-962-5507 - ehs.unc.edu

Establish online training that instructs users of DEA controlled substances about comply-ing with government regulations for use of these substances. Support Division of Laborato-ry Animal Medicine in creation of a pharmacy on campus that supplies DEA controlled substances to animal researchers.

Intrapreneurship*

Education

Compliance

Growth

Continue to lead cross functional team to review issue of false fire alarms. Team will ana-lyze 2015 false fire alarm data, identify improvements to fire alarm process and minimize number of false alarms so Chapel Hill false alarm ordinance will not be a financial burden to the University.

Explore other complimentary clinical services/training to better manage workers compensa-tion cases. Work with Campus Health to determine if there are cost saving opportunities of moving lab and imaging services.

In collaboration with Chemical Safety and Environmental Affairs, update and integrate code into Universitys Lab Design Guidelines.

Update new immunization requirements in Medical Staff Bylaws and make necessary chang-es to HASMIS. Publish Universitys experience with varicella titers in infection control.

Prepare and implement renewal process for possession, use, and transfer of biological agents listed in 7 C.F.R. Part 331, 9 C.F.R. Part 121, and 42 C.F.R. Part 73 (select agents and toxins).

Work with Facilities Services on development and implementation of campus wide oxygen monitor program for areas that have potential for oxygen deficiency (storage of cryogenics, carbon monoxide manifold systems, etc.).

Monitor startup of the new cyclotron facility. Establish appropriate safety programs for all imaging modalities in Marsico Hall.

Review 10 CFR 37 requirements for security of radionuclides in quantities of concern, cross-walk with present program, strategize filling of gaps, if necessary.

Develop and lead cross functional team of EHS, Energy Services and Facilities Services to determine applicability of ASHRAE Standard 188P-Prevention of Legionellosis Associated with Building Water Systems.

Continue to identify ways of using HASMIS to enhance compliance and support continuous improvement. Examples include lab equipment and freezer inventories, flood incidents, mold and indoor air quality concerns.

In collaboration with University Employee Occupational Health Clinic, develop and imple-ment personal heat stress monitoring for Grounds Department.

Key Completed In Process Stopped

2016 Goals

Explore Radio Frequency Identification (RFID) tag use for chemical inventory management and compliance.

Support the UNCs Informal Contracting Process to ensure that the best-qualified, responsible, responsive contractors perform construction work on campus and build the base of contractors from which UNC selects.

Finalize the chemical inventory tracking process for the on-line HMP program across campus.

Review and make improvements to the biosafety cabinet certification program.

Bring the Research Animal Handler Questionnaire form into Hasmis to take advantage of our existing data systems/lab exposure plans and improve accuracy of reporting.

Review and publish the Universitys last four years experience of PEP for needlesticks in order to improve efficiency and reduce costs.

Develop a white paper on the applicability of the ASHRAE Standard 188P-Prevention of Legionellosis Associated with Building Water Systems and the AIHA publication Recognition, Evaluation and Control of Legionella in Build-ing Water Systems for education across campus.

Review and update the Biological Safety online training pro-grams by adding modules for HIV/SIV, Non-human pri-mates / herpes B and viral amplification.

Continue the implementation of the States Hazard Hero pro-gram across campus and actively use the theme of June is Safety Month as a communication vehicle to enhance the safety culture across campus.

Education

Continue to work with Facilities Services on development and implementation of campus wide oxygen monitor program for areas that have potential for oxygen deficiency (storage of cryogenics, carbon monoxide manifold systems, etc.).

Develop Asbestos Management Plan for buildings with asbes-tos-containing fireproofing and acoustical ceiling treatments

Continue to work with NCDENR on development and imple-mentation of remedial action plan (RAP) for the Town of Chapel Hill Old Sanitary Landfill at Carolina North.

Apply for a Manufacturing and Distribution license for BRIC's cyclotron facility.

Update the Universitys construction design guidelines for hazardous materials, (lead and asbestos) to reflect new regula-tory drivers and best practices.

Implement the clinical laboratory inspection program to en-sure a safe work environment for employees working in clini-cal laboratory areas.

Update the Universitys Title V permit to incorporate the proposed new on-campus emergency generators.

Compliance

Support the Mary Ellen Jones renovation project including permitting, design review, demolition and construction activi-ties.

Develop, identify, and implement new clinical location classifi-cation mechanism in HASMIS for SOM personnel located off campus.

Implement and distribute the updated Emergency Action Plan (EAP) form to Emergency Coordinators, track compliance and follow-up with departments on campus as needed.

16

Growth

Intrapreneurship*

2016 Goals

Education

Compliance

Renew the Universitys Reclaimed Water Permit. Continue to monitor the design and start-up of the clean room in the cyclotron facility. Establish appropriate safety programs for all imaging modalities in BRIC.

Implement the 10 CFR 37 requirements for the for the irradiator security program.

Review the Universitys Lead Based Paint Policy and update as necessary to incorporate new legislation.

Review the Universitys Biosafety program for BSL2+ lab work. Create tiers for research labs based on risk assessments.

Continue to improve the fire extinguisher program by collecting and analyzing the program data on campus fire extinguishers and encouraging high-risk departments to conduct monthly fire extinguisher inspections.

Continue the development and implementation of an on-line Permitting program for Hot Work, Confined Space, and Ener-gized Work.

Develop and implement a waste tracking report in HASMIS for radioactive waste and mixed waste for decay in storage at the Radioactive Waste Storage Building, the Liquid Waste Pouring Facility and Storage Area 7 at the TSDF Building 53.

Implement an EHS cross-functional team to analyze the reason(s) for the generation of high hazard and unknown chemical waste from University laboratories. Develop an action plan which drives education with the ultimate goal of the reduction of high hazard and unknown laboratory chemical waste generation.

In collaboration with Chemical Safety and Environmental Af-fairs, continue the process of updating the construction design guidelines to reflect new regulatory drivers and best practices.

