U.S. Environmental
Protection Agency
Safety, Health and
Environmental Audit Protocol
September 1992
Safety, Health and Environmental
Management Division
401 M Street, SW
Washington, DC 20460
Printed on Recycled Paper
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NOV I 7 1993
U.S. ENVIRONMENTAL PROTECTION AGENCY
SAFETY AUDIT PROTOCOL
OPERATING UNIT:.
TEAM MEMBERS:
DATES OF REVIEW:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA safety audit program. It is intended to serve as a guide for
planning and conducting an evaluation of operating unit-level safety management systems and
internal controls. The protocol may require additions, revisions or other modifications to meet the
needs of specific operating unit assessments. The purpose of assessing EPA facility safety
management programs is to confirm that appropriate systems are in place and functioning effectively
to achieve continued compliance with applicable safety regulations and minimize EPA's risks.
SECTION XII — SAFETY
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U.S. ENVIRONMENTAL PROTECTION AGENCY
SAFETY AUDIT PROTOCOL
Table of Contents
Section Page Number
A. Introduction XII-1
B. Walking-Working Surfaces XII-2
C. Laboratory Fume Hoods and Local Exhaust Systems XII-4
D Hazardous Materials XII-6
E. General Environmental Controls XII-7
F. Material Handling and Storage XII-9
G. Machinery and Machine Guarding XII-10
H. Welding, Cutting, and Brazing XII-12
I. Electrical XII-13
J. Indoor Air Quality XII-15
K. Evaluation of Findings XII-19
SECTION XII — SAFETY
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U.S. ENVIRONMENTAL PROTECTION AGENCY
SAFETY AUDIT PROTOCOL
Table of Contents
Section Page Number
A.
B.
C.
D
E.
F.
G.
H.
I.
J.
K.
Introduction
Walking- Working Surfaces
Laboratory Fume Hoods and Local Exhaust Systems
Hazardous Materials
General Environmental Controls
Material Handling and Storage
Machinery and Machine Guarding
Welding, Cutting, and Brazing
Electrical
Indoor Air Quality
Evaluation of Findings
XII- 1
XII-2
XII-4
XII-6
XII-8
XII- 13
XII- 15
XII-18
XII- 19
XII-24
XII-28
Appendix A - Electrical Equipment Working Clearance
SECTION XII — SAFETY
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PROTOCOL
RESPONSE
COMMENTS
XII. SAFETY MANAGEMENT
A. Introduction
Background Information
1) Review the following background information before
arriving at the operating unit (If it is not available
before conducting the field work, review information
as early in the visit as possible):
a) Facility diagrams and floorplans
b) Description of primary facility
activities/operations
c) Previous safety audit reports or inspections of
the facility
2) Review the following background information related
to safety management programs and activities prior to
the on-site visit (If it is not available prior to
conducting the field work, review information as early
in the field visit as possible):
a) EPA and facility-specific safety directives and
orders
b) EPA and facility-specific safety operating
manuals and procedures
c) Organizational charts and staffing tables
d) Training and employee orientation documents
e) Applicable Federal, state and local regulations
XII-l
SAFETY
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f) Completed facility safety, health and
environmental pre-audit questionnaire.
Opening Meeting
3) The audit Team Leader will meet with facility
management and staff to provide an overview of the
objectives, scope and methodology, including
' approach and reporting for the review.
Preliminary Tour
4) Tour the facility to gain a general understanding of the
facility layout and operations. (NOTE: The tour is
intended only as an orientation step.)
Audit Planning
5) Based on your initial understanding of the facility and
operations as well as review of the completed pre-audit
questionnaire, develop a plan for conducting the audit.
Information Gathering and Finding Development
6) Using the safety management audit protocol provided
in the following section, perform the review of the
facility for compliance with applicable policies,
regulations and recommended professional practices.
B. Walking-Working Surfaces
Using information gained from the facility and the facility
orientation tour, verify that walking-working surfaces in the
facility meet applicable safety standards by completing the
following investigations.
XII-2
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COMMENTS
General Requirements
7)
8)
9)
10)
11)
Verify that all places of employment, such as
passageways, storerooms, and service rooms, are
clean and maintained in a sanitary condition [29 CFR
are
Verify that aisles and passageways are kept clear and in
good repair, with no obstruction across or in aisles that
could create a hazard [29 CFR 1910.22(b)(l)].
Verify that permanent aisles and passageways a
appropriately marked [29 CFR 1910.22(b)(2)].
Verify that ladders are maintained in reliable condition
[29 CFR 1910.25(b)(l) and .26(c)(2)(iv)].
Verify that floor load capacities are approved by the
building official. Note whether the building owner
marked load capacities on plates of approved design
and securely affixed them in a conspicuous location in
each space to which they relate. Typically, this relates
to spaces used for mercantile, storage or industrial
purposes, such as print shops, computer rooms, etc.
[29 CFR 1910.22(d)(l)].
Guarding Floor and Wall Openings and Holes
12) Verify that stairway floor openings are guarded by
standard railings on all exposed sides (top and
intermediate rails, railing height of 42 inches is
standard) [29 CFR 1910.23(a)(l)].
XII-3
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COMMENTS
13) Determine whether all floor openings into which
persons may accidentally walk are guarded by either
standard railings with toeboards or floor hole covers of
appropriate strength and construction [29 CFR
1910.23(a)(8)(i) and (ii)].
14) Determine whether floor holes which persons cannot
accidentally walk are protected by a cover that has
openings not more than 1 inch wide [29 CFR
1910.23(a)(9)].
15) Verify that flights of stairs with four or more risers are
equipped with standard stair railings or handrails [29
CFR 1910.23(d)(l)].
16) Verify that a standard toe rail is installed for railings
provided for an open-sided floor or a platform four feet
or more above the adjacent floor, if the open side is
above an area where:
a) A person can pass
b) There is moving machinery
c) Falling materials could create a hazard
[29 CFR 1910.23 (c) and (e)(4)].
C. Laboratory Fume Hoods and Local Exhaust
Systems
Determine whether the facility uses fume hoods or local
exhaust systems to control occupational exposure to toxic
substances. If so, verify the effectiveness facility's
engineering controls management program by conducting the
following investigations.
XII-4
SAFETY
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RESPONSE
COMMENTS
17) Verify that laboratories are provided with one-pass air
and maintained at negative pressure relative to
surrounding areas [EPA 4870 FS 1-07(10)].
18) Verify through a documentation review that hoods are
certified annually. Certification requires an average
face velocity of 100 to 120 feet per minute (FPM)
[EPA 4870 FS 1-05(13)].
19) Confirm through a documentation review that new
hoods or hoods that have undergone significant
maintenance are performance tested prior to use [EPA
4870 FS 1-05(13)].
20) Confirm that air movement (from make-up systems) at
the face of the hood does not exceed 25 FPM.
(NOTE: Measurements should be performed with the
hood exhaust in the off position) [EPA 4870 FS 1-05
(13)]
21) Determine that individual exhaust systems are provided
for each fume hood. (NOTE: Combining exhaust
systems for fume hoods in the same laboratory room
may be considered if users are aware of other fume
hood operations) [EPA 4870 FS 1-05(13)].
22) Determine that an audible and visual alarm system is
provided to verify the operation of hood exhaust fans
[EPA 4870 FS 1-05(13)].
23) Verify that perchloric acid hood systems (hoods, ducts
and fans) are posted with a service risk, constructed
with non-reactive, acid resistant materials, and
provided with a wash down system.
(NOTE: Perchloric acid should only be used in
perchloric acid hoods.) /EPA 4870 FS 1-05(13)].
XII-5
SAFETY
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COMMENTS
24) Verify that hood exhaust stacks extend at least 7 feet
above the roof level [EPA 4870 FS 1 -05(13)].
25) Verify through a documentation review and cursory
testing (using a sound level meter) that noise exposure
at the working position of the hood does not exceed 70
dbA [EPA 4870 FS 1-05(13)].
26) Verify that analytical instruments that produce toxic
vapors or aerosols are provided with local exhaust or
placed within a hood [EPA Occupational Health and
Safety Manual, 1440, Chapter 8(3)(b)(4)].
D. Hazardous Materials
Evaluate the facility's program for managing hazardous
materials by completing the following procedures:
(NOTE: Additional requirements for managing hazardous
materials are outlined in the Fire and Life Safety Protocol)
Compressed Gas Cylinders
27) By reviewing facility records and interviewing facility
personnel, determine whether visual safety inspections
of gas cylinders are conducted [29 CFR 1910.101(a)].
28) Verify that high pressure cylinder supply lines are
securely anchored every 5 feet [EPA 4870-1 FS 1-
07(6)].
29) Verify that flasks of cryogenic materials (- 100°F) are
not stored in places of routine access by non-involved
personnel (e.g. corridor) [EPA 4870-1 FS 1-07(6)].
Xll-6
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COMMENTS
30) Verify that the number of flammable gas and oxygen
cylinders does not exceed six in a sprinklered
laboratory and three in a nonsprinklered laboratory
[EPA 4870-IPS 1-07(6)].
31) Verify that gas cylinders are legibly marked identifying
the gas content [29 CFR 1910.101(a)].
32) Confirm that cylinders are securely supported in an
upright position via chain, nylon strap or metal
channel. (NOTE: Gang chaining is prohibited in
laboratories) [EPA 4870 FSI-07(6)].
33) Verify that cylinders are not used as rollers, supports,
or for any purpose other than to contain content as
received [29 CFR 1901.101(b)].
34) Confirm that cylinder valves are closed except when
the cylinder is in use [29 CFR 1910.101 (b)].
35) Confirm where gases of different types are stored,
cylinders are grouped by type of gas. (NOTE: Full
and empty cylinders should be stored separately) [29
CFR 1910.101(b)].
36) Verify that cylinders stored inside a building are not
located near exits, stairways, or in areas intended for
the safe exit of personnel [29 CFR 1910.101(b)].
37) Confirm that removable caps are maintained in place
until the cylinder valve is connected to equipment [29
CFR 1910.101(b)].
XII-7
SAFETY
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PROTOCOL
RESPONSE
COMMENTS
38)
Verify that a pressure regulator and pressure relief
device are used where gas is admitted to a system of
lower pressure rating than the supply pressure, and
where, due to the gas capacity of the supply source,
the system rating may be exceeded [29 CFR
Confirm that gas cylinders are not located where they
may become part of an electric circuit [29 CFR
39)
E. General Environmental Controls
Using information gained from the facility and the facility
orientation tour, evaluate the effectiveness of the facility's
environmental controls by completing the following
investigation.
Sanitation
40) Verify that all areas of the facility are kept clean [29
CFR 1910.141(a)(3)].
41) Confirm that receptacles used for solid or liquid waste
are constructed to ensure the receptacle does not leak
and may be thoroughly cleaned and maintained in a
sanitary condition [29 CFR 1910.141(a)(4)].
42) Verify that an enclosed workplace is constructed,
equipped, and maintained to prevent the entrance or
harborage of rodents, insects and other vermin [29
CFR 1910.141(a)(5)].
43) Confirm that potable water is provided in places of
employment [29 CFR 1910.141(b)(l)].
XII-8
SAFETY
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PROTOCOL
RESPONSE
COMMENTS
44) Verify that toilet facilities are provided in places of
employment [29 CFR 1910.141(c)(l)].
45) Verify that washing facilities are maintained in a
sanitary condition [29 CFR 1910.141(d)(l)].
46) Verify that there is no consumption of food or
beverages, smoking, chewing gum or tobacco,
application of cosmetics or storage of utensils, food or
food containers in any laboratory area [EPA
Occupational Health and Safety Manual, Chapter 8].
Confined Space
47) Determine if the facility contains permit required
confined spaces. If so, evaluate the effectiveness of
the Permit Required Confined Space Program through
interviews with selected employees and a review of
facility records. The Permit Required Confined Space
Program should include:
a) Hazard identification and control
b) Safe entry procedures and practice
c) Permit system
d) Information and training
e) Prevention of unauthorized entry
f) Rescue procedures and equipment
g) Contractor permit confined space hazard
information (if applicable)
[Proposed 29 CFR 1910.146(c)].
Xll-9
SAFETY
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COMMENTS
Accidental Prevention Signs and Tags
48) Confirm that caution signs are used to warn against
potential hazards or to caution against unsafe practices
[29CFR 1910.145(c)(2)]
49) Verify that safety instruction signs are used where
there is a need for general instructions and suggestions
relative to safety measures [29 CFR 1910.145(c)(3)].
(NOTE: Tags need not be used where signs,
guarding, or other positive means of protection are
used.)
50) Confirm that danger tags are used in major hazard
situations where the immediate hazard presents a threat
of death or serious injury to personnel [29 CFR
1910.145(f)(5)].
51) Verify that caution tags are used in minor hazard
situations where non-immediate, potential hazard or
unsafe practice presents a lesser threat of personnel
injury. (NOTE: Warning tags may be used to
represent a hazard between caution and danger.)
[29 CFR 1910.145(f)(6)]
52) Confirm that biological hazard tags are used to identify
actual or potential biological hazards [29 CFR
1910.145 (f)(8)].
Control of Hazardous Energy
53) Verify that the facility has a program for managing
employee maintenance of equipment that is capable of
unexpected energization [29 CFR 1910.147(c)(l)].
XIMO
SAFETY
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PROTOCOL
RESPONSE
COMMENTS
54) Confirm that procedures have been developed,
documented and utilized for the control of hazardous
energy [29 CFR 1910.147(c)(4)(i)].
(EXCEPTION: Where all of the following
elements exist for a machine or equipment the facility
need not document the energy control procedure:
a) Equipment has no potential for stored,
residual or reaccwnulation of stored energy
after shutdown which could endanger
personnel
b) Equipment has a single energy source which
can be readily identified and isolated
c) Isolation and locking out of the energy source
will completely deenergize and deactivate the
equipment
d) Equipment is isolated from the energy source
and locked out during maintenance
e) Locked-out condition will be achieved with a
single lock-out device
f) Lock-out device is under the control of the
authorized employee performing maintenance
g) Maintenance does not create a hazard for
other personnel
h) No accidents involving the unexpected
activation or energization of the equipment
have occurred
XII-ll
SAFETY
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PROTOCOL
RESPONSE
COMMENTS
55)
56)
57)
58)
59)
Verify that energy control procedures outline the
scope, purpose, authorization, rules and techniques to
be used for the control of hazardous energy, and the
means to enforce compliance [29 CFR
Confirm that lock-out and tag-out devices are
singularly identified and not used for purposes other
than controlling energy [29 CFR 1910.147(c)(5)(ii)].
Verify that lock-out and tag-out devices are capable of
withstanding the environment to which they are
exposed for the maximum period of time that exposure
is expected [29 CFR 1910.147(c)(5)(ii)(A)].
Verify through facility records and interviews with
facility personnel that annual inspections of the energy
control procedure are conducted [29 CFR
Confirm certification of employee training. Training
elements should include:
a) Authorized Personnel - Hazardous energy
sources available at the facility and the methods
for energy isolation and control
b) Affected Personnel - Purpose and use of the
energy control procedure
c) Other Employees Who Work in the Area Where
Energy Control Procedures May be Used -
Prohibition procedures relating to reenergize
locked-out or tagged-out equipment
[29CFR1910.147(c)(7)(iv)].
XII-12
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COMMENTS
60) Verify that retraining is provided for authorized or
affected personnel whenever there is a change in
assignments, equipment, or processes present a new
hazard, or a change in the energy control procedures
[29 CFR 1910.147(c)(7)(iii)(A)].
61) Confirm that lock-out or tag-out procedures are only
performed by authorized personnel who are
performing the maintenance [29 CFR 1910.147(c)(8)].
F. Material Handling and Storage
Using information gained from the facility and the facility
orientation tour, evaluate the effectiveness of the facility's
material handling and storage program by completing the
following investigation.
62) Verify that material storage does create a hazard (e.g.
limited in height and stable) [29 CFR 1910.176(b)].
63) Verify that storage areas are free from tripping, fire,
explosion or pest hazards [29 CFR 1910.176(c)].
64) Confirm that clearance limit signs are provided [29
CFR 1910.176(e)]
Powered Industrial Trucks
65) Verify that facilities for battery charging include spill
control, fire protection, ventilation and protection from
physical damage [29 CFR 1910.178(g)(2)].
66) Confirm that a conveyor, overhead hoist or equivalent
material handling equipment is provided for handling
batteries [29 CFR 1910.178(g)(4)].
XII-13
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RESPONSE
COMMENTS
67) Confirm through selected employee interviews and
facility records that only trained authorized operators
are permitted to operate powered industrial trucks [29
CFR 1910.178(1)].
68) Verify that concentration levels of carbon monoxide do
not exceed the permissible exposure limit (35 parts per
million) [29 CFR 1910.178(i)(l)].
i •
69) Verify that only approved powered industrial trucks are
designated to enter hazardous atmosphere locations [29
CFR 1910.178 (c)(2)].
70) Confirm that power-operated industrial trucks not in
safe operating condition are removed from service [29
CFR 1910.178(q)].
Cranes and Derricks
71) Verify, depending on the frequency of use, that either
frequent (daily to monthly) or periodic (1 to 12 month
intervals) crane/derrick inspections are conducted [29
CFR 1910.179(j)(D(ii) and .181(d)(ii)].
72) Confirm that a crane/derrick preventive maintenance
program has been established [29 CFR 1910.179(1)(1)
i and .181(f)(l)].
73) Verify monthly certification of crane/derrick running
ropes [29 CFR 1910.179(m)(l) and .181(g)(l)].
74) Verify that the rated load capacity of the crane/derrick
is clearly designated [29 CFR 1910.179(b)(5) and
XII-14
SAFETY
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COMMENTS
Verify that only designated personnel are permitted to
operate a crane or derrick [29 CFR 1910.179(b)(8) and
75)
G. Machinery and Machine Guarding
Evaluate the effectiveness of the facility's machine guarding
program by examining the following procedures:
76) Evaluate the methods of machine guarding and
determine whether one or more methods are provided
to protect the operator and other employees in the
vicinity of the machine(s) from hazards such as those
created by point of operation, ongoing nip points, or
rotating parts [29 CFR 1910.212(a)(l)].
77) Verify that guards are affixed directly to machines,
where feasible, and secured elsewhere if for any
reason attachment to the machines is not possible [29
CFR 1910.212(a)(2)].
78) Determine whether the point of operation of machines
whose operation exposes the operator to injury are
properly guarded to prevent injury [29 CFR
1910.212(a)(3)].
79) Evaluate whether all machines designed for a fixed
location are securely anchored to prevent walking or
movement [29 CFR 1910.212(b)].
