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Safety, Health & Environment Section
FM SHE 005
Procedural Guidance for
Protection from Hazardous
Substances
November 2014
Version 2.0
Document review due: November2016
Please Note: This is a controlled document, please ensure you are using the most recent
version. SHE Intranet
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Section
Contents
1.0
Introduction
3
2.0
Scope
3
3.0
Purpose
3
4.0
Definitions
3
5.0
Legal Requirements
The Management of Health & Safety at Work
Regulations
Control of Substances Hazardous to Health
Regulations
The Ionising Radiations Regulations
5
Hazards
5
6.1
Routes of entry into the body
5
6.2
Contaminated areas and equipment
6
6
7.1
7.2
Procedure
Identification of Hazardous Substances contaminated
equipment and areas
COSHH Risk assessment
7.3
Decontamination
7
7.4
Isolation
7
7.5
Communication
7
7.6
Emergency Arrangements
8
Glossary
8
APPENDICES
Equipment/Articles Decontamination Clearance
Certificate
Area Decontamination Clearance Certificate
10
5.1
5.2
5.3
6.0
7.0
8.0
1
2
Page
5
5
5
6
6
12
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1.0 Introduction
Many hazardous substances are used within the University. They range from chemical,
radiological and biological agents used in laboratory experiments to cleaning and
fumigation substances. Instances may occur where people are exposed to these
hazards where the risks of exposure need to be controlled. This procedure details the
safe systems of work to be followed in order to prevent injuries and ill-health to people
when working with hazardous substances.
2.0 Scope
This guidance applies to all hazardous substances used on University premises that
pose a risk to employees, contractors, students, visitors and members of the public.
3.0 Purpose
The purpose of this guidance is to:
 Provide procedural guidance for Managers and Supervisors so that employees,
contractors, visitors & students are not injured through exposures to hazardous
substances.
 Ensure a safe system of work is in place for the decontamination of equipment
and areas prior to maintenance or repair work being undertaken.
 Clearly define individual responsibilities for the control of risks when work on
contaminated equipment is carried out.
4.0 Definitions
The following table illustrates the labels likely to be displayed on containers and gives
brief definitions of the corresponding hazard. Chemical Hazard Information for
Packaging and Supply Regulations 2000 (CHIP) (note: CHIP is being replaced by the
European CLP Regulation and will be revoked from 1 June 2015.) require labels to be
affixed to containers by the supplier to indicate hazard classification for the end user.
The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment
Regulations 2009 (CDG) requires labels to be affixed to containers and vehicles by the
supplier to indicate transport hazards.
CHIP
CDG
None
Hazard Classification
HARMFUL - May cause death or acute/chronic damage to
health. Lethal dose > 250 mg/kg of body weight. Category 3
carcinogens, mutagens and toxic for reproduction are also
labelled as harmful.
IRRITANT - Immediate, prolonged or repeated contact with
the skin or mucous membrane may cause inflammation.
TOXIC – A substance, which in low quantities causes death
or acute/chronic damage to health. Lethal dose < 250 mg/kg.
Category 1 & 2 carcinogens, mutagens and toxic for
reproduction are also labelled as toxic.
VERY TOXIC – Lethal dose < 50 mg/kg.
CORROSIVE - will destroy living tissue on contact. Can
cause full thickness dermal burns.
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CHIP
CDG
Hazard Classification
FLAMMABLE - substance having a flash point of <21 oC
EXTREMELY FLAMMABLE – substance having a flash point
<0 oC and boiling point below 35 oC.
OXIDISER - substance which gives rise to an exothermic
reaction when in contact with other substances. Generally
they react with most organic substances, usually resulting in
a fire.
None
None
None
DANGEROUS FOR THE ENVIRONMENT - A substance,
which were it to enter into the environment, would present or
may present an immediate or delayed danger for one or more
components of the environment.
INFECTIOUS SUBSTANCE / BIOLOGICAL AGENT - These
are classified as any micro-organism, cell culture or human
endoparasite, including those that have been genetically
modified, which may cause infection, allergy, toxicity or
otherwise cause hazard to human health.
IONISING RADIATION – Gamma rays, X-rays and
corpuscular radiations capable of producing ions either directly
or indirectly.
The Globally Harmonised System (GHS) for labelling will eventually replace the CHIP
symbols detailed above. This transition will take place over several years so users will
need to be familiar with both sets of labels during this time.
GHS
Health Hazard:
Respiratory sensitisation, germ cell mutagenicity, carcinogen,
reproductive toxicity, specific target organ toxicity following single and
repeated exposure, aspiration hazard.
Acute toxicity (oral, dermal, inhalation) category 4
Acute toxicity (oral, dermal, inhalation) categories 1,2,3.
Skin corrosion, serious eye damage.
Flammable gases, aerosols, liquids, solids. Self-reactive substances and
mixtures, pyrophoric liquids and solids, self-heating substances and
mixtures
Oxidising gases, liquids and solids.
