v»EPA
Report of Audit
REVIEW OF REGION 2'S OCCUPATIONAL SAFETY AND
HEALTH PROGRAMS FOR SUPERFUND AND RCRA ACTIVITIES
Audit Report No. E5eH7-02-0216-9100213
March 15, 1989
MSHINGTON,DJGL2048P
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TABLE OF CONTENTS
Page
SCOPE AND OBJECTIVES 1
SUMMARY OF FINDINGS . 2
ACTION REQUIRED 5
BACKGROUND 5
FINDINGS AND RECOMMENDATIONS
1. Regional Safety Staff Lacks Expertise in
Moderate and High Risk Work Areas 8
2. Improvement Needed in Medical Monitoring Program . 14
3. Region Needs to Establish Respiratory Program .... 19
APPENDIX 1. Distribution 27
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UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
OFFICE OF THE INSPECTOR GENERAL
EASTERN AUDIT DIVISION
J.F KENNEDY FEDERAL BUILDING
Room 1911
Boston, Massachusetts 02203-2211
(617(565-3160
FTS 8-835-3160
NEW YORK OFFICE
90 Church Street
Suite 802
New York NY 10007
1212) 264-5730
March 15, 1989
xMEMORANDUM
SUBJECT:
FROM:
TO:
Review of Region 2's Occupational Safety and
Health Programs for Superfund and RCRA Activities
Audit Report No. E5eji7-02-0216 - 9100213
Paul D. McKechntf
Divisional Inspector General fo
Eastern Division
Audit
William J. Muszynski
Acting Regional Administrator, Region 2
SCOPE AND OBJECTIVES
We have completed our review of Region 2's occupational health
and safety operations for Regional employees working under the
Superfund Amendments and Reauthorization Act of 1986 (SARA/
Superfund) and the Resource Conservation and Recovery Act
(RCRA). The purpose of our review was to determine whether
Region 2's safety policies, programs, and procedures for
field activities are adequate to assure that EPA employees
are protected against known and unknown hazards for Superfund
and RCRA programs. We performed this review as part of our
internal audit program which reviews Agency operations. Our
objectives were to determine the adequacy of Region 2's:
Administration and management controls over occupational
health and safety programs for employees involved in
Superfund and RCRA field activities.
Health and Safety Committee's composition, training
and activities.
Occupational safety and health programs for employees
engaged in Superfund and RCRA field activities,
particularly the areas of guidance, training, respiratory
equipment, medical surveillance, accident and illness
investigations, reporting and recordkeeping, and hazardous
substances response.
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To accomplish our objectives, we interviewed personnel from the
Occupational Health and Safety Staff (OHSS) and the Office
of Solid Waste and Emergency Response (OSWER) at Headquarters;
the Facilities and Administrative Management Branch (FAMB), the
Human Resources Branch (HRB), the Air and Waste Management
Division (A&WMD), and the Emergency and Remedial Response
Division (ERRD) at the Regional Office in New York? and the
Response and Prevention Branch (RPB), the Environmental Services
Division (ESD), and the Environmental Response Team (ERT) at
Edison, New Jersey. We also reviewed training, medical monitoring,
personnel and equipment files, management reports, Agency and
Occupational Safety and Health Administration (OSHA) regulations,
policies and guidance, safety committee minutes, and Public Health
Service logs. Our review generally covered Region 2's occupational
health and safety operations from December 18, 1986 through
September 30, 1987. We did, however, extend beyond that date
when conditions required more current information be obtained.
We performed the review in accordance with the Standards for
Audit of Government Organizations, Programs, Activities, and
Functions, issued by the Comptroller General of the United states
and accordingly included such tests of the records and other
administrative procedures as we considered necessary in the
circumstances. No other significant issues came to our attention
that warranted additional audit time. An audit survey was
conducted from July 13, 1987 to October 30, 1987. Fieldwork on
the audit phase began on December 7, 1987 and was completed
July 28, 1988.
SUMMARY OF FINDINGS
Our review and interviews with Regional staff found that
there has been improvement in the organization and administra-
tion of the Region's health and safety program since the Region
filled its Health and Safety office position with the current
incumbent. Annual medical examinations were being scheduled,
training courses were being provided, and equipment was being
purchased. However, we did find that more progress was needed.
The following summarizes several areas we found that need
strengthening.
1. REGIONAL SAFETY STAFF LACKS EXPERTISE IN MODERATE AND HIGH
RISK WORK AREAS
Region 2's Occupational Health and Safety staff did not
include a member with managing experience or the expertise
to provide the technical guidance that Superfund and
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RCRA field personnel require. The Region's assigned safety
staff was comprised of one individual. The Region filled
its Occupational Health and Safety Manager position with a
temporary employee at the trainee level. The trainee
lacked management experience as well as adequate training
and field experience in hazardous waste operations and
emergency response activities. The Region believed the
individual had the potential to develop managerial skills
needed while at the same time administering the program.
The Region depended on the assistance of other employees
and outside contractors to provide field expertise. As a
result of the lack of available safety expertise, the Region
cannot be assure that its employees are or will be adequately
protected against moderate and high risk safety hazards. We
recommend that the Region consider supplementing the health
and safety staff with a full-time health and safety specialist
who has sufficient expertise concerning moderate and high
risk work areas.