Update the hazardous materials shipping training program in support of the Export Control program.

Recruit, train, equip, and implement a core group of Emergency Response Team members with enhanced capabilities and compe-tencies.

Lead the Universitys response to Zika Virus preparedness to manage the risks and implement activities as needed. All actions will be coordinated under the Universitys Emergency Opera-tions plan.

Growth

Intrapreneurship*

Biological Safety Chemical Safety Environmental Affairs Fire Safety and Emergency Response

Biological Safety

Department of Homeland Security Approves of UNCs Compliance

with New Federal Policy A new federal policy regulates Dual Use Research of Concern (DURC). A new UNC policy was written by the Biological Safety Officer and approved by the Institutional Biosafety Committee, the University Safety and Security Committee and the Chancellor. All high containment researchers were trained regarding the requirements of the new policy. The Institutional Review Entity was created to review projects with DURC potential. The program was reviewed by the Department of Homeland security and found to be fully compliant with the new federal policy.

Supporting UNC Collaboration with GSK / Qura Therapeutics As part of the collaboration between UNC and GlaxoSmithKline, Qura Therapeutics was formed to perform HIV research at UNC. Biological Safety served as liaisons between the GSK scientists and EHS to streamline their transition to the UNC campus. The staff participated in the planning committee to renovate various UNC labs for use by Qura Therapeutics. Requirements for Biosafety Level 2+ HIV labs at UNC were created in order to standardize and streamline the renovation of existing laboratories to meet the needs of the Qura researchers.

National Biosafety Stewardship Month

In response to recent lapses in biosafety practices at federal laboratories, the National Institutes of Health and other agencies within the Department of Health and Human Services declared October 2015 as Nation Biosafety Stewardship Month. As part of this awareness, UNCs EHS Biosafety section published an Avert newsletter to increase awareness of NIH requirements and highlight he new federal DURC policy. The Biological Safety employees staffed the EHS booth at the Graduate Student Fair and reviewed existing biosafety manuals and trainings during National Biosafety Stewardship Month.

Chemical Safety

Comprehensive Chemical Fume Hood Alarm Manual With more than 1,200 chemical fume hoods across campus, it is important to have an in-depth guide for those performing chemical fume hood alarm maintenance and calibration. This new manual notes all internal EHS processes used to track, inspect, and run reports and notes the types and brands of chemical fume hood alarms in use at the University, including detailed instructions regarding use and calibration of these alarms. A comprehensive list of the

alarms used in specific labs is also being developed.

DEA Controlled Substances Training Program Due to the complex regulations in the use of DEA Controlled Substances a comprehensive training module was developed offering much needed guidance to users, including information about how to obtain a license from the state and federal DEA offices, how to safely secure these substances, and how to properly dispose of any waste or unused product. The goal is to give campus researchers the ability to perform their work without having to decipher recondite guidelines but also to ensure that these workers understand how to safely and competently use DEA Controlled Substances.

Support for North Carolina School of Science and Mathematics EHS continues to be a resource for the science departments at the North Carolina School of Science and Mathematics (NCSSM), answering questions and performing audits on the schools chemical inventory management, chemical hygiene plan compliance, lab ventilation requirements and general safety questions. A sister school in the UNC system, NCSSM is a residential high school located in Durham serving juniors and seniors from across the state. The school focuses on science, technology, engineering and math (STEM) and the schools facilities include many laboratory areas.

18

Highlights of 2015

Biological Safety Chemical Safety Environmental Affairs Fire Safety and Emergency Response


New Title V Air Permits Environmental Affairs obtained a revised Title V Air Permit from the North Carolina Department of Environmental Quality - Air Quality to support the replacement of existing emergency generators at the Davie Hall and the New East Building and the extension of emergency backup power to the newly renovated Howell Hall.

RCRA TSD Facility Part B Permit Renewal Environmental Affairs prepared and submitted a RCRA TSD Facility Part B Permit renewal to the North Carolina Department of Environmental Quality Division of Waste Management for the operation and management of the University Hazardous Materials Facility, a ten year operating permit.

Dye Trace Testing In order to assist the HVAC shop with on-going maintenance activities, Environmental Affairs developed and implemented a program of dye trace testing for the Universitys Mechanical Room floor drains in order to determine where the drains discharge to the storm drainage system or sanitary sewer system.

Fire Safety and Emergency Response

870 new fire extinguishers To ensure that our University community is always prepared for fire, 870 new fire extinguishers were purchased to support the nearly 8,500 fire extinguishers already on campus, and, every year, these extinguishers are checked to ensure that that they are properly charged, in good working order and easily accessible.

Emergency Action Planning process Although the University maintains a campus-wide Emergency Operations Plan that is applicable to all students, faculty and staff, departments and work units are still required to provide employees emergency procedures specific to their work area. To assist departments and work units in this task, a new Emergency Action Planning process was developed. This process provides a worksheet to departments and work units to collect emergency information specific to their department. The information is then reviewed and placed into a customized Emergency Action Plan for that department or work unit, so that it is ready for use in any

emergency.

UNC Football Fire Safety When 63,000 fans come to Kenan Stadium each fall, members of the UNC Fire Safety team are also there to ensure a safe event. The Fire Marshal and one member of the Fire Safety team attend every game to perform pre-game inspections and to respond to any emergencies during the game. Additionally, in collaboration with the Chapel Hill Fire Department, a procedure for joint responses to fire alarms and fire safety issues was created to ensure that Tar Heel fans need only be concerned about the game.

Occupational & Environmental Hygiene Radiation Safety UEOHC Workplace Safety

Occupational and Environmental Hygiene

Ultrafine Particle Monitoring of 3-D Printers EHS conducted indoor environmental quality monitoring of ultrafine particle emissions from a newly installed desktop 3D printer at the School of Library Science. 3D printers produce ultrafine particles which are small enough to penetrate deep into the lungs. EHS conducted short and long-term sampling on multiple days to evaluate the emissions of the printer. The results showed that local exhaust ventilation must be used with this printer.

