Environmental Health and Safety Office
Health and Safety Procedure
Decommissioning of Laboratories or Equipment used with Chemical Biological or
Radioactive Material
Date revised:
October 26, 2007
Original version developed
January 14, 2004
Originating Department:
Environmental Health and Safety Office (EHSO)
Effected Departments:
Physical Plant
All Academic Departments using Controlled Products
Background:
At the University, Researchers within Academic Departments commonly use potentially hazardous materials in
research areas and with equipment. These potential hazards specific to the research activities must be identified
to all persons with access to these areas. Researchers must realize that Physical Plant staff (caretakers and
trades), Contractors and Security Services staff may enter areas during the normal course of their work, including
times when Researchers are not present. Researchers are obligated to protect the health and safety of these
workers by using hazards signage, engineering or administrative controls.
When possible, researchers who use the potentially hazardous materials (chemicals, biologicals or radioactive
material) are obligated to remove these materials and any related contamination before the public, or service
personal (University staff or contractor) have access to these areas or equipment. This process is known as
decommissioning and the process is defined herein.
Potential Hazards Present: Contamination may occur by touching surfaces or being exposed to airborne
contamination or liquids in the lab. Contamination may also occur by walking through a spill, breathing in vapours
or by producing contaminated dust, mists or aerosols. Contamination may result from the research activities or
from the servicing.
Additional precautions are required if asbestos or mould is present or suspected to be present. Refer to
the Asbestos or Mould Management Program.
CONTENTS
1.
Purpose: ...................................................................................................................................... Page 2
2.
Policy: ........................................................................................................................................... Page 2
3.
Definitions: ..................................................................................................................................... Page 2
4.
Responsibilities............................................................................................................................. Page 3
5.
Decommissioning Procedure for Rooms, Areas or Equipment used to store or manipulate chemical,
biological or radioactive materials: ................................................................................................ Page 3
6.
Procedure for disposal of Equipment ............................................................................................ Page 4
7.
PPE for Contamination Control: ................................................................................................... Page 5
8.
WORKERS DUTIES with Job Hazard Analysis ........................................................................... Page 6
Appendix A: Decommissioning/Decontamination Form for Equipment .............................................................. Page 7
Appendix B: Decommissioning/Decontamination Form for Laboratories or Rooms ............................................ Page 8
Purpose:
To define the decommissioning process to:
1.1
To reduce or eliminate exposure to potentially harmful chemical, biological or radioactive
material to service (Physical Plant), contractors and research (Academic Department) staff.
1.2
Update the EHSO inventory of lab equipment and advise on appropriate disposal of related
equipment.
1.
2.
Policy:
Prior to servicing or renovation, all laboratories, work areas or equipment used to store or
manipulate Controlled Products (chemical, biological or radioactive material) shall be
decommissioned by the Responsible User.
2.1
If the Responsible User is not available, the appropriate Department Head shall be
responsible for ensuring that the appropriate resources are available to accomplish the
decommissioning.
2.2
At the University, decommissioning of areas (rooms) or equipment used to manipulate or
store chemical, biological and radioactive materials shall be recorded by completing a
decommissioning form as prescribed by the Environmental Health and Safety Office.
2.3
Contractors and Physical Plant staff shall never be allowed to dispose or work with
equipment or in areas where potentially harmful chemicals, biological or radioactive material
has been used or stored without a documented decommissioning, unless they have
documented training to ensure they understand the risks and can identify and mitigate the
hazards.
2.4
Since decommissioning can only remove the apparent and accessible hazards, this limitation
must be clearly communicated to all Physical Plant or contracted service personnel prior to
servicing through training related to this procedure.
2.5
Decommissioned equipment shall be appropriately labeled to limit inappropriate re-use.
3.
Definitions:
3.1
Decommissioning: Decommissioning is the process of removing all the accessible
chemical, biological and radioactive materials and any related contamination from accessible
surfaces.
