| Related Documents |
| EHS Standards of Care |
1.1 Introduction #
The University of Michigan (U-M) is committed to:
- Promoting a culture of safety among faculty, staff, students, and visitors.
- Providing a safe and healthy place to work, study, live, or visit.
- Protecting the natural environment.
- Complying with all applicable workplace safety, health, and environmental rules and regulations.
The intent of this Comprehensive Safety Plan (CSP) is to promote a healthy and safe work
environment and to protect University of Michigan employees from hazardous chemicals and
physical hazards. The CSP includes information to ensure that all U-M personnel have working
knowledge about the hazards in their workplace.
University of Michigan believes that the prevention of injuries, occupational illness, and
environmental incidents are fundamental to our job and our success.
We are committed to maintaining a workplace, which will be characterized by:
- A strict adherence to safety procedures and rules by all employees.
- Effective risk management systems, which assess and control or eliminate risks.
- Management systems, which promote and reward safety excellence.
- The recognition and acceptance of safety as a personal and work group responsibility.
- A commitment to relevant safety and health training.
- The recognition of regulatory compliance as a primary goal.
- Implement a hierarchy of controls to avoid, eliminate or reduce exposure to safety and health risks.
- A commitment to employee participation in the safety process.
The CSP has been developed to assist employees in their (EHS) obligations. Deans, Directors, and Department Heads are responsible for ensuring that their employees are fully aware of and comply with these rules.
1.2 Scope #
The U-M CSP applies to all U-M colleges, departments, and units. Exceptions include the U-M Hospital and Health System, Facilities and Operations, and Regional campuses.
1.3 Responsibilities #
Everyone working at the University of Michigan has the right to expect a safe and healthy work environment. They also have a responsibility to help assure a safe and healthy environment for themselves and others. Everyone has an important role.
Standard Practice Guide 605.01 (Safety, Health and Environmental Policy) identifies the general responsibilities that various University groups have toward promoting a safe and legally compliant culture. The University academic, research, clinical, and operations units will assess the safety and environmental impact of all programs and implement strategies to reduce risks to health, safety, facilities, the environment, and legal obligations. University units with specialized health and safety requirements for their operations, based upon federal, state, or other
Complete and maintain the unit-specific EHS Blue Binder (Document Binder).
- Develop written Procedures when appropriate for hazards identified in the CSP.
- Enforce safe work practices and adherence to the CSP. Ensure personnel do not operate equipment or handle hazardous materials without proper training and authorization.
- Complete and update a list of hazardous chemicals annually.
- Perform routine periodic inspections of their operations and facilities as noted in this CSP. Confirm engineering controls and safety equipment is functional.
- Promptly correct problem areas and document all inspections and follow-up actions.
- Identify hazardous conditions or operations; determine safe procedures and controls.
- Provide personnel access to the CSP and EHS Blue Binder.
- Train personnel to work safely with hazardous chemicals and operations, and maintain records of training provided.
- Maintain appropriate and functional personal protective equipment (e.g., gloves, goggles).
- Report injuries to Work-Connections and EHS.
- Make available required medical surveillance or medical consultations/examinations for personnel.
- Inform outside contractors of potential hazards when they are required to work in the unit. Minimize potential hazards to provide a safe environment for the work.
- Continuously evaluate the efficacy and applicability of the documents in the EHS Blue Binder.
1.4 Authority to Suspend or Stop Work #
Ability to Suspend Work #
Any faculty, staff, student or visitor working at the University of Michigan has the ability to suspend their work if they believe there is a safety or environmental issue to deal with. The issue must be reported immediately to the Dean, Director, or Department Head or their delegate so that the issue can be quickly resolved and work can continue.
Authority to Stop Work #
If an issue presents an immediate danger to personnel, visitors, users, contractors, the public, or the environment, faculty and staff are empowered and obligated to stop that activity. This authority is referred to as “stop-work authority.” Individuals who exercise “stop-work authority” are also obligated to immediately report this action to their supervisor and EHS. After an individual has stopped work, it may not resume until the supervisor and EHS has verified that appropriate hazard control measures are in place.
Imminent Danger Situation #
The Executive Director of EHS, or designee, may issue an immediate Stop Work Order to the appropriate administrative authority in an imminent danger situation that may cause death, serious injury, or significant harm to the environment if not immediately addressed. The Order must be respected and adhered to by the faculty, staff, students, and guests engaged in the high risk situation; failure to comply with the Stop Work Order will incur unit-driven sanctions for the noncompliant individual(s). The Order may not be lifted until the concern(s) can be properly addressed.