2. IMPROVEMENT NEEDED IN MEDICAL MONITORING PROGRAM
Region 2 was permitting field personnel to work at
Superfund and RCRA sites without receiving required initial
medical monitoring examinations prior to their assignment
or termination examinations when leaving the Agency. This
occurred because Regional management had inadequate controls
to ensure that medical monitoring requirements were met,
and there was no Regional policy to conduct termination
examinations. As a result, employees were potentially
exposed to hazardous substances without adequate base-line
information or assurance to the Agency that they were fit
for duty. Furthermore, the Agency was not assured of
employees' medical conditions prior to working for or
leaving the Agency and the Agency could not take action,
if necessary, to see that undisclosed health problems
were treated. In addition, the Agency could face the
increased risks of unwarranted litigation. We recommend
that a policy be established and implemented for the perform-
ance of termination examinations in accordance with OSHA
regulations.
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REGION NEEDS TO ESTABLISH RESPIRATORY PROTECTION PROGRAM
Region 2 needed to establish a respiratory protection
program for its employees. There was no formal written
program, personnel were not always following proper
safety precautions, there was a lack of equipment, fit
tests were not conducted, equipment was not routinely
maintained, and recordkeeping was inadequate. This
occurred because the Region's respiratory protection
program was still somewhat in the formative stages. The
program was only in the draft stage and there was no
respiratory protection designee. As a result, management
could not be assured that personnel had been properly trained
in safety procedures and had adequate, well maintained
equipment. We recommend that a formal Regional respiratory
protection program be established.
A written response to the draft report was submitted by the
Region on February 27, 1989. An exit conference was held
with Regional Officials on March 2, 1989. We evaluated the
Region's comments and revised the report where appropriate.
Where differences still exist, we have summarized the
Region's comments and our response in the ensuing paragraphs.
These comments were considered when finalizing our report.
The entire response is available for review upon request.
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ACTION REQUIRED
In accordance with EPA Directive 2750, the action official is
required to provide this office with a written response to the
audit report within 90 days of the audit report date.
BACKGROUND
On December 19, 1986 the Occupational Safety and Health Admini-
stration (OSHA) issued an interim final rule, 29 CFR Part
1910.120, containing employees protection requirements for
workers engaged in hazardous substance incidents. Coverage
included employees involved in responses covered by Superfund,
certain hazardous waste operations conducted under RCRA, and
emergency response to incidents involving hazardous substances.
The issuance of the interim final rule was mandated by Section
126(e) of the Superfund Amendments and Reauthorization Act of
1986 (SARA). Various start-up dates were established? however,
EPA was required to fully implement all interim provisions by
March 16, 1987. EPA is required to comply with 29 CFR 1910.120
per Executive Order 12196 (February 1980).
Section 126 (a) of SARA directed the Secretary of Labor to
issue within one year a final standard under section 6 (b) of
the Occupational Safety and Health Act of 1970 for the health
and safety of employees engaged in hazardous waste operations.
On August 10, 1987, OSHA proposed a permanent final standard
to replace the interim final rule, as required by SARA, to be
followed by public hearings in October 1987. As of December
1988, these standards had not been finalized. In addition,
section 126(f) of SARA required the EPA Administrator within
90 days after the promulgation of final regulations under
section 126(a), (January 17, 1988), to promulgate standards
identical to 29 CFR 1910.120.
Before OSHA issued the interim requirements, EPA established
occupational health and safety provisions partially in response
to the Comprehensive Environmental Response and Liability Act
(CERCLA). CERCLA section 301 (f) mandated EPA to study the
problems of protecting the safety and health of workers at
hazardous waste sites and CERCLA section 111(c)(6) required
EPA to develop a program to protect the health and safety of
employees involved in response to hazardous substance releases,
removals or remedial actions.
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Superfund involves both emergency and longer-term cleanup of
releases for hazardous substances and inactive waste sites
through enforcement action (i.e. removals and remedial actions)
RCRA involves the regulation of hazardous waste handlers (i.e.
generators, transporters, and transport, storage and disposal
facilities) through a system for controlling hazardous waste
from the time it is generated until its ultimate disposal.
Treatment and disposal of hazardous wastes under RCRA and
Superfund creates a significant risk to the safety and health
of employees who work in treatment and disposal operations.
Exposure to hazardous wastes through skin contact, absorption
and inhalation poses the most significant risks to employees.
Employees' exposure to these risks occurs when employees
respond to hazardous waste emergencies, when they work with
hazardous wastes during storage, treatment and disposal
operations, or when they participate in the cleanup of
abandoned waste sites. Hazardous waste sites pose a multi-
tude of dangerous conditions due to chemical exposure, fire
and explosion, oxygen deficiency, ionizing radiation, heat
stress, cold exposure, noise, biologic hazard and safety
hazards such as sharp objects, steep grade, ditches, etc.
EPA Order 1440.5, issued June 1982, defined as EPA Reporting
Units, Establishments, Workplaces or field activities where the
potential exists for serious or disabling accidents, injuries,
or illnesses due to the use of chemicals, the presence of
hazardous materials, or material handling or loading operations,
The Occupational Health and Safety Staff (OHSS), within the
Office of Administration and Resources Management's (OARM)
Office of Administration (OA), has overall responsibility for
the development, organization, and administration of EPA's
Health and Safety Programs. OHSS establishes goals and
objectives for reducing injuries and illnesses and assures
compliance with all environmental regulations; formulates
occupational safety, health, and environmental compliance
policy; develops EPA-wide programs to meet the occupational
and environmental health and safety goals and policy; and
evaluates EPA's environmental and occupational health and
safety compliance programs at all operational levels. The
responsibilities for establishing, implementing, and enforcing
an Occupational Health and Safety Program have been delegated
to Assistant Administrators (AA) and Regional Administrators
(RA) by the EPA Occupational Health and Safety Manual (EPA
Order 1440).