3.2
Responsible User: Principal Investigator or PI/departmental designate that has authority for
the equipment or area and understand the hazards associated with the related chemical,
biological or radioactive materials.
3.3
Contractors: Non-Physical Plant staff that provide service or construction work as
authorized by Physical Plant, EHSO or Academic Departments.
3.4
Supervisors: Anyone who directs the work of another person.
3.5
PPE or Personal Protective Equipment: Safety devices or safeguards worn by workers to
protect against environmental hazards. PPE includes helmets, safety goggles, hearing
protectors, face shields, respirators, arm guards, smocks, gloves, protective clothing and
safety boots.
4. Responsibilities:
4.1
The Academic Department is responsible to ensure that all academic and support staff
working with chemical, biological or radioactive materials are aware of the requirement for
decommissioning prior to renovation or servicing by Physical Plant staff or Contractors as set
out in this procedure.
4.2
Physical Plant Department is responsible to ensure that all Physical Plant staff who may
work with equipment or in areas where chemical, biological or radioactive materials have
been used or stored, or who may direct the work of others are aware of the requirement for
decommissioning prior to renovation or servicing by Physical Plant staff or Contractors as set
out in this procedure.
4.3
The Environmental Health and Safety Office is responsible to communicate to Physical
Plant and Academic Department Heads the requirement for decommissioning and to advise
on appropriate procedures prior to renovation or servicing by Physical Plant staff or
Contractors as set out in this procedure.
4.4
Supervisors are responsible to:
a)
Identify the hazards and communicate the requirement for decommissioning to staff
and contractors,
b)
Verify that their staff is appropriately trained to recognise potential chemical,
biological or radioactive hazards, understand the risks and be able to control the
hazards.
c)
Supervise their staff to ensure that safe procedures are followed, prescribed personal
protective is worn and the existing potential hazards as known are communicated on
the decommissioning form.
SAFETY ALERT Laboratories have many hazards (chemical, biological, and physical hazards such as
radioactivity and sharps such as needles and scalpels). Check for signs and hazard labels. Even when chemical,
biological and radioactive hazards are removed from the accessible areas of the lab, BE AWARE that hidden
areas such as fume hood ducts and sink drains may still be contaminated!
5.
Decommissioning Procedure for Rooms, Areas or Equipment used to store or
manipulate chemical, biological or radioactive materials:
5.1
The Responsible Users shall decommission rooms, areas or equipment by removing all the
accessible chemical, biological and radioactive materials and any related contamination from
accessible surfaces. They shall record this decommissioning and actions taken on a
DECOMMISSIONING form provided by EHSO. Consult Section & for advise on appropriate
PPE and Section 8 for a detailed set up procedure with Job Hazards analysis.
5.1.1 Remove chemicals from the equipment and work area.
5.1.1.1 Chemicals, biological or radioactive materials need to be disposed via EHSO or stored in a
manner that does not:
a) Impede access to the equipment or area to be serviced.
b) Create a hazard to others.
c) Allow unauthorized access by persons that are not trained to identify, understand or
mitigate the hazard.
5.1.1.2 Chemical, biological or radioactive contamination must be removed by staff that:
a) Are trained to use approved decontamination methods.
b) Wear appropriate personal protective equipment (minimum lab coat, disposable
chemically resistant gloves and eye/face protection such as goggles or face shield) in a
manner to contain contamination.
c) Dispose of related chemical wastes via approved methods.
d) Biological contamination shall be decontaminated via methods that are effective.
e) Radioactive contamination shall be repeated until contamination monitoring documents
that the remaining removable contamination is below the limit prescribed by the internal
radioisotope permit.
