Presented Fumehood Awareness, Shipping Records Review, Biological Waste Management, and Surveillance and Emergency Response during a Mass Event training to CLIP team.+ Submitted 14 registration updates to the CDC in reference to laboratory operation changes.+ Trained 1580 new laboratory workers via the Laboratory Environment online self-study training module, complying with OSHA regulatory training requirements.+ Formaldehyde online training course completed by 560 employees, complying with OSHA regulatory training requirements.+ Participated in several joint training exercises at the Cogen facility as part of the One Plan compli-ance efforts.+ Conducted Reclaimed Water training for 69 employees: Athletic Department (13), Facilities Planning (43), Design Services (6), and Construction Management (7).+Trained 1,830 students, staff and faculty in proper use of fire extinguishers, using live fire and PowerPoint presentations including videos developed by students.+ Collaborated with Housing and Urban Residential Education to create a podcast for training of Resident Advisors on fire safety.+ Trained 537 Maintenance, Housekeeping, and Design and Construction Services employees in asbestos awareness.+ Presented asbestos program to 28 maintenance supervisors.+ Administered radiation safety training courses to 2228 persons; non-ionizing radiation safety training administered to 304 persons.+ Provided lectures to the Chemis-try Department‘s ―Chemical 073‖ Nuclear Chemistry class.+ Assisted the UNC Dental School in meeting CDC recommendations for infection control in dental health-care settings, adding more than 1,000 faculty and staff to the University‘s Immunization Program.+ Implemented the Clinical Occupational Exposures Subcommittee for Students, to address hazards in the teaching environment.+ Trained/Number of Employees: Respiratory Protection/1,580; EHS Office, Clinic, IMAC, SS Employee Orientation/2,147; Joint Com-mission/3,053; Clinical Tuberculosis Infection Control/4,889; Clinical Bloodborne pathogens/4868; Machine Guarding/331.+Presented ergonomic training and product assistance to UNC Kidney Center group and Dental students.+ Drafted, revised and standardized 21 standard operating procedures for containment laboratories, in order to ensure compliance across all areas of biological agent manage-ment.+ Expanded identification process within our compliance portal for DLAM personnel needing orientation, BSL-2, Zoonotic and Lab Animal Allergy training.+ Hazardous Waste Management online refresher training completed by 725 employees aiding compliance with EPA and NCDENR regulations.+ Nanotechnology Safety training completed by 64 employees.+ Sponsored a ―Plant a Rain Garden‖ at Kenan Stadium for Earth Week, with native plants suitable for rain garden conditions.+ Presented program on cross-connection mapping and methodology at a GIS Users group meeting.+ Created a microwave Safe-T-sensor magnet poster for the top of all student residence microwaves, in order to reduce microwave misuse.+ Held annual fire safety fair in collaboration with UNC Public Safety and Chapel Hill Fire Department.+ Trained 65 Maintenance and Design/Construction Services employees on OSHA Lead-in Construction Standard.+ Trained 209 Grounds, Public Safety, Chilled Water, Cogeneration, DLAM and Facilities Services‘ employees on hearing conservation.+ Provided two training sessions in CBRNE Standardized Awareness (radiological) to more than 40 members of the UNC Hospital Police Department.+ Hosted 10 students studying nuclear medicine technology for two-week rotations through radiation safety.+ Provided UNC Housekeeping with assistance in determining proper fit for backpack vacuums.+ Provided medical clearance for the University‘s Respiratory Protection, Hazwopper, Hearing Conservation, DLAM, TEACCH, and Asbestos program meeting federal and state require-

Environment, Health and Safety

University of North Carolina

ments for a medical surveillance program.+ Provided training on the Ergontron Sit-To-Stand seed units.+ Trained 39 Athletics Football video employees and Energy Services Chilled Water employees on scissor lift safety.+ Updated Ventilated Enclosure form to make col-lection of campus fume hood data more robust.+ Instituted a BSL2 inspection process throughout the division of Lab Animal Medicine (DLAM) to increase safety and compliance.+ Presented program at the annual CSHEMA conference titled ―Traditional RCRA or Subpart K – UNC-CH‘s Foray into the Waste Management Weeds.‖ Parallel manuscript submitted to the Journal of Chemical Safety (ACS) was accepted for publication.+ Presented program at the 2011 Water and Health Conference on the ―Regulatory Challenges of Utilizing Re-claimed Water.‖+Conducted over 20 Life Safety Meetings with a variety of UNC personnel, focusing on fire hazards, egress and evacua-tion protocol.+ Participated in the development and implementation of a confined space drill with Energy Services, South Orange County Fire and Rescue, Chapel Hill Fire Department, UNC Public Safety and EHS.+ Trained 68 Facilities Services, HMP Team, and Energy Services‘ employees on confined space.+ Trained 41 Facilities Services, Energy Services and EHS employees on confined space air moni-toring protocols.+ Coordinated training sessions with hospital CT/radiography equipment for NC-RPS x-ray branch personnel utilizing new radiation survey equipment.+ Supported the NC Science Teachers workshop by staffing an information booth giving away 35 radia-tion detectors and Understanding Radiation Resource Kits and presented a program on the use of radioactive materials in our society.+ Served 3,539 patients for the medical surveillance or workers‘ compensation program.+ Provided more than 6,200 flu vaccinations to UNC students and employees through a collaborative effort with Campus Health Services.+ Developed an ergonomic on-line self-assessment for laboratory researchers assisting with CAP accreditation.+ Developed on-line scaffolding training for Facilities Services and other users.+ Updated biological waste policy to include new Drosophila discard technique and implementation of plastic sharps containers.+ Updated the EHS Shipping webpage to reflect changes in Federal and International regulations.+ Trained 12 HHMI schol-ars and 15 UNC PREP students starting the summer program on the topic of general laboratory safety.+ Trained 15 housekeepers about chemical containers and how items should be marked for trash disposal.+ Staffed a stormwater education table at UNC‘s Sustainability Day event.+ Provided training on good housekeeping and pollution prevention practices to Carolina Inn engineering and managerial staff. Provided ThermoFisher TruDefender instrumental-specific training for the HazMat Team.+ Created and posted evacuation maps in the Smith Center to assist EHS and Life Safety staff in the event of a need for mass evacuation.+ Trained DLAM 51 employees on lockout/tagout requirements.+ Presented a program on HazMat – SPOTS to the local Environmental Information Association confer-ence in Myrtle Beach, South Carolina.+ Hosted Remote Monitoring Station webinar for Public Safety, UNCH Police, and Facilities Ser-vices‘ employees, regarding GTRI‘s irradiator security system.+ Provided the UNC-CH x-ray equipment operator-training module to the Philadelphia Veteran‘s Administration Medical Center for their use.+ Provided first care and medical management for the workers‘ com-pensation program, ensuring that University employees have immediate access to high quality, effective health care.+ Provided Fitness for Duty evaluations for UNC Public Safety as part of the CALEA accreditation program.+ Seventy -six on-line ergonomic self-evaluations were completed by the University community.+ Crossed trained seven EHS staff to participate in the Hazards Management Inspection Program.+ Worked with the Histology Core and LabCorp to determine and acquire proper packaging for large-scale study that requires North Carolina clinics to ship patient samples to UNC.+ Worked with CF/Pulmonary Research Group and UNC Purchas-ing to improve their shipping processes.+ Utilized Principal Investigator listserv to quickly distribute laboratory safety news, updates, and alerts on laboratory electrical safety and PPE, and other.+Created and distributed a new laboratory specific newsletter (Avert), to support educational efforts of principal investigators.+Provided training to approximately 40 Carolina Inn staff members on restaurant good housekeeping and stormwater pollution prevention best practices.+ Provided stormwater awareness training for 10 people from the office of Waste Reduction and Management, Athletics, Town of Chapel Hill, and catering contractors.+ Provided fire safety consultations for two Haunted Houses and Playmakers‘ Ball events.+ Provided fire watches at 28 Athletic events at Smith Center and Kenan Stadium.+ Presented a program on HazMat – SPOTS for Cornell University personnel interested in the SPOTS application.+ Attended Scaffold Competent Person Training, provided by Facilities Services.+ Taught a three-week module on Radiation and Environmental Radioactiv-

2011 Annual Report

3

Welcome to the Department of Environment, Health and

Safety annual report. This report is an important component

of the department’s integrated management system. It pro-vides a review of the accomplishments of the department and

serves as the introduction of the department’s 2012 goals.

This report also recognizes key individuals on our campus. Without their

time, effort, and dedication to health and safety, the goals of the depart-

ment in making the University a safe and healthy place would not be

achievable.