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GHS
Acute and chronic hazard to the aquatic environment
5.0 Legal requirements
5.1 Management of Health and Safety at Work Regulations 1999
A suitable and sufficient assessment of the risks for all work activities is required for
the purpose of deciding what measures are necessary to ensure safety.
5.2 Control of Substances Hazardous to Health Regulations 2002
Control of Substances Hazardous to Health (COSHH) is all about controlling the
exposure of persons to substances hazardous to health with the aim of preventing
illness or injury.
The COSHH Regulations hinge around the process of ‘risk assessment’ where the
employer (or self-employed person) has to decide whether the exposure levels in the
workplace are likely to cause risks to health and safety. The assessment process is
based on a number of factors including:
 Who is being exposed;
 What substances are being used;
 How long people are being exposed for;
 What levels they are being exposed to;
A hierarchy of control measures must be followed in order to limit the exposure to such
substances. The control measures must either eliminate the exposure or reduce it to
an acceptable level. These control measures must be properly used and maintained
in efficient working order.
5.3 Ionising Radiations Regulations 1999.
These regulations detail the requirements for the protection of persons against ionising
radiation from any work activity. Protection measures include;
 Notification of certain work.
 Restriction of exposure.
 Dose limits.
 Designation of controlled and supervised areas and classified persons.
 Appointment of Radiation Protection Advisers and Radiation Protection
Supervisors.
 Local rules.
 Medical surveillance and monitoring.
 Personal protective equipment and washing facilities.
 Contingency plans.
 Decontamination procedures.
6.0 Hazards
6.1 Routes of entry into the body.
The areas where hazardous substances may be absorbed into the body are through;
 The outer skin surface;
 The tissues covering the surfaces of the respiratory tract;
 The tissues covering the surface of the gastrointestinal tract;
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The four main routes of entry are via;
 Inhalation. The lung is the most vulnerable part of the body, as it can readily
absorb gases, soluble dusts and fumes.
 Absorption (Skin contact). The skin is the next most vulnerable area, as it
can be in contact with hazardous substances which may be solid, liquid or
gaseous and in very high concentrations in terms of quantity of substance to
skin area.
 Ingestion. The gastrointestinal tract is the least vulnerable area of the body
since the possibility of solid or liquid toxicants being ingested is limited.
 Injection. Sharp objects may break the protective surface of the skin leaving
the area vulnerable to penetration by biological and chemical agents.
6.2 Contaminated areas and equipment.
Contamination may be present;
 On equipment that has been used to handle or contain hazardous substances.
 In areas where hazardous substances have been stored, handled or used.
 In pipe-work that has been used to transport hazardous substances, or become
inadvertently contaminated.
Hazardous substances may be present in either gas, solid or liquid form and may not
be visibly detectable, this will almost certainly be the case for biological and radioactive
hazards.
Some substances may pose a significant hazard in very small, or even trace quantities.
7.0 Procedure
7.1 Identification of Hazardous Substances, Contaminated Equipment and Areas.
ALL containers of hazardous substances must be clearly labelled at all times, including
containers hazardous substances are decanted into. The label must include a name
or description of the contents, the hazard classification and the appropriate hazard
pictogram.
Prior to working in any area or on any equipment;
 Assess the historical use. This may give a good indication of any likely
contamination.
 Look for any signage or warning labels that may indicate that a hazard is
present. (See section 4.0). Pipe-work may be colour coded in line with BS 1710
– Pipeline identification markings.
 Talk to staff and students from the area, or who have control over the
equipment that is to be worked on. They will be able to indicate if any
contamination of a hazardous nature is present.
 Visually inspect the area or equipment for obvious signs of contamination.
It is the responsibility of all staff to notify others of hazards arising out of their activity.
7.2 COSHH Risk Assessment
A COSHH risk assessment shall be carried out and recorded prior to any work where
there is a risk of exposure to a hazardous substance. It is the responsibility of the
relevant supervisor(s) or manager(s) to ensure this COSHH risk assessment is
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undertaken. In shared areas communication and co-operation may be necessary when
undertaking the COSHH assessment and developing safe systems of work. COSHH
Risk
Assessment
Forms
can
be
found
at
the
following:
(https://intranet.uclan.ac.uk/ou/fm/Pages/Health-and-Safety-COSHH.aspx)
7.3 Decontamination
Any decontamination must be carried out by a suitably competent person. The level of
expertise will vary according to the task and level of risk. Simple decontamination
involving the cleaning of oils/greases will require a relatively low level of expertise.
More complex procedures and expertise will be necessary when decontaminating
areas or equipment contaminated with biological or radiological hazards.