5.1.1.3 Method of decontamination:
a)
Surface and accessible interior shall be totally empty; all chemicals and samples,
stray vials, debris or loose items must be removed. Any PCBs, Mercury, Lead, oil
or water must be drained and disposed of separately.
b)
Surface cleaning is required before items from research areas are moved to or
transported through publicly accessible areas:
a)
Except where water-reactive chemicals may be present, the exterior and
interior surfaces shall be wiped with a detergent solution.
b)
If biological contamination is a possibility, 1/5 bleach solution or 70%
ethanol solution, should be applied and let to soak for 30 minutes before
being wiped dry.
c)
If bleach is contraindicated due to the presence of stainless steel or the
possible presence of chemicals that may react, an alternate disinfectant
should be researched and used.
d)
Before cleaning equipment containing spoiled biological material or
mould, EHSO should be consulted.
c)
Loose or sharp parts, including doors and cords should be secured prior to
transport.
5.1.1.4 The method and related confirmation of decontamination shall be documented on the
Decommissioning form.
6.
Procedure for disposal of Equipment that has previously been used to store or
manipulate chemical, biological or radioactive materials: After appropriate
decommissioning, the following label must be attached to the equipment prior to disposal:
Equipment Disposal
This equipment has previously been used to store or manipulate chemical, biological
or radioactive materials.
All known chemical, biological and radioactive material has been removed; however,
this equipment should not be re-used for uses other than in a chemical laboratory.
Under no circumstance should this equipment
reused for food storage or food preparation.
Type of Equipment: _____________________________
Make and Model: _______________________________
Serial Number (if available): _______________________
be
7.
PPE for Contamination Control:
Supervisors may stipulate additional PPE be worn by their staff.
Type of PPE minimally required:
Lab coat, apron or coveralls (disposable or washable) must be worn if there is any possibility of
contamination of the workers body.
Gloves: If there is any possibility of contamination of the hands, wear re-useable chemically resistant
gloves (wash and dry after use) or disposable gloves.
Use thicker gloves when physical hazard is also present.
Disposable gloves are required if radioactive contamination is a possibility.
Eye protection (Safety glasses, goggles or face shield) required if procedure has any chance or producing
projectiles, dust, aerosols or splashes.
Respiratory protection required if procedure has any risk of producing dusts, hazardous vapors or
aerosols. Respiratory protection is required whenever the worker may be exposed to vented air
from fume hoods or other local ventilation. For exposure to hazardous particulates, dusts,
aerosols, the minimum is N-95. For exposure to hazardous volatile chemicals, a multicontaminant respirator for organic vapors is required. Respiratory train and fit testing are
mandatory.
Hygiene: Wash hands, clean and disinfect tools at the end of the job and whenever chemical, biological
or radioactive contamination is a possibility.
If no sink is readily available, take along hand wipes to use until you can wash your hands in a sink.
Disinfectant wipes are recommended if biological contamination on tools is a possibility.
Waste containers for any wastes generated - All wastes generated shall be disposed in accordance with
Controlled Product Standard, Part B.
Footwear: Feet should be completely covered and provide necessary grip for working conditions.
8.
WORKERS DUTIES with Job Hazard Analysis
Be cautions about hidden Chemical, Biological and Radiological Hazards. Stop and ask your supervisor if you are
not sure. Additional precautions are required if asbestos or mould is present or suspected to be present.
Refer to the Asbestos or Mould Management Program.
1. BASIC JOB STEPS
2. HAZARDS & POTENTIAL
ACCIDENTS
3. HAZARD CONTROLS & SAFE WORK
METHODS
PREPARATION OF WORK AREA or EQUIPMENT
1. Assemble PPE as indicated
above. Additional PPE may be
required by your supervisor.
Not using prescribed PPE or
using it incorrectly may
create a personal
contamination or injury such
as an acid burn.
Wear PPE. Wear PPE correctly. Be fit tested for
respirators. Be trained how to use PPE.
2. Be prepared to reduce/
eliminate the possibility of
becoming contaminated or
spreading contamination.
Contamination must be
contained on disposable or
washable surfaces. Care
must be taken to not spread
contamination other areas to
reduce the risk of personal
contamination.
Drape splash or spill areas area with plastic (6mil
poly) or plastic backed absorbent (if radioactive
contamination is possible). Secure drape with
tape. A kiddie pool may be needed to contain over
spray or drips.