Under federal and state laws, government agencies do have the authority to levy citations and fines against the unit, or individuals within the unit, for failure to follow appropriate laws and regulations. Unless there are extenuating circumstances agreed to by the executive officers on a case by case basis, the unit responsible for the activities will be responsible for paying the fines if they have not been following established precautions or clearly stated procedures.
1.5 Regulatory Introduction #
The Michigan Occupational Safety and Health Administration (MIOSHA) promulgates rules for
many aspects of occupational safety and exposure to hazardous chemicals. These MIOSHA
standards have legal requirements for all employees covered by the standard.
The CSP is a written program which sets forth policies and procedures for protecting employees
from the safety and health hazards present in our workplaces.
For Details on health and safety regulations impacting workplaces see the MIOSHA Regulatory
Overview.
1.6 Expectations to Plan Safe Work #
The Dean, Director and Department Head is responsible for the planning and conduct of work.
They are expected to be fully aware of the risks posed by their operations materials/methods
and effectively communicate this awareness to their staff and students. The expected method
for instilling this awareness is through written procedures and training to identify necessary
precautions. Written records of this instruction must be maintained by the unit. Equally
important to communication is direct involvement of the Dean, Director, or Department Head in
observing the behavior of their staff and enforcing safety procedures. The following paragraphs
detail the University of Michigan’s expectations:
PLAN FOR SAFETY – Some of the first considerations for working safely are the hazardous
materials to be used, potentially dangerous equipment to be purchased, and the potential injury
they may cause. The Dean, Director, or Department Head must be fully aware of the risks, have
a good working knowledge about the hazards, and a working knowledge of the hierarchy of
controls for preventing incidents. This will drive decisions to: minimize exposure; mandate
protective equipment; enclose processes; place guards, screens, or barriers between the hazard
and staff; and other prudent practices.
COMMUNICATE AWARENESS – Staff and students must be knowledgeable about the hazards of
their work and what action to take in the event something goes wrong. The Dean, Director, or
Department Head must ensure that students and staff working with hazardous materials and
equipment have been fully trained on the risks to which they are exposed.
WRITE PROCEDURES – The Dean, Director, or Department Head must write procedures that
include precautions and warnings that address protective equipment, chemical storage, use of
engineering controls, emergencies, and waste disposal. Staff and students must be familiar with
and follow prepared and approved procedures.
ASSURE EQUIPMENT SAFETY FEATURES – Hazardous equipment must have safety features that
prevent injury and are difficult to defeat. Most modern equipment contain features that reduce
or eliminate the potential for accidental exposure and injury to the user. Older equipment may
not have such features and the Dean, Director, or Department Head is responsible for
identifying and addressing hazard points.
ENFORCE SAFETY PROCEDURES – The Dean, Director, or Department Head instructions must be
followed in practice and on a daily basis. In the event personnel are not following standard
safety precautions, or ignoring good safety practices, firm action must be taken to clarify safety
expectations.
1.7 Safety Compliance #
The safety performance of each unit will be reviewed by EHS through compliance audits which
are comprised of comprehensive physical inspections, checks of relevant documentation,
reviews of self-inspection reports, and interviews with personnel. Deficiencies identified in the
audits will be reported to the supervisory personnel or Dean, Director, or Department Head.
Deficiencies identified during the audit must be addressed in a timely manner. An imminent
danger situation will result in immediate stoppage of work related to the situation and must be
addressed as soon as possible. Imminent danger means there is high probability that immediate
serious physical harm would result if the situation is allowed to continue.
Failure of a Dean, Director, or Department Head to submit verification of deficiency abatement
will impact their ability to obtain approvals for permits and grant certifications requiring
validation of compliance with applicable state and federal regulations.
Compliance Hotline #
The University of Michigan Compliance Hotline is a tool for U-M employees, students, vendors and others to raise concerns regarding financial, regulatory, NCAA, and patient safety issues.
U-M is committed to providing an environment where individuals feel comfortable
discussing compliance problems—no matter how big or small—and where people can
safely and confidentially come forward to identify instances of fraud or other serious
concerns. Callers to the U-M Compliance Hotline can also remain anonymous.