XH-15
SAFETY
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COMMENTS
Woodworking
80)
81)
82)
83)
84)
85)
86)
Determine if there is a means to prevent woodworking
machinery from automatically restarting after
restoration of power from a power failure or shutdown
[29 CFR 1910.21 3(b)(3)].
Verify that the cutting head on a radial arm saw will
gently return to the starting position when released [29
CFR 1910.213(h)(4)].
Verify that radial saws used for ripping are equipped
with anti-kickback devices [29 CFR 1910.213(h)(2)].
Confirm that an adjustable stop is provided on radial
saws to prevent the forward travel of the blade beyond
the position necessary to complete the cut in repetitive
operations [29 CFR 1910.21 3(h)(3)].
Verify that there is a power shut-off switch within
reach of the woodworking operator position [29 CFR
Confirm that band saw blade are enclosed or guarded,
except for the working portion of the blade between the
bottom of the guide rolls and the table [29 CFR
Verify that a hand-fed planer or jointer with a
horizontal head is equipped with a cylindrical cutting
head; the knife projection should not exceed one-eighth
inch beyond the cylindrical body of the head [29 CFR
1910.2130)0)1
XIM6
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COMMENTS
87) Verify that noncurrent-carrying metal parts of portable
electric woodworking machines operated at more than
90 volts are grounded [29 CFR 1910.213(a)(l 1)].
88) Confirm that profile and swing-head lathes have
cutting heads covered by a metal guard, and wood-
turning lathes have cutting heads covered as completely
as possible by hoods or shields [29 CFR
1910.213(0)].
89) Confirm that self-feeding sanding machine feed rolls
are protected with a semicylindrical guard to protect the
operator's hands from contacting the in-running rolls
[29 CFR.1910.213(p)].
90) Verify that dull, badly set, improperly filed or
improperly tensioned saws are removed from service
[29 CFR 1910.213(s)(l)].
91) Verify that knives and cutting heads are sharp, adjusted
and secured [29 CFR 1910.213(s)(2)].
92) Confirm that woodworking machines are maintained in
a sanitary manner [29 CFR 1910.213(s)(6)].
93) Confirm that cracked saws are removed from service
[29 CFR 1910.213(s)(7)].
Abrasive Wheel Machinery
94) Verify that the work rest on abrasive wheel machinery
is within one-eighth inch of the wheel [29 CFR
1910.215(a)(4)].
XII-17
SAFETY
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RESPONSE
COMMENTS
95) Confirm that the adjustable tongue on the top side of
the grinder is within one-fourth inch of the wheel [29
CFR 1910.215(b)(9)].
96) Verify that guards cover the spindle, nut and flange of
abrasive wheel machinery [29 CFR 1910.215(a)(2)].
Portable Power Tools
97) Verify that compressed air used for cleaning machinery
is controlled (less than 30 p.s.i., chip guarding and
personal protective equipment) [29 CFR 1910.242(b)].
98) Verify that portable power tools are used and
maintained with appropriate safety guards [CFR
1910.242(a)].
H. Welding, Cutting and Brazing
Evaluate the effectiveness of the facility's welding, cutting and
brazing program by examining the following procedures:
99) Verify that before welding or cutting is permitted, the
area is inspected by the individual responsible for
authorization, and precautions are designated [9 CFR
1910.252 (a)(2)(iv)].
100) Confirm that management designates an individual
responsible for authorizing welding and cutting in
areas not designed for such processes [29 CFR
1910.252(a)(2)(xiii)(B)].
101) Verify that management advises contractors about
hazardous conditions [29 CFR 1910.252
XII-18
SAFETY
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COMMENTS
102)
103)
104)
105)
I .
106)
Confirm that supervisors are responsible for the safe
handling of cutting or welding equipment and the safe
use of cutting and welding process [ 29 CFR
1910.252(a)(2)(xiv)].
Verify through interviews of selected employees and
facility records that authorized personnel and their
supervisors are trained in the safe operation of welding
and cutting equipment [CFR 1910.252(a)(2)(xiii)].
Confirm that welding and cutting personnel are
protected from hazards (non-ionizing radiation, heat,
noise, fumes and gases) by appropriate personal
protective equipment and clothing (e.g., helmets, hand
shields, face shields, aprons) [29 CFR 1910.252(b)(2)
and (3)].
Verify through the facility orientation tour and facility
records that ventilation is provided to maintain
concentration levels of toxic fumes, gases or dust
below their respective PEL (e.g., cadmium, fluorine
compounds, zinc, mercury, ozone, beryllium, copper,
nickel, phosgene and magnesium) [29 CFR
Electrical
Inspect electrical equipment to verify that it is free from
recognized hazards (e.g., equipment is U.L. listed,
insulation rating is appropriate, proper grounding and
polarity, no frayed cords, etc.) that are likely to cause
death or serious injury to employees [29 CFR
1910.303(b)(l)].
XII-19
SAFETY
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COMMENTS
107) Verify that no electrical equipment is used unless the
manufacturer's name, trademark, or other descriptive
marking identifying the organization responsible for
the product is provided [29 CFR 1910.303(e)].
108) Verify that all disconnect means and circuits are legibly
marked to designate its purpose [29 CFR
1910.303(f)]-
109) Verify that all electrical installations operating at 50
volts or more are constructed to guard all live parts
from unqualified personnel. If live parts are accessible,
verify that the installation is accessible to qualified
personnel only [29 CFR 1910.303(g)(2)].
110) Confirm that access to live parts operating at 600 volts
or less and likely to require examination or
maintenance while alive are not less than required in
Appendix A [29 CFR 1910.303 (g)(l)(i)].
Ill) Verify that a conductor used as a ground conductor is
identifiable and distinguishable from other conductors
[29 CFR 1910.304(a)(l)].
112) Confirm that a grounding device on a receptacle, cord
connector, or attachment plug is not used for purposes
other than grounding [29 CFR 1910.304(a)(3)].
113) Verify that outlet devices have an ampere rating no less
than the load to be served [29 CFR 1910.304(b)(2)].
XII-20
SAFETY
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RESPONSE
COMMENTS
1 14)
115)
1 16)
117)
1 1 8)
119)
120)
Verify that a means is provided to disconnect
conductors in a building from the service-entrance
conductors. (NOTE: The disconnecting means
should indicate the open or closed position and be
installed at a readily accessible location nearest the
entrance of the service-entrance conductors) [29 CFR
1910.304(d)(l)].
Confirm that conductors and equipment (600 volts or
less) are protected from overcurrent in accordance with
their ability to safely conduct current [29 CFR
1910.304(e)].
Verify that fuses and circuit breakers are located or
shielded to ensure personnel will not be injured by
their operation [29 CFR 1910.304(e)(l)(v)].
Confirm that circuit breakers clearly indicate whether
they are in the off or on position. (NOTE: Circuit
breaker handles should be operated vertically or
rotationally. The up position of the handle should be
the on position) [29 CFR 1910.304(e)(l)(vi)].
Verify that wiring systems are not installed in ducts
used to transport dust, loose stock, or flammable
vapors [29 CFR 1910.305(a)(l)(ii)].
Confirm that flexible cords and cables are protected
from accidental damage [29 CFR 1910.305(a)(2)
Verify that cabinets, cutout boxes, fittings, boxes and
panelboard enclosures in damp or wet locations are
installed to prevent moisture or water from entering the
enclosure [29 CFR 1910.305(e)(l)].
XII-21
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RESPONSE
COMMENTS
121) Confirm that switches, circuit breakers and
switchboards installed in wet locations are enclosed in
weatherproof enclosures [29 CFR 1910.305(e)(2)].
122) Verify that flexible cords and cables are approved and
suitable for conditions of use and location.
(NOTE: Flexible cords and cables should only be
usedfor:
a) pendants
b) wiring affixtures
c) connections of portable lamps or appliances
d) elevator cables
e) connection of stationary equipment to
facilitate the frequent interchange
f) prevention of the transmission of noise or
vibration
g) appliances where the fastening means and
mechanical connections are designed to
permit removal for maintenance and repair;
h) data processing cables)
[29 CFR 1910.305(g)(l)]
123) Confirm that flexible cords and cables are not:
a) Substituted for fixed wiring a structure
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b) Run through holes in walls, ceilings, or floors
c) Run through doorways or windows
d) Attached to building surfaces
e) Concealed behind walls, ceilings, or floors
[29CFR1910.305(g)(l)(iii)].
124) Verify that color coded ground fault circuit interrupters
(GFCIs) are used for all receptacles in:
a) Aquatic laboratories
b) Previous experience indicates GFCI use
c) All outside receptacles
d) Equipment requiring GFCI by the manufacturer
e) Contact with wet surfaces [EPA 4870, FS1 -06
(19)].
125) Evaluate temporary electrical power and lighting to
determine whether they meet minimum permanent
installation requirements as to grade and class.
Temporary electrical wiring is permitted during
remodeling, maintenance or repair operation;
experimental or developmental work; or not to exceed
90 days for decorative lighting (e.g., Christmas lights)
[29 CFR 1910.305(a)(2)].
126) Verify that all temporary wiring has grounding type
receptacles [29 CFR 1910.305(a)(2)(iii)(Q].
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127) For data processing systems, verify that a means is
provided to disconnect all power to all electronic
equipment and room air conditioning systems. The
disconnect must be readably accessible at the exit door
area [29 CFR 1910.306(e)].
128) Verify that equipment, wiring and installation in
hazardous locations is intrinsically safe for the
hazardous location [29 CFR 1910.307(b)].
129) Verify that space heaters are not used in laboratories,
hazardous material storage areas, or administrative
spaces [EPA 4870, FS 1-05(11)].
J. Indoor Air Quality
Ventilation is one of the most critical factors affecting indoor
air quality. Other factors are physical (e.g., dusts), chemical
(e.g., cleaners) and biological (e.g., fungus/molds) materials
present in the facility. The following ASHRAE Guidelines and
EPA Policy Requirements are provided to help the auditor
observe obvious indoor air quality problems.
130) Verify that the ventilation distribution system (both
return and supplies) is visible in each room and free
from obstructions/blockage [ASHRAE 62-1989].
131) Verify that ventilation systems are designed to prevent
recirculation of contaminants (e.g., air intakes should
not be located near cooling towers, vehicle exhaust or
laboratory exhaust systems) [EPA 4870, FS 1-05
(12)].
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132) If soil contains high concentrations of radon, determine
whether ventilation practices or building design
features should exist to remove radon gases from
under foundation and basement areas. These areas
should not be designed to be at less than atmospheric
pressure [ASHRAE 62-1989].
133) Review records to determine if the following
parameters have been tested and compared to the noted
requirements:
a) Temperature and Humidity:
1. Summer: Maximum 78 degrees F
and 60% Relative Humidity (RH)
2. Minimum: 68 degrees F and 30% RH
[ASHRAE 62-1989]
b) Carbon Dioxide should not exceed 1000 parts
per million (ppm) [EPA 4870, FS1-05(12)].
c) Carbon Monoxide:
1. Shops and industrial areas -18 ppm
2. Offices and laboratories - 9 ppm
[EPA Facilities Safety Manual, 4870, FS1-
05(12)].
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d) Formaldehyde:
1. Shops and industrial areas - 0.5 ppm
2. Offices and laboratories - 0.1 ppm
[EPA 4870, FS 1-05(12)].
e) Fresh Air Supply: 15 cubic feet per minute
(CFM) of outdoor air (OA) per person, non-
smoking office environment, 20 CFM of
outdoor air per person in laboratories and 60
CFM of outdoor air per person in smoking
lounges [EPA 4870, FS 1-05(12)].
If the above tests reveal measurements that are outside
guidelines, verify that appropriate corrective actions
were implemented by the building engineer under the
direction of a qualified indoor air quality professional
[ASHRAE62-1989].
134) Review the ventilation design to ensure that specialty
areas, such as rest rooms, locker rooms, smoking
lounges, etc., are exhausted directly to the outside with
no recirculation [ASHRAE 62-1989, Table 2].
135) Verify that the facility institutes and documents a
HVAC maintenance program [EPA 4870, FS 1-
05(12].
136) Review HVAC maintenance program documentation to
verify:
a) Air filters are changed and replaced as specified
[EPA 4870, FS 1-05(12)]
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137)
b) Periodic, on-site cleaning of cooling coils and
condensation pans are performed as specified
[EPA 4870, FS 1-05(12)] [ASHRAE 62-1989]
c) HVAC duct and air handler room cleaning
[EPA 4870, FS 1-05(12)]
d) Biological testing of water in cooling towers
and condensation drip pans [EPA 4870, FS1-
05(12)]
e) If steam is used as a source of humidification,
the boiler steam and steam supply additives
should not be used[ASHRAE 62-1989]
f) If cold water humidifiers are used, the water
supply should come from a potable source
[ASHRAE 62-1989]
g) If cold potable water is recirculated,
maintenance and blow-down specifications
must be followed [ASHRAE 62-1989]
h) Standing water used in conjunction with water
sprays in a HVAC distribution system should
be treated as specified with microbial
inhibitors. [ASHRAE 62-1989]
Review complaint records at both the medical center
and the building engineer office to verify that indoor air
quality complaints, symptoms and corrective actions
are documented. Documentation should include:
a) List of symptoms
b) Dates, times and durations of symptoms
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c) Specific building areas of complaint
d) Investigation results (e.g., source of potential
pollutant, HVAC measurements, etc.)
e) Corrective actions.
[EPA Building Air Quality: A Guide for Building
Owners and Facility Managers]
K. Evaluation of Findings
138) Review actions taken to complete each step of the audit
protocol and summarize your conclusions as to the
- facility's status.
139) Review and discuss any unresolved issues with
appropriate facility personnel. Note explanations and
the disposition of issues in your working papers.
140) Develop a written list of exceptions and observations.
Discuss this list at a team meeting prior to the exit
conference to substantiate the trends or identify overall
patterns or trends.
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U.S. ENVIRONMENTAL PROTECTION AGENCY
OCCUPATIONAL HEALTH AUDIT PROTOCOL
OPERATING UNIT: DATES OF REVIEW:,
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA occupational health audit program. It is intended to serve
as a guide for planning and conducting an evaluation of operating unit-level occupational health
management systems and internal controls. The protocol may require additions, revisions or other
modifications to meet the needs of specific operating unit assessments. The purpose of assessing
EPA facility occupational health management programs is to confirm that appropriate systems are in
place and functioning effectively to achieve continued compliance with applicable occupational health
regulations and minimize EPA risks.
SECTION XIII — OCCUPATIONAL HEALTH
-------
U.S. ENVIRONMENTAL PROTECTION AGENCY
OCCUPATIONAL HEALTH AUDIT PROTOCOL
Table of Contents
Section
A. Introduction
B. Occupational Health and Environmental Controls
C. Hazardous Materials
D. Personal Protective Equipment
E. Health and Safety Programs for Federal Agencies
F. Diving
G. Toxic and Hazardous Substances
H. Medical Surveillance
I. Evaluation of Findings
Appendix B, 10 CFR 20
Appendix C, 10 CFR 20
Diving Safety
Page Number
xm-1
XIII-3
XIII-13
XIII-24
XIII-26
XIII-31
XIII-33
XIII-47
XIII-47
Attachment A
Attachment B
Attachment C
SECTION XIII — OCCUPATIONAL HEALTH
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XIII. OCCUPATIONAL HEALTH MANAGEMENT
A. Introduction
Background Information
1) Review the following background information before
arriving at the operating unit (If it is not available
before conducting the field work, review information
as early in the visit as possible):
a) Facility diagrams and floorplans
b) Description of primary facility
activities/operations
c) Previous occupational health audit reports or
inspections of the facility.
2) Review the following background information related
to occupational health management programs and
activities prior to the on-site visit (If it is not available
prior to conducting the field work, review information
as early in the field visit as possible):
a) EPA and facility-specific occupational health
directives and orders
b) EPA and facility-specific occupational health
operating manuals and procedures
c) Organizational charts and staffing tables
d) Training and employee orientation documents
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e) Emergency response programs/plans
f)
g)
Applicable Federal regulations
Completed facility safety, health and
environmental pre-audit questionnaire.
Opening Meeting
3) The audit Team Leader will meet with facility
management and staff to provide an overview of the
objectives, scope and methodology, including
approach and reporting for the review.
Preliminary Tour
4) Tour the facility to gain a general understanding of the
facility layout and operations. (NOTE: The tour is
intended only as an orientation step.)
Audit Planning
5) Based on your initial understanding of the facility and
operations as well as a review of the completed pre-
audit questionnaire, develop a plan for conducting the
audit.
Information Gathering and Finding Development
6) Using the occupational health audit protocol provided
in the following section, perform the review of the
facility's compliance with applicable policies,
regulations and recommended professional practices.
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B. Occupational Health and Environmental
Controls
Ionizing Radiation
Ionizing radiation includes alpha rays, beta rays, gamma rays,
X-rays, neutrons, high-speed electrons, high-speed protons
and other atomic particles. Evaluate the effectiveness of the
facility's radioactive materials management program by
examining the following procedures.
7) Verify through a documentation review and interviews
with selected employees that employee exposure to
ionizing radiation does not exceed:
a) Whole Body: 1-1/4 Rems per calendar quarter
b) Hands/forearms: feet/ankles: 18-3/4 Rems per
calendar quarter
c) Skin of whole body: 7-1/2 Rems per calendar
quarter
Note the following exceptions:
a) The whole body dose does not exceed 3 Rems
in a calendar quarter
b) The dose to the whole body when added to the
whole body occupational dose does not exceed
5 (N-18) Rems, where "N" is the individual
age
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c) Exposure records demonstrate that an
additional dose will not exceed the applicable
limit [29 CFR 1910.96(b)(l) and (2).]
8) Verify that employee exposure (40 hours in any work
week of seven consecutive days) to airborne
radioactive material does not exceed the average
concentrations specified in Table 1 of Appendix B, 10
CFR 20. If the number of hours of exposure exceeds
40, then the limits specified in the table should be
decreased proportionately [29 CFR 1910.96(c)(l)].
9) Verify that employees who are likely to receive a dose
within a calendar quarter in excess of 25 percent of the
applicable dose or who enter a high radiation area are
appropriately monitored (film badges/pocket
dosimeters) [29 CFR 1910.96(d)].
10) Confirm that each radiation area is conspicuously
posted with a sign bearing the radiation caution symbol
and the words:
Caution
Radiation Area
[29 CFR 1910.96(e)(2)].
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11) Confirm that each high radiation area is conspicuously
posted with a sign bearing the radiation caution symbol
and the words:
Caution
High Radiation Area
[29 CFR 1910.96(e)(3)(i)].
and a control device which will either reduce radiation
below a dose of 100 milligrams in one hour upon entry
into the area or a visible or audible alarm that notifies
the employee and the employer of entry into the area
(NOTE: Control devices are not required for high
radiation areas established for 30 days or less.)