The theme of this year‘s report is Collaboration, Communications, and Customer Service. Collaborating with our internal and external stake-

holders is how we accomplish our job. Communications is the process of

sharing our knowledge and services and getting the important feedback.

Customer service is our value to faculty and staff in helping them meet

their compliance requirements. These three themes are the building

blocks of a culture of safety, the mechanism of continuous improvement

and the path to compliance.

We added a new section to the report this year: Goals and Accomplish-

ments of our working EHS health and safety committees. These commit-

tees are integral to the University as they deal with issues of governance,

policy and direction and are the cornerstone of the culture of safety.

Mary Beth Koza Director

From the Director 2011 has been an extremely busy year working with difficult budget and

regulatory challenges, but it was an extremely successful year as high-

lighted throughout this report. These successes would not have been pos-

sible without the collaboration of the 37,000-member campus community.

Our work touches every member of that community—from Athletics to

Zoology research and nearly every unit in between.

Two events of this year emphasis the importance of the University‘s com-mitment to safety and the importance of creating an accountable EHS cul-

ture. One is a celebration of our efforts; the other is a reminder of the im-

portance of organizational accountability.

In May of 2011, the North Carolina Department of Labor recognized the

University for its outstanding safety and health efforts with a Certificate ehs.unc.edu

of Safety Achievement-First Year Gold Award. This indeed was an

2About the covers: The front and back covers contain only a partial listing of the work activities by the EHS staff in 2011.

https://ehs.unc.edu

2

From the Director

accomplishment and an important rec-

ognition of our promotion of safe work

practices.

In October 2011, the US Chemical

Safety and Hazard Investigation Board

issued a report: ―The Texas Tech Uni-versity Laboratory Explosion.‖ This was the first time the board had investi-

gated an academic lab incident and

stated: ―[…] it is greatly concerned about the frequency of academic inci-

dents in the United States.‖ This report, as well as other laboratory incidents,

resulted in a review of our hazard

evaluation, oversight of laboratory

safety and organizational accountability.

This annual report is just one part of

that process and continues as our goal in

2012. As a leading research university,

we are also participating nationally in

this effort.

Overall, 2011 was a good year for the

Department of Environment, Health and

Safety at the University of North Caro-

lina at Chapel Hill. I hope you will take

the time to review this report and learn

something new about our department.

It would not be possible without the

dedication and commitment to excel-

lence of our EHS staff. As a team, we

take great pride in our accomplishments

and pride in contributing to the health

and safety of one of the world‘s 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 all of our

lives better.

W h o W e A r e

W h at W e D o The 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 Uni-

versity community. This includes education through

training and consultation, maintaining a safe environ-

ment through recognizing and controlling health and

safety hazards, ensuring a process of regulatory com-

pliance, and minimizing future potential liabilities.

Our mission is to ensure a process of compliance,

minimize future potential liabilities, and provide a

safe and healthy place to teach, learn and serve.

3

Responsibilities

5

EHS Functions & Communication - Collaboration - Customer Service = The Path to Compliance

Each service section within EHS has unique and

specific management duties and responsibilities

that are determined by any number of compliance

requirements, state and federal regulatory agen-

cies, university policies, industry standards, and a

commitment to going beyond compliance, when

possible, to ensure a safe and healthy campus,

community and state.

Chemical Safety

The main function of the Chemical Safety section is to

manage the process of improving safety through edu-

cation, compliance, and the constant task of identify-

ing and evaluating potential safety hazards in order to

reach the destination of a safe research laboratory en-

vironment. Because the breadth and depth of UNC

research is always expanding, the process of safety

improvement is ongoing and ever-changing, providing

daily challenges to support the research process.

Biological Safety

In 2008, UNC recognized the Biological Safety section

as a separate support division within the EHS Depart-

ment. Biological Safety provides guidance, assistance,

and surveillance over research activities involving bio-

hazardous agents, recombinant DNA, bloodborne

pathogens, and biohazardous waste management. Bio-

logical Safety monitors and reviews the performance

and maintenance of laboratory containment systems

and provides technical support to EHS incident re-

sponders.

Environmental Affairs

The Environmental Affairs section was created in

1994 to proactively manage the environmental permit-

ting of the campus and to ensure compliance with the

increasing number of permits required by state and

federal agencies. The section has responsibility for

oversight of underground/above ground storage tank

management, air quality permits (Title V), water qual-

ity (NPDES) permits, surface water quality, storm

water management, wetland issues, environmental

assessments at inactive waste sites, collection of radio-

active and hazardous materials/wastes from campus,

and operation of the Hazardous Materials Facility (a

fully permitted Treatment-Storage-Disposal facility),

and the storage-for-decay program for short-lived ra-

dioactive wastes.

4

EHS Functions &

4

Responsibilities Communication - Collaboration - Customer Service = The Path to Compliance

Fire Safety

and Emergency Response

Fire safety management includes six functions: inspec-

tions, enforcement, education, engineering, fire inves-

tigation, and response. With 438 buildings on campus

and a wide range of potential fire safety risks, EHS

personnel are constantly checking fire related equip-

ment, running test alarms, and assessing egress risks.

The section provides as much student and employee

fire education as possible, so that fire safety becomes a

collaborative effort and a fire safety culture becomes

the norm.

Radiation Safety

Radiation Safety integrates education, oversight,

compliance, service and consultation to protect the

students, staff, faculty, members of the general public

and the environment from the effects of both ionizing

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 materi-

als. These are designed to support—not impede— academic research.

Occupational

and Environmental Hygiene

OEH is responsible for ensuring that indoor campus

environments are conducive to good health and well-

being by recognizing evaluating and controlling health

and safety hazards, using knowledge and experience in

industrial hygiene, asbestos management, air and wa-

ter quality and safety engineering. The section as-

sesses potential safety hazards, possible instances of

exposure and suitability of protective equipment.

OEH works with facilities engineering and facilities

services personnel to find ways to keep historical

buildings functional, while protecting employee health,

and works with planning, construction and startup of

new and renovated buildings to anticipate and elimi-

nate building related health issues.

Workplace Safety

Workplace Safety provides services in the areas of

ergonomics, respiratory protection, safety training,

industrial maintenance and construction safety, clini-

cal safety, medical surveillance, Workers' Compensa-

tion, and the Safety Management Information Sys-

tem. The diversity of services provided by the

Workplace Safety section supports the University‘s overall mission of teaching and research for both

academic and non-academic divisions.

5

PDCA

Integrated

Management

System

UNC EHS

Management System

DoImplementation

and Operations

Training

Communications

Consultation

Outreach

Lab Safety and Hazard Man-

agement Plans

Emergency response

Check Checking

CLIP inspections

HMP inspections

Monthly reports

Annual reports

Performance reviews

7

EHS makes implementation of the UNC Academic Plan possible by providing regulatory

compliance in the areas of biological safety, chemical safety, controlled substances, envi-

ronmental permitting, export shipping controls, fire/life safety, emergency response, oc-

cupational hygiene, radiation safety and workplace safety.

University of North Carolina at Chapel Hill EHS Management System

With the breadth and depth of UNC research always expanding, the process of EHS com-

pliance management is ongoing and ever changing, requiring a robust and adaptive man-

agement system. In 2011, the department continued its emphasis on an integrated man-

agement system for the University‘s environment, health, and safety compliance

PDCA

Integrated

Management

System

UNC EHS

Management System

Plan

Act

Objectives

Targets

Corrective and

Preventive Actions

Goals

Objectives

Work plans

Program development

Policy & procedure adoption

Strategic planning process

Communication - Collaboration - Customer Service = The Path to Compliance

Environment, Health and Safety - 1120 Estes Drive Extension, Chapel Hill, NC 27599 - 919-962-5507 - ehs.unc.edu 6

https://ehs.unc.edu

PDCA

Integrated

Management

System

UNC EHS

Management System

PlanObjectives

Targets

Goals

Objectives

Work plans

Program development

ActCorrective and

Preventive Actions

Policy & procedure adoption

Strategic planning process

6

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.

Setting goals for the department is an important part of this management system. It trans-

lates purpose into action and drives continuous improvement. The goals are consistent with

our mission of providing a safe place, ensuring a process of compliance and minimizing fu-

ture liability.

