Guidelines

Laboratory Decontamination and Decommissioning - Guidelines

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1. Purpose and Objectives

This guideline applies to all laboratories and auxiliary spaces serving laboratories at The University of Queensland, including off-site premises and host organisations such as hospitals and Queensland Government buildings. This guide is for all Principal Investigators, Group Leaders or Chief Investigators who are moving laboratories, renovating or refurbishing laboratories or are no longer working in the University’s premises.

2. Definitions, Terms, Acronyms

Biological Materials - Includes, but is not limited to blood, blood products, tissues, body fluids and any derivatives produced by chemical or physical means; micro-organisms – wild type or GM; plants and plant material.

DAgWRB - Commonwealth Department of Agriculture and Water Resources – Biosecurity (formerly DAFF Biosecurity, formerly AQIS)

Decommissioning - A withdrawal process to ensure a facility meets environmental health and safety standards prior to its next use.

Decontamination - A process whereby Hazardous or infectious material are removed and neutralised from laboratories and laboratory equipment.

Hazardous materials - Materials that can harm people, other living organisms, property, or the environment.

IBC - Institutional Biosafety Committee

Principal Investigator (PI) - Individual who receives funding to perform a study.

QAP - Quarantine Approved Premises

RPA - Radiation Protection Advisor

RSO - Radiation Safety Officer

WHSC - Workplace Health and Safety Coordinator

3. Guideline Scope/Coverage

This guideline is for all staff participating in safe laboratory decommissioning and closure. This guideline may also apply to decommissioning of a specific project within a laboratory.

4. Guideline Statement

Prior to relocation or refurbishment of a laboratory, or when a Principal Investigator is vacating, relocating, or renovating a laboratory space, or when a specific project is being shut down, safe decommissioning is essential to ensure that the vacated space is safe for any authorised personnel to enter and handle equipment, fittings and fixtures without risk of contamination or harm.

All transport, storage and disposal of laboratory biological, chemical, radioactive, quarantine and genetically modified items must be in compliance with the regulations and licences applicable to the laboratory and its functions. Permission or notification may be required prior to transferral of material to a new laboratory. Specific disposal methods must be adhered to and documented.

5. Overview and Responsibilities

5.1 Deans, Heads of School, Institute Directors

Deans, Heads of School and Institute Directors must ensure that Principal Investigators (PI) using hazardous materials and equipment within the organisation are working in compliance with the various regulatory bodies governing their work including safe shutdown of laboratories and disposal of substances, materials and equipment.

5.2 Principal Investigator, Group Leader, Chief Investigator

The PI is responsible for the complete and safe decommissioning of their laboratory space prior to vacating, relocation or refurbishment. The PI is also responsible for compliant disposal and decontamination procedures to ensure the safety of their staff and any vendors, contractors, and removalists involved in removal of materials (including equipment) from the laboratory. The PI may delegate tasks to suitably competent staff members and give appropriate instructions and support to complete the decommissioning task. Written approval for the move should be obtained from the Dean or Organisational Unit Head prior to any action being taken.

In addition, permission from regulatory authorities governing the laboratory may be required prior to disposal or transfer of material from the laboratory. Consultation and advice should be sought from the Occupational Health and Safety Division before any action is taken.

5.3 Work Health Safety Coordinator

The WHSC is responsible for providing assistance regarding policies, procedures and regulatory issues during decommissioning in consultation with UQ OHS Division Advisors.

They will provide support and advice to the PI and facilities/project manager throughout the decontamination/decommissioning process.

5.4 Properties and Facilities Project Manager

All refurbishment and renovation projects of spaces owned or operated by the University of Queensland are assigned a dedicated Property and Facilities (P&F) Project Manager. The P&F Project Manager liaises with the host administrators and contractors, as well as with representatives from the organisational unit.

The P&F Project Manager inspects the facility before any final handover to contractors or the host contact person and before any demolition or renovation begins, providing a copy of any host required premises release form. The P&F Project Manager should inspect the space to ensure it is safe for contractors. If any form of contamination is found at handover, the P&F Project Manager will inform the host contact and no building works will commence prior to a full clearance being given.

5.5 Contractors

It is the responsibility of any contractor to:

  • Complete contractor safety induction with P&F and host organisation.
  • Ensure all contractor staff are informed of the risks and hazards.
  • Provide safe operating procedures or safe work method statements and personal protective equipment (PPE) fit for purpose and to ensure PPE compliance when working.
  • Obtain authorisation from the P&F Project Manager to enter the laboratory before entry.
  • Sight documentation (e.g.PF306) and check decontamination labelling prior to handling equipment and other items
  • Comply with all federal, state, and local regulations for the movement of laboratory equipment, supplies, dangerous goods, and hazardous materials.

