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Policy Area

ESH-Environment Safety & Health

Procedure Number

ESH100.2.IH.15

Procedure Title

Control Hazards Using Local Exhaust Ventilation and High Efficiency Particulate Air Filters

Procedure Manager

HOOPER, LISA Z.

Status

Active

Subject Matter Expert

  • Chad E. Hjorth
  • Daniel Kuey (Dan)—CA Contact

 

Applicability, Exceptions, and Consequences

This corporate procedure applies to all Members of the Workforce whose activities utilize local exhaust ventilation (LEV) systems and high-efficiency particulate air (HEPA) filters to control chemical, biological, or radiological hazards on Sandia-controlled premises.

This procedure does not apply to laminar flow hoods, HEPA-filtered vacuum cleaners used for routine (non-hazardous) housekeeping, or clean room HEPA filters used exclusively for product protection.

Exceptions to, or deviations from this procedure must be approved through the Executive Policy Sponsor or Policy Area Manager, if delegated. Click here to view Contacts for CPS Policies, Processes, and Procedures. See CG100.1.7, Request an Exception to a Policy, Process, or Procedure, for directions on how to obtain an exception to this procedure.

Granting or permitting exceptions or violations of policy, process, or procedure without authority, regardless of position or title, may be cause for disciplinary action up to and including termination of employment. Violating a policy, process, or procedure may be cause for disciplinary action up to and including termination of employment.

IMPORTANT NOTICE: A printed copy of this document may not be the document currently in effect. The official version is located on the Sandia National Laboratories Sandia Restricted Network (SRN).

Procedure Overview

This procedure describes the requirements for implementing local exhaust ventilation safety.

 

 

Procedure Requirements

Training

Activity Responsible Individual Required Action
Ensure Training Compliance Managers

Ensure that Members of the Workforce complete the training identified in ESH100.2.IH.15 prior to performing the indicated work activity or fulfilling the indicated role.

Note: See Sandia corporate procedure HR100.2.1, Identify and Complete Sandia Required Training for all Members of the Workforce.

Assessment and Selection of Engineering Controls

Activity Responsible Individual Required Action
Assess and Select Engineering Controls Managers

Ensure that Members of the Workforce:

  • Contact the appropriate division ES&H team industrial hygienist for an exposure assessment of activities involving chemical or biological agents; or the appropriate division ES&H team radiation protection representative to evaluate radiological work that may require Local Exhaust Ventilation (LEV) System or high-efficiency particulate air (HEPA) filters. 
  • Implement and maintain LEV systems and HEPA filters specified by the exposure assessment.
  • Contact the division ES&H team industrial hygienist or radiation protection representative, as appropriate, when a new hazard or activity is introduced that may require the re-evaluation of the adequacy of the existing LEV system or HEPA filter.

Acquisition and Installation of LEV Systems

Activity Responsible Individual Required Action
Acquire and Install LEV Systems Managers

Ensure that Members of the Workforce:

  • Contact the Local Exhaust Ventilation (LEV) System subject matter expert to provide requirements and guidance associated with LEV specifications, procurement, and installation, prior to purchase.
  • Purchase commercial LEV systems, rather than Sandia-fabricated systems, whenever feasible.
  • Contact the LEV SME to evaluate all proposed Sandia-fabricated LEV systems prior to construction.
  • Contact the facilities organization (FMOC at SNL/NM and ASH, Facilities, and Security at SNL/CA) to perform the design, installation, and modification of LEV systems, except as specifically approved and documented by the LEV SME.
  • Contact the LEV SME to initiate the first system performance test prior to use.
  • Purchase all new laboratory hoods with airflow indicators. 
  • Contact the performance-testing contractor (SNL/NM) or the ES&H Team industrial hygienist (SNL/CA) to install airflow indicators on existing laboratory hoods by September 30, 2010.
  • Contact the LEV SME to request documentation for any proposed deviations from LEV manufacturer specifications.
  • Do not procure self-contained, non-ducted LEV (e.g., bench top hoods) with HEPA or other filter media to control exposure—except in the instances of biological safety cabinets (BSC) and some welding LEV systems.
  • Do not procure low-flow laboratory hoods.