PDCA

Integrated

Management

System

UNC EHS

Management System

Training

Communications

Consultation

Outreach

Lab Safety and Hazard Man-

agement Plans

Emergency response

CLIP inspections

HMP inspections

Monthly reports

Annual reports

Performance reviews

Implementation

Do and Operations

Checking Check

Communication - Collaboration - Customer Service = The Path to Compliance

Environment, Health and Safety - 1120 Estes Drive Extension, Chapel Hill, NC 27599 - 919-962-5507 - ehs.unc.edu 7

https://ehs.unc.edu

Performance

9

2011 Goals & Product iv i ty

Continue collaborating with Facilities Services to proac-tively address indoor air quality concerns, expansion of the SPOTS program and management of the containment

12

Complete and document analysis of the applicability of the new EPA Subpart K, to the Resource Conservation and Recovery Act (RCRA) hazardous waste generator regula-tory requirements in Part 262. This alternative set of regulations is applicable to colleges and universities pro-viding the flexibility to make hazardous waste determina-tions in the laboratory, at an on-site central accumulation area, or at an on-site treatment, storage, or disposal facil-ity (TSDF).

√

Apply for laboratory certification of airborne asbestos analysis to support the asbestos abatement projects by streamlining the process and improving timing of sam-pling results.

√

Continue systematic review of all occupational injuries of the last three years for re-evaluation and implementation of new metrics ensuring proper EHS programming and identify work areas that need additional support.

12

Implement University Employee Occupational Health Clinic scheduling system, streamlining process for both internal and external users while improving clinic man-agement efficiencies.

√

Implement SharePoint for documentation management √ Continue reviewing the EHS website to identify required updates for compliance, increase ease of navigation and provide a customer feedback mechanism for training and EHS services.

►

Expand the EHS Hazards Management Program (HMP) to be a cross functional team, increasing its effectiveness and realizing synergies within the department.

√

Develop and implement a Biological Safety Level 2 In-spection checklist process for consistency in laboratory set -up and inspection in the Division of Laboratory Animal Medicine.

√

Implement the use of QuietDose in-ear noise dosimeters in departments enrolled in the Hearing Conservation Program to provide daily feedback on whether employees are properly wearing their hearing protection to prevent hearing loss.

►

Continue activities of EHS team supporting the activities of Division of Laboratory Animal Medicine. Team will continue to identify EHS opportunities for regulatory compliance, while preparing for the University‘s 2011 AALAC accreditation inspection.

√

Tra in ing

Plan and coordinate a live confined space rescue exercise with South Orange Rescue, Energy Services, and Facilities Services.

√

Coordinate training for the Department of Public Safety and UNC Healthcare dispatch personnel to use, operate, and respond to the Remote Monitoring Systems to meet enhanced security requirements for radionuclides in quan-tities of concern.

►

Develop and implement the EHS Compliance Portal pro-viding instant real-time data regarding medical surveil-lance and training compliance to the employee, their su-pervisor, and their Human Resource Facilitator.

√

Prepare an on-line and instructional Aerial Work Platform (AWP) training program for the campus community by evaluating the use of campus scaffolding systems and implementing an on-line training program assuring proper assembly and use.

►

Expand Fire Safety training by focusing on annual Fire Safety Fair and fire extinguisher training, providing a consistent message to the many diverse groups that live/ work on campus.

√

Key to Performance Chart

Accomplished: √

In Process: ►

Moved to 2012: 12

8

2011 Goals &

8

Performance Compl iance

Continue providing technical and permitting expertise for all environmental, biological, and ecological facets of the Carolina North project. In 2011,this includes the 401-water quality certification, environmental impact assessments and adding UNC-CH as a co-permittee on RDU Authority‘s stormwater permit to support the relocation of Medical Air Operations to RDU.

►

Support the construction and compliance activities of the wastewater treatment system at the Bingham Fa-cility.

►

Increase regulatory compliance with Homeland Secu-rity requirements for radioactive materials such as enhanced security hardware upgrades, new irradiator facilities, National Source Tracking System ―NSTS,‖ and increase scrutiny on training and documentation per10CRF 35. Partner with Department of Homeland Security‘s Global Threat Reduction Initiative to en-hance security to three additional facilities containing radionuclides in quantities of concern.

►

Implement a University Formaldehyde Exposure Plan p e r t h e O S H A f o r m a l d e h y d e s t a n d a r d (29CFR1910.1048), including specific policies for iden-tification of employees that use formaldehyde, training, monitoring, and medical surveillance.

√

Continue expansion efforts to detect and eliminate illicit connections to the stormwater system, com-mencement of education and inspection programs for food service facilities on campus, use of GIS to identify all locations where the sanitary sewer and stormwater system cross and inspect all inlets within a 50 foot radius of these crossings for potential sewer leaks in support of the UNC Stormwater permit.

√

Re-evaluate and implement process improvements to the University Employee Occupational Health Clinic Needlestick program.

►

Support the compliance requirements of training, and update of the Cogeneration facility‘s One Plan with Energy Services.

√

Support the compliance requirements of training, and update of the Cogeneration facility‘s One Plan with Energy Services.

√

Develop and submit the required information to renew the UNC-CH Title V air permit for the campus, which expires on 9/30/2011.

√

Work with Energy Services to develop an air permit-ting strategy incorporating new requirements pertain-ing to modeling, the boiler MCAT standard and en-

12

Growth

Continue providing technical, educational and regula-tory support to joint Energy Services-EHS projects including reclaimed water conjunctive use at athletic fields and the NC Botanical Garden, the investigation and mapping of UNC stormwater infrastructure, and Stormwater Master Plan-related elements.

√

Supporting and permitting the design, acquisition, and installation of new MRI research facilities at UNC. This consists of two facilities: modification of a current building (MRI) and design and building of a new building (IRB).

►

Supporting and permitting the design, acquisition, and installation of the new Cyclotron research facilities at UNC. This consists of two facilities: GMB enclosure and new IRB building.

►

Support the growth of the Kannapolis Site, and con-tinue to provide technical expertise in the design, op-eration, testing and commissioning of the limited ac-cess lab.

►

Complete Phase II update of the online Lab Safety Plan to improve campus wide compliance and reduce number of manual paper-based and standalone comput-erized processes required to achieve OSHA and NIH compliance.

√

Provide technical and regulatory support to key En-ergy Services initiatives such as the Alternative En-ergy and Climate Action teams.

√

Implement the University Travel Immunization pro-gram and advertise services to the campus community. √ Provide technical support, compliance assistance, and training for evolving Environmental Affairs initiatives in erosion and sedimentation control for construction/ renovation projects.

√

Provide technical support in the areas of radiation safety and hazardous waste management to the design of the UNC-Healthcare System Hillsborough hospital.

√

9

11

2012 Goals Intrapreneurship* Education

Utilize the Collaborative Laboratory Inspection Program

(CLIP) results to drive early identification of safety risks

and hazard prevention, communications and training

across the University. Implement a customer feedback

mechanism.

Continue to develop, implement, and upgrade job specific

online training programs such as Lockout/Tag-out Re-

quirements and Confined Space Entry.

Continue to improve and more broadly disseminate EHS

information via newsletters, special alerts and other com-

munication vehicles to raise awareness of laboratory

safety and the importance of PPE.

Expand and implement the limited access lab checklist to

assist inspectors in early identification of safety risks and

to increase regulatory compliance.

Continue to develop a strategy in collaboration with Fa-

cilities Services to expand air-handling unit cleaning to

improve energy savings as well as enhance indoor air

quality.

Complete training for Department of Public Safety per-

sonnel to use, operate, and respond to the Remote Moni-

toring Systems to meet enhanced security requirements

for radionuclides in quantities of concern.

Work with the Office of Waste Reduction & Recycling

(OWRR) to increase lab recycling by identifying new

items for recycling and disseminating proper procedures

to campus researchers.

Complete ABT Biomarker Generator User training by

vendor, including radionuclide production, chemistry,

QA/QC, and pre-clinical research applications.

Expand the Hazards Management Program (HMP) to

include an on-line HMP web application with an inven-

tory tracking process.

Expand the use of the EHS website by improving naviga-

tion, search functions and new applications.

Work closely with Public Safety to assure the University

is prepared for an emergency such as a hazardous materi-

als release and confined space incident by identifying and

implementing training exercises with local emergency

response agencies.

Evaluate and implement upgrades to the Hearing Conver-

sation program to reduce costs to the affected departments

and improve audiometric testing data management result-

ing in reduced incidents of progressive hearing loss for

affected personnel. Plan and coordinate six limited access drills with local

emergency response agencies.Utilization of the Qualitative Risk Assessment tool for evaluation of MSDSs and work activities in Facilities Ser-vices. Development of a sampling plan that validates this approach with supporting publication.