Pre-plan how to wash up self and decontaminate
supplies or tools that you plan to re-use another
time.
3. Visually inspect and remove
hazards (chemical, biological
and radioactive).
Chemical, biological and
radioactive materials may
create hazard.
Dispose of hazardous materials according to
University procedures. Consult EHSO as
appropriate. Hazardous material must be stored
safe from unauthorized access.
4. Security
Unauthorized people may
remove hazardous material.
Untrained people may not
recognize hazards.
Ensure unauthorized staff do not have access to
hazardous materials or enter the area. Possibly
post signage stating “Restricted area. Authorized
personnel only.”
Lock door when unattended. Do not place
equipment that may be contain or be contaminated
with hazardous materials in areas that the public
may access.
5.Personal hygiene
Personal contamination is
possible from improper
hygiene.
Avoid touching your face during work. Do not eat
or drink during procedure. Do not bring food or
beverages into work area.
6. Follow lab defined Safe
Work Procedure; consult
equipment manual or other
defined equipment related
procedures.
Be cautious of variations.
Consult supervisor or manufacturer for
clarifications.
7. Clean items that will be
reused with a moistened cloth
as appropriate.
Cross contamination to self
or other areas. Be cautious
of wetting electrical hazards.
Clean and monitor re-useable items prior to reuse.
8. Wipe works surfaces with a
damp cloth and remove drape.
Cross contamination to self
or other areas.
Bag all wastes including damp cloth and dispose of
appropriately.
9. Remove PPE as trained
Cross contamination of self
or other areas.
Be careful no to spread contamination. Wash
hands.
CLEAN UP
Appendix A
U of M Decommissioning/Decontamination Form for Laboratory Equipment
1.
2.
3.
4.
(ONE Form per Item please)
This Form must be completed prior to commencing service, maintenance, renovation or disposal.
Up to 2 weeks may be required for EHSO signature in Section D.
If ASBESTOS or MOULD is present or suspected, refer to the Asbestos or Mould Management Program (474-6633)
Fax completed form to Physical Plant at 474-7547 Fort Garry or 789-3933 Bannatyne
Section A:
Requestor:
Section B:
Equipment Description:
Reason:  Disposal
 Servicing
 Maintenance
Name (Please Print):
Department:
Location:
Room
Building
Type of Equipment:
Make and Model:
Serial Number
U of M Property # OR other ID (specify):
Tel:
Responsible user Name:
Date requested:
Date Required:
Is this part of a project or renovation?
 Y
 N
Physical Plant Coordinator OR Contractor Contact:
Name
If the equipment has a U of M property #, then the Asset Disposal Form
been completed and approved? 
Tel:
Section C:
To be completed by Senior Lab Staff
C1.
How many years of history do you have on this item? ______________
C2.
For the item above indicate the related hazardous materials usage:
If
If applicable, record related information here
Hazardous Material
C3. Decontamination
never
Information
used
Radioactive material

Specify isotope(s) and when:
Biological material or blood and
body fluids

Specify type and when:

Has BSC been surface disinfected-inside and out- if
it is to remain in the renovation area? 
Consider: Highly toxic material, perchloric acid,
hydrofluoric acid, corrosives, mercury. Specify type
and when:
Hazardous chemicals or
gas/vapour in equipment
Oil, vacuum pump oil, PCB’s in
equipment

Lead or other leachable metals
present, including in any internal
components of equipment
Other hazards or pertinent
information

Collect in sealed containers and label as hazardous
waste.
Drain vacuum pumps of oil into containers and label
and dispose with hazardous waste program (PCBs?)
Removed

or
List on green Equipment Disposal sticker


What was done (check all that apply):
 All needles, razor blades, broken glass
removed and disposed according U of M
Protocol
 Minimum requirement is that all
equipment from labs is surface wiped with
water & mild detergent to remove surface
dust, debris.
 interior only
 exterior only


both interior and exterior
monitored for radioactive contamination
(attach results)
Date___________________
 1/5 bleach with 30 min soaking


70% ethanol with 30 min soaking
other - specify type and concentration:
Date Completed:
Done by:
Name (Please Print)
C4.
