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Revised date
December 15, 2017
Effective date
January 1, 2018
Contact
William Robertson, PE, Engineering Services Department, UNC Facilities Services, CB #1821
Category
BSL-3 Maintenance Notification Procedure
Purpose
To describe the process for Facilities Services staff to schedule BSL-3 lab work with the BSL-3 engineer or Designated BSL-3 Response Person and Environment Health and Safety (EHS) to ensure that containment is maintained and the building occupants are safe.

Scope

This procedure applies to equipment located within a BSL-3 laboratory or equipment that affects a BSL-3 laboratory at UNC.

Equipment and controls that are located outside of the BSL-3 labs that are subject to these notification requirements have been labeled as shown below (red label with white letters):

  • Equipment Serves BSL3 Lab Prior to Any O&M Activity Be sure Work Complies With Facilities Procedures.
  • Serves BSL3 Lab See Facilities Procedures

This procedure applies to any activities which may affect the BSL-3 lab pressurization, may cause loss of pressurization control through unintended equipment failure, may cause loss of visibility of pressurization within the lab, repairs/maintenance of equipment that is located within the BSL-3 lab, or any other maintenance that might affect a BSL-3 lab. It does not apply to passive monitoring or inspection of equipment that is located outside of the BSL-3 lab.

BSL-3 Work Notification

Any work performed that affects or is within the BSL-3 labs must be performed by a member of the Facilities Sevices BSL-3 Entry Team. All work to be performed must be approved by Environment, Health and Safety (EHS), and coordinated with the Principal Investigator/Lab Manager as detailed in the procedures below.

Responsibilities

  • Recognize BSL-3 signage and facilitate the procedures described below.
  • If maintenance is required within a BSL-3 lab or on equipment that might affect a BSL-3 lab, STOP WORKING and contact the Designated BSL-3 Response Person (DBRP) via cell phone (919-883-8000) or pager (919-216-0884).
  • Review all work on BSL-3 labs as the BSL-3 systems expert and work supervisor to ensure that equipment operations maintain lab safety.
  • Coordinate with EHS to ensure that laboratory personnel have been contacted, safe work practices are implemented before work proceeds and the building systems are shut down/restarted properly and that they do not generate nuisance alarms.
  • Maintain knowledge of procedures and functionality of lab for normal and emergency operations to the point where immediate corrective action can be taken in cooperation with EHS staff. Maintain ability to operate HVAC graphical front end and mechanical controls including variable frequency drives, actuators, and controlled devices.
  • Inform the BSL-3 engineer and EHS before any work is started, give work progress updates as needed, and when work is completed.
  • Contact EMCS and inform them on the work before the work begins and when the work is completed.
  • Coordinate with the PI/Lab Manager to ensure safety and containment. Report back to the Designated BSL-3 Response Person when the laboratory is secured or when an individual from the lab can escort a Facilities Sevices BSL-3 Entry Team member into the lab.
  • Coordinate with Designated BSL-3 Response Person to ensure that the lab is out of commission before and while work is being performed in the lab. Also, coordinate with the Designated BSL-3 Response Person and the PI/Lab Manager when the lab is clear for the lab occupants to start their work again in the lab.
  • Coordinate with the alarm shop to place any necessary alarms on “test” so nuisance alarms are not generated.
  • Contact UNC-Police before any work begins to notify them of the maintenance and the alarms that will be affected. Contact UNC-Police once work is completed.
  • Review work to be completed to make sure there will not be a negative impact on lab integrity or environment.
  • Coordinate with the Designated BSL3- Response Person from beginning to end of the work being performed.
  • Coordinate with EHS to ensure that the notification process is being followed.
  • Ensure that any modifications to the lab is recorded in the System Description for the lab.

Scheduled/Planned work

  • All planned work will be preapproved and scheduled with EHS, the PI/Lab Manager and the BSL-3 engineer.
  • BSL-3 engineer shall monitor the ongoing work to assure all required processes are completed.
  • Person doing the work will inform EHS of the work that needs to be approved, possible dates and times, and the length of time it will take to complete the work.
  • EHS will coordinate with the PI/Lab Manager for a date and time that the work can be conducted and will inform the individual doing the work and the BSL-3 Engineer of the schedule. The schedule includes a set start and finish time without deviation. If the agreed on schedule is changed both EHS and the PI/Lab manager must agree to the change.
  • EHS will notify the alarm shop of the schedule.
  • The day of the work, EHS will notify UNC-CH Police of the schedule.
  • The person performing the work will notify EHS and EMCS before starting the work on the lab.
  • Once work is completed, the person performing the work will notify EHS and EMCS.
  • EHS will notify UNC-CH Police, the alarm shop and the PI/Lab Manager that work is completed and it is safe to enter the lab.