Develop and implement an online chemical fume hood

training to emphasize proper use and safe operating pro-

cedures for researchers who utilize chemical fume hoods

in their laboratories. Develop metrics for the hazardous waste /materials man-agement system to improve service and customer feed-back. Implement the roll out of the EHS compliance portal to

provide all supervisors and employees with the current

knowledge of their training status. Identification and creation of an EHS GIS users group to

develop EHS tools which support compliance.

*Intrapreneurship the practice of a corporate management style that

integrates [. . .] innovative approaches, as well as the reward and motivational techniques that are more traditionally thought of as being the province of entre-preneurship. —American Heritage Dictionary

10

http://en.wikipedia.org/wiki/Entrepreneurshiphttp://en.wikipedia.org/wiki/Entrepreneurship

10

Compliance Growth

Support the construction and compliance activities of the

wastewater treatment system at the Bingham Facility.

Continue to provide technical expertise for all environ-

mental, biological, and ecological facets and permitting of

the Carolina North project.

Support licensing, design, acquisition, and installation of

new IRB building and research equipment, including a

cyclotron, new MRI and NMR devices, and an irradiator.

Implement the second round of GTRI funded security

enhancements to irradiators to meet the requirements of

NRC and DHS regulations. The grant for this effort to-

taled approximately $143,000 for both UNC and UNCH.

Develop strategic plan to review and implement new re-

quirements promulgated in NRC regulation 10 CFR Part Support the Biology Department in creating and imple-

37. These are new requirements to increase administra- menting standard operating procedures for the new

tive processes to ensure robust security clearance for per- Physical Science Building greenhouse in compliance with

sonnel and robust operational testing of security systems. NIH guidelines.

Implement improvements to the X-Ray safety program

to meet expectations of the NC DENR RPS X-ray

branch, regulatory requirements.

Support the growth of the Kannapolis Site and continue

to provide technical expertise in the design, operation,

testing and commissioning of the limited access lab.

Establish comprehensive radiation safety program for

ABT Biomarker Generator facility to establish core re-

search program within Biomedical Research Imaging

Center).

Review and enhance the OSHA Bloodborne Pathogens

program compliance through collaboration with UNCH

LMS system and EHS and the implementation of the

EHS compliance portal.

Implement process improvements to the University Em-

ployee Occupational Health Clinic Needle Stick program.

Assure compliance in the areas of hot works permitting,

lockout/tagout requirements, grinding and welding ac-

tivities and confined space requirements. Update Lead

Paint policy/program to reflect new EPA regulations for

housing and child occupied facilities.

Work with Facilities Services on the development and

implementation of a campus wide oxygen monitor pro-

gram for areas that have potential for oxygen deficiency

(storage of cryogenics, carbon monoxide manifold sys-

tems, etc).

Receipt and implementation of the Phase II campus-wide

stormwater permit for the campus.

Implementation of the Registered Environmental Con-

sultant (REC) program at Cogeneration facility.

Develop an air permitting strategy which incorporates

the new requirements pertaining to modeling, the boiler

MCAT standard and energy generators on campus.

In partnership with Facilities Services and Energy Ser-

vices, develop a mechanical room inspection process to

identify and eliminate hazards.

11

13

In 2011, a change to the I-129 petition—the first step of the temporary work visa process for foreign scholars— required EHS to collaborate with International Student and Scholar Services (ISSS), University Counsel, and the Office of Spon-sored Research to develop a comprehensive internal review strategy to address the increased requirements for sponsoring visas of foreign scholars.

Before a foreign scholar can apply for their temporary work visa to the United

States, UNC must first submit an I-129 petition to U.S. Customs and Immigration

Services (USCIS) to obtain permission to sponsor the scholar. The I-129 form

requests information about the prospective employee and the job for which they

are being hired. In 2011, the I-129 petition was changed to include a deemed ex-

port attestation. This attestation requires the University to state whether or not

the visa applicant will require a deemed export license for their work.

Deemed export licenses are required for access to, or release of, information per-

taining to technology having military or dual use (civilian and military) applica-

tions. While strictly military technology is rare at the University, dual use tech-

nology is common in any research setting. The addition of the deemed export

attestation requires that each work visa applicant must be evaluated for his/her

potential access to these controlled technologies and the University must defini-

tively state whether a deemed export license is required for the applicant. EHS

built upon existing relationships with various campus departments that manage

export compliance at UNC to establish a review process that minimized the added

Biological Safety reporting requirements for the visa applicant and their department. This review

process involved collecting information about the visa applicant, their work envi-

ronment and the specific projects in which they will be involved to determine if a

deemed export license would be required. n 2011, 139 I-129 petitions were re-

viewed for the deemed export attestation. Through collaboration with ISSS, Uni-

versity Counsel, the Office of Sponsored Research and the departments hosting

international scholars, EHS was able to address the increased compliance require-

ment of the I-129 petition while minimizing the added burden on all affected par-

ties.

12

Biological Safety

12

W h o W e A r e

W h at W e D o In 2008, UNC recognized the Biological Safety sec-

tion as a separate support division within the EHS

Department. Biological Safety provides guidance,

assistance, and surveillance over research activities

involving biohazardous agents, recombinant DNA,

bloodborne pathogens, and biohazardous waste man-

agement. Biological Safety monitors and reviews the

performance and maintenance of laboratory contain-

ment systems and provides technical support to EHS

incident responders.

A n d W h a t T h e y S a y ―International Student and Scholar Services in col-laboration with the Department of Environment,

Health & Safety has created an efficient and quick

process to comply with a deemed export attestation

required when petitioning for work authorization on

behalf of non-immigrant employees.‖

Debbie Rad, International Student & Scholar Advisor

Ronit Weingarden, Assistant Director &

Advisor to Foreign Academic Staff,

International Student & Scholar Services

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15

Retrieved priceless 19th Century Recordings

The Biosafety staff worked with UNC Counsel to clear priceless 19th century recordings through U.S. Customs. The Southern Folk Life Collection in Wilson Library sent 19th century wax recording cylin-ders to Germany for refurbishment and transcription to modern for-mats. On their way back to the United States, they were stuck in customs and then returned to Germany. EHS worked with the Uni-versity Counsel to get these returned to the United States.

Successful Unannounced Shipping Inspection

The Department of Transportation conducted an unannounced in-spection of UNC shipping procedures. No shipping violations were found. An agent from DOT-Pipeline and Hazardous Materials Safety Administration (PHMSA) conducted the unannounced inspec-tion of infectious substance shipping procedures, selecting one lab at random and inspecting their packing materials and shipping records.

New DLAM Zoonotic/Lab Animal

Allergy Orientation training

The staff collaborated with DLAM staff to develop and facilitate DLAM Orientation, DLAM BSL-2, and Zoonotic/Lab Animal Al-lergy trainings for 140 staff members, researchers and personnel providing guidance to those individuals who work with laboratory research animals and potentially infectious materials.

Presented Overview of

Export Controls for Research

At the spring New PI Orientation event, the Biosafety staff assisted in training at the bi-annual Tar Heel Certificate in Research Admini-stration training. The Center for Faculty Excellence has a series of half-day orientations throughout the year with two each year dedi-cated to new principle investigators. Speakers from several depart-ments share information that pertain to new PI‘s at this orientation.

Added an Export Control chapter to the

Responsible Conduct of Research Brochure.

The Responsible Conduct of Research brochure issued by the UNC Research Compliance program was revised in 2011. In addition to revising the existing document, an Export Control chapter was added.

Deborah Howard:

Biological Safety Manager

Constance Birden:

Biological Safety Specialist

Kara Milton:

Assistant Biological Safety Officer

Penny Padgett:

Associate Biological Safety Officer

Dan Vick:

Export Control Specialist

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14

P e r f o r m a n c e L e v e l A s s e s s m e n t 2008 2009 2010 2008 2009 2010 2008 2009 2010

- - - - Level 4 Level 4 - - -

- Level 3 Level 3 Level 3 - - Level 3

Level 2 - Level 2

Level 1

Education Customer Service Internal Processes

Trained 867 researchers in basic principles of research at BSL-2, such as proper tech-nique and waste handling and 201 re-searchers in enhanced BSL-2 procedures.

Trained 5,494 Housekeeping staff, Facili-ties Services personnel, researchers, and Child Care providers in Bloodborne Patho-gens and Exposure Control programs.

Trained 107 researchers in identifying and registering projects meeting NIH Guide-lines for Research Involving Recombinant DNA Molecules.