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Region 2 has a Occupational Health and Safety Health Manager
located in the Facilities and Administrative Management Branch
(FAME). This individual is responsible for conducting safety
analyses and surveys, conducting routine investigations of
accidents, providing educational materials and courses to
alert employees to safety hazards, administering the Regional
medical monitoring program and keeping related informational
records, serving as an official member of all safety and
health committees, and preparing Regional directives and
monitoring the work place to ensure a safe work environment.
The Region also has two safety committees, one located in the
Regional Office in New York City and the other in Edison,
New Jersey. The objectives of these bodies are to advise and
assist Regional EPA management with respect to their responsi-
bilities under the Agency's Occupational Health and Safety
programs. The Committees are comprised of representatives from
the various branches and program offices at the facility.
The Edison Committee was established over ten years ago,
while the Regional Committee was initiated during Fiscal Year
1988.
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FINDINGS AND RECOMMENDATIONS
1. REGIONAL SAFETY STAFF LACKS EXPERTISE IN MODERATE
AND HIGH RISK WORK AREAS
Region 2's Occupational Health and Safety staff did not
include a member with managerial expertise or the expertise
to provide the technical guidance that Superfund and RCRA
field personnel require. The Region's assigned safety staff
was comprised of one individual. The Region filled its Occupa-
tional Health and Safety Manager position with a temporary
employee at the trainee level. The trainee lacked management
experience as well as adequate training and field experience
in hazardous waste operations and emergency response
activities. The Region believed the individual had the
potential to develop the managerial skills needed while at the
same time administering the program. The Region depended on the
assistance of other employees and outside contractors to provide
field expertise. As a result of the lack of available safety
expertise, the Region cannot be assured that its employees
are or will be adequately protected against moderate and
high risk safety hazards.
EPA's Occupational Health and Safety Manual {1986 Edition)
states that Occupational Health and Safety Designees are
responsible for "managing, developing, organizing, directing,
and evaluating the occupational health and safety programs,
and for coordinating illness and injury reporting and record-
keeping requirements? analyzing accidents and injuries for
prevention and control; and providing technical advise to
management officials in the implementation of program policy
and standards."
EPA Order 1440.5 establishes minimum Agency qualifications
and training requirements for occupational health and safety
employees. This Order states that it is the Agency's policy
to provide qualified, competent personnel to manage the
Agency's Occupational Health and Safety Programs at all
operating levels. The Order requires EPA to provide
sufficient staff with the necessary training and experience
to implement the Agency's Occupational Health and Safety
Programs at all operational levels. It also requires
that the Regional Occupational Health and Safety Manager
or Specialist be trained through courses, laboratory and
field experience, and other experiences to recognize hazards
or potential hazards in the workplace, to recommend specific
corrective actions where standards are not adequate or are
not being met, and to function as a consultant to Agency
management in the area of occupational health and safety.
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The Order defines three types of workplace: low, moderate
and high risk work areas. Moderate and high risk work
areas are defined as EPA reporting units establishments,
workplaces or field activities where the potential exists
for serious or disabling accidents, injuries, or illnesses
due to the use of chemicals, the presence of hazardous
materials, or material handling or loading operations.
Executive Order 12196 requires the Agency to provide qualified
personnel to manage and carry out its Occupational Health and
Safety Programs in accordance with the guidelines contained
in 29 CFR 1960, Basic Program Elements for Federal Employee
Occupational Safety and Health Programs.
OSHA regulation 29 CFR 1910.120 (b) sets the general require-
ments for a Health and Safety program. It requires each
employer to develop and implement a safety and health
program for its employees involved in hazardous waste
operations.
OHSS1 "Occupational Health and Safety in EPA Regions: A
Model Program" states that the Regional Health and Safety
staff should consist of a Health and Safety Manager and
full-time and collateral duty staff. The Health and Safety
Manager should be appropriately qualified, be directly
responsible for administering the program, and serve as a
technical advisor to Regional management on health and
safety issues.
SPA is an Agency whose work demands that its personnel observe
stringent health and safety requirements. Exposure to
hazardous wastes through skin contact, absorption and inhala-
tion pose the most significant risks to employees. In
addition, the Superfund area has historically suffered from
a high employee turnover rate resulting in currently assigned
personnel with limited field experience. With the expected
increase in Superfund sites commencing construction phases
there will be a commensurate increase in field activity
by Regional employees at these sites, and hence greater
potential exposure to dangerous conditions.
The Region had not included on its safety staff, personnel
with sufficient knowledge or expertise of moderate or high
risk work areas. The Region's safety complement consisted
of one health and safety specialist, who was considered
the safety staff, and several other individuals from various
program disciplines who provided collateral assistance.
Although the OHSS Model Program suggests a minimum of at
least 2.5 full time equivalents (FTEs) are needed for a
successful program, the Region's program consisted of
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2 FTEs. The Model Program also emphasizes that the
credentials of the individual administering the program
should not only include the appropriate academic courses,
but also professional industrial hygiene or safety experi-
ence because this individual is Regional management's
technical advisor.