[29 CFR 1910.96(e)(3)(ii)].
12) Confirm that areas containing airborne radioactivity are
conspicuously posted with a sign bearing the radiation
caution symbol and the words:
Caution
Airborne Radioactivity Area
[29 CFR 1910.96(e)(4)(ii)].
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13) Confirm that areas in which radioactive material is used
or stored and which contains any radioactive material
(other than natural uranium or thorium) in an amount
exceeding 10 times the amount specified in Appendix
C, 10 CFR 20, are posted with a sign bearing the
radiation symbol and the words:
Caution
Radioactive Materials
[29 CFR 19l0.96(e)(5)(i)].
14) Confirm that areas in which natural uranium or thorium
is used or stored in an amount exceeding 100 times the
amount specified in 10 CFR 20, are posted with a sign
bearing the radiation symbol and the words:
Caution
Radioactive Materials
[29 CFR 1910.96(e)(5)(ii)].
15) Verify the containers of radioactive materials (other
than natural uranium or thorium) in amounts greater
that the quantity specified in Appendix C, 10 CFR 20
and containers of natural uranium or thorium in
amounts greater than 10 times specified in Appendix
C, 10 CFR 20 have a durable, clearly visible label
bearing the radioactive symbol and the words:
Caution
Radioactive Materials
The label should also identify type and quantity of
radioactive material [29 CFR 1910.96(e)(6)(i)].
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16)
17)
(NOTE: Containers of radioactive material that do
not exceed the amount specified in Table 1,
Appendix B, 10 CFR 20 and laboratory containers
used transiently for laboratory procedures in which
the user is present are exempt from this requirement)
[29 CFR 1910.96(e)(6)].
Verify that radioactive storage containers state the
quantity and type of radioactive material and the date of
measurement of quantity [29 CFR 1910.96(e)(6)(iv)].
Confirm that exceptions to posting of signs are in
accordance with the following provisions:
a) A room or area is not required to be posted if
the radiation source is sealed and the radiation
level 12 inches from the surface of the source
container does not exceed 5 millirem per hour.
b) Medical facilities are not required to be posted
if personnel in attendance take precautions to
prevent radiation exposure in excess of
established limits.
c) Areas or rooms are not required to be posted if
the room contains radioactive material for less
than 8 hours and the materials are constantly
attended by individuals who take precautions to
prevent radiation exposure in excess of
established limits [29 CFR 1910.96(g)].
18) Determine if the facility is governed by the Nuclear
Regulatory Commission (NRC), or a State Program.
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For facilities governed by the NRC:
19) Verify that workers in or frequenting a restricted area
are:
a) Informed of storage, transfer and use of
radioactive materials and radiation in the area
[10CFR 19.12].
b) Instructed in health protection; precautions or
procedures to minimize exposure; purposes and
function of protective devices; their
responsibility to report license violations; the
appropriate response to warning of unusual
conditions; and radiation exposure reports that
they may request [10 CFR 19.12].
20) Confirm that current copies of the following
documents are posted for the information of the
worker:
a) Title 10 CFR Parts 19 and 20
b) Form NRC-3, "Notice to Employees"
c) License, license conditions or documents
incorporated into a license by reference and
amendments thereto
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d) Operating procedures applicable to the licensed
activities.
e) Notice of violation involving radiological
working conditions and any response from the
license or a notice which describes these
documents and states where they may be
examined [10CFR19.il].
For facilities not governed by the NRC:
21) Verify that the workers in or frequenting a radiation
area are:
a) Informed of the occurrence of radioactive
materials or of radiation in the area
b) Instructed in the safety problems and
precautions associated with exposure to
radioactive materials
c) Instructed in applicable sections of 29 CFR
1910.96 regulating worker exposure and
protection from radioactive materials
d) Advised of radiation exposure reports that they
may request [29 CFR 1910.96(i)(2)].
22) Confirm that current copies of operating procedures
applicable to radiological activities are posted
conspicuously or are available for examination by the
worker [29 CFR 1910.96(i)(3)].
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23) Verify that radioactive materials stored in a non-
radioactive areas are secured against unauthorized
removal [29 CFR 1910.96(j)].
24) Verify that the disposal of radioactive material is
managed by an authorized recipient or in a manner
approved by the NRC or by or an approved State
program [29 CFR 1910.96(k)].
25) Verify that the facility has established procedures for
reporting incidents to the appropriate governing
authority 29 CFR 1910.96(1)].
Nonionizing Radiation
Nonionizing radiation (radio frequency region of the spectrum)
includes radiation originating from radio stations, radar
equipment and other possible sources of electromagnetic
radiation.
26) Confirm that employee exposure to electromagnetic
energy of frequencies from 10 MHz to 100 GHz does
not exceed the recommended guide of 10
averaged over a 0.1 hour period [29 CFR
1910.97(a)(2)].
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Occupational Noise Exposure
Evaluate the effectiveness of the facility's hearing conservation
program by considering the following:
27)
28)
29)
30)
31)
Determine whether the facility has a program covering
all work areas where employee noise exposures equal
or exceed an 8-hour time-weighted average sound level
of 85 decibels measured on the A scale. (If no
exposures equal or exceed the above values, do not
complete audit steps 28 through 43) [29 CFR
Verify that sound level monitoring programs are
developed whenever information indicates that an
employee's exposure may equal or exceed an 8-hour
time-weighted average of 85 decibels [29 CFR
Verify that sound level monitoring is repeated
whenever a change in equipment or controls increases
noise exposures [29 CFR 1910.95(d)(3)].
Determine whether employees exposed at or above an
8-hour time-weighted average of 85 decibels are
notified of the results from the monitoring [29 CFR
1910.95(e)].
Determine whether affected employees or their
representatives are provided with the opportunity to
observe any noise measurements conducted [29 CFR
1910.95(f)].
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32)
33)
34)
35)
36)
37)
38)
Evaluate the facility's audiometric testing program and
determine whether it is provided for all employees
whose exposures equal or exceed an 8-hour time-
weighted average of 85 decibels [29 CFR
Verify that audiometric tests are performed by a
licensed or certified audiologist, otolaryngologist, or
other physician, or by a technician certified by the
Council of Accreditation in Occupational Hearing
Conservation [29 CFR 1910.95(g)(3)].
Verify that baseline audiograms are established for
employees within 6 months of their first exposure at or
above the action level to compare with subsequent
audiograms [29 CFR 1910.95(g)(5)].
Determine whether new audiograms are obtained from
employees at least annually after obtaining the baseline
audiogram [29 CFR 1910.95(g)(6)].
Verify that employee's annual audiograms are
compared against baseline audiograms to determine
whether the audiogram is valid and if a standard
threshold shift has occurred [29 CFR 1910.95(g)(7)]
Verify that employees are informed in writing within
21 days of any determination indicating the occurrence
of a standard threshold shift from their audiograms
(baseline and annual) [29 CFR 1910.95(g)(8)].
Determine whether hearing protection is provided and
used by employees exposed to an 8-hour time-
weighted average of 85 decibels or greater [29 CFR
1910.95(i) (1) and (2)].
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39)
40)
4 1 )
42)
43)
Verify that all employees exposed to noise at or above
an 8-hour time-weighted average of 85 decibels are
required to participate in a training program [29 CFR
Verify that training is repeated annually for employees
included in the hearing conservation program [29 CFR
1910.95(k)(2)].
Determine whether copies of the 29 CFR 1 9 1 0.95
standard have been provided to affected employees and
posted in a conspicuous location in the workplace [29
CFR 1910.95(1)0)].
Evaluate the accuracy of employee exposure
measurement records and verify that they are
maintained for at least 2 years [29 CFR 1910.95(m)(l)
and (3)(i)].
Verify that employee audiogram test records are
retained for the duration of the affected employee's
employment [29 CFR 1910.95(m)(2) and (m)(3)(ii)].
C. Hazardous Materials
Evaluate the facility's program for managing hazardous
materials by completing the following procedures.
XIII-13
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Rcon/ttic* rr
CO r~ xsuxj i_
COW
1MENTS
Hazardous Waste Operations
44) Verify that personnel working at a hazardous waste site
and exposed to health and safety hazards received the
following training:
a) Names of personnel responsible for site safety
and health
b) Safety and health hazards present on the site
c) Use of personal protective equipment
d) Safe work practices
e) Safe use of engineering controls and equipment
f) Medical surveillance requirements, including
symptoms which may indicate overexposure to
hazards
g) Decontamination procedures
h) Emergency response plan
i) Confined space entry procedures.
45) Confirm that general site workers at a hazardous waste
site potentially exposed to hazardous substances and
health hazards receive no less than 40 hours of
instruction off site and three days of field experience
under the supervision of a trained, experienced
supervisor [29 CFR 1910.120(e)(3)(i)].
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46)
47)
48)
49)
50)
Verify that workers on site only occasionally for a
specific limited task and who are unlikely to be
exposed over permissible exposure limits (PEL)
receive a minimum of 24 hours of instruction off site
and one day of field experience under the direct
supervision of a trained, experienced supervisor [29
CFR
Confirm that workers regularly on site who work in
areas which have been monitored and fully
characterized indicating exposure under the PEL,
where respirators are not necessary and the
characterization indicates there are no health hazards or
the possibility of an emergency receive 24 hours of
instruction off site and one day of field experience
under the direct supervision of a trained, experienced
supervisor [29 CFR 1910.120(e)(3)(iii)].
Verify that on-site management and supervisors
directly responsible for or who supervise employees
engaged in hazardous waste site operations receive 40
hours of training and three days of supervised field
experience. (Training may be reduced to 24 hours and
one day if the only area of their responsibility is
employees covered by procedures 46 and 47 of this
protocol) [29 CFR 1910.120(e)(4)].
Confirm that personnel trained in hazardous waste site
operations receive a certificate of training [29 CFR
1910.120(e)(6)].
Verify that personnel engaged in emergency response
at hazardous waste sites are properly trained [29 CFR
1910.120(e)(7)].
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51) Confirm that personnel engaged in hazardous waste
activities receive eight hours of annual refresher
training [29 CFR 1910.120(e)(8)].
(NOTE: With documentation that employee work
experience or training has resulted in equivalent,
training, the employer need not provide initial
training requirements except for site-specific training)
[29 CFR 1910.120(e)(9)].
52) Verify through training records that the following
personnel have completed the appropriate level of
training:
a) Field employees should have completed a 24-
hour Basic course
b) Field employees involved in uncontrolled
hazardous waste sites and hazardous spill
investigations should have completed an 8-hour
Intermediate course and 24-hour Basic course
c) Field employees involved in managing basic
activities at field sites should have completed an
8-hour Advanced course, a 24-hour Basic
course and an 8-hour Intermediate course.
Also verify that all of the above personnel participate in
the medical surveillance program [EPA Order 1440.2].
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53) Confirm that a written safety and health program is
developed for employees involved in hazardous waste
site operations. The program should include the
following elements:
a) Organizational structure
b) Comprehensive work plan
c) Site-specific safety and health plan
d) Safety and health training program
e) Medical surveillance program
f) Safety and health standard operating
procedures
g) Interface between general program and site-
specific activities.
[29CFR 1910.120(b)(l)]
54) Confirm that a medical surveillance program is
implemented for employees:
a) Exposed to hazardous substances at or above
the PEL
b) Who wear a respirator 30 days or more a year
c) Injured, ill or develop symptoms due to
possible overexposure to a hazardous
substance
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55)
56)
57)
d)
Members of a HAZMAT team.
[29 CFR 1910.120(f)(2)]
Confirm that medical examinations are provided:
a) Prior to assignment
b) Every 12 months unless the examining
physician believes a longer interval is
appropriate
c) At termination or reassignment to an area where
the employee is not covered if the employee
had an examination within the previous six
months
d) Upon notification of symptoms of possible
overexposure to health hazards
e) If the examining physician determines that an
increased examination frequency is medically
necessary
[29CFR1910.120(f)(3)(i)]
Verify that medical surveillance records are maintained
for the duration of employment plus 30 years [29 CFR
1910.120(f)(8)].
Confirm that engineering controls, work practices and
personal protective equipment are implemented to
protect personnel from overexposure hazardous
substances and safety hazards [29 CFR 1910.120(g)].
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58) Confirm that air monitoring is used to identify and
quantify airborne levels of hazardous substances and
safety hazards to determine the appropriate level of
protection on site [29 CFR 1910.120(h)(ii)].
59) Verify that an emergency response plan is developed
for hazardous waste operations [29 CFR 1910.120(1)].
TSD Operations and Emergency Response
60) Confirm that a written safety and health program is
developed for employees involved in hazardous waste
operations. The program should address as
appropriate:
a) Site analysis
b) Engineering controls
c) Maximum exposure limits
d) Hazardous waste handling procedures
e) New technologies
[29CFR1910.120(p)(l)].
61) Verify that a medical surveillance program is
implemented in accordance with procedures 54 through
56 of this protocol [29 CFR 1910.120(p)(3)].
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62) Verify that employees exposed to health hazards
receive 24 hours of initial training and eight hours of
refresher training annually [29 CFR 1910.120(p)(7)].
(NOTE: With documentation that employee work
experience or training is equivalent to initial training,
the employer need not provide initial training) [29
CFR 1910.120(p)].
63) Confirm that an emergency response plan is developed
for TSD operations. (NOTE: Employers who
evacuate employees during an emergency and do not
permit them to assist in handling the emergency are
exempt from this requirement if an emergency action
plan complying with 29 CFR 1910.38 has been
established) [29 CFR 1910.120(p)(8)].
64) Verify that members of TSD facility emergency
response organizations are trained to a level of
competence in the recognition of health and safety
hazards [29 CFR 1910.120(p)(8)(iii)].
Emergency Response to Hazardous Substance Release
65) Confirm that an emergency response plan is developed
to handle anticipated emergencies (NOTE:
Employers who evacuate employees during an
emergency and do not permit employees to assist in
handling the emergency are exempt from this
requirement if an emergency action plan complying
with 29 CFR 1910.38 has been established.) [29 CFR
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66) Verify that the emergency response plan contains the
following elements:
a) Pre-emergency planning and coordination with
outside parties
b) Personnel roles, lines of authority, training and
communication
c) Emergency recognition and prevention
d) Safe distances and places of refuge
e) Site security and control
f) Evacuation routes and procedures
g) Decontamination
h) Emergency medical treatment and first aid
i) Emergency alerting and response procedures
j) Critique of response
[29 CFR 1910.120(q)(2)].
67) Verify that employees who are expected to participate
in emergency response are provided with the following
training:
a) First Response Awareness Level - Demonstrate
competency in: understanding the risks
associated with an incident; ability to recognize
the presence of hazardous substances; ability to
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identify hazardous substances; understanding
the role of the first responder awareness
individual; and the ability to realize the need for
additional resources and to notify the
communication center
b) First Responder Operations Level - Receive
eight hours of training or sufficient experience
to demonstrate competency in the following
elements in addition to the elements of the
awareness level: knowledge of basic hazard
and risk assessment techniques; selection and
use of personal protective equipment provided
to the first response level; perform basic
containment operations; understanding of basic
hazardous material terms; implementation of
basic decontamination procedures; and
understanding of standard operating and
termination procedures
c) Hazardous Material Technician - Receive no
less than 24 hours of training equal to the first
responder operations level and have
competency in the following areas:
implementation emergency response plan;
classifying, identifying and verifying of known
and unknown materials using field equipment;
functioning within an assigned role in the
incident control system; selecting and using
personal protective equipment; hazard and risk
assessment techniques; advance control and
containment operation; decontamination
procedures; termination procedures; and basic
chemical lexicological terminology and
behavior
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d) Hazardous Material Specialist - Receive no less
than 24 hours of training equal to the technician
level and, in addition, have competency in the
following areas: implementing emergency
response plan; classifying, identifying and
verifying known and unknown material by
using advanced field equipment; knowledge of
state emergency response plan; selecting and
using personal protective equipment; in depth
knowledge of hazard and risk techniques;
specialized control and containment operations;
determining and implementing decontamination
procedures; ability to develop a site safety and
control plan; and knowledge of chemical,
radiological and lexicological terminology and
behavior
e) On-Scene Incident Commander - Receive no
less than 24 hours of training equal to the first
responder operations level; in addition, have
competency in the following areas:
implementing incident command center,
implementing emergency response plan;
understanding the hazards and risks associated
with personnel working in chemical protective
clothing; implementing state emergency
response plan and the Federal Regional
Response Team; and decontamination
procedures.
[29CFR 1910.120(q)(6)]
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68) Confirm that emergency responders receive annual
refresher training or demonstrate competency annually
[29CFR 1910.120(q)(8)].
69) Verify that members of a HAZMAT team and
hazardous material specialist receive baseline physical
examinations in accordance with procedures 54
through 56 of this protocol [29 CFR 1910.120(q)(9)].
D. Personal Protective Equipment
Determine whether the facility's personal protective equipment
program is designed and implemented to ensure the safety of
personnel by performing the following:
70) Determine whether appropriate personal protective
equipment is provided, used and maintained in a
sanitary and reliable condition [29 CFR 1910.132(a)].
71) Verify that employees who perform animal
experimentation with toxic substances are provided and
use head cover, foot cover, gloves, jump suit or
complete clothing change and, if appropriate,
respiratory protection [EPA Occupational Health and
Safety Manual, Chapter 8].
72) Determine whether suitable eye protection is provided
to employees working with machines or operations that
present a hazard from flying objects, glare, liquids,
injurious radiation, or any combination of these
hazards [29 CFR 1910.133(a)(l)].
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73) Evaluate the overhead and foot exposures to determine
if hazards exist. If hazards exist, then verify that the
appropriate head and foot protection is used [29 CFR
1910.135 and. 136]
74) Verify that employees have access to first aid supplies
[29 CFR 1910.151(b)]
75) Verify that emergency eye wash stations and showers
are provided within the immediate work area of any
operations where the eyes or body may be exposed to
injurious corrosive materials [29 CFR 1910.151(c)].
76) Verify that the emergency showers and eyewash
stations are plumbed and capable of providing
15 minutes of water, by single action activation.
(NOTE: Eye washes should be capable of washing
both eyes simultaneously.) /EPA Facilities Safety
Manual, 4870-1,FS 1-07(12)].
Respiratory Protection
77) Determine whether engineering controls are feasible to
prevent occupational disease caused by breathing
atmospheric contamination during operation of
equipment or procedures. If not, verify through
interviewing selected employees and reviewing facility
records that employees are provided respiratory
protection as part of a respiratory protection program.