Trained 567 researchers, maintenance and emergency personnel in specialized bio-logical safety, meeting regulatory require-ments of the CDC and NIH.

Trained 159 Facilities Services personnel in responding to potentially infectious sewage spills.

With Facilities Services, developed and implemented a training program on sys-tem descriptions to aid in understanding of building systems.

Presented program at North Carolina Association for Biomedical Research con-ference on IBC‘s and Role of Community.

Collaborated with ECU‘s Director of Re-search Compliance to present a seminar on Export Controls at the NC Society of Re-search Administrators‘ annual conference.

Posted a dry ice shipping training module increasing shipping compliance and easing training burden on lab personnel; Trained 52 researchers and campus personnel.

Trained 15 UNC researchers at the Dur-ham Health Department and Rex Health-care on shipping infectious samples.

Trained 159 researchers and staff members on proper use of campus autoclaves via online training module.

Trained 353 campus researchers, staff and administrators in federal and international shipping, importing and exporting regula-tions via classroom and online programs.

Certified 401 biological safety cabinets, ensuring safety of product, personnel, and environmental protection.

Tested 767 fume hoods and initiated 121 maintenance requests to correct variances, ensuring workers are adequately protected from hazardous chemicals.

Conducted 240 on-site BSL-2 lab safety audits to verify implementation of new CDC/NIH Biosafety regulations and pro-cedures.

Provided direct assistance for 212 ship-ments of equipment, samples, and research materials.

Investigated four incidents of laboratory spills, accidents and procedural problems involving potentially infectious materials, resulting in changes to work processes.

Conducted 13 Institutional Animal Care and Use Committee inspections in accor-dance with their guidelines and regula-tions.

Assisted the University of Virginia and Appalachian State University with export control and shipping requirements.

Worked closely with the Department of Commerce‘s Bureau of Industry Security to classify purified Dengue Virus proteins for export to Israel.

Applied for and received three USDA Im-port Permits, three CDC Import Permits and one DOC Export License.

Collaborated with UNCH on strategies for transferring tissue samples from the hospi-tal to UNC labs via vehicles.

Provided an overview of shipping and ex-port regulations to the Vice Dean of the School of Pharmacy.

Pr e s e n t e d ‘ F u m e h o o d A w a r e n e s s , ‗Shipping Records Review,‘ Biological Waste Management‘ and ‗Surveillance and Emergency Response during a Mass Event‘ trainings to CLIP team.

Submitted 14 registration updates to the CDC in reference to laboratory operation changes.

Drafted, revised and standardized 21 stan-dard operating procedures for containment laboratories in order to ensure compliance across all areas of biological agent man-agement.

Expanded identification process within our compliance portal for DLAM personnel needing orientation, BSL-2, Zoonotic and Lab Animal Allergy training.

Updated Ventilated Enclosure form to make collection of campus fume hood data more robust.

Instituted a BSL2 inspection process throughout the division of Lab Animal Medicine (DLAM) to increase safety and compliance.

Updated biological waste policy to include new Drosophila discard technique and implementation of plastic sharps contain-ers.

Updated the EHS Shipping webpage to reflect changes in Federal and Interna-tional regulations.

Worked with the Histology Core and Lab-Corp to determine and acquire proper packaging for large-scale study that re-quires North Carolina clinics to ship pa-tient samples to UNC.

Worked with CF/Pulmonary Research Group and UNC Purchasing to improve their shipping processes.

Created a comprehensive export documen-tation process for the Fiscus lab to allevi-ate import problems for collaborations in Brazil and South Africa.

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COMPLIANCE 15

17

Collaboration, communication, and customer service are re-ferred to as the building blocks of a safety culture, mecha-nisms of continuous improvement and the path to compli-ance. These 3cs were the guiding principals in the creation of new communication devices, more data analysis, prepara-tion for an accreditation visit and training for a potential chemical spill event.

One of the most significant events in the history of university lab safety occurred

in 2011 with the release of a major report on academic lab research safety by the

U.S. Chemical Safety Board (CSB). For the very first time, the CSB investigated a

university lab accident. The explosion in a chemistry lab at Texas Tech Univer-

sity severely injured a graduate student and the report noted that there have been

at least 120 known university lab accidents since 2001. The report strongly urged

university research communities to make a better effort in safety communications

and to strongly promote the wearing of proper personal protective equipment. To

support the report‘s recommendations, the Chemical Safety staff created and dis-tributed a new Personal Protective Equipment (PPE) Fact Sheet and a Laboratory

Electrical Safety alert to the Principal Investigators and Safety Supervisors. The

staff also created and distributed a new newsletter: Avert. The first edition focused

on procedures for working with hazardous drugs and highlighted Tamoxifen, a

hazardous drug commonly used in research labs.

The newsletter also gave an overview of 2010‘s lab injuries and incidents high-lighting the most common injuries (cuts/punctures) and the most common inci-

dents (chemical spills). The newsletter was designed so that some of the informa-

tion could be used at safety meetings and the reverse side could be hung in labora-

Chemical Safety tories as a poster. The section also began the development of a comprehensive lab

safety survey and hazardous waste poster to be rolled out in 2012.

Collaboration and customer service also played a major role in guiding the activi-

ties as the staff collaborated with others on a DLAM team to assist the Division of

Lab Animal Medicine in preparing for a site visit by the accrediting agency;

trained other EHS emergency response team members on the proper use of the

Emergency Response Guidebook and trained EHS inspectors to look for machin-

ery that would pose a threat to users.

Building a vibrant safety culture is often not accomplished by instituting any one

major idea or process. It is done by instituting many seemingly small and incre-

mental ideas or processes in the areas of collaboration, communication and cus-

tomer service. In 2011, the Chemical Safety section was busier than ever before,

instituting many improvements on a positive path to compliance and the health

and safety of our campus community.

16

Chemical Safety

16

Who We Are

What We Do With more than 500 laboratories on campus,

UNC is one of the world‘s leading research institutions. The Chemical Safety section man-

ages the process of improving lab safety through

education, compliance, and the constant task of

identifying and evaluating potential safety haz-

ards in order to reach the destination of a safe

research laboratory environment. On average,

EHS conducts more than 1,000 lab inspections

every year and checks 150 separate safety issues.

A n d W h a t T h e y S a y ―The Division of Laboratory Animal Medicine (DLAM) is very appreciative of all the assistance that EHS Chemical

Safety has provided to us over the past year. When we needed

updated strategies, they collaborated with us to develop a new

SOP for handling soiled bedding contaminated with chemical

hazards and create a new room sign to help make identifica-

tion easier. They continue to work with us to ensure our staff

and the researchers at this University are properly trained.‖

Kenneth R. Muller, B.A., RLATG

Training Coordinator

Division of Laboratory Animal Medicine

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19

Weapons of Mass Destruction

Training for EHS Emergency Responders

Training in 2011 included ―Weapons of Mass Destruction Radiologi-cal/Nuclear HazMat Technician‖ offered by the Department of Homeland Security. Additionally, the Chemical Safety section staff trained other EHS Emergency Response team members on the use of the Emergency Response Guidebook and coordinated training for a new FTIR instrument that will aid the team in identifying unknowns from a chemical spill.

DLAM Team” Helped Prepare for the AAALAC Visit

In 2011, the University‘s animal research program underwent ac-creditation and the internal EHS ―DLAM Team‖ helped prepare for the AAALAC visit. The team also addressed any health and safety issues found during the inspection process. As a result of the staff assisting with this inspection event, the animal research program received full accreditation.

Database Change Improves

Formaldehyde Training Compliance

To better track the compliance of researchers using formaldehyde, tie-ins to the research animal protocol system to the EHS internal database enabled the Chemical Safety staff to run reports on non-compliance. The addition of formaldehyde compliance information to the lab safety plan training compliance page, helps principal inves-tigators and safety supervisors ensure that employees who need for-maldehyde training, have completed the training. At the end of the year, 80% of users were compliant in their training—a substantial increase from the roughly 30% who were compliant before these measures were implemented.

New Section on Machinery

Use Added to Lab Safety Plan

The death of an undergraduate student at Yale University in a Chemistry department shop from a machinery accident was an unfor-tunate event, but it alerted all in the academic research community to review their labs safety measures for machinery use. At UNC, a new section of the lab safety plan was implemented that identifies the types of machinery in individual labs and the safety measures taken. Additionally, the CLIP inspectors were trained to be aware of ma-chinery safety issues during inspections and flagging them in the EHS internal database so that training and safety measures are in place.