The Region decided to replace its former Health and Safety
Manager with a temporary GS-7 employee. On June 29, 1987,
Region 2 filled the key permanent health and safety manage-
ment position with a temporary trainee, GS-7. This individual
had just graduated from College and had one year's prior health
and safety experience in the private sector obtained as a
Coop student. This position had been previously occupied
by a GS-11 whose employment was terminated, effective
April 7, 1987 because of serious performance deficiencies.
The new employee was promoted to a GS-9 on November 22, 1987?
later converted to a permanent appointment, and then promoted
to a GS-11.
Our review disclosed that the grade level of comparable
positions in the other nine EPA Regions were significantly
higher (two employees at the grade 13 level, five at the
grade 12 level, and two at the grade 11 level). According
to the Chief, Facilities and Administrative Management Branch
(FAMB), the Region had been unable to fill this position and
finally decided on the curent incumbent, since the individual
seemed to cffer the enthusiasm, background and intelligence
they were seeking to put the program back on a steady course.
The Assistant Regional Administrator for Policy and Management
in the Region's response to the draft report also stated
that the current incumbent was deemed "a strong candidate
with the potential to make a significant contribution to a
critical area that needed leadership."
The employee's supervisor of record was the Support
Services Supervisor who also lacked adequate training and
experience in moderate and high risk work areas and had little
functional relationship to the health and safety program. The
Chief, FAMB, stated however, that he himself had six to
seven years of general safety program experience and provided
the Health and Safety Manager with advice when requested.
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while the collateral duty staff had health and safety
experience, the Regional Health and Safety Manager who
should be the Region's technical advisor, did not have
sufficent experience to provide the technical assistance
needed by field personnel. We found that the Region only
had one individual with field safety experience and that
was an On-Scene Coordinator (OSC) located in the Emergency
Response Division in Edison, New Jersey. This individual
provided part-time collateral assistance (such as drafting a
respiratory protection program and conducting fit testing
of equipment) in addition to other duties.
Almost all Regional program personnel interviewed from Branch
Chiefs to line staff stated that they did not seek advice
from the Health and Safety Manager when it came to Superfund
or RCRA hazards. Instead, they sought guidance from many
other sources including EPA contractors, the Environmental
Response Team, the OSC in Edison, other EPA Regions, and
other agencies. We believe the Region should have a member
of its health and safety staff with the expertise to provide
the technical guidance that Superfund and RCRA field
personnel require. This need for hazardous waste safety
information should become more acute within the next year
when the construction phase commences on many Superfund
sites managed and overseen by the Region.
The Region's need for qualified, competent personnel in its
safety program was expressed in an August 14, 1987 memorandum
requesting graduate school courses for the Health and Safety
Officer. In the memorandum, the Chief, FAME, stated a
desire to provide the employee with "important graduate level
skills in the occupational health and safety field... to
increase proficiency in the key elements of her job." The
Chief, FAME added that the employee was the only health
and safety professional in the Region and no one else was
available to perform her duties.
We believe that the Region's Occupational Health and Safety
program has not been adequately staffed so as to provide
the necessary expertise needed by employees involved in
moderate and high risk work areas. While the individual
currently comprising the health and safety staff has
contributed to an improved program, the Region needs to
add to its health and safety staff an individual with
sufficient expertise to advise management and staff about
moderate and high risk areas. Employees engaged in these
activities should have someone available in-house to provide
necessary information and guidance and not have to seek
outside assistance.
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Region's Comments to Draft Report
The Region in its response disagreed with the presentation of
the draft audit finding. The Region stated it utilized the
temporary appointment authority because this enabled it to
bring the individual on board as quickly as possible while
maintaining the flexibility of taking immediate personnel action
if the individual did not perform adequately.
The Region detailed the current incumbent's background, job
experience and qualifications that led to the decision of her
enventual hiring. The individual's experience included one and
one-half years of health and safety experience at a firm which
was a subsidiary of Johnson and Johnson. Her duties included
participating in the development of health and safety policies
and performing industrial hygiene surveys, accident investiga-
tions, machinery audits, employee training and medical surveil-
lance. The response also enumerated the excellent job she
has done and her various program accomplishments.
The Region also stated that management had made the decision to
hire the individual based on several factors including the
contribution she could make to the program and her potential for
leadership. It pointed out that the appointment was discussed
with the Agency's safety program director prior to offering the
individual the position, and approval was received.
With regard to health and safety resources, the Region stated
that its "health and safety staff is, indeed, complemented by
regional program staff and contractor personnel." The Region's
approach was "to have a small health and safety staff supplemented
by a variety of other resources." Thus, the Region's own large
program staff had outlets from which to seek necessary advice.
In this way the Region "has maximized all available resources in
order to protect the health and safety of its employees."
Auditor's Response
We have restructured our final audit finding to better focus on
our concerns about adequate staffing and managerial experience
for the Region's health and safety program and the need for
moderate and high risk expertise on the Region's health and
safety staff.
The Region made a management decision to replace its prior Health
and Safety Manager (GS-11) due to unsatisfactory performance.
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As a result, another decision was made to hire a replacement
at the GS-7 level. A vacancy announcement was issued allowing
applicants only eight days to apply. From the two applicants,
the Region decided to hire a young, bright, recent college
graduate, who had 14 months of work experience in the health
and safety field, to comprise its full-time safety staff. While
this individual has apparently performed well and contributed
to and improved health and safety program, we believe the Region
should have sought a more qualified individual with managerial
and field experience in the safety area or at least supplemented
the current one person staff with another individual with field
expertise. This would have been consistent with EPA Order 1440.5
requirements.