The respiratory protection program should include:
a) Written standard operating procedures
b) Selection
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E.
c) Fit testing
d) Inspection, cleaning, maintenance and storage
(NOTE: A record of inspection dates and
findings for emergency use respirators must be
maintained)
e) Medical examinations
f) Work area surveillance
g) Approved respirators
h) Program evaluation
i)
Training.
(NOTE: EPA Order 1440.3 requires six hours of
initial training and 2 hours of annual refresher
training) [29 CFR 1910.134].
Health and Safety Programs for Federal
Agencies
Using information gained from the facility and interviews of
selected employees, evaluate the effectiveness of the facility's
Health and Safety Programs by completing the following
investigation.
Reporting and Recordkeeping Occupational Injury and Illness
Evaluate the effectiveness of the facility's reporting and
recordkeeping program through examination of the following
procedures.
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78) Confirm that the Agency's Occupational Safety and
Health Program poster is displayed [29 CFR
1960.12(c)].
79) Verify through Office of Workers' Compensation
Program (OWCP) documents that all accidents and
illnesses are promptly investigated [EPA Occupational
Health and Safety Manual, 1440, Chapter 3].
80) Confirm that the facility maintains a log and
supplementary log of occupational injuries and
illnesses. (NOTE: If the logs are not maintained at
the facility, a copy of the logs updated within 6 months
of an injury or illness should be available at the facility)
[29 CFR 1960.67, .68 and 71].
81) Confirm that yearly totals of injuries and illnesses are
posted in each facility by November 14. The summary
report should remain posted for 30 consecutive days
[29 CFR 1960.69].
82) Verify that the occupational injury and illness logs are
maintained for 5 years [29 CFR 1960.73].
83) Confirm that the facility submits an annual narrative
report describing its occupational health and safety
program to SHEMD [EPA Occupational Health and
Safety Manual, 1440, Chapter 3].
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Inspections
84) Verify that formal (annual in-depth evaluations),
informal (unscheduled and frequent) and walk-through
(formal documentation not required) inspections are
conducted [EPA Occupational Health and Safety
Manual, 1440, Chapter 4].
Health and Safety Committee
85) Confirm that the facility has an active health and safety
committee that effectively represents all employees
[EPA Occupational Health and Safety Manual, 1440,
Chapter 5].
86) Verify that the committee meets at least quarterly,
develops meeting agendas, and records minutes [EPA
Occupational Health and Safety Manual, 1440, Chapter
5].
87) Evaluate the committee's policy and procedure
document to determine whether it addresses:
a) Scope and authority
b) Frequency and location of meetings
c) Recordkeeping
d) Attendance
[EPA Occupational Health and Safety Manual, 1440,
Chapter 5].
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Health and Safety Program Personnel Training
88) Evaluate the facility's training program to determine
whether supervisors receive training in:
a) Providing and maintaining healthful working
conditions
b) EPA's Health and Safety Program
c) Requirements of the Occupational Safety and
Health Act, Executive Order (EO) 12196 and
29 CFR 1960
d) Applicable health and safety standards
e) Procedures for reporting and investigating
accidents and illnesses
f) Recognition, evaluation and control of hazards
89) Evaluate the facility's training program to determine
whether Health and Safety Specialists receive training
in:
a) Development and management of a health and
safety program
b) Recognition, evaluation and control of hazards
c) Understanding EPA's Health and Safety
Program
d) Reviewing equipment and facilities designs for
safety
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e) Analysis of accident and illness data
[29 CFR 1960.56].
90) Evaluate the facility's training program to determine
whether collateral duty health and safety personnel
receive training in:
a) Understanding the Agency's health and safety
program and requirements of the Occupational
Safety and Health Act, EO 12196 and 29 CFR
1960
b) Reporting and recordkeeping procedures
c) Evaluating and controlling hazards
[29 CFR 1960.58].
91) Evaluate the facility's training program to determine
whether health and safety committee members receive
training in:
a) Understanding the Agency's health and safety
program and requirements of the Occupational
Health and Safety Act, EO 12196 and 29 CFR
1960
b) Reporting and investigating employee
allegations reprisals
c) Duties of committee members
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d) Identifying and using health and safety
standards [EPA Occupational Health and Safety
Manual, 1440, Chapter?].
92) Evaluate the facility's training program to determine
whether employees receive training that is appropriate
to the operations they perform and their rights and
responsibilities [29 CFR 1960.59].
Mine Safety Training
93) Confirm that employees who enter underground and
surface mines receive 8 hours of initial and 4 hours of
annual refresher training [EPA, 1440.4, Mine Safety].
F. Diving
Determine whether the facility conducts diving
operations. If so, evaluate the effectiveness of the
facility's diving program by verifying the following.
(NOTE: Attachment C, Draft EPA Diving Health and
Safety Protocol, outlines additional requirements for
diving operations).
94) Verify that the Unit Diving Officer, Dive Supervisor
and individual divers have been certified by the EPA
Diving Safety Committee Chairperson [EPA
Occupational Health and Safety Manual, 1440, Chapter
10].
95) Verify that divers participate in an annual diving
physical examination [EPA Occupational Health and
Safety Manual, 1440, Chapter 10].
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96) Verify that working divers (completed at least 15
dives), senior divers (completed at least 100 dives) and
diving instructors have attended the National Oceanic
and Atmospheric Administration (NOAA) "Diving
Accident Management" Class [EPA Occupational
Health and Safety Manual, 1440, Chapter 10].
97) Verify that the following personal and support
equipment are available for each dive site:
a) Flotation compensation device
b) Tank harness and weight belt
c) Tank pressure gauge
d) Diving watch
e) Decompression meter
f) Compass
g) Dive flag
h) First aid kit
i) Safety plan
j) Two-way radio/underwater communicator
k) Support tanks
[EPA Occupational Health and Safety Manual,
1440, Chapter 10].
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98) Verify that all dives are logged [EPA Occupational
Health and Safety Manual, 1440, Chapter 10].
99) Verify through facility records that all regulatory
valves, depth gauges and decompression meters are
calibrated and inspected by an appropriate specialist
every 18 months [EPA Occupational Health and Safety
Manual, 1440, Chapter 10].
G. Toxic and Hazardous Substances
Evaluate the effectiveness of the facility's management of toxic
and hazardous substances by conducting the following
investigation.
Air Contaminants (Non-Laboratory Areas) Status
100) Evaluate the facility's chemical exposure monitoring
program by preparing a list of substances that appear to
be significant based on permissible exposure limits,
quantity present, nature of process and degree of
toxicity. Cross check the list against monitoring data
to confirm the facility has identified potential employee
overexposure to chemical substances in the workplace.
Verify whether the actual versus potential exposures to
these chemicals have been determined [29 CFR
1910.1000].
Asbestos
101) Review the facility's 1985/1986 asbestos survey and
other subsequent surveys to assess the presence of
asbestos-containing material (ACM) in the facility. If
the surveys did not identify any ACM, request a copy
of the reports to review what building materials were
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sampled. The survey(s) should have been completed
in accordance with Guidelines for Controlling
Asbestos Containing Materials in Buildings.
102) If ACM was identified in the survey report(s) (and is
still present in the facility), obtain and document your
understanding of the asbestos management program
utilized by the facility to prevent employee exposure to
asbestos. The Operations and Management (O&M)
Program should include:
a) Location and description of Asbestos
Containing Material (ACM)
b) Inspection frequency
c) Procedures to control potential fiber release
episodes, either planned or unplanned
d) Removal and disposal procedures
e) Notification to all building workers, tenants,
and other building occupants, listing ACM
locations in their areas, how and why to avoid
disturbing the ACM and emergency reporting
procedures
f) Detailed recordkeeping of all activities
g) Air monitoring (optional).
[GSA Safety and Environmental Management
Program, PBS P5900.2c, Chapter 4-22c and EPA
560/5-85-024, June 1985 and 20T-2003, July 1990]
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103) If an occupational exposure to the asbestos action level
is expected, verify that employee exposure has been
monitored by breathing zone air samples representative
of the 8-hour time-weighted average (TWA) of each
employee [29 CFR 1910.1001(d)(l)(i)].
104) Determine whether airborne fiber concentration
monitoring is conducted at least semi-annually to
represent with reasonable accuracy the levels of
exposure for employees when occupational exposure
to the asbestos action level is expected [29 CFR
1910.1001(d)(3)].
Bloodborne Pathogens
105) Determine through observation, review of
documentation and interviews with select personnel
whether employees have an anticipated occupational
exposure to blood or other potentially infectious
material. If so, evaluate the effectiveness of the
facility's bloodborne pathogens program by examining
the following procedures.
106) Confirm that the facility has established an Exposure
Control Plan to minimize employee exposure. The
plan should contain the following elements:
a) Exposure determination
b) Universal precautions
c) Hepatitis B Vaccination and Post-Exposure
Evaluation and Follow-Up
d) Communication of hazards
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e) Recordkeeping
f) Procedure for the evaluation of exposure
incidents
[29 CFR 1910.1030(c)]
107) Verify that the Exposure Control Plan is available to
employees, and reviewed and updated no less than
annually or modified as appropriate to reflect new or
revised employee positions [29 CFR
19l0.1030(c)(l)(C)].
108) Confirm that the facility's exposure determination
contains a:
a) List of occupational exposure job
classifications
b) List of tasks and procedures in which
occupational exposure occurs
109) Verify that universal precautions are observed to
prevent contact with blood or other potentially
infectious material [29 CFR 1910.1030(d)(l)].
110) Confirm that engineering and work practice controls
are used to minimize employee exposure. (NOTE:
Engineering controls should be maintained regularly to
ensure effectiveness) [29 CFR 1910.1030(d)(2)].
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111) Verify that personnel wash hands after removal of
personal protective equipment or after contact with
potentially infectious material [29 CFR
1910.1030(d)(2)(v)and (vi)].
112) Confirm that contaminated reusable sharps are placed
in containers that are:
a) Leak proof
b) Puncture resistant
c) Labeled or color-coded
d) Easily accessible, maintained upright and
replaced routinely
[29 CFR 1910.1030(d)(2)(viii)].
113) Confirm that eating, drinking, smoking, applying
cosmetics and handling contact lenses are prohibited in
areas where there is a likelihood of occupational
exposure [29 CFR 1910.1030(d)(2)(ix)].
114) Verify that food and drink are not maintained in areas
where blood or other potentially infectious material is
present [29 CFR 1910.1030(d)(2)(xi)].
115) Confirm that mouth pipetting/suctioning of blood or
other potentially infectious material is prohibited [ 29
CFR 1910.1030(d)(2)(xii)].
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116)
1 17)
118)
1 19)
120)
121)
122)
Verify that specimens of blood or other potentially
infectious material are placed in a container which
prevents leakage during collection, handling,
processing, storage, transport, or shipping [29 CFR
1910.1030(d)(2)(xiii)].
Confirm that personal protective equipment (gloves,
gowns, laboratory coats, face shields, etc.) is
accessible, used and provided [29 CFR
1910.1030(d)(3)].
Verify that when personal protective equipment is
removed it is placed in a designated area for storage,
washing, decontamination, or disposal [29 CFR
1910.1030(d)(3)(viii)].
Verify that a schedule of cleaning and method of
decontamination has been established [29 CFR
1910.1030(d)(4)].
Confirm that receptacles intended for reuse which have
a likelihood of becoming contaminated with infectious
material are inspected and decontaminated on a
regularly scheduled basis and also cleaned and
decontaminated upon visible contamination [29 CFR
Verify that hepatitis B vaccine and vaccination series
are available for personnel who have an occupational
exposure, post-exposure evaluation and follow-up to
an exposure incident [29 CFR 1910.1030(f)].
Confirm that vaccinations are performed under the
supervision of a licensed physician or licensed health
care professional [29 CFR 1910.1030(f)(l)(ii)(D)].
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123) Confirm that a confidential medical evaluation is
immediately available following an exposure incident
[29CFR 1910.1030(0(3)].
124) Verify that warning labels are affixed to containers of
regulated waste, refrigerators and freezers containing
potentially infectious material, and other containers
used to store, or transport potentially infectious
material with the following exceptions:
a) Red bags or red containers
b) Containers of blood or blood products that are
labeled and have been released for clinical use
c) Individual containers of potentially infectious
material that are placed in a labeled container
during storage, transport or disposal
[29CFR 1910.1030(g)(l)]
125) Confirm that personnel with an occupational exposure
participate in a training program at the time of initial
assignment to tasks where occupational exposure may
take place, annually thereafter, and when modifications
of tasks or new tasks affect the employee's exposure.
The training program should include:
a) Copy of the standard and an explanation of its
content
b) Epidemiology and symptoms of bloodborne
disease
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c) Modes of transmission of bloodborne
pathogens
d) Exposure control plan
e) Methods of recognizing tasks that may involve
potentially infectious material
f) Engineering controls, work practices and
personal protective equipment
g) Hepatitis B virus
h) Emergency procedures
i) Reporting
j) Post-exposure evaluation
k) Signs and labels
[29 CFR 1910.1030(g)(2)]
126) Verify that training records include:
a) Date of training session
b) Summary of training session
c) Names and qualifications of persons
conducting the training
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127)
d) Names and job titles of persons attending the
training session.
[29CFR1910.1030(h)(2)]
Confirm that medical records are maintained for each
employee for the duration of employment plus 30 years
[29 CFR 1910.1030(h)].
Hazard Communication Program (Non-Laboratory Areas)
128) Evaluate whether the chemicals known to be present in
the workplace present an exposure hazard under
normal conditions of use or in a foreseeable
emergency. Evaluate whether a written hazard
communication program has been developed and
implemented in each work area. The hazard
communication program should include:
a) A list of hazardous chemicals known to be
present
b) Methods used to inform employees of chemical
hazards of non-routine tasks
c) Methods used to inform contractor employees
of hazardous chemicals they may be exposed to
d) A chemical labeling system
e) An employee information and training program
on the hazards if chemicals are routinely used
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f) A list of warning methods (i.e., list of Material
Safety Data Sheets (MSDSs) [29 CFR
1910.1200(e)].
129) Review records to determine whether they document
that all employees have received information and
training on hazardous chemicals in their work place at
the time of their initial assignment or when a new
hazard is introduced [29 CFR 1910.1200(h)]
130) Evaluate the training program to determine whether it
addresses:
a) Methods of observations used to detect the
presence or release of a hazardous chemical
b) Physical and health hazards of the chemical
c) Employee protection measures
d) Detail of the hazard communication program
e) Labeling system
f) MSDS explanation, availability and location
[29 CFR 1910.1200(h)(2)].
131) Verify that each hazardous chemical container is
labeled with the identity of the hazardous chemical and
the appropriate hazard warning or precaution. For
containers pre-labeled by the manufacturer, additional
labels are not required. If chemicals are transferred
from one container to another, labeling is required
unless used immediately by the employee who
performed the transfer [29 CFR 1910.1200(f)(5)(7)].
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132) Verify that copies of MSDSs or similar comprehensive
information are maintained for each hazardous
chemical in the workplace, and this information is
accessible to employees during each work shift when
they are in the work area [29 CFR 1910.1200(g)(8)].
Hazardous Chemicals in Laboratories
133) Verify the presence of a Chemical Hygiene Plan. The
plan should include each of the following elements:
a) Health and safety standard operating
procedures
b) Criteria to determine and implement control
measures to reduce employee exposure to
hazardous chemicals (e.g., engineering
controls, personal protective equipment and
hygiene practices)
c) Methods to ensure fume hoods and other
protective equipment are functioning properly
d) Circumstances under which laboratory
operations require prior approval from the
employer
e) Employee information and training
f) Medical consultations and medical
examinations
g) Chemical Hygiene Officer
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h) Additional employee protection for work
involving particularly hazardous substances
(e.g., select carcinogens, reproductive toxins
and substances with a high degree of toxicity)
[29CFR 1910.1450(e)(3)].
134) Verify that the employer updates the Chemical Hygiene
Plan as necessary and evaluates its effectiveness at
least annually [29 CFR 1910.1450(e)(4)].
135) Review the facility's chemical inventory for substances
that appear to be significant based on exposure limits,
quantity present, operations and degree of toxicity.
Based on your knowledge of laboratory chemical
exposures and available monitoring data, determine if
the Chemical Hygiene Plan is capable of keeping
exposures below the action level or, in the absence of
an action level, the PEL [29 CFR 1910.1450(e)(l)(ii)].
136) Verify that initial employee monitoring has been
conducted for any substance regulated by a standard
which requires monitoring if there is reason to believe
that exposure levels for that substance routinely exceed
the action level or, in the absence of an action level, the
PEL. If initial monitoring data demonstrate employee
exposure levels over the action level or the PEL,
ensure the employer is complying with exposure
monitoring provisions of the relevant standard [29
CFR 1910.1450(d)(l) and (2)].
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137) Review records to verify that all employees handling
toxic substances have received 24 hours of health and
safety training at the time of their initial assignment and
four hours of annual refresher training thereafter [EPA
Occupational Health and Safety Manual, 1440,
Chapter 8].
138) Evaluate the training program through interviews of
selected employees and facility records to determine if
the program effectively addresses:
a) Methods of observation used to detect the
presence or release of a hazardous chemical
b) Physical and health hazards of the chemical
c) Employee protection measures
d) Details of the Chemical Hygiene Plan
e) Signs and symptoms of hazardous chemical
exposure
f) PELs for hazardous chemicals
g) Location and availability of the chemical
hygiene plan and reference material
[29CFR 1910.1450(f)(4)].
139) Verify that labels on incoming containers of hazardous
chemicals are not removed or defaced [29 CFR
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140)
141)
142)
143)
144)
Verify through selected employee interviews and
facility records that copies of MSDSs are maintained
from incoming shipments of hazardous chemicals and
are readily accessible to employees [29 CFR
Verify the development of a laboratory safety manual
and laboratory safety plans for each toxic substance
used [EPA Occupational Health and Safety Manual,
1440, Chapter 8].
Verify that the quantity of toxic substances in the work
area does not exceed the amount required for use in
one week (NOTE: This does not include substances
located in a specific storage area or cabinet.) [EPA
Occupational Health and Safety Manual, 1440,
Chapter 8].
Determine through facility tours and MSDS review that
a current inventory of hazardous substances is
maintained [EPA Order 1440.7].
Verify that entrances to work areas where toxic
substances are located are posted "Caution - Toxic
Substances - Authorized Persons Only" [EPA
Occupational Health and Safety Manual, 1440,
Chapter 8].
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H.
145)
146)
I.
147)
148)
Medical Surveillance*
Confirm that a pre-assignment health assessment is
provided to employees who will work with or work in
areas where toxic substances are regularly used [EPA
Occupational Health and Safety Manual, 1440,
Chapter 8].