6. Decommissioning Process

6.1 Planning

  1. Consult with the personnel responsible for space management within the organisational unit and external host organisations and coordinate the move with them.
  2. Decommissioning Plan must take into consideration:
  • All processes must be conducted in a safe manner in line with UQ policies and procedures
  • Obtain all permissions and notify all governing and regulatory bodies prior to taking any action in consultation with the UQ OHS Division for example:
    • Radioactive material-UQ Radiation Protection Advisor
    • Drugs-Occupational Hygiene Advisor
    • Dangerous goods-Occupational Hygiene Advisor
    • Chemical-Occupational Hygiene Advisor
    • Quarantine- Biosafety Quarantine Advisor
    • OGTR –Biosafety Advisor
  1. Ensure that premises where licenced materials are to be housed is also licenced to the appropriate level and compliant with the appropriate regulatory authorities to the appropriate standard.
  2. Ensure all transportation complies with UQ policies and procedures and any regulatory authority specifications.
  • Ensure all materials are labelled and packed as specified by regulatory authorities.
  • Ensure the removals contractor is equipped and licenced to transport the types of material being transferred.

6.2 Prioritising tasks

6.2.1 Waste disposal

Dispose of all waste material not to be moved must be in accordance with the regulatory requirements for the material (including decontamination of equipment prior to disposal through UQ waste streams).

Hazardous waste must be identified and disposed of in accordance with UQ policy.

6.2.2 Decontamination

Radiation

Any laboratory surfaces where work with radiation sources has been conducted must be assessed by a Radiation Safety Officer and decontaminated using an appropriate decontaminant if required. Areas contaminated with radioactive isotopes have additional decontamination requirements. See PPL 2.80.05 Management of Unsealed Radioactive Waste or contact the local Radiation Safety Officer (RSO) or the University’s Radiation Safety and Protection Advisor in the OHS Division for clarification.

Biological

All laboratory surfaces must be decontaminated using appropriate detergent/disinfectant (appendix F of AS2243.3). All laboratory equipment, including Class II Biosafety Cabinets and CO2 incubators must also be decontaminated prior to removal to a new laboratory. Any staff involved in this process must be suitably trained and conduct all activities wearing appropriate PPE. Equipment must be labelled with a PF306 form once decontaminated.

A completed PF306 form must be affixed to all equipment that has been decontaminated. This will allow the removalist to safely handle and move the equipment to the new laboratory space.

6.2.3 Packing and removals

The Principal Investigator is responsible for establishing safety and emergency procedures for all phases of the move.

Trained laboratory staff are responsible for collecting and packaging items compliant with Dangerous Goods, Biosafety and other regulatory packing procedures. Spill kits may need to be supplied to the couriers and removalists and be sufficient for the quantities being transported. Each container or piece of equipment must be labelled as per regulatory requirements.

Removalists must be trained and licenced to transport potentially hazardous material or laboratory equipment and must pack equipment (which has been decontaminated) with adequate padding and packaging and restrain in transit, to eliminate the risk of damage whilst being transported. Adequate insurance must be secured prior to removal of items from the lab space and inventory of items recorded by the sender and checked off by the receiver on arrival at the new site to minimise the risk of loss.

6.2.4 Special considerations

Radioactive isotopes and lasers

All class 3b and 4 laser devices used for cosmetic or health related procedures are registered with the Queensland Government and UQ for a specified location. If you are relocating laser devices, UQ OHS Division must be notified of the new location of the laser device, contact the OHS Division Radiation Protection Advisor for application to Queensland Health approval prior to the relocation. Note also, work in any new location must not be undertaken until the new premises are certified. If premises are longer used for certain radiation practices (e.g. unsealed sources) then specific procedures must be followed to have the space decertified. Contact the OHS Division Radiation Protection Advisor for more information.

Biological Material and quarantine

Biological Materials must be appropriately packed as per PPL 2.40.11 Transport of Biological Materials.

Some biological material may also have special quarantine requirements prior to movement including movement of material within the state (e.g. moving sugarcane from UQ St Lucia to northern Queensland). See PPL 2.40.10 Importing or Working with Quarantine Material and the Queensland Department of Agriculture and Fisheries for more information.

Material Transfer Agreements (MTA) are sometimes used when materials and equipment are transferred from one institution to another. For more information, see Research Management site of standard and pre-approved research contracts http://www.uq.edu.au/research/research-management/rl-standard-agreements.

Liquid nitrogen and dry ice

If liquid nitrogen or dry ice is used during transport of materials then consideration must be given to the quantity of liquid nitrogen or dry ice, the transport vehicle and the containers used. See PPL 2.70.20 Working Safely with Liquid Nitrogen and Dry Ice for more information.

7. Contact for Additional Information

OHS Division

Phone: 336-52365

Email: ohs@uq.edu.au

Custodians
Director, Occupational Health and Safety
Mr Jim Carmichael
Custodians
Director, Occupational Health and Safety
Mr Jim Carmichael