C5.
C6.
Tel:
All hazard labels removed once equipment is decontaminated?
Y N
If this is an equipment decontamination/disposal have you checked with the manufacturer regarding any specific instructions
or hazardous internal components?
If yes, please append information (check here if information is appended)  Y
N
Do you have any specific recommendations for PPE or disposal? If yes, please list on back
DECLARATION OF COMPLIANCE:
Y
N
Signature confirms information is Section C is accurate.
Signature of Responsible User
Print Name and Phone # of Responsible User
Section D1:
Section D2:
Any special instructions (itemize and initial) use extra page
as required: Check here if information is appended 
For Personnel carrying out disposal minimum PPE are:
 Coveralls
Bio/Chem Decommissioning:
Rad Decommissioning verified:
Eye and Face Protection
Additional workplace protection required by units:
 Gloves, specify type ____________________________
Name_______________________
Name_______________________
Signature____________________
Signature____________________
Respiratory Protection- specify _____________________
Date________________________
Date________________________



Other – describe________________________________
Reviewed by EHSO
Appendix B
U of M Decommissioning/Decontamination Form for Laboratory Areas or Rooms
Used to store or manipulate Chemical, Biological or Radioactive Materials
Required to prepare a room for renovation, Principal Investigator moving or close-out.
1.
2.
3.
4.
This Form must be completed prior to commencing service, maintenance, renovation or disposal.
Up to 2 weeks may be required for EHSO signature in Section D.
If ASBESTOS or MOULD is present or suspected, refer to the Asbestos or Mould Management Program (474-6633)
Fax completed form to Physical Plant at 474-7547 Fort Garry or 789-3933 Bannatyne
Section A:
Requestor
Section B:
Requestor Name (Please Print):
Department:
Tel:
Location - Room
 Whole room
or
Building
 Specific area in room – describe:
Responsible user Name:
Date requested:
Reason for request:
Date Required:
Physical Plant Coordinator OR Contractor Contact:
Is this part of a project or renovation?
Y
N
Name:
Tel:
Call EHSO (474-6633) for consultation. A site visit may identify
specific hazards that require special attention.
Date contacted EHSO:
Section C:
Declaration To Be Completed by Supervisor/Senior Lab Staff
Name: ________________________________________ Tel: ________________
Site history - How long have you been in this space? ______________ years
If less than four years, get information on the history of room use from someone else in the department.
 when
completed
ACTIONS Taken:
C1
Inventory - review your inventory in the U of M chemical inventory database and ensure that:
C1.1
all material is located,
C1.2
all disposed chemicals removed from inventory,
C1.3
potential unstable chemicals identified to hazardous waste program for direct pick-up (e.g. ether, tetrahydrofuran,
picric acid).
all chemicals and chemical waste must be removed from the room – ((Fill in Haz. Waste Removal Form on web:
http://www.umanitoba.ca/admin/human_resources/ehso/emanagement/haz_waste_forms.html).
C1.4
C2.1
Is your chemical inventory list current? Y
N
Have any of the surfaces or remaining equipment been used with potential explosives, mercury, azides, and highly
toxic materials?
Y
N
C2.2
Was the Fume hood used with perchloric acid or hydrofluoric acid?
C2.3
Have all potential explosive hazards been removed or identified?
C1.5
C2
C3
Has this space been used for biological material?
C3.1
C3.2
C4
Y
Y
N
Y
N
N
IF YES, Is the inventory info in your Biosafety Permit current? Y
C3.1.1
Has permit information changes been notified to EHSO?
N
Y
N
All biological waste must be decontaminated (by autoclaving or chemically as appropriate) and disposed as per U of
M Biological Waste Disposal Chart.
Has this been done?
Y
N
Has Radioactive material been used here?