Confirm that periodic health assessments are provided
to employees who work with or work in areas where
toxic substances are regularly used. The assessment
should include:
a) Names of toxic substances that employee is
exposed to
b) Probability, frequency and extent of exposure
c) Exposure sampling results
[EPA Occupational Health and Safety Manual, 1440,
Chapter 8].
Evaluation of Findings
Review actions taken to complete each step of the audit
protocol and summarize your conclusions as to the
facility's status.
Review and discuss any unresolved issues with
appropriate facility personnel. Note explanations and
the disposition of issues in your working papers.
SHEMD is currently reviewing the Agency's Medical Surveillance Programs
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149) Develop a written list of exceptions and observations.
Discuss this list at a team meeting prior to the exit
conference to substantiate the trends or identify overall
patterns or trends.
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Attachment A
Appendix B, 10 CFR 20
-------
'!• M
I Ipnwinl (Htiirnir
ClINCI N MIA IK INK IN AlH AND WATER ABOVE NAfllRAI BACKGROUND
t Snn NvilHMln* a> **n(l of Appandii Rl
A, Mmjm (B9)
Antimony
Aigon (Ifl)
Afvinr C1.1)
Attain*) |R5)
Rimim (5fi)
Boiknlnjm (P/|
Boryflium (4)
Rnmulh (Bni
Biomtn* (.15)
('Mtmum (4ft)
(".•Icum (70)
r»ldorniuoi (08)
Kolnpo '
Ac 777
Ar 77H
Am 741
Am 747m
Am 74?
Am 743
Am 744
Sb 17?
Sb 174
Sb I7S
A 3)
A 41
As 73
As 74
As 78
As 77
At 211
0. 131
Rl 140
Bk 749
Bk 750
Be 7
Ri 70S
Ri?07
Ri 710
H. 717
fli R7
Cd 109
Crt 115m
Crt 115
Cl 45
Cl 47
Cl 749
S
1
S
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
Sub'
Sub
S
1
S
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
1.1*. 1
Col I-A»
<"'•'"""
2- 10 '
3« 10 '
8« 10
2*10
Sx 10 '
1x10 "
8-10 "
3. 10 '•
4* 10 •
Sx 10''
8x10 "
1 x 10 "
4x 10 '
2x10 '
2x10 '
1x10 '
2x10 '
2x10 '
5x10 '
3x10 •
8» 10 •
2x 10 •
2- 10 •
4 - 10 '
3« 10 '
1x10 '
1x10 '
Ix 10 '
SxtO '
4x10 '
7x10 •
3x10 •
1x10 •
4x10 '
1x10 '
4x10 •
Bx 10' "
IxlO '
IxlO •
IxlO •
8xtO •
I. 10 •
2x10 '
1x10 '
2x10 '
t x 10 •
8x10 •
8x10 •
1x10 '
?x 10 '
1 . 10 •
2> 10 '
So 10 •
7. 10 '
4, 10 •
4. 10 '
?« 10 '
2« 10 '
3> 10 •
1 . 10 '
2x 10 '
2- 10 '
2-10 "
1 x 10 '•
Col ?~
Wile>
diCi'ml)
< 10 •
. 10 •
x 10 '
. 10 '
X 10 '
x 10 •
x 10 '
xlO •
xlO '
XlO •
xlO •
X 10 '
xlO '
-. 10 '
xlO •
xlO •
7x 10 •
7x10 '
3x10 •
3x10 '
Ix 10 '
Ix 10 •
2x 10 '
2x10 '
8x10 '
8x10 <
2x10 •
2x10 •
5x10 •
2x10 •
SxlO '
5x10 '
8x10 •
7x10 •
2x10 '
2x10 •
8x10 •
8x10 •
SxtO '
5x10 '
1x10 •
Ix 10 '
2x10 •
2x 10 '
1x10 '
IxtO '
1x10 '
Ix 10 •
8x10 •
1 » 10 •
S- 10 •
5« 10 '
7x 10 '
7- 10 '
Ix 10 '
1 xlO '
3x 10 •
Sx 10 '
Ix 10 '
1 v 10 '
1 . 10 •
7. 10 '
InblR II
Col 1-A»
(MCI/ml)
8-10 "
0- 10 "
3> 10 •
8x 10 '•
2« 10 '•
4-10 "
2x 10 "
0x10 "
1x10 •
2x10 •
2-10 "
4x 10 "
1x10 '
8x10 '
8x10 •
5x10 •
5x10 •
7x 10 "
2x10 •
0. 10 "
Ix 10 •
4x 10 •
7x10 •
Ix 10 •
1x10 •
4x10 •
4x10 •
3x10 '
2x10 •
1x10 •
2x 10 '•
txlO •
4x10 •
1x10 •
4x10 •
1x10 •
3x10 "
4x10 •
5x10 •
4x10 •
2x10 '
4x10 *
8x10 •
SxlO •
8x10 •
5x10-"
2x10 '•
2x10 "
3x10 •
7x10 •
4x10 •
8x10 •
2x10 •
3.10 •
t » 10 •
1 olO •
8x10 •
8x10 •
|x 10 '
4x 10 •
6x10 •
8.10 •
Sx 10 "
3. 10-"
Col 2-
W.ter
(pO/ml)
2x10 •
3x10 •
0x 10 f
9x 10 '
4x 10 •
3x10 •
4> 10 •
0x 10 •
1x10 '
Ix 10 '
4x10 •
3x10 '
5x10 '
SxlO •
3x10 •
3x10 •
2x10 •
2x10 •
1x10 •
Ix 10 •
Sx 10 •
5x10 •
5x10 •
SxlO •
2x10 •
2x10 •
8x10''
8x10 •
2x10''
7x10-'
2x10 '
2x10 •
3x10''
2x10 •
8x10 •
8x10 •
2x10 •
2x10 •
2x10-'
2x10 •
4x10 •
4x10 •
8x10 •
8x10 •
4x10''
4x10 •
4x10 •
4x 10 •
3x10 •
4x10 •
2x10 '
2x 10 •
3x 10 •
3x10 •
• 3x 10 •
4x10 '
0x10 •
2x10 '
SxlO •
3x10 •
4x 10 •
2x10 •
APPENDIX B CONCENTRATIONS IN AIR AND WATER ABOVE NATURAL BACK(
I S»e tootnolM «l •"» at App«ndi« BI
Element (fllomic mrnibm)
Conliniind
Cirboo(6|
Cwutn (58)
Cowjm (55)
CNorinoM')
Chromium (24)
CotMH (11}
Copp«(29)
Curium (98)
Dysprosium (88)
Isotope '
Cl 250
CI251 .
Cl 252 .
Cl 253
Cl 254
C 14
(CO.)
C* 141
C* 143 ..
C« 144
Ct 131
Ct 134m
Cl 134
Cl 135
Ct 138
Ct 137
a 38
a 38
Cf 51
Co 57
Co 58m
Co 58
Co 80
Cu84
Cm 242
Cm 243
Cm 244
Cm 245 .
Cm 248
Cm 247..
Cm 248
Cm 249
Oy 185 .
Dy 188
S
1
S
1
S
1
S
1
s
1
s
Sub
S
1
S
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
a
s
i
s
i
s
1
3
1
S
1
S
1
s
1
s
1
s
1
s
1
s
tnble 1
Col t— Aii
(MCi/ml)
5. 10 "
1 x 10 '•
2x 10 "
1 x 10 ••
8. 10 "
3x10 "
8x 10 "
8x10 "
5x10 "
5>:10 "
4x 10 •
5x10 •
4x 10 '
2x10 '
3x 10 '
2x10 '
1 x 10 •
8x10 '
Ix 10 •
3x10 •
4x 10 •
8x10 •
4x 10 •
1 x 10
SxtO
9x10
4x 10
2x10
8x10
1x10
4x10
2x10
3x10
2x10
tx 10
2x10
3x10
2x10
2x10
9x10
8x10
SxtO
3x 10
9x10
2x 10
t x 10
Ix 10 '•
2x10 '•
8x10 "
1x10 "
0x10 "
1 x 10 "
Sx to "
1 . 10 »
5-10 "
1 x 10 '•
SxlO "
1 x 10 ••
8x10 '
Ix 10 '
Ix 10
1- 10
3- 10
2x to
2x 10
Cd 2-
WltlH
4v 10 '
7* 10 '
1 . 10 '
8 < 10 •
2x 10 '
2- 10 '
4x 10 '
4x 10 '
4x 10 •
4x 10 *
2x 10 '
3x 10 '
3x 10 '
Ix 10 *
1 x 10 '
3x 10 '
3x 10 '
7x 10 •
3x 10 '
2x 10 '
3x 10 '
3x 10 •
1 x 10 •
3x 10 •
7x 10 '
2x10 •
2x10 •
4x 10 •
1x10 •
2x10 •
2x10 •
tx 10 '
Ix 10 '
Sx 10 '
SxlO •
2x10 •
IxlO •
8x 10 '
8x 10 '
4x 10 •
3x10 •
1 x 10 '
Ix 10 '
Ix 10 •
8x10 '
7x10 •
7x 10 •
tx 10 •
7x 10 '
2x10 '
8x 10 •
1 x 10 '
8x10 •
1 x 10 '
8- 10 '
1 • 10 '
8- 10 '
1x10 •
4, 10 •
8' 10 •
8« 10 •
1 . 10 '
1- 10 •
l«hl« II
Col I-.A«
(pCi/ml)
2-10 "
3. to ••
8« 10 "
3- 10 "
2-10 "
1 x 10 '•
3. 10 "
3-10 "
2-10 "
2x 10 "
1 v 10 '
1 . 10 •
2x 10 •
S. 10 •
9x 10 •
7 . IO •
3* 10 '•
2 x 10 ••
4x 10 '
1 , 10 '
1 . 10 •
2- 10 '
1 » 10 •
4> 10 "
2* 10 •
3- 10 •
Ix 10 •
8x 10 •
2« 10 •
5x 10 '•
1 x 10 •
8x 10 "
9x 10 *
7x10 '
4x 10 '
8x 10 •
IxlO '
8x10 •
8x 10 '
3x 10 '
3x10 •
2 x 10 •
1 x 10 •
3x 10 '•
7x 10 •
4x 10 •
4 < 10 "
8x 10 "
2- 10 "
3-10 "
3, 10 "
3x 10 "
2- IO "
4x 10 "
2-10 "
4. 10 "
2x 10 "
4-10 "
2-10 ••
4- 10 "
4. 10 '
4. 10 '
9- 10 •
7- 10 '
1 • 10 • 1 8> 10 •
Col 7
1 . 10 '
3. 10 «
4 . 10 •
3- 10 '
7- 10 •
7. 10 *
1 - 10 '
1 - 10 •
1 . 10 '
Ix 10 •
8. 10 '
0v 10 '
9x 10 •
4 - 10 *
4. 10 •
1 - 10 '
1 . 10 •
2» 10 '
9- 10 •
8x 10 •
Ix 10 •
9. 10 •
4. 10 •
1 « 10 •
2- 10 •
9- 10 '
e« to •
2x10 '
4x10 '
8x10 •
8x10 '
4x10 '
4x10 •
2x10 '
2x10 •
Sx 10 •
4x10 •
3x10 '
2« 10 •
1 x 10 '
9x10 •
So 10 '
3x 10 •
3. 10 '
2x 10 '
2-10 •
2- 10 •
S< 10 •
2x 10 '
7. 10 '
3- 10 '
4 » 10 •
3- 10 •
4- 10 •
3> 10 •
•4o 10 •
2xtO •
4. 10 '
1- 10 •
2- 10 •
2. 10 •
4- 10 '
4. 10 '
4 . 10 '
-------
i NIMAIKINS IN Ant ANP WAifn ABOvf NAtuRAi f)ACKCn()uNi>— Continued
f HI
Plutonium (94)
Polonium (fl4)
i (S9)
i (61)
Ki.inr... •
Nil »',
NH 1!
(>* tflfS
OS Illin
(>•; 191
l)s 111
P 731
Pe 233
Rl 773
Re 774
Re 778
S
1
S
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
1
s
s
s
5
s
>
)
s
9
s
s
s
s
s
i
1,1.1,. 1
Col I -»«
("f'"m"
5- 10
1 - 10
6- 10 '
5- 10 '
5- 10
5> 10 '
2- 10 '
9« 10 '
1 • 10 •
4- 10 '
4- 10 '
3*10 '
1 , 10 •
7x 10 '
6- 10 '
4 . 10 '
7 . 10 •
8. 10 '
8 • 10 '
6- 10 '
7. 10 '
S> 10 '
t . 10 •
3. 10 '
8* 10 •
Sr 10 •
8- 10 '
SxlO '
2-10 "
3* 10 "
?. 10 ••
4-10 "
2-10 "
4. 10 "
9-10 "
4x 10 '
?• 10 "
4» 10 "
7- 10 •
2x10 •
2. 10 '•
3. 10 "
5-10 "
2x10 ™
2. 10 *
1 x 10 '
2. 10 '
2x10 '
3. 10 '
2x10 '
8x 10 T
1 xlO '
3.10 '
2. 10 '
2x 10 •
8x10 "
Ix 10 "
1 x 10 '•
8x 10 '
2x 10 '
2x 10 •
2x 10 '•
5x to •
7> 10 "
3. 10 "
Tot 7
Wfllei
(,,CVml|
3 • 10
3 • 10
3- 10 '
3. 10 '
7- 10
2- 10 '
7* 10 '
7. 10 '
5. 10 '
5- 10 '
2- 10 '
?. 10 '
1 . 10 '
8- 10 '
3- 10 '
2- 10 '
5- 10 •
7. 10 •
4- 10 '
3. 10 '
3- 10 •
3- 10 '
3- 10 •
5> 10 •
3- 10 '
3- 10 '
4. 10 •
3« 10 •
1 . 10 •
8. 10 •
1. 10 '
8 - 10 •
1 . 10 •
8*10 •
7x10 •
4, 10 '
t .10 •
0.10 •
1 xlO •
1. 10 •
1 . 10 •
3. 10 '
2x10 '
8. 10 '
9.10 •
e«io •
9* 10 •
9x10 •
1 . 10 '
1 . 10 •
8.10 •
8x 10 •
1 x. 10 '
1 x 10 '
7.10 •
7x10 •
3x 10 •
8x 10 '
4x 10 '
3x10 •
2x 10 •
1 x 10 '
7x 10 •
2x10 •
4.10 '
I»Mo it
Col 1 --*«
1,.0/ml)
2- 10
3- 10 '
2- 10
?. 10
?• 10 '
?• to •
6- 10
3. 10 •
4 • 10 •
1 • 10 '
t - 10 '
9- 10 •
Sx 10 •
3- 10 •
2. 10 •
1 v 10 •
2. 10 •
3 • 10 •
3. 10 •
2« 10 '
2.10 '
2x10 '
4^ 10 •
1 * 10 *
2. 10 '
2x10 •
3x 10 •
1*10 •
7x IO "
I v |0 "
8. 10 "
1 - 10 "
8 . 10 "
IxlO "
3x 10 "
1 . 10 •
8. 10 "
1 . 10 "
8x10 •
8x10 •
8x 10 "
Ix 10 "
2x10 "
7x 10 "
7x 10 •
4. 10 •
7. 10 •
5- 10 •
tx 10 •
8. 10 •
2- 10 •
3.10 •
tx 10 •
8. 10 •
8x10 "
3x10 "
4. 10 "
4x10-"
2x 10 •
8x10 •
8x10 "
8x tO "
2x10 "•
2x10 "
3< 10 "
Col 7
Wato.
(M( :i/mi)
1 • 10 •
1 • 10 •
9- IO •
9- 10 •
7- 10 •
7. 10 '
3.10 •
2.10 •
2.10 •
7x10 •
8-10 '
5. 10 •
3. 10 •
3. 10 •
9- 10 •
7* 10 '
2« 10 •
2- 10 •
1 . 10 •
1 . 10 •
1- 10 •
1 - 10 •
9. 10 •
2x 10 •
Ix 10 •
9x10 •
1 x 10 •
t . 10 •
Sx 10 •
3x 10 •
5. 10 •
3. 10 •
s> to •
3x10 >
2 - 10 •
tx 10 '
S«10 •
3x 10 •
3x 10 •
3. 10 •
4x10 •
1 X 10 '
7x 10 '
3n 10 '
3< 10 '
7- 10 •
3. 10 •
3x 10 •
5. 10 '
5. 10 •
2- 10 •
2- 10 •
4x 10 •
4x,10 •
2* 10 •
2x10 •
»x 10 '
2x 10 '
IxlO •
tx 10 *
7x 10 '
4x tO '
2x10 •
S- 10 •
3. 10 •
APPENDIX B— CONCENTRATIONS IN AIR AND WATER ABOVE NATURAI BACKGROU.
ISeo lootnotn it *nd oi App«ndi« B1
Element (stone numbei)
R«ton(86)
Rhenium (75)
Rhodium (45)
Rubidium (37)
Ruthenium (44)
Senttnum (82)
Scandium (21)
Selenium 34)
Silicon (14)
Silver (471
Sodium (II)
Strontium (38)
Isotop*
R< 228 .
Rn 220
Rn 222 • .
R» 183
R« 188 . . .
R* 187
Re 188
Rh 103m . .
Rh IOS
Rb88
Rb87
Ru97
Ru 103
Ru IOS
Ru 108
3m 147
Sm tSt
Sm 153
Sc 46
SC47
Sc48
8»75
SI 31
Aj 105
Ag 110m
Ag 111
N«22
N«24 .
Sr 85m
S> 85
St89
Sr 90 .