While any written or verbal form of communication is acceptable, the person initiating the communication must receive some type of acknowledgement from the recipient of the message before moving ahead with the desired work. For example, leaving a voice mail message without hearing back and proceeding with work is not acceptable.

Unplanned Emergency Work

  • Work to be performed must be reviewed and approved by the Designated BSL-3 Response Person, EHS and the PI/Lab Manager. EHS can always be reached via the BioSafety pager 919-216-3963.
  • After determining the work to be done, the Designated BSL3 Response Person will coordinate the scope of work with EHS.
  • EHS will then coordinate with the PI/Lab Manager and contact the Designated BSL-3 Response Person to let them know that the work can be performed.
  • EHS will notify UNC-CH Police and the alarm shop that work will be performed on the lab.
  • The Designated BSL-3 Response Person will notify EMCS that work will be performed on the lab.
  • In the event of an emergency, all attempts will be made to bring the lab back to normal operation. At a minimum, the lab will placed in a safe operating condition (preferably negative but static is also considered safe) with EHS support until full staffing is available during regular hours to restore normal lab operations.
  • Once work is completed, the Designated BSL-3 Response Person will verify that the lab is operational and will notify EHS and EMCS that the work has been completed.
  • EHS will notify the PI/Lab Manager, UNC-CH Police and the alarm shop that the work has been completed and that the lab can be placed back in normal operation.
Facilities Services Staff
Any employee that works in the Facilities Service Division. These individuals receive yearly BSL-3 General Awareness Training.
Facilities Sevices BSL-3 Entry Team
Facilities Services Staff that have been approved by the Director of EHS and the Director of Facilities to work on equipment that is within or may affect BSL-3 labs on campus. These individuals receive yearly BSL-3 training and are involved in the BSL-3 medical surveillance program.
Active/Hot
Any of the subject labs that contain live agents.
BSL-3 engineer
The team leader overseeing work on the BSL-3 labs including routine maintenance, emergency calls and modifications. The BSL-3 engineer is the primary contact for Facilities Services staff with questions which concern the BSL-3 laboratories. He/she is also the primary contact for notifications to EHS and is the manager for the BSL-3 Entry Team.
Designated BSL-3 Response Person (DBRP)
The rotating technician is scheduled by the BSL-3 engineer to oversee work on the BSL-3 labs including routine maintenance, emergency calls and modifications. The DBRP will also be in possession of the on call cell phone and pager. The DBRP will also have a binder with procedures and the weekly call back duty list and the emergency contact list.
EHS
Department of Environment, Health and Safety – Biological Safety Group
BSL
Biosafety Level
EMCS
Energy Management Control System
Contact Information for Personnel Mentioned in Procedure
Name Title Title Per Procedure Cell Phones/Office Phone
William Robertson BSL-3/DCM Engineer BSL-3 Engineer Cell 919-923-6401
Artie Neese Lead Technician in HVAC Shop 245501 Designated BSL-3 Response Person Cell 919-201-7979
Steve Howard Technician in HVAC Shop 245501 Designated BSL-3 Response Person Cell 919-904-0178
Kyle Shelley Technician in HVAC Shop 245501 Designated BS-L3 Response Person Cell 919-904-0182
Brian Cook Technician in HVAC Shop 245501 Designated BSL-3 Response Person Cell 919-904-0174
Ray Morris Technician in HVAC Shop 245501 Designated BSL-3 Response Person Cell 919-904-0181
Chris Turner DDC Lead Specialist in HVAC Shop 245502 Designated BSL-3 Response Person Cell 919-428-3081
Mary Beth Koza Director of Environmental Health & Safety EHS Contact Office 919-843-5913
(Cell 1) 919-883-7027
(Cell 2) 732-267-5943
(Home) 919-545-0638
Jessica Poole Assoicate Biological Safety Officer EHS Contact Office 919-962-5726
(Cell 1) 919-883-7020
(Cell 2) 704-267-6684