Catherine Brennan:

Chemical Hygiene Officer

Michael Long:

Associate Chemical Hygiene Officer

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18

P e r f o r m a n c e L e v e l A s s e s s m e n t 2008 2009 2010 2008 2009 2010 2008 2009 2010

- Level 4 - - - - -

Level 3 Level 3 - Level 3 Level 3 - Level 3 Level 3

Level 2 Level 2

Education Customer Service Internal Processes

Trained 1580 new laboratory workers via the Laboratory Environment online self-study training module, complying with OSHA regulatory training requirements.

Formaldehyde online training course com-pleted by 560 employees, complying with OSHA regulatory training requirements.

Hazardous Waste Management online refresher training completed by 725 em-ployees aiding compliance with EPA and NCDENR regulations.

Nanotechnology Safety training completed by 64 employees.

Trained 12 HHMI scholars and 15 UNC PREP students starting the summer pro-gram on the topic of general laboratory safety.

Trained 15 housekeepers about chemical containers and how items should be marked for trash disposal.

Utilized Principal Investigator listserv to quickly distribute laboratory safety news, updates, and alerts on laboratory electrical safety and PPE, and other.

Created and distributed a new laboratory specific newsletter (Avert), to support educational efforts of principal investiga-tors.

Updated EHS web pages with personal protective equipment and reproductive hazards information.

Trained hospital security force about chemical weapons of mass destruction, as part of Department of Homeland Security training course.

Assisted in coordinating and participated in Graduate Student Orientation Fair, informing new laboratory researchers about EHS services and policies.

Reviewed 466 new and/or updated Labo-ratory Safety Plans and reviewed deficien-cies with PI‘s and Safety Supervisors, en-suring compliance with the University‘s Chemical Hygiene Plan.

Supported regulations on animal care and use by participating in semi-annual inspec-tions of satellite facility.

Assessed potential chemical exposures by monitoring air concentrations in four em-ployee-breathing zones and four laboratory work areas, and made suggestions for con-trols to eliminate/minimize chemical health hazards.

Supported animal care and use research by monitoring vaporizers with waste gas scavengers in animal surgeries.

Participated in clean up of nine chemical spills in campus laboratories.

Investigated nine research laboratory acci-dents/incidents, evaluated root causes, and provided recommendations for modifica-tions of work operations to prevent future incidents.

Coordinated with DLAM on new SOP-Handling Chemical Hazards, ensuring husbandry staff and researchers follow safe operating procedures when hazardous chemicals are used in animals.

Reviewed more than 300 IACUC applica-tions, including reviewing and approving Chemical Hazard forms, ensuring research compliance for animal care and use.

Performed more than 90 CLIP inspections, assessing campus laboratory safety and compliance.

Worked with OACU and DLAM to sub-mit letter to AAALAC for upcoming site visit and University accreditation.

Met with Waste Industries, OWRR and EHS Biosafety section regarding switching from metal cans to red sharps containers.

Initiated ventilation shutdown protocol (signage and walkthrough) for installation of chemical fume hoods on second floor of GMRB.

Added Machinery section to online lab safety plan.

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COMPLIANCE 19

ffairs

21

Against a backdrop of sweeping new federal air regulations, the Environmental Affairs unit worked closely with Energy Services and an air pollution consultant to obtain permits for critical new life safety equipment in near record time— facilitating growth while protecting air quality.

Recently completed renovations at Kenan Stadium included the addition of new life

safety equipment, specifically, a fire pump and emergency generator to be utilized

in the event of a catastrophic fire. The Environmental Affairs staff, working with

an air quality expert, was charged with the responsibility to ensure that this equip-

ment was properly permitted in time for the opening kick-off of the 2011 football

season. However, the revision of the University‘s Title V air permit was not a sim-ple or routine undertaking. Major changes in federal air pollution regulations were

enacted by USEPA in 2010. These new regulations resulted in significantly ex-

panded stringent limitations for nitrogen dioxide (NO2) and sulfur dioxide (SO2)

emissions from large sources. The ever-tightening federal emissions limits in-

creased the difficulty of permitting new sources (like the Kenan emergency genera-

tor and fire pump), and contributed to growing uncertainty between USEPA and

state regulatory agencies about how the new regulations would be administered

and enforced. Moreover, the North Carolina Division of Air Quality (DAQ) re-

quired UNC to perform detailed air emissions modeling associated with any pro-

posed permit revisions. Because of the tightened regulatory limitations on emis-

sions, the modeling effort proved to be particularly challenging.

Title V operating permits administered by state regulatory agencies and the

USEPA regulate large sources of criteria air pollutants such as NO2, SO2, hazard-

ous air pollutants, mercury, and particulate matter. UNC has a Title V permit for

Environmental A the Cogeneration facility and Manning Drive steam plant. Smaller air emissions

sources such as smaller boilers, hot water heaters, and the University‘s 86 emer-gency generators now must also be listed on the permit as the result changes im-

plemented by DAQ. Thus, UNC needed to strike a balance between needed

growth (i.e. the addition of critical new equipment) and maintaining its longstand-

ing commitment to environmental stewardship.

Environmental Affairs, Energy Services, and the air quality consultant developed a

novel strategy that enabled the University to permit the new equipment based

upon the results of air emissions modeling of the proposed new sources. Working

with DAQ, the modeling demonstrated that the new sources would not contribute

to any exceedance of the new SO2 and NO2 national ambient air quality standards.

This proactive stance fostered greater cooperation with DAQ and helped pave the

way for the permit application to be reviewed and approved within 2 months—a

pace well ahead of the typical six-month timeframe for a Title V renewal.

20

Environmental A

20

W h o W e A r e

W h a t W e D o The Environmental Affairs section was created in 1994 to

proactively manage the environmental permitting of the

campus and to ensure compliance with the increasing

number of permits required by state and federal agencies.

The section has responsibility for oversight of under-

ground/above ground storage tanks, air and water quality

permits, surface water quality, storm water management,

wetland issues, environmental assessments at inactive

waste sites, collection of radioactive and hazardous mate-

rials/wastes and operation of the Hazardous Materials

Facility and the storage-for-decay program for short-lived

radioactive wastes.

ffairs

A n d W h a t T h e y ―Energy Services works closely with the Environmental Affairs section of EHS to help ensure that our complex plants are com-

plying with an ever-changing regulatory landscape and meeting

our compliance goals. A perfect example is the recent renewal of

the University's Title V air permit. EHS coordinated with plant

personnel, University Counsel, our consultants, as well as NC

Division of Air Quality personnel to accomplish the renewal in

near record time. Environmental Affairs staff is responsive to

our needs, knowledgeable, professional, and a pleasure to work

with.‖

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S a y

Phil Barnar Interim Director, Energy Services

Cogeneration Systems Manager

23

New Pole Camera Enables

Rapid Detection of Illicit Discharges

EHS and Energy Services jointly purchased a pole camera in 2011 to enable more facile and rapid detection of illicit discharges as well as cracks and/or breaks in the stormwater system piping. Under the University‘s illicit discharges program, piping outfalls are in-spected under dry weather conditions and if flows are detected (e.g. often from broken or damaged overlying or nearby sanitary sewer lines), investigations of potential sources are conducted.

Non-potable Water

for Athletic Field Irrigation

In 2011, UNC began using non-potable water for both athletic field irrigation and for toilet flushing. Non-potable water consists of both reclaimed wastewater and stormwater collected in large cis-terns. Several departments, including Energy Services, EHS, Fa-cilities Services, and OWASA worked jointly to obtain and imple-ment the necessary non-potable water permits from the North Carolina Department of Environment and Natural Resources.

Electronic System for Management

of Hazardous and Aqueous Radioactive

Wastestreams

Over the past 7 years, the Environmental Affairs staff in collabora-tion with Information Technology Services (ITS) has been devel-oping and expanding an electronic system for the management of hazardous and aqueous radioactive wastestreams generated by the University‘s more than 500 teaching and research laboratories. The e-510 process for hazardous waste and e-102 process for aqueous radioactive waste provide a more robust management system for these wastestreams, improving the tracking of these materials from the lab to EHS storage and ultimately to final disposal. In 2011, major enhancements to the e-510 system included the addition of YES/NO check boxes for ―formaldehyde,‖ ―to be recycled,‖ and ―universal waste.‖

Potential Alternative Fuels

for the Cogeneration Facility

EHS staff worked closely with Energy Services and outside con-sultants on a variety of projects in 2011 related to potential alter-native fuels to be combusted at the 32 megawatt Cogeneration fa-cility. Major highlights included an assessment of alternative fuels such as residual derived fuels (RDF), in conjunction with coal and wood in the Gogen boilers.