S> 91
1
S
1
S
S
1
S
1
S
1
S
1
S
1
S
1
S
S
S
1
S
1
S
S
S
1
S
1
S
S
S
S
1
S
S
1
S
1
S
1
s
1
8
1
S
1
S
1
S
1
S
1
S
1
S
1
Tab
Col i-A»
(pCi/ml)
5x10 "
7. 10 "
4. 10 "
3x 10 '
3x 10 '
3x 10 •
2x10 '
8x10 '
2x10 '
9» 10 •
Sx 10 '
4x 10 '
2x 10 '
8x10 •
8x10 •
8x 10 '
5x10 '
3x10 '
7x10 •
SxlO '
2x10 •
2x10 •
SxlO '
8x10 •
7x10 '
SxlO '
8x10 •
8x10 •
7x10 "
3x10 ••
8x10 •
1x10 '
5x10 '
4x10 '
2x10"'
2x10 •
SxlO '
2x10 •
1x10 '
1x10 '
8x10 •
1x10 •
8x10 '
8x10 •
2x10 '
IxlO •
3x10 '
2x10 '
2. 10 '
9- 10 •
1 . 10 •
tx 10 '
4. 10 •
3x10 •
2x10 '
1x10 '
3x10 •
4x10 •
1 x 10 *
5.10 •
4. 10 '
3. 10 '
la 1
Col 2-
W«le»
|MCi/mf)
9> 10 •
8- 10 '
7. 10 •
2x 10 •
8x 10 •
3x10 •
Ix 10 '
7x 10 '
4x 10 '
2x 10 •
9x 10 •
4x 10 '
3x10 '
4x 10 *
3x 10 '
2x 10 •
7x 10 '
3. 10 '
Ix 10 '
1 x 10 '
2x 10 '
2x10 •
3x10 '
3x10 '
4x10 •
3x10 '
2x10 •
2x10 •
1x10 •
IxlO •
2x10 •
2x10 •
1x10 •
IxlO •
3x10 '
8x10 •
8x10 •
8x10 •
3x10 •
8x10 '
3x10 '
3- 10 '
9x10 •
9x tO •
Ix 10 '
1 xlO '
IxlO '
9x 10 •
8x 10 '
8< 10 '
2. 10 '
2- 10 '
3« 10 '
5x10 '
3x 10 •
8x 10 '
1 • 10 •
1 • 10 '
2- 10 '
1 > 10 '
lull
Col 1 An
(MC,/ml)
7-10 "
7-10 "
t - 10 "
1 . 10 '
3- 10 •
9- 10 '
5- 10 •
2x 10 •
6- 10 •
3- 10 '
2- 10 •
1x10 •
8x10 •
3x 10 •
Jx 10 '
3- 10 '
2> 10 '
1 « 10 •
2« 10 •
7v (0 •
8> 10 '
8> 10 •
7x 10 •
3x 10 •
2x 10 •
2x 10 •
3x10 •
2 x 10 '•
2x 10 "
9x 10 "
2x10 '
5x10 •
2x10 •
t . 10 '
8x10 •
8x10 "
2x 10 •
8x 10 •
Sx 10 •
4x10 •
2x10 '
3x10 •
2x 10 '
3. 10 •
7. 10 *
3x 10 '•
1 x 10 •
8- 10 •
8- 10 •
3. 10 ••
4 . 10 '
5- 10 f
1 . 10 '
1 . 10 '
8- 10 '
4 • 10 •
3 . 10 ••
t x 10 •
3-10 "
7- 10 "
2- 10 •
9. 10 •
n II
Col 7
Wnlnr
3 • 10
3 • 10
3- 10
6- 10
3. 10
9- 10
5- 10
3. 10
2x10
8. 19
3.19
IxlO
1 x 10
1 xlO
IxlO
7. 10
2x10
1 x 10
4x 10
3x 10
8x 10
8x 10
IxlO
1 x 10
l> 10
1 . 10
8x 10
7x 10
4x 10
4x 10
8. 10
8. 10
4x 10
4x 10
9- 10
3- 10
3. 10
3. 10
9. 10
2. 10
1 .10
1 . 10
3' 10
3- 10
4. 10
4x 10
4.10
3< 10
2. 10
3. 10
7. 10
7. 10
1 • 10
2- 10
3. 10
3.10
3- 10
4 . 10
7- 10
s. to
-------
APPENDIX 8—CONCENTRATIONS IN AIR AND WATER ABOVE NATURAL BACKGROUND—Continued
(See lootnotes •' end o< Appendii B)
i»oiooe ' ___^ Tame i
Eiemeni (atomic number)
Col i-Air
Col 2—
Water
Col t-An
(uCi'ml)
Cd 2-
watef
Any jjngte radionuchde not listed
above, when decays ov arpna ems
sion or spontaneous IISMX*
6- 10'"
2-10 "
3. 10-
'Soluble IS), insoluble (II
'"Sue" means mat values yven are lex submersion m a semispnencai infinite cloud of airborne material
'These radon concentrations are appropriate lor protection from rsdon-222 combined witn its snort-lived daughter*
Alternatively the value m Table I may be replaced Oy one-third Ih) working lever (A working level" is defined as any
comomatnn o< snort-lived radon-222 daughters. polonium-2t8. lead-214. bwnuth-214 and pokjnum.214. in one Mer ol air.
without regard to trie degree ol eguMmum. trial will result m me ultimate enwaen ot 1 3 * 10 • MeV ol alpfia parocM energy)
The Tabieii value may be replaced by one-ttwtietn l*o) ol a "working level" The kmt on radon.222 concentrations m
restricted areas may be baaed on an annual average
'For soluble mmures ol U-238 U-234 and U-235 m air chemical toncfly may be the limiting tactor. If the percent by
weighi-emcnment) ol U-235 is less man S. the concentration value tor a 40-hour workweek. Table I. is 0.2 mftgnim* uraraum
peVcuDK meter ol air average For any enrichment, me product ol the average concentration and time ol expoaure during a
te* snail not eiceed 6 * 10 ' SA uOnr/ml. where SA if the spent* activity of ma uranum mnalad. The
: actMty for natural uraraum
40-hou »urk«ee> snail not eiceed - - -----
concentration value for Table II is 0 007 rmkgrams uranium per cubic meter of air The I
6 77 . 10 ' cunes per gram u The apecrfc activity tor other matures of U-238. U-235 and U-234. it not known, snan be
SA = 3 6 '10 "curies/gram u U-depwted
SA = (04.>038 E. 00034 E1) 10'« ES0.72
where E is me percentage by weqnl of U-235. expressed as percent
NOTE in any case where there a a mature in air or water of more man one rarjonucaoa. the krmng values for purposes of
Ihrs Appendn should be determined as follows:
1 if me «»entity and concentration of each raOonurkrte n the mMure are known, me kmlong values shot*) be derived as
loaows Oetermne for each radnnuckde in me mature, me run between me ouenwy present m the mture and ma kmn
omarweje eatabkanad m Appencn 8 for the apeeifc raoonuckoe when not m a mature The aurn ot aucn ratios lor an (he
radariuckde* «i the mature may not eiceed "1 ' (i.e.. "unrly") ______ _ __,_ .„„. .,„
EUMPIE. If radonuckdes A. 6. and C are preeent n coiicei ill atone C.. C,. and Cf. and * ma appkcabM MPCt. are MPC,.
and MPC,. and MPQ respectively, than the UMicentraliOMa aMN be kmrted so mat the following nMtenan* enata:
(C./MPCj*(C./MPC,)»(Cr/MPC<.) Si
2 If either the «tenwy or the concentration of any radonuckde m the mature • not known, (he trrabng vakiee for purpoaea
of Appendn B snail be
a. For purpoees of Table I. Col 1— 8x10'"
b For purpoeea of Table I. Col 2—4 x 10- '
c. For purpoees of Table II. Crt 1—2x10'"
d For purpoees of Table II. Col. 2—3x10''
3. II any of me oondmona specmed below are met the
specrted m paragraph 2 above
may be used m keu of thoae
a It ma kjennty ol each radonuckde n the mature » known but the concenlrakon of one or more of me radnnuckdea »i
the mure m not known me uonuengaaon kmt for me manure • the kmrt specified In AppendB "B" for me radionijckde n me
mure hevng me lowest concentration kmt or
b H m* idenoty of each rarJanuetrts n ma manure • not known, but it ia known mat certain radonuckdea apecrfted n
Appendn "B" era not preeeni m Ihe mature, the uumaiejaiBii fcr* lor ma mure a> M toweet uuncenuauni kr
n AppendB "B" for any radnnuckoe wmcti • not known n be absent ftom tie maduni: or
c. Element latomc number) and njmope
n it • known that Sr W. I 125. I 120. I 128. I 131 (I 133. Table II only). Pb
210. Po 210. At 21 1 Ra 223 Fuj 224. Re 22«. Ac 227. Ra 221. Th 230. Pa
231. Th 232. Ttvnat. Cm 248 Cf 264. and Fm 2S» are rw messnl
If it • known mat Sr 90. 1 12S. 1 126. I 129 (1 131. 1 133. Table II only). Pb
210. Po 210. Ra 223. Ra 226. Ra 226. Pa 231. Th-net. Cm 246. Cf 254.
II it • known that Sr 90. 1 129 (1 125. 1 126. I 131. Table II onfy). Pb 210. Ra
226 Ra 228 Cm 246 and Cf 254 are not rjraaeni
If n • known mat (1 129 Table n only). Ra 226. and Ra 276 are not preeent
Pa 230 Pu 241 and Bk 249 are rm preeent .
II it • known «Mt eMa ananas end Pb 210. Ac 227. Ra 226. end Pu 241
Hdaj known mat a»he enertsis and Ac 227 an not preaant
H ii is known mat Ac 227. Tn 230. Pa 231. Pu 236. Pu 239. Pu 240. Pu 242.
Tat
Col. 1-
A»
C"(iC
-------
Attachment B
Appendix C, 10 CFR 20
-------
Attachment B
Appendix C, 10 CFR 20
-------
'22
i24
Antimony- '25
"»•«<:• '5
Aflame- •"*
3a/xjm-'3'
3«num.'33
3 arum- 1 <0
3ismum-2'0
1 5
v ' ' 5
Ca/oon-14
141
M4J
C«*um.'34m
.i34
.l35
CMonna-38
Chionn»-38
Chromum-Si
Cooifl-Mm
Cootit-Sfl
Zooait-60
E!ttun>i89
EurocMW-152 13 f
tS
Oott-tM
QoU.190
natnun-tst
MokTIMTVtM
induivliSm
lnauiv'15
(.125
WOW*. 128 .........
1.131 .........
• 32 ..........
..133 .........
135
193
imn-SS ...............
iron-M .............
Kn/pion-as ..........
nrvptorvar .........
Lwnnwwn.140..
U«rcury-t97m
M«ra»y.l97 ...
S«ooyn«um.i47
. '49
Nottum-97
. 1 9 1 m
rv 1 9 1
Chmwm-193
Palladium- > 03
s'etinom- '91
n- '93m
•00
•o
'0
•'00
•o
•o
•00
•o
-.0
•a
'0
10
10
100
10
10
too
100
100
1
t.OOO
too
10
10
10
10
10
1 000
10
10
1
too
too
100
too
'
1
10
too
10
100
100
100
10
too
t.OOO
too
10
100
10
1
1
1
10
1
10
10
10
100
100
too
10
to
100
•o
to
'0
•00
•00
'00
•00
'00
•o
•00
•o
'0
'0
•o
'00
100
•00
'00
too
10
'00
'00
100
•oo
•00
°'a»oavmium.i4j '00
D'as«oOvmium.i43 'OO
Orom«tnium- 149' '0
"fwnmm-186 '00
Rhooium-iOS too
BuMum-Sfl '°
Sumamum-97 '00
fluthanum-i03 '0
flutnennim.108 '
Sammjm-153 . too
Scanum-ta ... .. . to
5*000-31 too
S*Mr-t05 10
StMMIt 100
Sodum-24 10
Stronaun-as to
SfrnjlVwwoo 0 1
SVonaunv91 10
Stremun.92 10
Solonur-35 100
Tantatom-182 to
Tjjjiauuii-oriii 100
T«exnnum-t7 100
TacflnMum-Min too
Ta*njm_l29.234— Ufinxm.235 01
vanadun-4« to
X«nor>131m 1.000
Xanon-133 tOO
X«non-i35 100
vn«ro»jm.17S 100
Yttnum-90 to
vnnum-92 100
rnnum-W 100
Zinc -«S ... 10
Zinc^B '.000
Zireon»jm.»3 10
Zrconun-06 . 10
Zreonjwii-97 10
or monurtt ot aiona cnMan of unknown
compoamon ot
Any rtaonucao* omar than ajona ammng 'a-
dtonucMn. not mtad apov* or irniura* of
•BaaM on anna o»m»ontion rua of nv23Z. Th-?30 ana
trw aauaniar oroduca
'flaaad on alon* aamiauiaon rat* of U-230. U-234. and
U-235
Nor«: For purposes of J 20.303. where
there Is involved a combination of Isotopes
In known amounts, the limit for the combi-
nation should be derived as follows: Deter-
mine, for each Isotope In the combination.
the ratio between the quantity present In
the combination and the limit otherwise es-
tablished for the specific Isotope when not
In combination. The sum of such ratios for
all the Isotopes in the combination may not
exceed "1" (I.e.. "unity").
oiafmum-197
C3S FR 8425. Apr. 22. 1970. aa amended at 36 PR 10808. Aug. 28. l»7i; 38 PR 2»ju. Oct.
")4 tOTT 'O PD •"»OO1 T.._, ->~ ..-. .. ~
-------
Attachment C
Draft EPA Diving Safety Audit
Protocol
-------
PROTOCOL
RESPONSE
COMMENTS
DIVING SAFETY PROTOCOL
A. Introduction
Background Information
1) Review the following background information before
arriving at the dive site (if not available before
conducting the field work, review information as early
in the visit as possible):
a) Diving safety plan and/or dive plan
b) Personal dive logs
c) Previous diving safety audit reports or
inspections of the activity
2) Review the following background information related
to diving safety management programs prior to the site
visit (if not available prior to conducting the field
work, review information as early in the field visit as
possible):
a) Chapter 10 of EPA's Occupational Health and
Safety Manual
b) Organizational staffing charts
c) Training documents
d) Medical monitoring documents
-------
PROTOCOL
RESPONSE
COMMENTS
Opening Meeting
3) The audit team leader will meet with the unit diving
officer and divers to provide an overview of the
objectives, scope and methodology, including
approach and reporting for the review.
Information Gathering and Finding Development
4) Using the diving safety management audit protocol
provided in the following section, perform the review
of the diving operations for compliance with applicable
policies and recommended professional practices.
B. Diving Safety Plan and Dive Plan
Evaluate the effectiveness the activities' diving safety
plan and dive plan by verifying the following:
5) Confirm that the nearest medical facility (i.e., hospital
or clinic) and recompression chamber are identified,
and communications procedures are established
6) Confirm that emergency evacuation procedures are
developed.
7) Verify that communication with emergency
transportation is established.
8) Confirm that the Divers Alert Network (DAN)
telephone numbers [(919) 684-2948 or (919) 684-
8111] for medical advice are delineated.
9) Verify that a copy of EPA's Diving Safety Policy is
readily available at the dive site.
-------
PROTOCOL
RESPONSE
COMMENTS
C. PROJECT SPECIFIC INFORMATION
10) Verify that the dive plan accurately describes the
proposed dive project.
11) Confirm that the objectives of the proposed dive
project are clearly delineated.
12) Verify that the potential hazards are identified including
sources of pollution.
13) Confirm that other environmental conditions such as:
a) Tidal heights
b) Water currents
c) Maximum expected water depth during dive
d) in-water visibility
e) weather
f) boat/vessel traffic
are discussed in the dive plan or in the daily briefings.
14) Verify that divers, boat operators, and support
personnel are identified in the plan.
15) Confirm that the dive plan is approved by the Unit
Diving Officer.
C-1
-------
PROTOCOL
RESPONSE
COMMENTS
D. PREDIVE BRIEFING AND ACTIVITIES
16) Verify that the following procedures are reviewed
during predive activities:
a) Emergency evacuation
b) Accident management and emergency
equipment
c) Diving safety
d) Dive-to-dive and tender-to-tender
communications
e) Decontamination for polluted water operations
0 Specialized diving equipment
17) Verify that diving safety protocols are reviewed (e.g.
safety stop at 15 feet when repetitive diving).
18) Verify that the project's description and objectives are
reviewed.
19) Verify that dive teams are identified (i.e. divemaster,
alternate divemaster, tender, and, if needed, standby
diver) during predive activities.
20) Confirm that tank pressures are inspected and
documented before divers enter the water.
21) Verify personal emergency information (e.g., medical
history) is available for each diver
-------
PROTOCOL
RESPONSE
COMMENTS
22) Verify that vessel traffic control is notified during
predive activities (if necessary).
E. OPERATIONS DURING THE DIVE
23) Confirm that tenders monitoring the divers are not
performing other functions that may interfere with
tending responsibilities.
24) Verify that support vessels are clear of the diving area.
25) Confirm that appropriate dive flags are displayed on
vessels tending divers:
a) Red and white "diver down" flag in internal or
coastal waters.
b) Red and white "diver down" and blue and
white code flag Alpha in waters with
international vessel traffic.
c) Wire stiffeners supporting small flags.
26) Confirm that standby divers are equipped and ready to
provide immediate assistance.
2i) Confirm that a tender-to-diver communication system
is deployed during diving operations (i.e., diver recall
unit).
28) Verify that the emergency first aid and oxygen kits are
readily available.
C-
-------
PROTOCOL
RESPONSE
COMMENTS
F. POSTDIVE PROCEDURES
29) Confirm that the divemaster and/or tender monitors
each diver exiting the water for signs or symptoms of
"bubble trouble".
30) Verify that divers protect themselves from hypothermia
or hyperthermia.
31) Verify that freshwater is available to ensure that divers
can avoid dehydration.
32) Confirm that each diver's water depths, bottom times,
and tank pressures are documented.
33) Confirm that a postdive report is prepared which
includes information specific to the diving operation
(e.g., dive water depths and bottom times, tank
pressures, achievement of objectives, hazards
encountered, malfunctions and lost equipment).
34) Verify that appropriate decontamination procedures are
followed when diving in polluted water.
35) Confirm that divers properly clean and store dive
equipment.
G. DIVING PERSONNEL
36) Confirm that divers receive diving physical
examination no less than annually.
37) Verify that divers are currently certified in
cardiopulmonary resuscitation and first-aid training.
-------
PROTOCOL
RESPONSE
COMMENTS
38) Confirm that divers receive training in oxygen
administration.
39) Verify that divers are certified for their respective level
of responsibility (i.e., Working Divers or Divemasters,
etc.).
40) Confirm that divers maintain diving proficiency (i.e.,
performed a dive within the past three months).
41) Verify that divers are experienced with anticipated
project conditions (e.g. water depths, sea conditions,
water currents, or reduced in-water visibility, etc.).
42) Verify that divers using air compressors are trained in
safe operating procedures.
Scuba Equipment
43) Confirm that self-contained underwater breathing
apparatus (SCUBA) cylinders have been
hydrostatically tested within the past five years.
44) Verify that all SCUBA cylinders have been visually
inspected within the past 12 months.
45). Confirm that all regulators have been critically
examined, calibrated, or overhauled within the past 18
months.
46) Confirm that diver gauges (e.g., pressure, depth,
compass, bottom timers, and watches) are critically
examined and calibrated or replaced within the past 18
months.
C-
-------
PROTOCOL
RESPONSE
COMMENTS
47) Verify that valves and hoses are critically examined and
replaced or overhauled as necessary.
48) Verify that belts and buckles are in proper working
condition.
49) Verify that dry suits are leak-free for polluted water
diving.