It is the responsibility of the relevant supervisor(s) or manager(s) in charge of the area
and equipment to ensure that sufficient decontamination is carried out by a person who
is suitably qualified and experienced for the task. A test, validating the level of
decontamination should be carried out where reasonably practicable and a
Decontamination Clearance Certificate completed (see section 7.5 and appendices 1
& 2)
7.4 Isolation
Where there is a need to break into potentially contaminated pipe-work, or where there
is a risk of material ingress into a pipe while work is being undertaken, then isolation
shall be carried out.
Isolation may be carried out by the following methods:
 Physical disconnection
 Closing valves and securing in the closed position by means of a lock
 Fitting blanking flanges into pipe-work
Sometimes it may be appropriate to flush or purge pipe-work with a suitable agent prior
to work starting. Water or nitrogen are the preferred option for purging as they are less
likely to pose a pollution/disposal problem. An assessment of all used flushing agents
must be undertaken and the appropriate disposal route identified. Additional hazards,
such as flooding and asphyxiation, may be introduced during purging. Control of these
additional risks must be addressed in the COSHH risk assessment.
7.5 Communication
The University operates a Decontamination Clearance Certificate system for declaring
when equipment or areas are clean and safe to work on. Copies of these forms can
be found in Appendices 1 and 2 of this procedure. It is the responsibility of the relevant
supervisor(s) or manager(s) in charge of the area or equipment to ensure all necessary
decontamination is carried out and to complete the relevant Decontamination
Clearance Certificate.
For work on University premises involving University Maintenance Staff or External
Contractors, a Permit-to-Work form should be utilised. It is the responsibility of the
relevant supervisor(s) or manager(s) in charge of the area or equipment to ensure all
necessary decontamination is carried out and the Permit-to-Work completed.
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7.6 Emergency Arrangements.
Arrangements must be in place to deal with any contamination accidents, loss of
containment or a fire. Where contamination involves radioactive materials, the Local
Rules must be strictly adhered to and the Radiation Protection Supervisor (RPS) and
Radiation Protection Officer (RPO) informed immediately. Some emergencies would
require the Radiation Protection Adviser (RPA) to be notified. Emergency
arrangements may include some or all of the following:











Presence of a First-Aid trained member of staff.
Presence of other key personnel (e.g. RPS, Senior Technician).
First-aid equipment.
Emergency showers.
Procedures for contacting the Emergency Services.
How other members of staff / students will be notified of the emergency.
Evacuation procedures.
Spillage equipment.
Cleaning equipment.
Fire extinguishers of the appropriate type.
Personal protective equipment and respiratory protective equipment.
8.0 Glossary
CDG
CHIP
COSHH
Flash Point
GHS
mg/kg
RPA
RPO
RPS
Carriage of Dangerous Goods Regulations.
Chemical Hazard Information for Packaging and Supply
Regulations
The Control of Substances Hazardous to Health
Regulations 2002
The minimum temperature at which the vapour above the
surface of a liquid will ignite, if impinged upon by a source
of ignition
Globally Harmonised System (labelling of hazardous
chemicals)
Milligrams per kilogram of body weight. The unit of measure
for a lethal dose of a toxic substance
Radiation Protection Adviser
Radiation Protection Officer
Radiation Protection Supervisor
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APPENDIX 1
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University of Central Lancashire – Equipment/Articles Decontamination
Clearance Certificate
To:
From:
Works are required to be
carried out in your area
containing the following
equipment/articles:
(Model/Serial/Batch No.)
Please certify by signing below that the above equipment/article has so far as
reasonably practicable been decontaminated in accordance with the relevant
risk assessment prior to inspection, service, repair or disposal and is
radiologically, chemically and biologically clean.
Name
Date:
Job Title
If the equipment/article cannot be fully decontaminated please state the nature
of the risk and safety precautions necessary:
Please return to sender once the above is completed.
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APPENDIX 2
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University of Central Lancashire
Area Decontamination Clearance Certificate
To:
From:
The following works are
required to be carried out
in your room/area:
Please certify by signing below that the above Room/Area is free from the
following hazards:
Biological*
name
job title
Date:
Chemical*
Date:
Radiological*
Date:
* Where there has been no material used which represents a hazard, please write
‘N/A’ in the appropriate signature column.
PLEASE PROVIDE ANY ADDITIONAL INFORMATION THAT MAY BE
RELEVANT TO POTENTIAL CONTAMINATION IN AREAS SUCH AS PIPEWORK AND DUCTING ON THE REVERSE OF THIS SHEET. WHERE
NECESSARY, APPEND APPROPRIATE MSDS SHEETS.
Please return to sender once the above is completed.
TO BE COMPLETED BY PROJECT MANAGER
Please certify by signing below that the above Room/Area is free from the
following hazards:
*Asbestos
(Asbestos Clearance
Certificate attached)
Date:
(Project Manager)
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Additional hazard/safety information
Action taken by the School/Department
Potential hazards
Control measures
First Aid Measures
Fire Extinguishing Media
Risk Assessment
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