Carrington Hall Asbestos Abatement and Stabilization The Facilities Coordinator for the School of Nursing noticed that the asbestos acoustical treatment applied to the ceilings of the original building of Carrington Hall was delaminating causing debris on work surfaces. Efflorescence was also occurring along exterior plaster walls that contain asbestos. The building envelope has a history of moisture intrusion. EHS conducted a risk assessment and created a strategy to mitigate the hazard and worked closely with Facilities Services, the asbestos design consultant, the abatement contractor and the School of Nursing to schedule the work so that there was minimal impact to faculty and staff.

Bynum Hall Painting Project Responding to a concern about excessive paint odors and possible lead-based paint contamination associated with the renovation of the main lobby. EHS reviewed the work practices and the safety of the products used in the renovation. Modifications to the contractors work practices were implemented to minimizing the odor in the occupied areas of the building and EPA recommended cleaning practices were also initiated. Volatile organic compound levels were monitored on a daily basis to verify that the modified engineering controls were effective.

Radiation Safety

Radiation Safety Program in Good Shape The Radiation Safety unit administers eight radioactive materials licenses and about 20 x-ray registrations. These licenses and registrations are audited by the NC Radiation Protection Section on a regular basis on differing schedules. The unit hosted seven different inspections which covered licenses, registrations, and operations. The results of the inspections were that the radiation safety program was in good shape and there were few citations that were minor in nature.

Supporting UNC Cancer Hospital The Radiation Safety unit assisted in acquiring, installing, commissioning, and licensing of a new medical accelerator, the Elekta VersaHD. This cutting edge medical accelerator is the convergence of conventional radiotherapy with advanced stereotactic precision.

Implementing the Radiation Effluent Release Monitoring System The Radiation Safety Office successfully implemented the radiation effluent release monitoring system at the cyclotron facility. The very first annual report was generated documenting the radionuclide gases released from the cyclotron facility during production.

New Semester Course Offered The Radiation Safety unit added a new semester course (an elective) titled Radiation and Radiation Protection in the OEES (Occupational and Environmental Exposure Science Program) in the Environmental Sciences and Engineering Department. The inaugural class was given in Spring 2015.

20

Highlights of 2015

Occupational & Environmental Hygiene Radiation Safety UEOHC Workplace Safety

UEOHC

Fitness for Duty Evaluations Fitness for duty evaluations help determine whether an employee is able to perform his or her job duties in a safe and efficient manner. EHS and the UEOHC have fitness for duty programs in place for employees who work in high containment laboratory settings, employees in the Division of Laboratory and Animal Medicine, and the UNC Department of Public Safety.

Blood Borne Pathogen Program The Universitys blood borne pathogen program is a joint effort with Campus Health and UNC Healthcare. Efforts are ongoing to streamline the administration of post-exposure prophylaxis (PEP) medications for occupational HIV exposure. In addition, health care providers traveling internationally are now required to document the availability of PEP in their international practice setting.

Travel Services The UEOHC supports international travel for employees on University business. International locations include the University of North Carolina Project-Malawi (UNC Project) in Lilongwe, Malawi, several clinical sites in West Africa and the UNC/USFQ Galapagos Science Center located on San Cristobal Island in the Galapagos Archipelago.

Workplace Safety

Princeton Benchmarks with UNC In an effort to analyze their workplace safety efforts, Princeton University asked to review the UNC Workplace Safety program. The director and assistant director from Princetons Environmental Health and Safety department visited the UNC campus and met with the Workplace Safety manager, the Hazards Management Plan Inspection Team, the University Occupational Health Clinic staff as well as other staff. They discussed the pros and cons of programs and saw a demonstration of the Health and Safety Information Management System. The benchmarking data was utilized to identify gaps in Princetons existing program and facilitate the design of their strategic plan.

Climbing Walls EHS continues its partnership with UNC Campus Recreation, a unit in the department of Exercise and Sports Science, to enhance its internal procedures for recreational climbing walls. The two climbing walls on campus are located in Fetzer Gym C and Rams Head Recreation Center. From the novice to the expert climbing sports enthusiast, the climbing walls offer a variety of climbing terrain for University students, faculty and staff. To ensure that staffing procedures are fully understood and followed, job Safety Analysis for various tasks, staff orientation, and certification procedures for equipment were established.

Partly in response to public concerns over experiments that

might expand the host range of highly pathogenic avian influ-

enza that could easily spread to mammals, the U.S. Govern-

ment issued policies on oversight of dual use research of con-

cern (DURC) in March 2012 and September 2014. While the

first policy placed the burden of oversight for previously fund-

ed research on the NIH, the 2014 policy required federally

funded institutions to provide oversight of such research prior

to obtaining funding.

In 2015, the new federal DURC policy went into effect. In

order to ensure institutional compliance, the Biological Safety

Officer wrote a new UNC policy which was reviewed and ap-

proved by the Institutional Biosafety Committee, the Univer-

sity Safety and Security Committee and the Chancellor.

To inform the research community a special edition of the

Avert newsletter was mailed to all UNC research faculty as

part of National Biosafety Stewardship month to bring atten-

tion to the new DURC policy and to highlight the importance

of NIH training and incident reporting. NIH training and

Biological Safety

incident reporting was emphasized by the NIH after conducting

more than one hundred institutional audits over the last decade and

seeing those areas as needing improvement.

In order to ensure compliance with the new federal and UNC

DURC policies, all high containment researchers were trained on

the requirements of the new policy during their annual Biosafety

level 3 training. The Biological Safety Officer serves as the Institu-

tional Contact for Dual Use Research of Concern and a new com-

mittee, the Institutional Review Entity, was created to review pro-

jects with DURC potential. The UNC DURC oversight program

was reviewed by the Department of Homeland security and found

to be fully compliant with the new federal policy.