50) Confirm that buoyancy compensators are maintained in
proper condition and in accordance with manufacturer
specification for wet suit diving.
51) Confirm that buoyancy compensators are capable of
being inflated by no less than two methods (one other
than oral).
52) Confirm that diver communication equipment is
inspected prior to use.
53) Verify that a dive ladder is available on boats (required
to have a dive ladder) to ensure that divers can safely
enter the tending vessel.
54) Verify that hygienic maintenance is performed on full-
face masks.
55) Confirm that full-face masks and dive equipment are
free of corrosion and maintained in proper operating
condition.
56) Confirm that head harnesses and buckles are
maintained in proper operating condition.
-------
PROTOCOL
RESPONSE
COMMENTS
57) Verify that manufacturer maintenance manuals are
available for the specialized dive equipment (e.g.,
communication equipment and full-face masks).
58) Verify that adequate spare parts and repair materials are
available at the dive site.
Air Compressors
59) Confirm that air compressors are operated by
experienced personnel in accordance with manufacturer
specification.
First Aid Equipment
60) Confirm that emergency oxygen kits are capable of
simultaneously serving two divers with demand
second stage regulators.
61) Verify that emergency oxygen kits include an oxygen
cylinder that is no less than size "E" (626 liters).
62) Confirm that the oxygen cylinder regulators are
maintained in accordance with manufacture
specifications.
63) Verify that oxygen kits contain a cylinder wrench for
manipulating tank valves.
64) Verify that oxygen kit hoses, valves, and regulators are
maintained in proper condition free from oil and
grease.
65) Confirm that oxygen cylinders have been
hydrostatically tested within the past 10-years.
C-
-------
PROTOCOL
RESPONSE
COMMENTS
66) Confirm that the oxygen cylinder O-rings are
maintained in proper condition.
67) Verify that oxygen cylinders are stored in areas that do
not exceed 125 degrees Fahrenheit.
68) Verify that fully-equipped medical (first-aid) kit is
available for divers.
69) Verify that spare oxygen cylinder "O"-rings are
available.
70) Confirm an emergency use blackboard is available on
the vessel.
H . Evaluation of Findings
71) Review actions taken to complete each step of the audit
protocol and summarize your conclusions as to the
facility's status.
72) Review and discuss any unsolved issues with
appropriate facility personnel. Note explanations and
disposition in your working papers.
73) Develop a written list of exceptions and observations.
Discuss the list at a team meeting prior to the exit
conference to substantiate trends or identify overall
patterns.
-------
U.S. ENVIRONMENTAL PROTECTION AGENCY
FIRE AND LIFE SAFETY AUDIT PROTOCOL
OPERATING UNIT: DATES OF REVIEW:.
TEAM MEMBERS:
PERIOD UNDER REVIEW:
This protocol was designed for the EPA fire and life safety audit program. It is intended to
serve as a guide for planning and conducting an evaluation of operating unit-level fire and life
safety management systems and internal controls. The protocol may require additions,
revisions or other modifications to meet the needs of specific operating unit assessments. The
purpose of assessing EPA facility fire and life safety management programs is to confirm that
appropriate systems are in place and functioning effectively to achieve continued compliance
with applicable fire and life safety management regulations and minimize EPA's risks.
SECTION XIV — fi^fcAND LIFE SAFETY
-------
U.S. ENVIRONMENTAL PROTECTION AGENCY
FIRE AND LIFE SAFETY AUDIT PROTOCOL
Table of Contents
Section
A. Introduction
B. Means of Egress
C. Hazardous Materials
D. Fire Protection
E. Elevators
F. Material Handling and Storage
G. Welding, Cutting and Brazing
H. Electrical
I. Evaluation of Findings
Page Number
XIV-l
XIV-2
XIV-12
XIV-15
XIV-25
XIV-27
XIV-27
XIV-28
XIV-29
SECTION XIV —
AND LIFE SAFETY
-------
PROTOCOL
RESPONSE
COMMENTS
XIV. FIRE AND LIFE SAFETY MANAGEMENT
A. Introduction
Background Information
1) Review the following background information before
arriving at the operating unit (If it is not available
before conducting the field work, review information
as early in the visit as possible):
a) Facility diagrams and floorplans
b) Description of primary facility
activities/operations
c) Previous fire and life safety audit reports or
inspections of the facility
2) Review the following background information related
to fire and life safety management programs and
activities prior to the on-site visit (If it is not available
prior to conducting the field work, review information
as early in the field visit as possible):
a) EPA and faculty-specific fire and life safety
directives and orders
b) EPA and facility-specific fire and life safety
operating manuals and procedures
c) Organizational charts and staffing tables
d) Training and employee orientation documents
e) Occupant Emergency Plan
FIRE AN
E SAFETY
-------
PROTOCOL
RESPONSE
COMMENTS
f) Applicable Federal, State and local regulations
g) Completed facility safety, health and
environmental pre-audit questionnaire.
Opening Meeting
3) The audit Team Leader will meet with the facility
management and staff to provide on overview of the
objectives, scope and methodology, including
approach and reporting for the review.
Preliminary Tour
4) Tour the facility to gain a general understanding of the
facility layout and operations. (NOTE: The tour is
intended only as an orientation step.)
Audit Planning
5) Based on your initial understanding of the facility and
operations as well as a review of the completed pre-
audit questionnaire, develop a plan for conducting the
audit.
Information Gathering and Finding Development
6) Using the fire and life safety audit protocol provided in
the following section, perform the review of the facility
for compliance with applicable policies, regulations
and recommended professional practices.
B. Means of Egress
Evaluate whether sufficient exits and other safeguards are
provided to permit prompt escape of building occupants in
case of fire or other emergency by verifying the following.
XIV,
FIRE AND L
AFETY
-------
PROTOCOL
RESPONSE
COMMENTS
General Requirements
7) Verify that the facility has not installed locks or
fastenings on a means of egress that would prevent
free escape from the inside of the building [29 CFR
1910.36(b)(4)].
8) Assess whether exits are provided with due regard to
the character of the building occupancy, the number of
persons exposed, fire protection equipment available,
and the height and type of construction of the building
to afford all occupants convenient facilities for escape.
Refer to NFPA 101, Life Safety Codes, for a list of
occupancy descriptions. [29 CFR 1910.36(b)(3)].
9) Verify that at least two means of egress, remotely
located from each other, are provided to minimize any
possibility that both may be blocked by any fire or
other emergency condition [29 CFR 1910.36(b)(8)].
10) Determine whether exits connecting three stories or
less have a fire resistance rating of at least 1 hour
whether above or below the level of exit discharge [29
CFR 1910.37(b)(l)].
11) Determine whether exits connecting four or more
stories have a fire resistance rating of at least 2 hours
whether above or below the level of exit discharge [29
CFR 1910.37(b)(2)].
12) Verify that exits are protected by approved self-closing
fire doors to prevent the spread of fire and smoke [29
CFR 1910.37(b)(3)].
FIRE AN
y-3
E SAFETY
-------
PROTOCOL
RESPONSE
COMMENTS
13) Determine whether exit enclosures have openings only
for access to the enclosure from normally occupied
space and for egress from the enclosure [29 CFR
1910.37(b)(4)].
14) Determine whether exit access requires occupants to
travel through a bathroom or other room subject to
locking, except where the exit is required to serve only
the room subject to locking [29 CFR 1910.37(f)(3)].
15) Determine whether exit access and the exit doors to
which they lead are designed and arranged so that they
are clearly recognizable (i.e., no drapery or mirrors
should be placed on or in front of the doors) [29 CFR
1910.37(f)(4)].
16) Evaluate whether exit access is arranged so that it is not
necessary for occupants to travel toward any area of
high hazard occupancy in order to reach the nearest exit
[29 CFR 1910.37(0(5)].
17) Verify that the minimum width of any exit access is not
less than 28 inches (32 inches for new construction
post-1991) and that the maximum width is 48 inches
[NFPA101, 5-2.1.3] [29 CFR 1910.37(0(6)].
18) Determine whether any exterior way of exit (i.e.,
corridor outside of a room) has dead ends in excess of
20 feet [29 CFR 1910.37(g)(5)].
19) Determine whether all exits discharge directly to a safe
access to a public way (i.e., street, yard, court, etc.)
[29 CFR 1910.37 (h)(l)].
FIRE AND
SAFETY
-------
PROTOCOL
RESPONSE
COMMENTS
20) Evaluate whether adequate headroom of at least 7 feet
from the floor with no projections below a 6 feet 8
inches nominal height is provided in all means of
egress [29 CFR 1910.37(i)].
21) Determine whether stairs or ramps are provided for any
means of egress not substantially level and having an
elevation difference exceeding 21 inches [29 CFR
1910.37(j)]
22) Verify that all doors, stairs, ramps, passages, signs,
and all other means of egress components are of
substantial, reliable construction and installed in a
workmanlike manner (i.e., properly installed and
maintained) [29 CFR 1910.37(k)(l)].
23) Determine whether means of egress are continuously
maintained free of all obstructions or impediments to
allow instant use in the event of fire or other
emergency [29 CFR 1910.37(k)(2)].
24) Verify that devices and alarms installed on doors to
restrict the improper use of an exit are designed and
installed so that they cannot impede or prevent
emergency use of the exit [29 CFR 1910.37(k)(3)].
25) Evaluate whether furnishings and decorations obstruct
exits, access thereto, egress therefrom, or visibility
thereof [29 CFR 1910.37(1)(1)].
26) Determine whether fire retaidant paints or solutions are
renewed at intervals necessary to maintain adequate
flame retardant properties [29 CFR 1910.37(o)].
27) High density occupancies (i.e., offices, conference
rooms, dining areas, and public assembly areas)
XIV-5
FIRE AN
SAFETY
-------
PROTOCOL
RESPONSE
COMMENTS
a) Calculate square feet per person per floor (use
the Table for Occupant Load Factors in Chapter
5 of the Life Safety Code.)
b) Measure the width of the means of egress,
using the narrowest point of the exit component
under consideration.
c) Divide the width in inches by the factors listed
in Section 5-3.3.1 of the Life Safety Code
(i.e., high hazard occupancies: .4 for level
components, .7 for stairs; all others: .2 for
level components and .3 for stairs).
d) Compare the occupant load to the exit capacity.
Ensure that the main exit is capable of
accommodating 50% of the total occupant load
on that level. [Refer to NFPA101, 5-3 for
Tables.]
Verify that exits and access to exits are marked with
readily visible signs [29 CFR 1910.37(q)(l)].
Verify that all doors, passageways, or stairways which
are neither exits nor access to exits and which could be
mistaken for an exit are identified by signs reading
"NOT AN EXIT" or similar designation [29 CFR
1910.37(q)(2)].
30) Verify that all exit signs are distinctive in color and
provide contrast with other decorations, interior finish,
or other signs [29 CFR 1910.37(q)(4)].
Signs
28)
29)
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31) Verify that signs with the word "EXIT" having an
arrow indicating the appropriate direction of travel are
provided in locations where the direction of travel to
reach the nearest exit is not immediately apparent [29
CFR 1910.37(q)(5)].
32) Verify that exit signs are illuminated by a reliable light
source which provides at least 5-foot candles on the
illuminated surface [29 CFR 1910.37(q)(6)].
33) Verify that exit signs have the word "EXIT" in plainly
legible lettering at least 6 inches high with the width of
lettering at least 1/2-inch [29 CFR 1910.37(q)(8)].
Corridors and Enclosures
34) Evaluate whether corridors used as exit access and
serving an area with an occupant load of more than 30
are separated from other parts of the building by a fire
barrier having a 1-hour fire resistance rating [NFPA
101, Sec. 5-1.3.4].
35) Evaluate whether enclosing walls of exits are arranged
to provide a continuous protected path of travel,
including landings and passageways, to an exit
discharge [NFPA 101, Sec. 5-1.3.2].
36) Verify that exit enclosures are not used for any purpose
that could interfere with their uses as an exit and, if so
designated, as an area of refuge [NFPA 101, Sec. 5-
1.3.3]
37) Verify that exits or exit access doors that swing into an
aisle or passageway do not restrict the effective
minimum exit width which is 44-inch clearance [29
CFR 1910.37(c)(3), EPA 4870, 4.6].
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38) Verify that all doors in the means of egress leading to
an exit or exit access are side-hinged or pivoted-
swinging type and swing in the direction of exit travel
when serving a room or area with an occupant load of
50 or more or a Class A and B laboratory [29 CFR
1910.37(f)(2), NFPA 101, Sec. 5-2.1.4.1], and
NFPA 45, Sec. 34.2].
Doors
39) Verify that every stair enclosure door allows re-entry
from the stair enclosure to the interior of the building
for fire fighting purposes and to exit the stairway at
such floor should the fire render the lower part of the
stair unusable during egress [NFPA 101, 5-2.1.5.2].
40) Evaluate whether doors are provided with a knob,
handle, panic bar, or other simple type of releasing
device having an obvious method of operation under
all lighting conditions [NFPA 101, Sec. 5-2.1.5.3].
41) Evaluate whether doors designed to normally be kept
closed in a means of egress, such as a door to a stair
enclosure or horizontal exit, are self-closing and not
secured in the open position unless maintained open by
a hold-open mechanism, which upon release the door
becomes self closing. The device must be released by
the smoke detection system or any other fire detection
system [NFPA 101, Sec. 5-2.1.8].
42) Verify that power-operated doors (actuated by sensing
devices upon the approach of a person) or doors with
power-assisted manual operation may be opened
manually to permit exit travel or closed where
necessary to safeguard means of egress [NFPA 101,
Sec. 5-2.1.9].
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43) Verify that revolving doors are not used within 10 feet
of the foot of or top of stain or escalators and are
capable of being collapsed into a book-fold position
with an aggregate width of 36 inches [NFPA 101, Sec.
5-2.1.10.1 (b) and (c)].
Stairs
44)
45)
46)
47)
Evaluate whether stairs serving as required means of
egress are of permanent fixed construction [NFPA
101, Sec. 5-2.2.3.1].
Verify that stairs and intermediate landings continue
with no decrease in width along the direction of exit
travel [NFPA 101, Sec. 5-2.2.3.3].
Verify that stair treads are uniformly slip resistant and
free of projections or lips that could cause stair users to
trip and fall [NFPA 101, Sec. 5-2.2.3.4].
If the facility is equipped, verify that activation of
mechanical ventilation and pressurized stair enclosure
systems is initiated by a smoke detector installed in an
approved location within 10 feet of the entrance to the
smoke proof enclosure [NFPA 101, Sec. 5-2.3.10.1].
48) If equipped with a smoke proof tower, verify that
activation of an automatic closing device on any door
in the smoke proof enclosure will activate all other
automatic closing devices on doors in the smoke proof
enclosure [NFPA 101, Sec. 5-2.3.11].
49 ) Verify that fire barriers forming horizontal exits are not
penetrated by ducts [NFPA 101, Sec. 5-2.4.3.3].
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SO) Verify that handrails are installed on at least one wall of
stairs. If the stairway is greater than 60 inches in
width, additional handrails will be necessary.
Handrails must be at least 34 inches, but less than 38
inches high and firmly secured. A 1-1/2 inch clearance
' must exist between the handrail and wall [NFPA 101,
Sec. 5-2.2.4].
Illumination
51) Evaluate whether floors of means of egress are
illuminated during emergencies at all points including
angles and intersections of corridors and passageways,
stairways, landings or stairs, and exit doors to values
of an average of 3-foot candles measured at the floor.
During non-emergency situations, average illuminating
should measure at least 5-foot candles [EPA 4870, FS
1-07(11)].
52 ) Evaluate whether illumination in a means of egress is
arranged so that the failure of any single lighting unit
will not leave any area in darkness [NFPA 101, Sec.
5-8.1.4].
53) Verify that no battery operated electric light nor any
type of portable lamp or lantern is used for primary
illumination of means of egress [NFPA 101, Sec. 5-
8.2.2].
54) Evaluate whether emergency lighting can be provided
for a period of 1-1/2 hours in the event of failure of
normal lighting [NFPA 101, Sec. 5-9.2.1].
55) Verify that the emergency lighting system can be
continuously in operation or capable of repeated
automatic operation without manual intervention
[NFPA 101, Sec. 5-9.2.5].
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56) Verify that emergency lighting in laboratories provide
at least 10 foot candles, measured at the face of the
hood and at the exit door [EPA 4870, FSI-06(17)].
Emergency Procedures
57)
58)
59)
60)
Review the facility's emergency action plan to
determine whether the designated actions required by
the employer and employees to ensure employee safety
from fire and other emergencies have been established
and communicated to employees [29 CFR
Determine whether the types of evacuation to be
followed during emergency circumstances have been
included in the emergency action plan [29 CFR
1910.38(a)(4)].
Verify that employees are provided training on how to
assist in the safe and orderly emergency evacuation of
the building [29 CFR 1910.38(a)(5)].
Review the facility's written fire prevention plan to
determine whether it includes the following:
a) List of major fire hazards or sources (e.g.,
welding), and their handling, storage and
control procedures
b) Names and job titles of personnel responsible
to maintain control equipment and fuel source
hazards (if any)
c) Housekeeping procedures for accumulation of
flammable and combustible waste materials and
residues
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61)
62)
63 )
d) Employee awareness training
e) Maintenance schedules of control equipment
(e.g., fire extinguishers)
f) Availability for employee review [29CFR
Evaluate the accumulation of flammable and
combustible waste materials and residues to determine
if it is controlled to reduce their contribution to a fire
emergency [29 CFR 1910.38(b)(3)].
Verify that employees are provided training on fire
hazards associated with the materials and processes to
which they are exposed [29 CFR 1910.38(b)(4)].
Determine whether the equipment and systems installed
on heat-producing equipment are regularly and
properly maintained to prevent accidental ignition of
combustible materials. Also verify that this
maintenance procedure is included in the written fire
prevention plan [29 CFR 1910.38(b)(5)].
C. Hazardous Materials
Evaluate the facility's program for managing hazardous
materials by conducting the following procedures:
Compressed Gas Cylinders
64) Verify that the number of flammable gas and oxygen
cylinders does not exceed six in a sprwklered
laboratory and three in a nonsprinklered laboratory
(EPA Facilities Safety Manual, Volume 4870-1 FS 1-
07(6)].
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65) Verify that gas cylinders are legibly marked identifying
the gas content [29 CFR 1910.101(a)].
66) Confirm that cylinders are supported securely in an
upright position via chain, nylon strap or metal
channel. (NOTE: Gang chaining is prohibited in
laboratories) [EPA 4870 FSI-07(6)].
67) Verify that oxygen-fuel gas welding cylinders stored
inside a building are dry, protected, ventilated and at
least 20 feet from highly combustible material [29 CFR
1910.253(b)(2)(ii)].