Daniel Elliott:

Environmental Affairs 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

Daryle White:

Senior Radioactive Materials Specialist

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22

P e r f o r m a n c e L e v e l A s s e s s m e n t 2008 2009 2010 2008 2009 2010 2008 2009 2010

- - - - Level 4 - - -

Level 3 Level 3 - Level 3 Level 3 - - Level 3

Level 2 Level 2 Level 2

Education Customer Service Internal Processes

Participated in several joint training exer-cises at the Cogen facility as part of the One Plan compliance efforts.

Conducted Reclaimed Water training for 69 employees: Athletic Department (13), Facilities Planning (43), Design Services (6), and Construction Management (7).

Sponsored a ―Plant a Rain Garden‖ at Kenan Stadium for Earth Week, with na-tive plants suitable for rain garden condi-tions.

Presented program on cross-connection mapping and methodology at a GIS Users group meeting.

P r e s e n t ed p r og r am a t t he a n n ua l CSHEMA conference titled ―Traditional RCRA or Subpart K – UNC-CH‘s Foray into the Waste Management Weeds.‖ Parallel manuscript submitted to the Jour-nal of Chemical Health and Safety was accepted for publication.

Presented program at the 2011 Water and Health Conference on the ―Regulatory Challenges of Utilizing Reclaimed Water.‖

Staffed a stormwater education table at UNC‘s Sustainability Day event.

Provided training on good housekeeping and pollution prevention practices to Caro-lina Inn engineering and managerial staff.

Provided training to approximately 40 Carolina Inn staff members on restaurant good housekeeping and stormwater pollu-tion prevention best practices.

Provided stormwater awareness training for 10 people from the office of Waste Re-duction and Management, Athletics, Town of Chapel Hill, and catering contractors.

Conducted 4,947 pick-ups of hazardous and non-hazardous wastes.

Conducted 1,212 pick-ups of radioactive wastes.

Collected 90,041 kg of RCRA hazardous and non-hazardous waste and 42,667 kg of RCRA hazardous waste.

Processed 19 shipments of hazardous and mixed waste totaling 79,720 kg.

Processed 24 shipments to TSDFs, total-ing 29,429 kg of hazardous waste.

Recycled 12,565 kg of spent fluorescent light tubes.

Recycled 13,881 kg of lead, non-PCB bal-lasts, and other metals.

Reclaimed 1,377,000 gallons of water at Kenan Stadium in one month.

Performed 121 stormwater outfall inspec-tions to identify potential illicit discharges, including physical inspection of the out-fall and development of documentation.

Assisted the Archaeology department in constructing a sediments settling basin at Carolina North as a sediment control measure protecting nearby surface water outfall(s).

Facilitated renewal of the University‘s Title V air permit by NC DENR‘s Division of Air Quality to include three new emer-gency generators.

Obtained a provisional Large Quantity Generator ID number to support the abatement of lead debris and non-friable asbestos during renovation of the Finley Course Pro Shop and closed out the ID number with EPA.

Prepared two stormwater permit renewal applications on behalf of the Institute of Marine Sciences in Morehead City and submitted DWQ.

Utilized a new pole camera to quickly lo-cate a leaking OWASA sewer line, saving 6–9 hours of UNC employee time over previous investigation methods.

Collaborated with Energy Services person-nel on installation of reclaimed water sign-age at all toilets and urinals in the new NC Botanical Gardens Visitor Education Cen-ter.

In conjunction with UNC Information Technology department, upgraded the online e-510 waste disposal process im-proving tracking of hazardous versus uni-versal waste requests.

Provided oversight and compliance of the University remediation projects covering underground tank removal and source area treatment of saturated soils and ground-water.

Worked with personnel at Horace Wil-liams airport to repair piping in contain-ment sump and to facilitate final hydro-static testing of repaired systems.

Conducted erosion and sedimentation con-trol compliance inspections at various projects: Duct Bank, Finley Golf Course, Dental School and Hospital Parking Ser-vices Building.

Working with OWASA, successfully in-vestigated sewage leak entering Bell Tower outfall and verified repairs.

Submitted Phase 1 Stormwater Manage-ment Plan for Carolina North to DWQ: the final requirement for 401 Water Qual-ity Certification request.

Submitted Phase II Stormwater Permit Renewal to DWQ.

Worked with the Town of Chapel Hill and their consultant regarding ongoing inves-tigations at old bus garage and removed hydraulic oil-impacted soils.

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rgency response

Between 2009 and 2012, the Fire Safety section received two FEMA grants for a grand total of $440,086. These unique grants enabled the department to put fire safety sensor de-vices on more than 1,000 electric stoves and 315 microwaves 36 UNC residence halls and 88 apartment units, reducing the risk and cost of false fire alarms.

The FEMA Fire Prevention and Safety Award was the work of an EHS Fire

Safety Officer who maintains on-going contact with FEMA to watch for funding

opportunities. She recognized the opportunity to provide an extra margin of safety

to more than 19,134 students and families in UNC residence halls by installing

various stovetop safety devices through a grant.

The Safe-T-element stovetop safety device and the microwave Safe-T-sensor have

reduced many of the 800 or more fire calls that the Chapel Hill Fire Department

(CHFD) makes to campus every year. Reducing unnecessary fire calls saves the

Town of Chapel Hill more than $800 per call, an estimated annual cost to the tax-

payers of more than $600,000. Additionally, every false alarm run that the CHFD

does not have to make, keeps fire personnel and their equipment ready and avail-

able for a real fire, while removing the risk to the firefighters of unnecessary expo-

sure responding to false fire alarms.

In addition to installing Safe-T-sensor microwave devices in residence halls, EHS

created a magnetic poster to sit on top of the microwave to detail proper use of the

sensor and provide important safe cooking tips. Fire Safety also produced a series

Fire Safety & Eme of podcasts that reenacted the four most problematic alarm activations in resident

halls: unattended stove and microwave cooking; shower steam, and hairspray acti-

vations.

While the overall goal of the program was to eliminate dangerous kitchen fires

and reduce unnecessary fire alarm activations, EHS also saw an opportunity to let

students participate in their own fire safety education by recruiting students to

create and act in fire safety training podcasts. The funding from FEMA also en-

abled the department to purchase video cameras for future training programs and

podcasts, obtain a five year supply of safety brochures and poster magnets and pro-

vide fire safety training for 42,000 students over a five year period using bro-

chures, posters and videos.

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Fire Safety & Eme

Who We Are

What We Do Fire safety management includes six functions:

inspections, enforcement, education, engineering,

fire investigation, and response. With 438 build-

ings 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 as much student and employee fire edu-

cation as possible, so that fire safety becomes a

collaborative effort and a fire safety culture be-

comes the norm.

rgency response

A n d W h a t T h e y S a y

―The Fire Safety section staff perform an annual fire watch at all Kenan football games to ensure personnel and visitor safety, and

the continuity of all of our football games. Every football event

has 105 ball players, 300 employees and contractors, and up to

62,000 people on a sell- out day including our concessions employ-

ees, Show-Pros, First aid medics, ushers, and all of the athletic

personnel. Even during regular business hours, the Fire Safety

team protects us by keeping our facility safe and well maintained.

We appreciate our relationship with EHS Fire Safety staff and

hope to continue to gain valuable training opportunities in the

future.‖ James Spurling Director of Kenan Stadium/Football Facility

UNC Athletics-Kenan Football

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27

Completion of Fire Safety

Devices in All Residence Halls

Fire Safety completed the final installation of the Safe-T-elements and Safety Sensor with another FEMA grant of $219,068. This fund-ing provided Safe-T-elements for 1000 electric stoves and Safe-T-sensors for more than 300 microwaves in student and family hous-ing. (See full story on page 24)

Fire Safety Supports the

Hazards Management Plans

Fire Safety Supports the Hazards Management Plans (HMP) pro-gram with two inspectors. This program inspects small shop units on campus for proper chemical and fuel storage, medical surveillance, required training, and writes a report to the work unit to summarize results and explain any deviations from University, State, and Fed-eral Regulations. The inspector also goes over any PPE require-ments for the work unit.

Developing Evacuation Egress Maps

Fire Safety continues the assistance to University departments in developing evacuation egress maps. These egress maps are placed in hallways and corridors to help people get out of the building in an emergency, showing all exits and the shortest path to those exits.