In response to UNCs efforts to ensure compliance with the new

federal DURC policy, Fred Sparling, MD, Emeritus Chair of Mi-

crobiology and Immunology, member of the UNC Institutional

Biosafety Committee, member of the UNC Institutional Review

Entity and Former member of the National Science Advisory

Board on Biosecurity said, we have done a thorough job of prepar-

ing for dual use types of research and are fully compliant with the

22

UNC Implements System of Oversight of Dual Use Research

Biological Safety

Photo courtesy of NIH.

Dual use research of concern (DURC) is life sciences research that, based on current understanding, can be reasonably anticipated to provide knowledge, information, products, or technologies that could be directly misapplied to pose a significant threat with broad potential consequences to public health and safety, agricultural crops and other plants, animals, the environment, materiel, or national security.

Biological Safety Performance

Performance measurement is a critical part of the EHS management system. Education, customer service and internal processes are the three most essen-

tial components of our work. The chart below indicates the performance in these areas over a five-year period with Level Four representing optimum

performance. The adjacent page shows the specific performance activities and the level of that performance for 2015.

Education Customer Service Internal Processes

2011 2012 2013 2014 2015 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015

Level 4 - - - - - - -

Level 3

-

Level 2

Level 1

Compliance

24

2 0 1 5 P e r f o r m a n c e


Trained 8,385 healthcare workers, facilities services employees, researchers, and childcare providers in bloodborne pathogens annual requirement. Conducted 279 online training in DLAM Orientation, DLAM BSL-2, and Zoonotic/Lab Animal Allergy for DLAM employees. . Trained 471 researchers and other campus personnel in proper requirement for shipping with dry ice. Trained 502 campus researchers, staff and administrators about federal and international shipping, importing and exporting regu-lations through online and in-class sessions. Trained 1042 researchers in basic principles of conducting re-search at BSL-2, such as proper technique and waste handling and trained 271 researchers in enhanced BSL-2 procedures. Trained 355 researchers, maintenance and emergency personnel in specialized biological safety, meeting regulatory requirements of the CDC and NIH for biological agent management in labora-tory environment. Trained 13 Facilities Services employees on how to respond to potentially infectious sewage spills. Trained 217 researchers and staff members on proper use of campus autoclaves through online training. Trained 177 researchers on policies about Dual Use Research of Concern through online training. Trained 177 researchers in identifying and registering projects meeting NIH Guidelines for Research Involving Recombinant DNA Molecules. Provided training to veterinarians on Biohazards, Occupational Health and Biological Safety at Biosafety Level 2 and Biosafety Level 3 as part of the Research Triangle Laboratory Animal Training Program.

Investigated 14 incidents of laboratory spills, accidents, and pro-cedural problems involving potentially infectious materials with no laboratory acquired infections resulting from incidents. Conducted 10 Institutional Animal Care and Use Committee inspections in accordance with their guidelines and regulations. Assisted Appalachian State University in developing a BSL-2 training program. Submitted 15 registration updates to CDC in reference to labora-tory operation changes. Certified 472 campus biological safety cabinets ensuring safety of product, personnel, and environmental protection. Conducted 232 on-site BSL-2 lab safety audits verifying imple-mentation of new CDC/NIH Biosafety regulations/procedures. Reviewed 54 I-123 visa applications. Met with Collaborative Cross researchers to review/address new safety concerns involving use of Collaborative Cross mice in infec-tious disease research. Collaborated with biosafety cabinet manufacturers to develop a new engineering control for mice in biosafety cabinets. Collaborated with North Carolina A & T State University to reviews SOPs and conduct functional testing on their high-containment laboratory at Kannapolis. Revised facility use agreement contracts to allow a greater range of research applications for startup companies leasing space from the University.

Established the Export Control Working Group to conduct inter-nal review of UNCs export control program. Developed various improvements to the Institutional Biosafety Committee review process including simplifying registration forms, allowing for expedited review of low risk / exempt re-search and developing a reporting function to streamline adminis-trative processes. Developed a Dual Use Research of Concern policy, establishing the Institutional Review Entity oversight committee and provid-ing in-person training to relevant groups. Created a special immunizations program for BSL-2 research. Developed design guidelines for BSL2+infectious disease labora-tories. Developed guidelines for research involving Non-Human Primate materials. Developed guidelines for cryo-preservation of biohazardous mate-rials. Participated in Biosafety Stewardship month through the distribu-tion of the Avert newsletter and staffing of EHS booth at the Graduate Student Fair.

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COMPLIANCE

When Principal Investigators and their staff move to another

on-campus location or leave the university lab safety plans

must be updated, chemical inventory must be transferred, lab

entrance signs for new spaces must be generated and posted,

and a lab closeout must be performed in the old space to ensure

the closeout meets safety guidelines. That requires timely and

extensive work by the Chemical Safety staff and in 2015 there

were a record number of moves.

This record number was due to the continuing occupancy of the

new imaging building, Marsico Hall, and the impending total

renovation of the Mary Ellen Jones building. As a result, the

Chemical Safety team performed 53 lab closeouts which is more

than three times the number of closeouts in 2014. The lab

closeout process involves an inspection and at times a lengthy

follow-up for items not properly completed. This could involve

contacting the Principal Investigator for removal of equipment,

or in some cases, having the EHS Environmental Affairs staff

remove abandoned chemicals or biological waste.

Nearly two-thirds of those 53 moves were due to the impending

closure of the Mary Ellen Jones building, an eleven story re-

search building comprised of approximately 120,000 square feet

of laboratory space. The Chemical Safety staff led an EHS in-

terdisciplinary team charged with ensuring that all lab spaces

were clear of hazards, surplus equipment properly deconned

and posted, and hazardous material signage and any remaining

biological, chemical or radiological wastes was removed. The

team worked for approximately two months, moving floor by

floor as researchers left. Several items that had been abandoned

by researchers had be deconned or properly discarded. Biologi-

cal waste had to be boxed up for incineration and chemical

waste had to be prepped for pickup by a hazardous waste ven-

dor. The team was able to clear all floors by the deadline so that

that the building renovation could move forward on schedule.