We further believe that while collateral duty personnel or
outside contractors complement the current safety staff. Regional
Superfund and RCRA personnel should have in the Region someone
who can be available full time to provide necessary field safety
expertise. As we noted in the body of the finding the DHSS1
Model Program states that the Regional Health and Safety staff
should consist of a Health and Safety Manager and full-time
and collateral duty staff. Especially with an essentially young
and inexperienced Superfund and RCRA field staff, the Region
should have a centralized figure to whom employees can consult
as a technical expert.
Recommendation
We recommend that you:
1. Consider supplementing the health and safety staff with
a full-time permanent health and safety specialist
who has sufficient expertise concerning moderate and
high risk work areas.
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2. IMPROVEMENT NEEDED IN MEDICAL MONITORING PROGRAM
Region 2 was permitting field personnel to work at Superfund
and RCRA sites without receiving required initial medical
monitoring examinations prior to their assignment or
termination examinations when leaving the Agency. This
occurred because Regional management had inadequate controls
to ensure that medical monitoring requirements were met,
and there was no Regional policy to conduct termination
examinations. As a result, employees were being potentially
exposed to hazardous substances without adequate baseline
information or assurance to the Agency that they were fit
for duty. Furthermore, the Agency was not assured of
employees' medical conditions prior to working for or
leaving the Agency and the Agency could not take action,
if necessary, to see that undisclosed health problems were
treated. In addition, the Agency could face the increased
risks of unwarranted litigation.
EPA Order 1440.2 establishes policy, responsibilities, and
mandatory requirements for occupational medical monitoring
of Agency employees engaged in field activities. This Order
states that it is the policy of the Environmental Protection
Agency to carry out its field activities in a manner that
assures the protection of its employees. It requires that
all employees routinely engaged in field activities which
present the probability of exposure to hazardous or toxic
substances, which are arduous or physically taxing, or
which require the use of respiratory protective equipment
shall be included in the Agency's Occupational Medical
Monitoring Program. Employees should not be permitted to
engage in field activities unless they have undergone a
baseline medical examination (as defined in the Agency's
Occupational Medical Monitoring Guidelines), which will
show physical fitness and provide a base to measure any
adverse effects their activities may have on these
individuals. The Order further requires EPA supervisors
to identify those employees who require medical monitoring,
assure they receive it, and insure this requirement is
contained in position descriptions and job postings.
OSHA regulation 29 CFR 1910 (f) (1) establishes the guide-
lines for a medical surveillance program. OSHA regulation
29 CFR 19lO{f}(2) requires the employer make available
examinations and consultations to each employee covered
at termination of employment or reassignment to an area
where the employee would not be covered if the employee
has not had an examination within the last six months.
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A medical monitoring program serves to "watch" over the
health of those employees whose work regularly poses the
possibility of exposure to toxic materials or other hazardous
working conditions. It is not a substitute for "general
checkup" or other periodic examinations to monitor or promote
general health. This program first establishes a baseline
and then screens for evidence of adverse effects of occupa-
tional exposure, particularly to toxic substances. The
program objectives are to: ensure fitness for duty;
detect adverse effects of occupational exposure; and initiate
prompt corrective action when needed.
In Region 2 employees who regularly conduct field work were
covered by the medical monitoring program, but this coverage
was being expanded to persons who occasionally go into
the field. Physical examinations and all medical monitoring
were provided by the U.S. Public Health Service (PHS).
Our review disclosed that the Region had made improvements in
its management of the program since the hiring of the current
Safety Officer. All personnel who required coverage under
the program were provided annual examinations. However,
we found areas of the medical monitoring program that
needed improvement.
a. Initial Examinations
The Region allowed employees to engage ir. field activities
such as environmental and pesticides sampling, and
hazardous material spills and waste site investigations,
inspections, and sampling before they received initial
baseline medical examinations. In addition, many examina-
tions were scheduled several months after personnel joined
the Agency.
Baseline examinations provide the Agency and the employee
with a measure by which any future adverse effects can be
weighed. It is essential that these be made in a timely
manner so that medical personnel can promptly analyze
individuals' conditions and the effect that working on
Superfund or RCRA activities have on their health. The
examinations also identify pre-existing conditions that
might limit or restrict an individual from performing
certain activities and provide data which may be important
in potential personal injury litigation situations.
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During the period of our review (December 1986 to
December 1987), the Region hired 20 individuals who
were subject to the medical monitoring program. While
all received initial examinations, seven of these
baseline examinations were not performed until four
to nine months after the employees began working at
EPA.
For example, in one instance an employee transferred
to EPA from a Technical Assistance Team (TAT) contractor
in May 1987 and immediately began work at the same
site, but in the capacity of an OSC. His duties
required him to be in "hot zones" which are moderate
and/or high risk work areas. He did not receive his
first medical monitoring examination until February
1988. The individual previously had a medical examina-
tion in January 1987 while employed on the TAT contractor,
four months prior to his EPA employment. The Regional
Personnel Specialist who processed the hiring waived
the baseline examination based on this fact. The
employee, however, did not sign a waiver form.
In another case, an OSC who had not had an initial
examination was required to undergo a cholinesteruse test
because of possible exposure to pesticides. An addition,
a heavy metal screen was given because of a possible
exposure to heavy metals (e.g. cadmium and lead). This
incident occurred more than two months after employment
with EPA began. The special test was run two weeks
later and the baseline examination was then performed
two weeks after that.