New Fire Safety Video for Podcasting

Fire Safety implemented a custom video project and turned it into a pod cast on the EHS main webpage. The video incorporated actual fire events on campus with student actors and provided them with a working knowledge of fire safety. The video seeks to improve safety eliminating false alarms from shower steam, stove cooking dangers, and unattended microwave cooking. A local professional cinematog-rapher provided guidance to create a one-of-a-kind video and pod-cast.

New Bar Code System for Tracking

and Inspecting 5,000 Fire Extinguishers

The Fire Safety section inspects more than 5,000 fire extinguishers both on campus and in other remote UNC buildings. In 2011, EHS obtained a state of the art bar-code tracking system. The process to attach these bar codes to more than 5,000 extinguishers and enter the location data into the tracking software is ahead of schedule. This new system enables to the staff to track extinguishers for re-quired testing and inspections more efficiently.

Billy Mitchell:

Fire Safety &

Emergency Response Manager

T.J. DeLuca:

Fire Safety Professional

Kitty Lynn:

Fire Safety Professional

Adam Swift:

Fire Safety Technician

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P e r f o r m a n c e L e v e l A s s e s s m e n t 2008 2009 2010 2008 2009 2010 2008 2009 2010

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

Level 3 Level 3 Level 3 - - Level 3

Level 2 Level 2

Education Customer Service Internal Processes

Trained 1,830 students, staff and faculty in proper use of fire extinguishers, using live fire and PowerPoint presentations includ-ing videos developed by students.

Collaborated with Housing and Urban Residential Education to create a podcast for training of Resident Advisors on fire safety.

Created a microwave Safe-T-sensor mag-net poster for the top of all student resi-dence microwaves, in order to reduce mi-crowave misuse.

Held annual fire safety fair in collaboration with UNC Public Safety and Chapel Hill Fire Department.

Conducted over 20 Life Safety Meetings with a variety of UNC personnel, focusing on fire hazards, egress and evacuation protocol.

Participated in the development and imple-mentation of a confined space drill with Energy Services, South Orange County Fire and Rescue, Chapel Hill Fire Depart-ment, UNC Public Safety and EHS.

Provided ThermoFisher TruDefender instrumental-specific training for the HazMat Team.

Created and posted evacuation maps in the Smith Center to assist EHS and Life Safety staff in the event of a need for mass evacua-tion.

Provided fire safety consultations for two Haunted Houses and Playmakers‘ Ball events.

Provided fire watches at 28 Athletic events at Smith Center and Kenan Stadium.

Participated in the annual Fall Festival providing instruction in safe environments, fire safety, and compliance with NC Fire Code.

Worked with Friday Center staff in devel-oping occupancy loads for their conference rooms and added required exit lights for safe egress paths.

Provided 102 fire drills for residence halls, libraries and health facilities.

Completed installation of Safe-T-elements and Safe-T-Sensors in residence halls with funding from a second FEMA grant.

Distributed Safety First newsletter to more than 200 UNC Building Emergency Coordinators.

Completed bar code system for identifica-tion, providing a comprehensive and effi-cient tracking and inspection process for the campus fire extinguishers.

Provided new safety tools for the emer-gency response team. Items included True Defender meter, mercury clean-up pads, formaldehyde pads, and two new Sperian gas meters.

Provided six work-study students an op-portunity to assist in fire safety‘s day-to-day operations, giving them a better un-derstanding of fire safety while improving response and staff availability for other responsibilities.

Provided eight monthly training sessions for EHS emergency response team, im-proving their knowledge effectiveness.

With Chemical Safety staff, designed and implemented hands on-drill for use of the TruDefender in the event of a spill.

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COMPLIANCE 27

ronmental Hygiene

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The UNC campus contains thousands of confined spaces that few people notice, because they are often behind walls, above ceilings or under ground. They are the access points to ser-vice tunnels, manholes, air handlers, crawl spaces, tanks and underground vaults that UNC employees enter every day to keep our campus working. Without proper procedures, these spaces can be unsafe to enter.

OSHA defines confined spaces as ―spaces that are large enough that people can enter and perform work, have limited or restricted entry or exit, and are not de-

signed for continuous occupancy.‖

Some of these confined spaces contain hazards, including toxic gases, oxygen defi-

ciency and mechanical and electrical hazards. Annually, more than 1.5 million

workers enter confined spaces and are at risk for injury when precautions are not

taken to control or eliminate these hazards. The risks are real. In 2011, four peo-

ple in North Carolina died from incidents in confined spaces.

OSHA requires any employer whose employees enter confined spaces to implement

a written program to ensure their safety and EHS administers the UNC policy and

program. One of the key components of this program is to select a rescue provider

to respond to confined space emergencies. The campus rescue provider is the South

Orange Rescue Squad (SORS) Technical Rescue Team. As required by OSHA,

SORS conducts annual mock rescue drills on campus. The drills usually only in-

clude the department responsible for the space involved in the drill, but there are

Occupational & Envi other entities that are vital in the response to confined space incidents. They are

UNC Public Safety (Dispatch and Officers), Orange County Dispatch Center, UNC

EHS, Orange County Emergency Services, Chapel Hill Fire Department, and the

SORS Technical Rescue Team.

In 2011, EHS assisted in planning and coordinating the first system-wide confined

space drill. Staged at the UNC Cogeneration facility, the exercise scenario began

with a call to 911 announcing a confined space emergency and ended with the re-

trieval of the victim: mannequin Rescue Randy.

Participating in a comprehensive drill was invaluable for all parties in providing

opportunities for collaboration and improvements to the current system. From

that exercise, the responders decided to conduct annual system-wide drills and

meet quarterly to discuss their response efforts. EHS developed a standard operat-

ing procedure for the EHS Emergency Response Manual. Dozens of UNC employ-

ees enter confined spaces every day to keep our campus working. EHS and the

other local response units are working to make sure those employees can do it

safely. 28

Occupational & Envi

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A n d W h a t T h e y ―The CHFD enjoys excellent working relationships with our mutual aid partners and UNC. The opportunities to work together to en-

sure we can work under a common plan to accomplish safe and ef-

fective service delivery is taken for granted. The confined space drill

with the University, Orange County Emergency Services, and the

South Orange Technical Rescue team demonstrated the capabilities

of the various agencies and the excellent working relationships.

The lessons learned from this drill will be used to strengthen both

our emergency response abilities and our communication with our

partners.‖

W h o W e A r e

W h at W e D o OEH is responsible for ensuring that indoor campus

environments are conducive to good health and

wellbeing using knowledge and experience in indus-

trial hygiene, asbestos management, air and water

quality and safety engineering. The section assesses

potential safety hazards, possible instances of expo-

sure and suitability of protective equipment. OEH

works with facilities engineering and facilities ser-

vices personnel to find ways to keep historical build-

ings functional, while protecting employee health,

and works with planning, construction and startup

of new and renovated buildings to anticipate and

eliminate building related health issues.

ronmental Hygiene

S a y

Robert Bosworth, Deputy Chief,

Emergency Management Coordinator

NC Task Force 8 USAR Team,

Town of Chapel Hill

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Staff Asked to Serve

on the NCDOL PEL Advisory Committee

Environment, Health and Safety was invited by The N.C. Depart-ment of Labor (NCDOL) to participate in an advisory committee to determine if Permissible Exposure Levels (PELs) for carbon monox-ide need to be modified in North Carolina. NCDOL was considering introducing a Short Term Exposure Limit (STEL) to address acute exposures. The committee consisted of industrial hygienists from a cross-section of environments, including manufacturing, academia and consulting industries.

New Database for Hearing Loss Prevention

Annual audiometric tests for employees enrolled in the campus Hear-ing Conservation Program (HCP) are conducted at the UNC Speech and Hearing Clinic. The clinic purchased the Examination Manage-ment Network database operated by Examinetics, Inc for data man-agement of audiometric testing results. The database allows the HCP administrator to generate various reports that help support the goal of hearing loss prevention versus hearing loss conservation. Instead of only focusing on employees that have reached the OSHA standard threshold shift (STS), the database can generate a report of employees approaching the STS. Now the administrator can inter-vene and work with these employees to prevent them from reaching a shift.

Confined Space Program Improvements

EHS worked with various groups to improve the campus confined space program and coordinated monthly meetings with Energy Ser-vices to discuss program improvements. Energy Services also imple-mented daily bump testing of gas monitors to ensure the monitors are operating appropriately, prior to conducting entries. EHS as-sisted in coordinating the first system-wide confined space exercise that included all of the local emergency response agencies.

DLAM Lockout Tagout

Standard Operating Procedures

EHS assisted the Department of Laboratory Animal Medicine (DLAM) with the development of lockout tagout standard operating procedures for