Chemical Safety 26 A Record Fifty Three Lab Closeouts

Photos depict similar renovations planned for the Mary Ellen Jones building

Chemical Safety

Chemical Safety Performance


tial components of our work. The chart below indicates the performance in these areas over a five-year period with Level Four representing optimum per-

formance. The adjacent page shows the specific performance activities and the level of that performance for 2015.


2011 2012 2013 2014 2015 2011 2012 2013 2014 2011 2012 2013 2014 2015 2015

Level 4 - - - - - - - -

Level 3

-

Level 2

Level 1

Compliance

28


Trained 2181 new laboratory employees on Laboratory Environment through online self-study.

Trained 808 employees on Formaldehyde to comply with OSHA requirements.

Trained 171 employees on Nanotechnology Safety online.

Trained 158 employees on Chemical Fume Hoods through online training.

Trained 84 employees on Compressed Gas Safety through online training.

Trained 15 UNC SPIRE summer program students Gen-eral Laboratory Safety.

Trained six Chapel Hill Fire Department shifts on EHS monitoring equipment and gave tour of Hazardous Mate-rials Facility.

Conducted chemical safety training for incoming Chemis-try department Teaching Assistants, Chemistry 550L undergraduate class and Chemistry 701 graduate class.

Utilized Principal Investigator listserv to distribute up-dates, alerts, laboratory safety news, Avert newsletter, and LCSC meeting minutes.

Updated EHS web pages and added new Safe Science webpage.

Completed a new online DEA controlled substances train-ing for researchers that utilize controlled substances on campus.

Reviewed 596 new and/or updated Laboratory Safety Plans and reviewed deficiencies with PIs and Safety Su-pervisors, ensuring compliance with the Universitys Chemical Hygiene Plan.

Uploaded 46 chemical inventories into online system and reviewed 273 annual inventory updates as part of Chemi-cal Hygiene Plan compliance.

Supported animal care and use in research regulations by participating in satellite facility, semi-annual inspections and AAALAC site visit.

Assessed potential chemical exposures by monitoring air concentrations in the breathing zones and laboratory work areas of 14 employees and made suggestions for controls to eliminate/minimize chemical health hazards.

Assessed five lab employee work environments as part of the Conceptus Protection Program.

Participated in clean-up of six chemical spills in campus laboratories.

Investigated two research laboratory accidents/incidents, evaluated root causes, and provided recommendations for modifications of work operations to prevent future inci-dents.

Generated and delivered lab entrance signs for 652 labora-tory rooms.

Assessed chemical storage compliance and safety at North Carolina School of Science and Math in Durham.

Performed 172 CLIP/Radiation/HazWaste inspections, assessing campus laboratory safety and compliance.

Reviewed all IACUC applications including reviewing and approving Chemical Hazard forms, ensuring research compliance for animal care and use.

Verified 53 lab closeouts to ensure lab spaces were clean, decontaminated and free of waste.

Inspected 1265 chemical fume hoods and submitted 111 Facilities repair requests for fume hoods.

Calibrated EHS Departmental thermo-anemometers for use in chemical fume hood face velocity checks during inspections.

Participated in EOC University tabletop exercise and campus-wide full-scale active shooter drill.

Supported DLAM in the investigation into creating a pharmacy on campus that supplies DEA controlled sub-stances.

Developed a comprehensive chemical fume hood alarm manual that notes types used on campus, building loca-tion, specifications and calibration information.

Supported the shut-down of the Mary Ellen Jones build-ing by addressing lab closeout procedures in vacated labs throughout the 11 story building.

Attended several emergency response trainings including Computer-Aided Management of Emergency Operations (CAMEO), Ebola Decontamination and AED/CPR.

2 0 1 5 P e r f o r m a n c e

COMPLIANCE

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In an effort to prevent discharges of polluted, non-storm

water into campus streams, Environmental Affairs

partnered with Facilities Services, Energy Services,

Grounds, and Athletics to investigate drainage piping in

basement mechanical rooms and other facilities that could

potentially allow polluted water to discharge improperly.

Mechanical rooms in buildings often contain heating and air

conditioning equipment which can be a source of polluted

water discharge if piping in basements discharges to the

stormwater system.

To test the plumbing drains, the team poured bright yellow-

green dye into mechanical room floor drains and then added

water to the drains. A team member stays inside with a

water hose, while other team members are outside watching

for the dye to show up in either a sanitary sewer or storm

drain pipe. The outside team opens one or more manhole

covers, looks down into the access shafts and watches as the

pipes carrying water from the building converge in the shafts. If the

brightly-colored water appears in the sanitary sewer pipes, it will

continue on to the water treatment plant along with other building

wastewater. In some of the historical buildings, the water exits the

building through the storm drains and travels through the pipes

ending up in one of the campus streams. The nontoxic dye causes

the creek to appear green for a few hours, but the dye breaks down

in sunlight and will not harm aquatic life.

If the drains connect to the storm drain system, EHS works with

the maintenance staff to capture any potential pollutants by using

drums or other collection method. Then the pipes are rerouted to

the sanitary sewer. This process can take time and money, but it

significantly improves the water quality in streams.

The Environmental Affairs team collaborating with numerous cam-

pus units fulfills the requirements of the National Pollutant Dis-

charge Elimination System, and keeps our environment healthy by

preventing pollutant discharges into our local streams.

Environmental Affairs 30

Preventing the discharge of pollutants into local streams.