The Region needed to improve its controls to assure
that employees subject to the medical monitoring program
received timely baseline examinations, so that the
employee's fitness for duty was known. The Region has
initiated action to correct this weakness. On October 26,
1987, a policy memorandum was issued which made it a
requirement for new hires that will be subject to medical
monitoring, to have a baseline examination conducted as
a preemployment condition. This mandatory requirement
is now stated in their job description.
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The Region has also taken positive action concerning
the feedback received from PHS physicians. The Region
previously had not received information from physicians
regarding the employee's ability to carry out work
activities. Therefore, management had no information
concerning the employee's fitness for duty. However,
the Fiscal Year 1988 agreement with PHS requires
physicians to submit appraisals to the Region.
b. Termination Examinations
We also found that Region 2 had neither performed a
termination examination on employees leaving the
Agency for private sector or other government jobs
nor implemented the examination into the medical
surveillance program. Of the 29 Region 2 Superfund
and RCRA employees who left the Agency during the
period of our review, none received a termination
examination.
The Chief, FAME, stated that, it was his opinion that
while it would be preferable for termination examinations
to be conducted, it was unrealistic to expect departing
employees to undergo them. However, we could find no
evidence that the Region attempted to educate employees
about the benefits of undergoing these examinations, nor
was there any evidence to support the Chief, FAME,
intention that employees would not be willing to take the
tests. Further, it is our position that termination
examinations provide a benchmark of the employee's
health status at the time he or she leaves the Agency.
Should they later suffer an illness that might be a
result of exposure to toxic material, the Region
would have medical documentation to cover the period
of employment. Such documentation can protect EPA
from being potentially vulnerable to liability suits.
Furthermore, the Occupational Safety and Health Guidance
Manual for Hazardous Waste Site Activities (prepared by
four Agencies, including EPA) recommends termination
examination as an effective surveillance component to
complement other controls. We believe that these
examinations are essential to assess and monitor
employee's health and the quality of the safety program.
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Region's Comments to Draft Report
The Region acknowledged that some problems were posed to the
administration of the medical monitoring program by the rapid
staff build-up of the hazardous waste program. Supervisors in
some instances did utilize newly hired personnel in priority
field activities before baseline examinations could be
administered. However, the Region stated that it independently
took the necessary steps to remedy this problem and established
procedures to track the medical monitoring needs of new hires
from the inception of the recruitment process. Medical
monitoring examinations were scheduled for all covered employees
and each request for Personnel Action (SF-52) must include a
certification by the hiring official as to whether or not medical
monitoring coverage is required for that position.
The Region further noted that the case involving the employee
with the possible pesticide exposure was a unique situation.
The employee in question was hired for the summer and was
subsequently converted to a full-time status as OSC. As a
result of that conversion, an oversight occurred which resulted
in the employee by-passing the normal procedure of enrolling all
new hire OSCs in the medical monitoring program.
The Region also agreed that termination examinations were a
problem area. It stated that it could not force departing
personnel to undergo a termination examination, and such
personnel frequently gave the Agency relatively little notice
to arrange such an exam. The Region plans to have a termina-
tion examination policy in place by the end of the second quarter
of FY 89.
Auditor's Response
We are pleased that the Region recognized the weaknesses existing
in the medical monitoring program and took or plans to take
corrective action. We noted for example, that except for one
instance, all our cited cases or statistics concerning initial
examinations occurred prior to the Region's October 26, 1987
policy memorandum.
Our draft report had included a recommendation for the Region not
to allow employees to engage in Superfund or RCRA field activities
unless they had undergone an initial baseline examination. Since
the Region has taken action to respond to this concern we have
deleted the recommendation from the final report.
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Recommendation
We recommend that you Implement a policy to perform termination
examinations in accordance with OSHA regulations.
3. REGION NEEDS TO ESTABLISH RESPIRATORY PROTECTION PROGRAM
Region 2 needed to establish a respiratory protection program
for its employees. There was no formal written program,
personnel were not always following proper safety precautions,
there was a lack of equipment, fit tests were not conducted,
equipment was not routinely maintained, and recordkeeping was
inadequate. This occurred because the Region's respiratory
protection program was still somewhat in the formative stages.
The program was only in the draft stage and there was no
respiratory protection program designee. As a result,
management could not be assured that personnel had been
properly trained in safety procedures and had adequate,
well-maintained equipment.
OSHA regulation 29 CFR 1910 (3)(ii) states that personal
protective equipment should be selected and used to
protect employees from the hazards and potential hazards
they are likely to encounter during the site characterization
and analysis. In addition, 29 CFR 1910(5) states that a
personal protective equipment program shall be established
for hazardous waste operations. This program must cover
selection and purchase of respirators, issuing policy and
procedures, training in proper respirator use, fit testing,
personal hygiene, and respirator maintenance, storage,
and repair. Furthermore, 29 CFR 1910.134 requires management
personnel to establish and operate a respiratory protection
program to adequately protect its employees.
EPA Order 1440.3 Respiratory Protection, dated July 24, 1981,
sets out the Agency policy* responsibilities, and basic
requirements for a respiratory program to protect its
employees whose jobs require the use of respiratory protective
devices. EPA management is required to establish and
implement a respiratory protection program at each Agency
location where employees may encounter atmospheres that
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contain or are suspected of containing unhealthy quantities
of airborne contaminants or atmospheres with insufficient
oxygen content, or where there is the threat of an imminent
release of toxic agents. Respiratory protection may also
be necessary for routine but infrequent operations and
for non-routine operations in which the employee is exposed
briefly to high concentrations of a hazardous substance,
i.e., during maintenance or repair activities, or during
emergency conditions.