Y
N
If YES, Have you completed and submitted to EHSO a Radioisotope Permit Decommissioning Form?
Door signs and Radioisotope Permits may only be removed by Radiation Safety staff.
C5
C6
Actions Taken:
Y
N
All unused supplies and apparatus removed from drawers and cupboards and shelves? Y N
All empty laboratory glassware and containers removed? Glassware and brittle plastic disposed in plastic bag lined
cardboard boxes or commercial ‘Broken Glass” boxes.
 when
completed
C7
All areas inspected or needles, razor blades, scalpel blades and broken glass and placed in a sharps
container?
Y N
C8
All containers and apparatus removed from in and under fume hoods and sinks?
C9
All hazard labels (rad, chem, bio) removed/defaced when the hazards is no longer present?
C10
All general garbage removed?
C11
All unwanted lab equipment and apparatus disposed/removed?
C12
EQUIPMENT DISPOSAL (green) sticker applied to all equipment and cabinets going for final disposal? (Sticker can
be obtained from EHSO)
All freezers, fridges, cold rooms, searched for errant vials, samples or glass/mercury thermometers)?
C13
Remove all visible residues, standing liquids, loose particulate material, and quantifiable radiological hazards on
floors, bench tops, shelves, cabinets, refrigerators, surfaces of local exhaust enclosures, inside drawers, and other
potentially contaminated surfaces.
At a minimum, wipe all horizontal surfaces and equipment exterior surfaces with mild detergents such as soap and
water.
If this is a room decommissioning is it possible hazardous materials may be present in the building systems?
 Not applicable  fume hood ducts  drains  other – specify:
C14
C15
C16
Do you have any specific recommendations for PPE or disposal? If yes, please list:
C17
DECLARATION OF COMPLIANCE:
Signature confirms information is Section C is accurate:
______________________
_______________________
Signature of Responsible User
Print name and phone numbers
SECTION D: (to be completed by EHSO only)
EHSO MINIMALLY RECOMMENDED PPE and WORK PRACTICES:
HAZARDS IDENTIFIED:
NOTE:
Physical Plant or Contractor Minimum PPE: Coveralls, Eye and Face Protection and other workplace protection as required by PP or
supervisor.
Lab coat, apron or coveralls (disposable □ or washable □) must be worn if there is any possibility of contamination of the workers body.
When there is any possibility of contamination of the hands, wear re-useable chemically resistant gloves (wash and dry after use) □ or
disposable gloves (required if radioactive contamination is a possibility) □.
Use thicker gloves when physical hazard is also present □.
Eye protection:
(Safety glasses □, Chemical splash goggles □ or face shield □) required if procedure has any chance or producing projectiles,
dust, aerosols or splashes.
Body:
Gloves:
Respiratory protection: required if procedure has any risk of producing: dusts □, hazardous vapors □ or aerosols □.
Respiratory protection is required whenever the worker may be exposed to vented air from fume hoods or other
local ventilation. For exposure to hazardous particulates, dusts, aerosols, the minimum is N-95. For exposure to
hazardous volatile chemicals, a multi-contaminant respirator for organic vapors is required. Respirator training
and fit testing are mandatory.
Hygiene: Wash hands □, clean and disinfect tools □ at the end of the job and whenever chemical, biological or radioactive contamination is a
possibility.
If no sink is readily available□’, take along hand wipes to use until you can wash your hands in a sink.
Disinfectant wipes are
recommended if biological contamination on tools is a possibility □.
Waste containers for any wastes generated - All wastes generated shall be disposed in accordance with Controlled Product Standard, Part B.
specifically: http://www.umanitoba.ca/admin/human_resources/ehso/media/CPSPartB.pdf
Footwear: Feet should be completely covered and provide necessary grip for working conditions.
Specifically:
Bio/Chem Decommissioning :
Name:_________________________
Signature:_____________________________________ Date:___________________________
Rad Decommissioning verified:
Name:_________________________
Signature:_____________________________________ Date:___________________________