Environmental Affairs Performance





2011 2012 2013 2014 2015 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015

Level 4 - - - - - - - - -

Level 3

-

Level 2

Level 1

Compliance

32


Conducted annual Medical Air Operations NPDES Storm-water Discharge Permit Storm Water Pollution Prevention Plan training for 4 RDU Airport Medical Air Operations personnel. Conducted annual Service Station NPDES Stormwater Dis-charge Permit Storm Water Pollution Prevention Plan train-ing for seven Service Station personnel. Trained 27 Grounds and Athletic department personnel on Reclaimed Wastewater Beneficial Use. Trained 710 UNC employees from Facilities, Energy Services and Public Safety including restaurant staff and managers from Carolina Dining Services, Aramark, Rizzo Center, and Carolina Inn, restaurant contractors, football stadium volun-teers and football stadium concession volunteers. Presented Integrating GIS into NPDES Monitoring at the NCDENR/WRRI Erosion and Sedimentation Control Plan-ning and Design Workshop for 130 design professionals, contractors and developers. Trained 20 people on Techniques to Help Facilities Employ-ees Understand Their Role in Environmental Compliance at the North Carolina Association of Higher Education Facilities Officers. Trained 24 UNC Emergency Responders on EHS Hazmat Response at Stormwater Outfalls. Trained 880 people from Facilities Services, Electrical Distri-bution, EHS, Construction Services, Electric Shop, Student Services (Student Union) and OWRR on handling universal waste. Trained 50 personnel from EHS and Construction Services on Hazardous Waste Management. Trained 10 EHS employees on the NPDES Stormwater Dis-charge Permit Storm Water Pollution Prevention Plan. Conducted annual RCRA HW training, OSHA HAZWOPER refresher training and TSDF Hazardous Waste Contingency Plan training for 10 EHS employees. Conducted USDOT Security Awareness Plan training for 15 EHS personnel.

Conducted 8,856 waste pickups of 44,949 kg of hazardous waste and 46,502 kg of non-hazardous solid waste from Uni-versity generators. Conducted 741 pickups of radioactive waste. Completed 31 HW manifests for transport of hazardous waste and solid waste to an offsite vendor TSDF for treatment and disposal. Shipped 104,684 kg of waste from the TSDF to an offsite vendor TSDF for treatment and disposal. Created 54 waste manifests associated with the direct ship-ment of solid and hazardous waste from UNC-CH laboratories to offsite vendor TSDFs for treatment and disposal. Shipped 29,517 kg of solid and hazardous waste directly to offsite vendor TSDFs. Shipped 1,071 mCi of radioactive waste offsite for treatment and disposal. Shipped 10,461 kg of scrap metal (ferrous and non-ferrous) offsite for reclamation and recycle. Shipped 958 regulated medical waste boxes to Stericycle for incineration. Conducted 60 sediment and erosion control inspections of NPDES permitted land disturbance project. Implemented 103 corrective actions as a result of inspection findings from NPDES Land Disturbance Permit inspections. Conducted 22 NPDES Stormwater Discharge Permit Outfall inspections.

Requested and received a revised Title V Air Permit from NCDEQ DAQ to support the replacement of an emergency generator at the University and to incorporate new operating limits for managing fuel combustion operations at the Cogen-eration Facility. Prepared and submitted a RCRA TSD Facility Permit renew-al to the NCDEQ DWM. Prepared and submitted a revised notification to manage mixed low level waste as conditionally exempt to include an additional characteristic waste, D039 to the list of EPA HW numbers managed as conditionally exempt low level mixed waste at the TSD Facility. Requested and received a revised Small Source Air Permit for the UNC-CH LFG to Energy Project landfill gas fired gener-ator; the revision amended the emissions limits for NOx and CO gases Requested and received a 404 Permit from the USACE for the Battle Grove Regenerative Stormwater Conveyance Project Assisted in implementing a program of dye testing for me-chanical room floor drains to determine where they discharge (storm drainage system or sanitary sewer system) for the HVAC group.

COMPLIANCE

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2 0 1 5 P e r f o r m a n c e


Daryle White Oct. 4, 1963 - August 31, 2015

34 In Memoriam

Here is some of the important work Daryle White did for all of us.

Managed the decay-in-storage for short lived radio-isotopes at the

University Radioactive Waste Storage facility.

Tested and monitored University radioactive waste radio-isotope decay-in-

storage pursuant to North Carolina Administrative Code.

Treated and disposed of radioactive waste including long-lived and short-

lived radio-isotopes for both dry waste and liquid waste in accordance with

NCAC regulations.

Managed the collection, storage, treatment and disposal of regulated

medical waste from University laboratory and UNC Hospital generators.

Managed the collection, storage, treatment and disposal of universal waste

from University and UNC Hospital generators.

Managed the collection, storage, treatment and disposal of mixed waste

from University and UNC Hospital generators.

Served as a member of the EHS Emergency Response Team.

For most of us, and for most of our adult lives,

we are in a work place where we go about our tasks

while working with others. And, day after day, week

after week, and, sometimes year after year, we learn

about our coworkers. We learn about their lives, their

families, their hopes and their dreams. Sometimes we

become more than co-workers, we become friends. In

the more than 5,000 days that Daryle White was with

us in that workplace, anyone and everyone who

worked with him became his friend. We liked him. We

enjoyed working with him. We all wanted to be his

friend. He was smart, kind, funny, positive, and caring,

and dedicated to the task of keeping us all healthy and

safe.

It is with great sadness that Daryle has left us. We all

miss him. But, we have those memories. Memories that

made those days, weeks, and years pleasant ones for all

of us.

Daryle contributed to our lives, but he also contributed

to the health and safety of thousands of others in those

21 years. His work made this University and this

community safer.

There is a hidden part of campus that most people never see

but is equal in square feet to about 300 basketball courts.