EPA's policy is to carry out its field activities in a
manner that assures the protection of its employees. The
Occupational Safety and Health Guidance Manual for Hazardous
Waste Site Activities requires employees to obtain as
much information as possible on a particular site {site
characterization) before site entry so that the hazards can
be evaluated and preliminary controls instituted to protect
initial entry personnel. This information is used as the
basis for selecting the protective equipment for site entry.
We found the Region's respiratory protection program was still
somewhat in the formative stages. The following details
the results of our review.
a. Lack of Respiratory Protection Program
The Region lacked a formal respiratory protection program
although required under EPA Order 1440.3. The Region's
program was still in the draft stage and there was
no respiratory protection program designee. Therefore,
written Regional operating procedures were not developed
which addressed such areas as the issuance of respiratory
equipment, the conducting of fit testing, the conducting
of respiratory training, and the maintenance and use
of respiratory equipment.
The OHSS Respiratory Protection Program Guideline
{February 1983) states that:
As a minimum a respiratory protection program must
contain all the elements outlined in EPA Order
1440.3. These requirements are:
a. Approved respiratory protective devices must be
properly selected.
b. There must be a determination of the need for
respiratory protective devices.
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c. An employee training program must be established
in which the employee becomes familiar with the
respiratory protective devices and is trained in
the proper selection and use of respirators
and their limitations.
d. There must be provisions for:
Proper inspection, maintenance, storage and
repair of respiratory protective devices.
Assigning respiratory protective equipment to
employees for their exclusive use, where
practical.
Testing for the proper fit of the respiratory
protective equipment.
Surveillance of the work area and for employee
exposure and stress.
Medical screening of each employee assigned to
wear respiratory protective devices to determine
if he/she is physically and psychologically able
to wear a respirator.
e. Written standard operating procedures must exist for
the selection and use of respiratory protective
devices.
The Guideline also states that:
Management at each EPA location where it has been
determined a Respiratory Protection Program is
required should designate one person responsible for
administering the program at that location. This
person should have the responsibility for the entire
respiratory program and develop the standard operat-
ing procedures.
The Region had assigned the preparation of a respiratory
protection program to the Response Prevention Branch safety
committee representative. A working draft of this program
had been prepared in October 1987. However, as of June
1988, it still had not been issued.
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The lack of a program impacts upon the degree of assur-
ance management has that personnel have been properly
trained in safety procedures and have adequate, well-
maintained equipment. The deficiencies noted in the
other subsections of this finding are directly related
to the absence of a formal respiratory protection
program.
b. improper Respiratory^ Protection Worn By Employees
Prudent safety policy requires that individuals obtain
sufficient information about the hazards at a site so
they can select appropriate protective equipment.
During the period of our review, there was one incident
where two Edison employees entered a Superfund site
without adequate respiratory protection and were
potentially exposed to pesticides including several
suspected carcinogens.
On September 1, 1987, two OSCs and a New Jersey Department
of Environmental Protection (NJDEP) employee toured a
hazardous waste site in Moorestown, New Jersey. They
were outfitted in only Level D protection. Level D
protection provides no repiratory protection and only
minimal skin protection. In 1986 NJDEP reported this
site as having various hazardous wastes including
DDT, ODD, ethylene oxide, hexachlorophene, Alpha BHC,
and 2, 4-dichlorophene. Several of these can lead to
dioxin formation, while others are suspected carcinogens.
These employees should have been clothed in Level B
protection. In fact, the safety plan subsequently
prepared for this site indicated that the anticipated
level of protection during the assessment phase would
be Level B with probable upgrading during sampling.
The plan also noted "high" personnel exposure hazards
for inhilation, skin contact, and ingestion.
Field Standard Operating Procedures for Site Entry No. 4
published by the Office of Emergency and Remedial
Response states"
Personnel entering sites of hazardous
substance incidents must use adequate
safety precautions to minimize
exposure to a host of contaminators
which may have long term or immediate
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health effects... In situations
where the type(s) of chemical(s),
concentration(s) and possibilities
of contact are not well characterized,
experienced professionals must select
the appropriate level of protection
based on potential exposure, until
the hazards can be better characterized.
The Occupational Safety and Health Guidance Manual,
Chapter 6, Site Characterization states "the ensemble
of clothing and equipment referred to as Level B
protection is generally the minimum level recommended
for an initial entry until the site hazards have been
further identified and the most appropriate protective
clothing and equipment chosen." Level B protection
includes the wearing of a pressure demand, full facepiece
self-contained breathing apparatus (SCBA) or a
pressure-demand supplied-air respirator with escape
SCBA. Level D protection requires no respiratory
protection.
At the time of this site visit one of the OSCs was
experienced in emergency response removals while the
other had only been employed by EPA for two months.
The latter OSC had not (i) had an initial medical
monitoring examination (it was conducted October 7,
1987), (ii) had the required 40 hours of initial
training {it was received September 21 to 25, 1987),
(iii) received a fit test to certify use of respi.ratory
protection equipment (the test was conducted October 8,
1987).
Once the OSCs1 supervisor was appraised of the incident
a cholinesterase test and a heavy metal screen were
scheduled. The results of the September 25, 1987
medical test disclosed no adverse effects on the
employees.
