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Chemical Hygiene Plan, Chapter 7 : Inspections and Compliance

Chemical Safety Site Visits

EH&S has a comprehensive chemical safety compliance program to assist laboratories and other facilities that use, handle or store hazardous chemicals to maintain a safe work environment. This program helps to ensure compliance with regulations and to fulfill UCLA’s commitment to protecting the health and safety of the campus community. 

Chemical Safety Survey

As part of this chemical safety program, EH&S conducts inspections of laboratories and other facilities with hazardous chemicals to ensure the laboratory is operating in a safe manner and to ensure compliance with all federal, state and university safety requirements.  The primary goal of inspections is to identify both existing and potential accident-causing hazards, actions, faulty operations and procedures that can be corrected before an accident occurs.  UCLA Policy 811 authorizes EH&S to order the cessation of any activity that is “Immediately Dangerous to Life and Health” (IDLH) until that hazardous condition or activity is abated. 

The chemical safety program has developed a systematic approach to surveys that prioritizes the highest chemical hazard laboratories. This approach prioritizes safety measures according to the level of risk present. All laboratories are categorized by chemical hazards into three categories: low, moderate, high chemical hazards. All laboratories categorized by high chemical hazard will be visited annually. Laboratories categorized as moderate hazard will be visited every other year. All low hazard labs will be expected to complete a self-audit survey in EHSA. A portion of low chemical hazard laboratories will be randomly selected annually for an in-person survey. Updated information regarding the process and expectations can be found on our lab safety visits website.

The chemical safety survey is comprehensive in nature and looks into key aspects of working with hazardous chemicals.  While surveys are a snapshot in time and cannot identify every accident-causing mistake, they provide important information on the overall operation of a particular laboratory.  They can also help to identify weaknesses that may require more systematic action and strengths that should be fostered in other laboratories. See: Laboratory Inspection Checklist.  for a list compliance items. 

Compliance categories include:

  • Documentation and Training; 
  • Hazard Communication (including review of SOPs);
  • Emergency and Safety Information; 
  • Fire Safety; 
  • General Safety; 
  • Use of personal protective equipment (PPE); 
  • Housekeeping; 
  • Chemical Storage; 
  • Fume Hoods; 
  • Chemical Waste Disposal and Transport; 
  • Seismic Safety; and
  • Mechanical and Electrical Safety. 

Once the survey is completed, EH&S issues a Laboratory Survey Report via email. The report identifies findings in the laboratory, both serious and non-serious. Serious findings are those that have the potential to lead to serious injuries or be of critical importance in the event of an emergency. These findings must be promptly corrected. Non-serious findings must be corrected within 30-days. Any finding that requires a “Facilities Service Request” (FSR) for completion should be submitted by the Principal Investigator. Include in the FSR that this is a health and safety issue so that it is prioritized by Facilities. A copy of the most recent Inspection Report should be maintained as part of the records either electronically or inside the Laboratory Safety Manual. 

EH&S encourages laboratories and departmental safety coordinators to conduct their own audits and inspections. Any reports from these departmental inspections should also be maintained in the Laboratory Safety Manual.

Notification and Accountability

The compliance program requires that PIs/Laboratory Supervisors and other responsible parties take appropriate and effective corrective action upon receipt of written notification of inspection findings. Serious findings are required to be corrected within 48-hours; non-serious findings must be corrected within 30-days. Failure to take corrective actions within the required timeframe and confirm their completion to EH&S may result escalation to the Department Chair, Dean and Vice-Chancellor for Research and Creative Activities.  Depending on the severity of the finding, the Assistant Vice Chancellor of EH&S, in consultation with the Vice-Chancellor for Research and Creative Activities and Office of the Vice Chancellor Safety Oversight Committee (OSOC), may suspend research activities until the finding is corrected. In some cases, the PI may be required to provide a corrective action plan to the Laboratory Safety Committee prior to resumption of research activities.

Laboratory Safety Compliance Procedure (LSCP) 

The Office of the Vice Chancellor Safety Oversight Committee (OSOC) is charged with promoting a safe work environment for all personnel working in research and teaching laboratories on campus. In an effort to ensure that issues identified during lab safety inspections are adequately addressed and corrected in a timely matter, the committee established a three-tiered Laboratory Safety Compliance Procedure (LSCP).

In order to provide a highly responsive process, the OSOC has delegated administration of the first two tiers of the procedure to the campus Chemical and Physical Safety Committee (CPSC). Both the OSOC and CPSC are faculty-led committees. While the three-tiered procedure is designed to provide a progressive compliance process, it may be by-passed in the event of a significant disregard for safety that results in a condition that is immediately dangerous to life and health (IDLH). Any such findings will be reported to the OSOC Chair immediately for review at the discretion of EH&S. This may result in suspension of the PI’s laboratory activities, in whole or in part, by EH&S in accordance with UCLA Policy 811, with concurrence of the OSOC or appropriate Subcommittee and the Assistant Vice Chancellor for Environment, Health & Safety, without instituting the LSCP. Should this occur, the PI will be required to appear before the OSOC or an appropriate Subcommittee before laboratory activities may resume. 

The tiers are defined below:

Tier One 

When a repeat issue of noncompliance by a group has been identified by the LSO during an inspection, a Tier One Memorandum may be issued. 