Acquisition and Installation of HEPA Filters

Activity Responsible Individual Required Action
Acquire and Install HEPA Filters Managers

Ensure that Members of the Workforce:

  • Contact the Local Exhaust Ventilation (LEV) System subject matter expert (SME) to provide requirements and guidance associated with high-efficiency particulate air (HEPA) filters specifications, procurement, and installation within a LEV system prior to purchase.
  • Contact the HEPA filter-testing contractor to:
    • Perform in place poly alpha olefin (PAO) testing on fixed HEPA filters, portable HEPA filters, and HEPA-filtered vacuum cleaners prior to initial use; and
    • Label them with a dated test sticker.
  • Send HEPA filters to the DOE HEPA Filter Test Facility in Baltimore, MD, at the time of procurement (when the LEV SME or division radiation protection representative determines that this is necessary).
  • Contact the LEV SME for additional information on sending HEPA filters for testing.

Operation Requirements

Activity Responsible Individual Required Action
Operate LEV Systems Managers

Ensure that Members of the Workforce:

  • Train in the proper use of  local exhaust ventilation (LEV) or high-efficiency particulate air (HEPA) filters through site-specific training [e.g., CHM103 (Site-Specific Chemical Safety Training). 
  • Have Local Exhaust Ventilation (LEV) System performance tested at least biennially.
  • Contact the performance-testing contractor (SNL/NM) or the ES&H Team industrial hygienist (SNL/CA) to procure and install airflow indicators on all laboratory hoods by September 30, 2010.
  • Follow general LEV safe-work practices including, but not limited to:
    • Knowing how to use airflow indicators and how to respond to indications of inadequate flow, such as airflow indicator alarms or odors.
    • Performing work only in LEV systems with valid performance test stickers.
    • Ensuring that all laboratory apparatus and operations take place at least 6 inches from the face of an enclosing hood.
    • Discontinuing work inside hoods that alarm due to low flow.
    • Positioning LEV (e.g., elephant trunks, snorkels) as close to the process as possible, and in such a way as to draw airborne hazards away from the worker’s breathing zone.
    • Keeping the LEV intake free of obstruction.
    • Using the Safe Operations of Laboratory Hoods summary sheet as appropriate.
  • Use SF 2001-OUS, Out of Service Tag (Word file/Acrobat file), if the Local Exhaust Ventilation (LEV) System and/or HEPA filters fail to pass a performance test. 
  • Remove the out-of-service tags, once the Local Exhaust Ventilation (LEV) System and/or HEPA filters have passed performance tests.

Change Control and Maintenance Requirements

Activity Responsible Individual Required Action
Modify and Maintain LEV Systems and HEPA Filters Managers

Ensure that Members of the Workforce:

  • Contact the Local Exhaust Ventilation (LEV) System subject matter expert (SME) to provide requirements and guidance associated with any modifications to existing LEV systems.
  • Notify the division ES&H team industrial hygienist or radiation protection of any process or procedure changes that may affect the adequacy of current LEV and HEPA system configurations. Examples of changes that may impact LEV systems and HEPA filters include:
    • Additional process equipment served by the system.
    • Reconfiguration of process equipment with respect to LEV systems and high-efficiency particulate air (HEPA) filters, including proximity of the process to the LEV opening.
    • Increase in quantity, concentration, or type of hazardous material.
    • Heating processes resulting in increased vaporization of materials.
    • Acceleration of materials exhausted by the LEV (e.g., grinding).
    • The introduction of moisture, high-air temperatures, direct contact with fire, high-pressure drops, or shock pressures.
  • Contact the HEPA filter-testing contractor to perform in place poly alpha olefin (PAO) testing on high-efficiency particulate air (HEPA) filters, portable HEPA filters, and HEPA-filtered vacuum cleaners used for hazardous chemicals—after any major system modifications, filter replacement, repairs—and annually, thereafter.
    • HEPA Filters used for radiological applications shall not exceed their service life of 10 years.  This service life includes a maximum shelf life of 3 years.
  • Contact the HEPA filter testing contractor to apply a current PAO test sticker (before use) to fixed HEPA filters, portable HEPA filters, and HEPA-filtered vacuum cleaners used for hazardous chemicals or radiological applications.
  • Contact the HEPA Filter Testing Contractor to perform in-place PAO testing of HEPA filters used in radiological applications at scheduled intervals not to exceed 6 months, unless the division ES&H Team radiation protection representative approves and documents otherwise.
  • Notify the LEV SME of any major maintenance activities that may affect LEV systems and HEPA filters. Examples of maintenance that may impact LEV systems and HEPA filters include:
    • Modification or relocation of the LEV system and HEPA filter.
    • Modification of the laboratory ventilation system.
  • Contact the LEV performance-testing contractor  to performance test LEV systems after the completion of all repairs, modifications, or maintenance prior to resuming work.

Disposal Requirements

Activity Responsible Individual Required Action
Remove an LEV System Managers

Ensure that Members of the Workforce:

  • Contact the Local Exhaust Ventilation (LEV) System subject matter expert (SME) prior to removal of any LEV systems or high-efficiency particulate air (HEPA) filters.
  • Dispose of used HEPA filters appropriately, and do not re-use them (see ESH100.2.ENV.22, Manage Hazardous Waste at SNL/CA and waste management program lead at SNL/CA).

Biological Safety Cabinets Requirements

Activity Responsible Individual Required Action
Work with a Bio-Safety Cabinet Managers

Ensure that Members of the Workforce:

  • Contact the local exhaust ventilation (LEV) subject matter expert (SME) to provide requirements and guidance associated with the bio-safety cabinet (BSC) specifications, procurement, and installation prior to purchase.
  • Follow safe work practices including, but not limited to:
    • Keeping the face and grill of the BSC clear of obstructions.
    • Keeping laboratory apparatus and operations at least 6 inches from the face of the BSC.
  • Contact the LEV SME prior to moving the BSC to another location, modifying the BSC, or changing the BSC filters.
  • Contact the LEV performance-testing contractor to schedule performance testing of BSC annually.

Implementing Tools

Guidance

  • Local Exhaust Ventilation.

Form

  • SF 2001-OUS, Out of Service Tag (Word file/Acrobat file).

Websites

  • Airflow Indicators.
  • Safe Operations of Laboratory Hoods.

Additional Drivers

  • 10 CFR 830, Attachment 1, “Subpart A – Nuclear Safety Management Quality Assurance.”
  • 10 CFR 851, Worker Safety and Health Program.

Training Requirements

Responsible Individual Required Recommended
Members of the Workforce using LEV to control chemical hazards CHM100 (Chemical Safety) and CHM103 (Site-Specific Chemical Safety Training) N/A
Members of the Workforce using LEV to control biological hazards BIO105 (Biosafety in Microbiological and Biomedical Laboratories) N/A
Members of the Workforce using LEV to control radiological hazards RAD230 (Radiological Worker II Training) N/A

Related Processes and Procedures

Processes

Procedures

 

Change Summary

Date Summary
12/09/2010

Administrative

Modified

  • Changed the contact link to industrial hygienist.
  • Changed the link to radiation protection.
  • Updated SAPLE link to subject matter expert for system consistency.
  • Updated all dictionary terms to contain term identification numbers for system consistency.
08/13/2010

Administrative

Modified

  • Changed SME first name from Dan Kuey to Daniel Kuey in Subject Matter Expert.

06/11/2010

Administrative

Modified

  • Changed the heading from “Forms” to “Form.”
05/06/2010

Administrative

Modified

  • Corrected links to Local Exhaust Ventilation (LEV) and high-efficiency particulate air (HEPA) filters in Requirements & Instructions.