68) Verify that oxygen gas welding cylinders in storage are
separated from fuel gas cylinders or combustible
materials by 20 feet or by a noncombustible barrier at
least 5 feet in height with a one-half hour fire resistance
rating. [29 CFR 1910.253(b)(4)(iii)].
69) Verify that empty oxygen-fuel gas cylinders have their
valves closed [29 CFR 1910.253(b)(2)(iii)j.
70) Confirm that oxygen-fuel gas cylinders are not located
where they may become part of an electric circuit [29
CFR 1910.253(b)(5)(ii)(J)].
Flammable or Combustible Materials
Inventory the types, quantities and storage of flammable or
combustible liquids.
71) Verify that only approved containers and portable tanks
are used to store flammable or combustible liquids [29
CFR 1910.106(d)].
XIV-13
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72)
73)
74)
75)
76)
Verify that storage cabinets contain not more than 60
gallons of Class I or Class II liquids or more than 120
gallons of Class HI liquid [29 CFR 1910.106(d)
Verify that storage cabinets are labeled, "Flammable -
Keep Fire Away" [29 CFR 1910.106(d)(3)(ii)].
Verify that storage cabinets are vented by mechanical
exhaust at a rate of 5 to 20 cubic feet per minute
(CFM). Air should be supplied at the top of the
cabinet and exhausted from the bottom. (NOTE: This
requirement is waived where prohibited by local
jurisdiction.) [EPA 4870-1, FS1-07 (4)].
Verify that the quantity of liquid outside a storage room
or cabinet in a fire area (one hour fire resistance rating)
of a building does not exceed:
25 gallons of Class IA liquids
120 gallons of Class IB, 1C, II or HI liquids in
containers
660 gallons of Class IB, 1C, II or HI liquids in
a single portable tank [29 CFR
a)
b)
c)
Verify that inside flammable liquids storage rooms are
provided with 2-hour fire resistance construction and
mechanically vented at a rate of 1-CFM per square foot
of floor area. (NOTE: The location of supply and
exhaust diffusers should be within 12 inches of the
floor on opposite walls of the room.) [EPA 4870- 1 ,
FS1-07(4)].
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77) Verify that the control switch for the inside flammable
storage room's ventilation system is located outside of
the door [29 CFR 1910.106(d)(4)(iv)].
78) Verify that electrical wiring and equipment within an
inside storage room containing Class I liquids is Class
I, Division fi. General use wiring is permitted for
Class II and in liquids [29 CFR 1910.106(d)(4)(iii)].
79) Verify that adequate precautions are taken to prevent
the ignition of flammable vapors from chemical
reactions, mechanical sparks, smoking, and hot
surfaces [29 CFR 1910.106(e)(6)(i)].
D. Fire Protection
Using information generated from the facility and the facility
orientation tour, verify that the facility's fire protection system
meets applicable standards by completing the following
investigation:
Portable Fire Extinguishers
80) Verify that portable fire extinguishers are mounted and
located so that they are readily accessible to employees
[29 CFR 1910.157(c)(l) and NFPA 10, Sec. 1-6.3].
81) Verify that no portable fire extinguishers containing
carbon tetrachloride or chlorobromomethane
extinguishing agents are provided in the building [29
CFR 1910.157(c)(3)].
82) Determine whether portable fire extinguishers are
maintained in a fully charged and operable condition,
and kept in their designated locations [29 CFR
1910.157(c)(4) and NFPA 10, Sec. 1-6.2].
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83) Evaluate how portable fire extinguishers were selected
and distributed based on the classes and size of
anticipated workplace fires [29 CFR 1910.157(d)(l)].
84) Verify that the travel distance for any employee to
reach a portable fire extinguisher is not more than 75
feet, unless approved uniformly spaced standpipe
systems or hose stations connected to a sprinkler
system are provided for emergency use by employees
[29 CFR 1910.157(d)(2) and (3)].
85) Verify that annual maintenance checks are performed
on all portable fire extinguishers [29 CFR
1910.157(e)(3) and NFPA 10, Sec. 4-4.1.1].
86) Evaluate the employee educational program on the
general principles of fire extinguisher use and the
hazards involved with incipient stage fire fighting if
required in the emergency action plan. Verify that only
trained personnel are allowed to use portable fire
extinguishers. Determine whether fire extinguisher
training is provided annually to designated employees
[29 CFR 1910.157(g)].
87) Verify that portable fire extinguishers are inspected
when initially placed in service and thereafter on a
monthly basis. Note whether personnel making
inspections of portable fire extinguishers maintain
records of extinguishers identified as requiring
corrective action. Dates of portable fire extinguisher
inspections and the initials of the person performing
them should be recorded on a monthly basis [29 CFR
1910.157(e)].
88) Verify that cabinets housing portable fire extinguishers
are not locked [NFPA 10, Sec. 1-6.4].
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89) Verify that portable extinguishers are not obstructed or
obscured from view [NFPA 10, Sec. 1-6.5].
90) Verify that portable fire extinguishers are equipped
with either a label, tag, stencil, or other form of
identification to inform the user of the contents inside
the extinguisher [NFPA 10, Sec. 1-7].
91) Verify that portable fire extinguishers out of service for
maintenance or recharge are replaced with spare, fully
operational extinguishers of the same type and at least
equal rating [NFPA 10, Sec. 4-4.1.4].
92) Verify that information indicating the month and year
inspections, maintenance, and recharging of portable
fire extinguishers were performed is attached to each
extinguisher on a label or tag [NFPA 10, Sec. 4-4.3].
93) Verify that rechargeable portable fire extinguishers are
recharged after any use or as indicated by an inspection
or when performing maintenance [NFPA 10, Sec 4-
5.1.1].
94) Verify that support personnel trained in inspection,
testing and maintenance of the building's fire
protection systems are available to assist at any time
when the authorized individual is unavailable [NFPA
13A, Sec. 1-5.5].
Automatic Sprinkler Systems
95) Verify that the automatic sprinkler system is
continuously maintained in reliable operating condition
at all times and periodically inspected and tested to
assure proper maintenance [29 CFR 1910.37(m)].
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96) Verify that a main drain flow test is performed on the
automatic fire sprinkler system annually and the test
valve is opened every 2 years [29 CFR
1910.159(c)(2)].
97) Determine whether the automatic sprinkler system is
provided with at least one automatic water supply
capable of providing design water flow for at least 30
minutes [29 CFR 1910.159(c)(4)].
98) Verify that automatic sprinkler system piping is
protected against freezing and exterior surface
corrosion [29 CFR 1910.159(c)(6)].
99) For sprinkler system having more than 20 sprinklers,
verify that a local waterflow alarm is provided which
sounds an audible signal on the premises upon water
flow through the system equal to the flow from a
single sprinkler [29 CFR 1910.159(c)(9)]
100) Evaluate sprinkler spacing to determine if it provides a
maximum protection area per sprinkler with a
minimum vertical clearance between sprinklers and
materials below of at least 18 inches [29 CFR
1910.159(c)(10)]
101) Verify that sprinklers are visually checked regularly to
ensure that they are free from corrosion, foreign
material, paint, and not bent or damaged [NFPA 13A,
Sec. 3-1.1].
102) Verify that sprinklers that are exposed to mechanical
injury are protected with approved sprinkler guards
[NFPA ISA, Sec. 34].
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103) Verify that sprinkler protection is provided for all:
a) Laboratories
b) Any buildings over 75 feet in height
All below grade areas
All Group IV occupancies
Group II occupancies over 1000 square feet
Windowless areas exceeding 1000 square feet
Cooling towers of combustible construction
c)
d)
e)
f)
g)
h)
Areas re-occupied with a higher hazard
operation that now exceeds fire separation
design
i) Open office plans exceeding 6 pounds per
square feet of fuel load
j) Electronic equipment areas [EPA 4870, FSI-
05(6)].
Fixed Extinguishing Systems, General
Audit steps 104 through 118 apply only to fixed systems not
installed to meet an OSHA requirement, but where the
extinguishing agent may expose employees to adverse health
consequences. (Example: a carbon dioxide extinguishing
system for computer rooms.)
104) Verify that Halon 1301 Fire Extinguishing Systems are
not used in EPA facilities [EPA 4870 FSI-05(7)].
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105) Evaluate the procedures used when the fixed
extinguishing system becomes inoperable. Verify that
employees are notified and appropriate precautions are
taken to assure employees' safety until the system is
restored to operating condition [29 CFR
1910.160(b)(2)].
106) Verify that threads provided for Fire Department
connections, hose outlets or other threads used for the
connection of fire hoses comply with Fire Department
specifications [UBC, Sec. 3801 (d)].
107) Verify that a distinctive alarm or signaling system
capable of being perceived above ambient noise or light
levels is provided [29 CFR 1910.160(b)(3)].
108) Evaluate whether effective safeguards are provided to
warn employees against entry into discharge areas
where the atmosphere remains hazardous to
employees' safety and health [29 CFR
1910.160(b)(4)].
109) Verify that hazard warning or caution signs are posted
at the entrance and inside areas protected by fixed
extinguishing systems known to use agents in
concentrations hazardous to employee safety and health
[29CFR1910.160(b)(5)].
110) Verify that fixed extinguishing systems are inspected
annually by a person knowledgeable of the system to
assure that the system is maintained in good operating
condition [29 CFR 1910.160(b)(6)].
Ill) Verify that the weight and pressure of refillable
containers is checked at least semi-annually [29 CFR
1910.160(b)(7)].
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112)
113)
1 14)
115)
116)
1 17)
118)
Determine whether factory charged nonrefillable
containers with no means of pressure indication are
weighed at least semi-annually [29 CFR
1910.160(b)(8)].
Verify that inspection and maintenance dates are
recorded on all containers by a tag attached to the
container, or in a central location [29 CFR
1910.160(b)(9)].
Verify that a record of the last semi-annual check is
maintained for each container until it is checked again
or for its life, whichever is less [29 CFR
1910.160(b)(9)].
Determine whether employees designated to inspect
fixed extinguishing systems have received training
annually [29 CFR 1910.160(b)(10)].
Verify that chlorobromomethane or carbon
tetrachloride are not used as extinguishing agents in
fixed extinguishing systems [29 CFR
Verify that there is at least one manual station provided
for discharge activation of each fixed extinguishing
system [29 CFR 1910.160(b)(15)].
Verify that manual operating devices are identified as to
the hazard against which they will provide protection
[29 CFR 1960.160(b)(16)].
Fire Detection Systems
Audit steps 1 19 through 126 apply to all systems installed to
meet OSHA requirements.
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119) Determine whether the building fire detection system
and components are restored to normal operating
condition as promptly as possible after each test or
alarm [29 CFR 1910.164(b)(2)].
120) Verify that the building fire detection system is
maintained in an operable condition except during
repairs or maintenance [29 CFR 1910.164(c)(l)].
121) Evaluate whether fire detectors and other fire detection
systems are tested, adjusted and cleaned as often as
necessary to maintain proper reliability and operating
condition [29 CFR 1910.164(c)(2)].
122) Verify that service, maintenance, and testing of the
building fire detection system are performed by a
person knowledgeable in the operations and functions
of the system [29 CFR 1910.164(c)(4) and NFPA
ISA, Sec. 1-5.4].
123) Evaluate the methods by which fire detection
equipment is protected from mechanical or physical
impact which may render it inoperable [29 CFR
1910.164(d)(2)].
124) Verify that smoke detectors are installed in all of the
following areas:
a) Essential electronic equipment
b) Air handling systems:
1. Downstream of fan filter, main
supply duct if system is more than
2000 cfm
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125)
126)
2. Return air ducts, each flow or fire
area if air handling systems supply
multiple floors
3. Elevator lobbies (exception full
sprinkled buildings where elevator
recall is activated by floor alarms).
[EPA 4870, FS1-06 (16), NFPA 90A]
Verify that elevators are recalled upon initiation of any
fire alarm initiating device [EPA 4870, FS 1-05(15)].
Verify that the Fire Department is notified within 90
seconds of any alarm initiation [EPA 4870, FS1-
05(16)].
Employee Alarm Systems
Audit steps 127 through 131 apply to work places with more
than 10 employees where alarm systems are required by
OSHA, EPA or as stated in the emergency action plan.
Alarms may include building alarms, public address system,
telephones, etc.
127)
128)
129)
Determine whether the employee alarm system
provides warning for necessary emergency action as
specified in the emergency action plan [29 CFR
Verify that the employee alarm system is capable of
being perceived above ambient noise or light levels by
all employees in affected portions of the building [29
CFR 1910.165(b)(2)].
Determine if the facility's employee alarm system is
distinctive and recognizable as a signal to evacuate the
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work area or to perform designated actions as specified
in the emergency action plan [29 CFR
1910.165(b)(3)].
130) Verify that procedures for sounding emergency alarms
in the work place are established and communicated to
employees [29 CFR 1910.165(b)(4) and (5)].
131) Determine whether manually operated actuation devices
for employee alarms are unobstructed, conspicuous
and readily accessible [29 CFR 1910.165(e)].
Emergency Power
132) Verify that emergency power is provided by battery
generator or automatic switching systems. Verify that
emergency power is supplied to emergency lighting
fire safety systems and elevator, as required [EPA
4870FS1-06(18)].
Ventilation
133) Evaluate the adequacy of cooking equipment exhaust
system. The exhaust system should be:
a) Exhausted directly to the outside and not in
contact with combustible construction
b) Manufactured of non-combustible materials
c) Filtered, with filters cleaned regularly [EPA
4870, FS 1-05(9) NFPA 96].
134) Verify that automatic fire dampers are provided in air
return and exhaust systems to maintain fire separation
areas (for example, computer rooms) [EPA 4870,
FS 1-05(10) and NFPA 90A].
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Boiler/Furnace Rooms
135) Verify that the fire-rated construction of the boiler or
furnace room is adequate [EPA 4870, FS 1-05(11)].
136) Verify that no flammable or combustible materials are
used in the boiler or furnace rooms, unless the room is
sprinklered [EPA 4870, FS 1-05(11)].
E. Elevators
137) Verify that elevator lobbies and elevator machine
rooms are provided with an approved smoke detector
(unless the building is fully sprinklered, then no smoke
detectors are required in the lobby) [EPA 4870, FS 1-
05(15)].
138) Verify that standby power is provided to at least one
elevator in each bank and is capable of being manually
transferable to all elevators in each bank. A generator
located in a separate room enclosed by at least a 2 hour
fire resistive separation is provided to supply standby
power automatically whenever there is a loss of
electrical power in the building [UBC, Sec. 5103 (c)]
NOTE: Check local codes to verify applicability of
UBC codes to EPA facilities.
139) Verify that all elevator machine rooms and hoist ways
can be vented directly to the outside. A remote means
should operate the vents, and exhaust fans should be
included when serving six or more levels. Exhaust
fans must be initiated by any areas fire detection
system (sprinkler, smoke detector, etc.).
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140) Verify that there is at least one elevator serving all
floors which accommodate a wheelchair, and is
equipped as follows:
a) Automatic doors with self-leveling feature
b) Automatic horizontally sliding car and hoistway
doors
c) Minimum clear width of 36 inches for elevator
doors
d) Door reopening device that will reopen the
elevator doors when they are obstructed.
[UBC, Sec. 5103 (d) (1-4)].
141) Verify that elevator doors remain fully open for at least
3 seconds. [UBC, Sec. 5103 (d) (5) (B)].
142) Verify that car position indicators are provided above
each car operating panel or over each car opening to
show the position of the car in the hoistway [UBC,
Sec. 5103 (d) (8)].
143) Verify that each elevator is equipped with a means of
two-way communication [UBC, Sec. 5103 (d) (9)].
144) Verify that floor coverings in each elevator are of a
nonslip hard surface type which permits easy
movement of wheelchairs [UBC, Sec. 5103 (d) (10)].
145) Verify that each elevator is equipped with at least one
handrail (preferably on the rear wall) [UBC, Sec.
5103 (d) (11)].
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146) Verify that minimum illumination in each elevator is
not less than 5-foot candles [UBC, Sec. 5103 (d)
(12)].
147) Verify that approved pictorial signs are posted adjacent
to each elevator call station to indicate that the elevator
will not operate in case of fire and that exit stairways
should be used [UBC, Sec. 5103 (f)].
148) Verify that elevator lobbies have access to at least one
exit which does not require the use of a key, tool,
special knowledge, or effort [NFPA 101, Sec. 5-
4.1.5].
F. Material Handling and Storage
149) Verify that the storage areas are free from tripping, fire
explosion or pest hazards [29 CFR 1910.176(c)].
Powered Industrial Trucks
150) Verify that facilities for battery charging include spill
control, fire protection, ventilation and protection from
physical damage [29 CFR 1910.178(g)(2)].
151) Verify that only approved powered industrial trucks are
designated to enter hazardous atmosphere locations [29
CFR 1910.178(c)(2)].
G. Welding, Cutting and Brazing
152) Verify that welding and cutting is only conducted in
fire safe areas [29 CFR 1910.252(a)(2)(xv)].
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FIRE ANHfcFE SAFETY
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PROTOCOL
RESPONSE
COMMENTS
(153) Verify that before cutting or welding is permitted, the
area is inspected by the individual responsible for
authorization. The permit should be written [29 CFR
1910.252(a)(2)(iv)].
H. Electrical
Evaluate the facility's program for managing electrical safety
by completing the following procedures:
NOTE: Additional requirements for managing electrical are
delineated in the safety audit protocol.
154) Inspect electrical equipment to verify that it is free from
recognized hazards (e.g. equipment is U.L. listed,
insulation rating is appropriate, proper grounding and
polarity, no frayed cords, etc.) that are likely to cause
death or serious injury to employees [29 CFR
1910.303(b)(l) and .304(a).]
155) Verify that no electrical equipment is used unless the
manufacturer's name, trademark, or other descriptive
marking identifying the organization responsible for
the product is provided [29 CFR 1910.303(e)].
156) Verify that all disconnect means and circuits are legibly
marked to include its purpose [29 CFR 1910.303(f)].
157) Verify that all electrical installations are constructed to
guard all live parts from unqualified people. If live
parts are accessible, verify that the installation is
accessible to qualified people only [29 CFR
1910.303(g)(2)].
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AFETY
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PROTOCOL
RESPONSE
COMMENTS
I. Evaluation of Findings
158) Review actions taken to complete each step of the audit
protocol and summarize your conclusions as to the
facility's status.
159) Review and discuss any unresolved issues with
appropriate facility personnel. Note explanations and
the disposition of issues in your working papers.
160) Develop a written list of exceptions and observations.
Discuss this list at a team meeting prior to the exit
conference to substantiate the trends or identify overall
patterns or trends.
XIV-29
FIRE AND^FE SAFETY
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