The campus Chemical Hygiene Officer (CHO) will provide the Chair of the CPSC with a report indicating which operations have safety findings that qualify as a repeat issue. Repeat issues that require consideration from the Chair include, but are not limited to the following:

  • All findings which have not been corrected and reported within 90 days of the initial inspection 
  • Any serious findings which have not been corrected and reported within 72 hours of the initial inspection

Corrections that require infrastructure upgrades will be considered on a case-by-case basis and alternative risk mitigation strategies may be approved or ordered by the CPSC (or a subcommittee consisting of at a minimum, the Chair, the CHO, and a third committee member to be appointed by the Chair) and the Assistant Vice Chancellor of EH&S. 

Once a report has been issued to the CPSC, the committee may move to issue a Tier One Memo or defer issuance of the memo. If the committee wishes to defer, it must establish a rationale for deferring issuance and set date for re-evaluation. 

A Tier One Memorandum will be sent to the PI and his/her Department Chair informing them of the noncompliance issue(s) and of the potential for suspension of operations. The memorandum will indicate the item(s) of noncompliance and indicate the timeframe for implementing corrective action and confirming such action to EH&S.  

A written response to the Tier One memo is required. The response should contain details regarding either the corrective action taken or plans to take corrective action. Failure to respond within the stated time period (for non-serious issues, 15 days from the date of issue will be used as a standard but this can be changed as determined by the sub-committee) may escalate the memorandum level to Tier Two. Lack of corrective action within the prescribed problem-resolution peri­od following a Tier One Memorandum may result in the issuance of a Tier Two Memorandum. If the committee wishes to defer issuance of a Tier Two memo, it must establish a rationale for deferring issuance and set a date for re-evaluation.

Should the item(s) of noncompliance be corrected within the specified timeline the CPSC will issue a Resolution Memorandum indicating that corrective action has been taken and verified by EH&S.  Since corrective action must be verified by EH&S, labs should provide sufficient time for EH&S to respond to claims of corrective action (at least one business day).

Tier Two 

A Tier Two Memorandum will be sent to the PI and his/her Department Chair informing them of the noncompliance issue(s) and of the potential for suspension of operations. This notice will be sent to the PI informing him/her that this is a repeat item of noncompliance that was not resolved in response to the Tier One memo. The PI, or their designee, must provide a formal written response to the CPSC and EH&S as to the reasons for a second instance of non-compliance and/or why the previous corrective action(s) was/were ineffective and what further corrective action(s) will be implemented to prevent recurrence. In addition, the Principal Investigator (or other responsible manager) will be asked, along with the Department Chair, to appear before a sub-committee of the CPSC to discuss the proposed corrective action plan. The Committee will offer recommendations and/or additional requirements to the Principal Investigator to ensure future compliance.

Failure to respond within the stated time period (for non-serious issues, 15 days from the date of issue will be used as a standard but this can be changed as determined by the sub-committee) may escalate the memorandum level to Tier Three. Lack of corrective action within the prescribed problem-resolution period following a Tier Two Memorandum will result in the CPSC sending a report to the OSOC detailing the issues related to repeat non-compliance and recommending issuance of a Tier Three Memorandum. If the committee wishes to defer its recommendation to the OSOC for escalation to Tier Three, it must establish a rationale for postponement of a recommendation and set a time for re-evaluation. 

Should the item(s) of noncompliance be corrected within the specified timeline the CPSC will issue a Resolution Memorandum indicating that corrective action has been taken and verified by EH&S. Since corrective action must be verified by EH&S, labs should provide sufficient time for EH&S to respond to claims of corrective action (24 hours minimum).

Tier Three 

Upon recommendation of the CPSC, the OSOC will review cases where safety issues are not resolved following a Tier Two Memorandum. Should the OSOC agree with CPSC regarding non-compliance, they will issue a Tier Three Memorandum. 

This notice will be sent to the Principal Investigator, the Department Chair, and the Vice Chancellor for Research informing them of the continuing noncompliance and recommending that the Principal Investigator’s operations be suspended until corrective action is taken. The Vice Chancellor for Research will decide on the course of action following consultation with the OSOC and the Assistant Vice Chancellor of EH&S and will provide authority and instruction on enacting suspensions. During the suspension period, the Principal Investigator and Department Chair will be instructed to appear before the OSOC to explain why the operation should be reinstated and to present a formal written corrective action plan.

Recordkeeping Requirements

Accurate recordkeeping is an important part of promoting a safe and healthful research environment, integrity of research, and protection of the environment. EH&S is responsible for maintaining records of inspections, accident investigations, equipment calibration, and training conducted by EH&S staff.  Per OSHA regulations, departments or laboratories must document health and safety training, including safety meetings, one-on-one training, and classroom and online training.  Additionally, the following records must be retained in accordance with the requirements of state and federal regulations:

  1. Accident records;
  2. Measurements taken to monitor employee exposures; 
  3. Chemical Hygiene Plan records should document that the facilities and precautions  were compatible with current knowledge and regulations; 
  4. Inventory and usage records for high-risk substances should be kept; 
  5. Any medical consultation and examinations, including tests or written opinions required by CCR, Title 8, Section 5191; and
  6. Medical records must be retained in accordance with the requirements of state and federal regulations. 

If you have questions about these requirements, or how they apply to your laboratory, contact EH&S at laboratorysafety@ehs.ucla.edu.