These hidden areas are known as mechanical rooms. They

contain almost everything a building needs to operate, elec-

trical panels for heating, air conditioning, and fire suppres-

sion systems. The campus has more than 3,000 mechanical

rooms, totaling almost 1.4 million square feet of floor space,

and University employees work in these spaces regularly to

keep our buildings functioning.

But these areas can be full of hazards: non-functional or

insufficient lighting, storage, equipment with improper

safety devices, slip and trip hazards, and other safety issues.

The most common hazard and a serious safety violation is

improper storage. Mechanical rooms can often become a

storage area for inappropriate items. To make these build-

ings safer, the Fire Safety staff developed a program to

inspect these mechanical spaces. A pilot program was creat-

ed in 2015 to conduct inspections of 237 mechanical rooms

in 17 buildings, buildings managed by Housing and Resi-

dential Education, the School of Medicine, Athletics and

Finance and Administration

With data collected during the inspections, the fire safety

section developed a new mechanical room inspection model.

Each member of the Fire Safety unit has been assigned a

zone of campus where they will conduct inspections of pub-

lic areas and mechanical rooms on a regularly scheduled

basis. This new inspection program will roll out in 2016. If

safety hazards are found during these inspections, the staff

will then work collaboratively with Facilities Services and

building occupants to correct eliminate these hazards. EHS

will also work with individual departments and shops to

prevent new safety problems from occurring.

Fire Safety and Emergency Response 36

What is Hidden Can be Hazardous.

Fire Safety and Emergency Response

For graphic purposes only. Not an actual UNC-CH mechanical room.

Fire Safety & Emergency Response Performance


tial components of our work. The chart below indicates the performance in these areas over a five-year period with Level Four representing optimum per-

formance. The adjacent page shows the specific performance activities and the level of that performance for 2015.


2011 2012 2013 2014 2015 2011 2012 2013 2014 2015 2011 2012 2013 2014

Level 4 - - - - - - - - - - - -

Level 3

- -

- - - - - -

Level 2

Level 1

Compliance

38


Provided 275 Emergency Coordinators with annual emergen-cy preparedness and fire safety training via the Safe Passag-es electronic newsletter. Held annual fire safety fair in collaboration with UNC Public Safety, Chapel Hill Fire Department, Carolina Dining Services and Orange County Emergency Services to develop on-going fire safety relationships with students and to provide hands-on training. Conducted annual fire alarm testing and drills at all campus buildings. In compliance with North Carolina Fire Code 405.2, conduct-ed after hour fire drills for all residence halls. Trained 2,200 students and staff on fire safety and fire extin-guisher use. Presented comprehensive data regarding Fire Safety annual work management duties to University Safety Security Com-mittee

Improved emergency response capability at UNC football games with the addition of a third Fire Safety staff member during football games. Initiated new permitting process for on-campus public assem-bly events, simplifying and streamlining the process for cam-pus customers and stakeholders. Inspected dining facilities with 35 bi-annual cooking hoods. Provided life safety recommendations and monitored the annual Fall Festival for safety issues. Assisted the Chapel Hill Fire Department with scheduling of on-campus high rise drills at Craige Residence Hall. Evaluated all seating plans and occupancy loads, and provided best practices for storage of combustible materials and other fire safety issues at Carolina Union. Completed fire safety and assembly occupancy evaluations for UNC General Administration to facilitate the Board of Gover-nors move to the Center for School Leadership Development. Conducted regular stakeholder meetings with campus groups to discuss the Town of Chapel Hill Fire Alarm Ordinance in order to develop ways to minimize financial impact to the University.

Began a transformation of the EHS Emergency Response Team in an effort to improve response capabilities to campus emergencies. Implemented a mechanical room inspection procedure to ensure fire safety and worker safety. Developed a new Emergency Action Plan process for campus work units and departments to improve emergency prepared-ness for all University employees. Maintained 22 Fleet vehicles including bi-annual service and permitting requirements. Provided two work-study students an opportunity to learn about fire safety and how to operate fire extinguishers, while freeing staff for other critical responsibilities. Purchased 870 fire extinguishers to replace obsolete and outdated fire extinguishers in campus buildings.

2 0 1 5 P e r f o r m a n c e

COMPLIANCE

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The UNC-CH department of Obstetrics and Gynecology de-

partment contacted EHS in 2015 out of concern for the health

of women and children who were part of their Horizons pro-

gram. The department asked EHS to inspect their apartments

for indoor quality concerns. The inspection revealed chronic

water damage, HVAC systems that needed maintenance and

badly worn carpeting.

Based on the inspections, EHS made several recommenda-

tions which allowed the UNC Property Management to work

with the building management firm to repair the water dam-

aged sections of walls and ceilings, apply a preventative

maintenance plan for the HVAC system, and develop a plan

to replace the carpeting. Through these efforts, EHS helped

the program support its women and children.


In 2014/15 UNC Horizons provided services to 236 women,

raised one million dollars to match the Oak Foundation gift

challenge, hosted their 11th annual conference, partnered

with Orange County Early Head Start and awarded a federal

partnership grant for a new child care center.

They welcomed 51 babies born to mothers attending their

prenatal clinic and assisted women with finding employment.

Fifty-three percent of Horizons graduates were employed

when they completed treatment and 13% were in school full

time and 100% of mothers and children who completed the

residential program had stable or positive Child Protective

Services outcomes. Through Horizons effort, more than

5,000 people were educated through webinars, conferences

and seminars across North Carolina and around the world.

40

Helping UNC Horizons Help Others


The one thing I like about this program is that they never give up on you. And, even if you have given up on yourself, they will say something that makes you realize that you are not alone.

Program Graduate UNC Horizons

Occupational and Environmental Hygiene Performance Performance measurement is a critical part of the EHS management system. Education, customer service and internal processes are the three most essen-




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Compliance

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Trained 676 Maintenance, Housekeeping, and Design and

Construction Services employees in asbestos awareness

through online and in-class training.

Trained 128 Maintenance and Design/Construction Services

employees on OSHA Lead-in Construction Standard through

in-class and online training.