A formalized Regional respiratory protection plan
could have helped prevent this incident since written,
standard operating procedures would have been available
for employees' guidance. While fortunately the employees
apparently suffered no ill effects, in the area of
hazardous waste safety even one incident is too many.
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c. Equipment Safety, Inspection, Maintenance and
Recordkeeping in Needof Improvement
The Region needs to greatly improve the operational
aspects of its respiratory protection program to meet
the requirements of EPA Order 1440.3. Superfund and
RCRA staff lacked equipment, fit tests were not conducted,
equipment was not routinely maintained, and recordkeeping
was inadequate.
We found, for example, that very few personnel in the
Emergency and Remedial Response Division's Remedial
Action Branches had been assigned respiratory equipment.
These individuals are responsible for overseeing
Federal Lead Superfund remedial sites. The Division
was aware of the problem and ordered equipment which was
finally received in April and May 1988. According to
both Branch Chiefs, the lack of equipment had not
affected the functioning of the offices because such
equipment was not usually necessary until the construction
phase commenced. Very few Superfund sites had reached
that phase, though many are expected to during Fiscal
Year 1989.
Fit testing was not conducted on a regular basis until
late 1987, and then only at the Edison Facility.
Fit testing for New York Regional employees was not
scheduled until July 1988. The proper fitting of
respiratory protective devices requires the use of some
type of fit test. The fit test is needed to determine
a proper match between the facepiece of the respirator
and the face of the user.
Fit testing at Edison was conducted by a Response and
Protection Branch OSC for personnel in his Branch and
the Environmental Services Division (BSD). Previously,
records were not maintained to document fit test
certification or maintenance of equipment. Furthermore,
Regional Superfund personnel had to rely on fit tests
conducted by EPA site contractors. The Chief, New Jersey
Remedial Action Branch, and the Chief, Southern New Jersey
Remedial Section, advised us that their equipment had not
been tested by EPA, but rather their fit tests were
performed by contractors at Superfund sites prior to
their admittance to those sites.
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An example of the importance of fit testing and routine
maintenance in general involved an incident that occurred
in November 1987 in Edison. A member of the Superfund
Support Section, Surveillance and Monitoring Branch, ESD,
had taken a mask for a fit test from an empty office
where masks were stored. The test disclosed a quarter
inch hole in the mask where a component was missing.
Since documentation associated with this mask was
nonexistent, there was no evidence to determine the
past history of the mask usage, inspections or maintenance,
Therefore, there was no assurance that another employee
had not been unnecessarily exposed to anything harmful
by using this malfunctioning equipment.
The OHSS Respiratory Protection Program Guideline states
that "Scrupulous respirator maintenance must be made an
integral part of the overall respirator program. Wear-
ing poorly maintained or malfunctioning respirators
is in one sense, more dangerous than not wearing a
respirator at all."
We believe the Region needs to take prompt action to enact a
respiratory protection program for its employees to assure that
they are adequately trained, properly equipped, and have the
necessary guidance for safe performance at work sites.
Region's Comments to Draft Response
The Region stated that the deficiencies identified in the audit
were substantially resolved. Besides the receipt of needed
respiratory equipment and the conducting of regular fit testing
which we have previously reported on, a Regional respiratory
protection program designee has been assigned? respiratory
equipment will be provided to all trained personnel requiring
it; a routine maintenance program was established; and a
recordkeeping system has been developed. In addition, the
formal Regional respiratory protection program is expected to
be issued in final by March 1989.
With regard to the case detailed in this finding, the Region
stated that it was ic State-lead site and as such, the State
was responsible for on-site health and safety. The State site
manager determined, that Level D was appropriate. The Region
disagreed that a formalized respiratory protection plan could
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have avoided the incident, since a respiratory protection
plan contains general guidelines and procedures for wearing
respiratory protection, but is not designed to take the place
of a site-specific safety plan.
Auditor's Response
We are pleased that the Region initiated action to comply with
the recommendation in the draft audit report. Therefore, we
are deleting from the final report the recommendations concerning
assignment of a respiratory protection program designee; provision
of equipment to necessary personnel; establishment of a routine
maintenance program; timely conduction of fit testing; and
implementation of an adequate recordkeeping system for all
equipment and personnel in the program. The final recommenda-
tion will be complied with when the formal respiratory protection
program is issued in March 1989.
Concerning the example, while the incident occurred at a State-
lead site, it still could have resulted in a potentially serious
outcome. EPA field employees must be extremely careful at all
hazardous waste sites, State or Federal level. The various
regulations, orders, guidance and manuals cited in our finding
reiterate that concern, while a formal respiratory protection
plan may not take the place of a site-specific safety plan, its
establishment would set forth the tenets of the program and
better emphasize to employees their responsibilities. An
improved understanding of general safety practices could help
individuals avoid problems in the future.
Recommendation
We recommend that you establish a formal Regional respiratory
protection program.
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APPENDIX 1
DISTRIBUTION
Recipient
Office of Inspector General
Inspector General (A-109)
Deputy Inspector General
Divisional Inspector General for Audit,
Internal Audit Division
Director, Audit Operations Staff
Other Divisional Inspectors General
for Audit
Headquarters Liaison
Regional Office
Acting Regional Administrator, Region 2
Audit Followup Coordinator
Headquarters
Comptroller (PM-225}
Agency Followup Official (PM-208)
Agency Followup Official (PM-225)
Attn: Director, Resource Management Division
Audit Followup Coordinator (PM-208)
Attn: Program Operations Support Staff
o
V)
1
O
o
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