Trained 425 employees enrolled in the Hearing Conservation

Program on Occupational Noise Safety through in-class and

online training.

Trained 19 new hires and employees with standard threshold

shifts in the Hearing Conservation Program on the proper fit

of ear plugs using the Veripro system.

Trained 242 employees from Facilities Services and Energy

Services on confined space via in-class and online training.

Trained 17 employees from Facilities Services, Energy Ser-

vices and EHS on confined space job-specific protocols.

Trained 142 employees from Facilities Services and Energy

Services on lockout/tagout through online training.

Two EHS staff attended Asbestos Inspector, Management

Planner and Designer refresher training provided by NC

OSHERC.

Two EHS staff attended Asbestos Supervisor Refresher train-

ing along with 6 Facilities Services employees arranged by

EHS and provided by AAA Environmental.

Two EHS staff attended Lead Renovator training along with

3 Facilities Services employees arranged by EHS and provided

by AAA Environmental.

Presented Why Worry about Asbestos and Hearing Con-

servation Program Overview to Facilities Services as part of

OSHA training conducted by the Safety Officer.,

Conducted 128 lead and asbestos inspections, including build-ing and material testing to support in-house maintenance and construction activity. Performed personal and area noise-monitoring assessments for Taylor Hall, Marsico Hall, Cogeneration, and the Art Lab during noise generating work activities or in response to noise concerns. Coordinated mobile hearing tests for 145 employees enrolled in the Hearing Conservation Program, saving $4000 for the tested departments. Participated in the planning, review, and implementation of 38 environmental remediation projects involving asbestos, lead, and mercury abatement. Conducted silica monitoring for the Art Lab and Masonry Shop to assess exposure during activities. Provided support to confined space program by the following: conducting atmospheric monitoring during four in-house confined space entries; reviewing contractors entry program for projects at Navy Field and Global Fed Ex; and auditing the Electric Distribution Systems entry forms. Assisted DLAM in purchasing and installing sensor for hy-drogen peroxide monitor in Genetics Cage Washing. Monitored for ultrafine particles in Makerspace hub at Kenan Science Library and Manning SILS Library during 3D print-ing. Determined ventilation requirements. Met with Art Lab to discuss monitoring for crystalline silica during classes involving the molding of pottery/ceramics. Met with Facilities Services to develop a plan to eliminate the ventilation concerns within the Art Lab. Performed 25 indoor air quality investigations within various campus buildings and responded to 17 odor complaints and recommended response actions. Responded to 8 flood events, 4 of which were black water events. Assisted Building Services in determining the extent of the water damage. Investigated 15 instances of mold contamination and recom-mended remediation protocols.

Attended EHS meeting to discuss the campus hot work pro-gram and identified action items. Assisted EHS BioSafety with containment test of equipment in BSL2 Lab in Marsico Hall. Participated in the PAT program to provide cost savings to EHS by conducting PCM asbestos analysis in-house. Provided 17 mercury and asbestos abatement design specifica-tions, including provision of a written scope of work, contrac-tor pricing and hiring of the abatement contractor and con-sultant for Facilities Services, saving $12K for Facilities Ser-vices clients. Provided mercury assessments and mercury cleanup guidance for 17 laboratory renovation projects and spill responses. Developed JSAs for the Case 580 Backhoe and Showers-n-Stuff cleaning product for residential showers for use by Facil-ities Services. Met with audiologists from the Hearing and Communication Center to discuss program and improvement opportunities. Conducted walkthroughs for UNC-TV Bryan Center and Carrboro Public Works to identify opportunities for safety improvements and exposure monitoring. Conducted 74 Hazard Management Plan inspections for Facilities Services, Energy Services and departmental shops throughout campus.

2 0 1 5 P e r f o r m a n c e

COMPLIANCE

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Supporting the Opening of a New UNC Community Hospital

In 2015, UNC Healthcare opened a new hospital at the

Hillsborough Campus, an area adjacent to Durham Tech-

nical Community College about 5 miles from downtown

Hillsborough, NC. This expansion of UNC Healthcare is a

68-bed, 265,000 square foot facility focusing on many elec-

tive surgery programs. In order to provide appropriate pro-

fessional care, this new hospital must use radioactive mate-

rials and radiation-producing machines for diagnostic pur-

poses.

Since the inception of this new facility about five years ago,

the Radiation Safety staff provided radiological engineering

oversight and input into the design of the facility. In 2015,

EHS supported the opening of the hospital by assisting in

the acquisition, installation, and licensing or registration of

14 radiation producing machines including radiography,

fluoroscopy, computed tomography, mammography, and

DEXA (Dual energy x-ray absorptiometry); as well as port-

able radiographic units and c-arms. Radiation Safety had to

Radiation Safety register each device with the NC RPS X-ray Branch prior

to their installation, conduct radiation shielding plan re-

views, acquire the FDA installation reports, conduct post-

installation radiation surveys, and submit to NC RPS X-ray

Branch for final approval.

The section also supported the opening of the hospitals

new nuclear medicine clinic which includes a hot lab, a

room for dosing the patient, a room with the gamma cam-

era, and a stress treadmill room. All existing radiological

procedures for package receipt, check-in, accounting, use,

waste production, occupational exposure, etc., had to be

replicated at the Hillsborough Campus since it is operating

under the UNCH Medical broad-scope license.

Through the specialized expertise and commitment of the

EHS Radiation Safety staff to the health and safety of our

community, UNC Healthcare continues to serve the citizens

of North Carolina.

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Radiation Safety

Photo courtesy of Summit Design and Engineering Services

Radiation Safety Performance Performance measurement is a critical part of the EHS management system. Education, customer service and internal processes are the three most essen-

tial components of our work. The chart below indicates the performance in these areas over a five-year p

2015 annual report department of environment, health and … · 2015 annual report department of...

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