Call 1-866-990-0111 or visit compliancehotline.umich.edu.
Inspections #
A program of periodic inspections helps keep facilities and equipment in a safe operating condition by identifying and addressing potential health and safety deficiencies. Periodic inspections will also help to ensure all regulatory compliance requirements are being met. Inspections safeguard the quality of the institution’s safety program.
The goals of the inspection program are to:
• Maintain facilities and equipment in a safe, code-compliant operating condition.
• Provide a comfortable and safe working environment for all personnel and the public.
• Ensure that all activities are conducted in a manner to prevent employee exposure to
hazardous materials.
• Ensure that trained personnel follow the CSP.
EHS Safety Inspections #
A program of periodic inspections helps maintain facilities and equipment in a safe operating condition by identifying and addressing potential health and safety deficiencies. Periodic inspections also help to ensure all regulatory compliance requirements are being met. U-M EHS conducts inspections on a routine basis. These inspections may be comprehensive, targeted to certain operations, focused on a particular type of inspection such as safety equipment and systems, or audits to check the work of other inspectors. EHS also conducts short unannounced inspections for key indicators of safety. These unannounced visits may take place on weekends or other off hours.
Routine Self-Inspections #
Each Director or designee is required to conduct an annual self-inspection of their space. The self-inspection should be conducted by knowledgeable and trained personnel with the oversight of the Director. The focus is on the facility, equipment, operating procedures, training and documentation. This is an excellent opportunity to promote a culture of safety. Supervisors should take a close look at the facilities and operations. They can discuss with workers, issues of interest or concern that may fall outside the scope of the actual inspection.
For certain types of equipment in constant use, daily inspections may be required. Other types
of equipment may need only weekly or monthly inspection or inspection prior to use if operated
infrequently. Keep a record of these inspections attached to the equipment or in a visible area.
Inspections by External Entities #
Many types of inspections or audits can be conducted by outside experts, regulatory agencies, emergency responders, or other organizations. As a matter of safety and security, if someone requests entry to a work site for the purpose of an inspection or audit without a recognized escort, ask to see his or her credentials and contact U-M EHS at (734)647-1143.
Regulatory agencies may conduct announced or unannounced inspections on a routine or
sporadic basis. Departments must keep their programs and records up-to-date at all times to be
prepared for such inspections. Any significant incident or accident may trigger one or more
inspections or investigations by outside agencies. Evidence that the underlying safety programs
are sound may help limit negative findings and potential penalties. All such inspections by
regulatory agencies must be reported to U-M EHS at (734)647-1143 as soon as possible.
Performance Verification of Engineering Controls and Safety Equipment #
To help assure that primary engineering controls such as paint booths, biosafety cabinets other types of local exhaust ventilation provide proper and adequate performance, U-M EHS provides annual performance verification checks. Additional information about the services provided can be found in the EHS Standards of Care:
EHS Standard of Care # 1: Ventilation Engineering Controls
EHS Standard of Care # 2: Unsafe Engineering Control Equipment
EHS Standard of Care # 3: Biological Safety Cabinet (BSC) Service Criteria
EHS Standard of Care # 4: Biological Safety Cabinet (BSC) Maintenance
EHS Standard of Care # 5: Biological Safety Cabinet (BSC) Warranty Work
EHS Standard of Care # 6: Biological Safety Cabinet (BSC) Decommissioning for Sale, Transfer
or Scrap
Safety equipment including fire extinguishers, eyewash stations and emergency showers
must function properly at all times and must be tested as indicated below. Documentation of
a monthly emergency eyewash flush for each emergency eyewash is required. The
department must complete an eyewash checklist (Appendix 4) for each. EHS will provide the
Appendix 4 eyewash checklist tags to be attached to each unit.
| Equipment | Frequency | Responsible Party |
| Eyewash | Annual Inspection | Facilities & Operations Maintenance |
| Monthly Flush in labs | Department Personnel | |
| Monthly Flush in public corridors | Facilities & Operations Maintenance | |
| Safety Shower | Annual Flush and inspection | Facilities and Operations Maintenance |
| Weekly Visual | Department Personnel | |
| Fume Hoods, Biological Safety Cabinets, Gas Cabinets, Paint Booths, and other Local Exhaust Ventilation (LEV) | Annually | EHS |
| Glove boxes | Weekly | Department Personnel |
| Fire Extinguishers | Monthly | Facilities & Operations Maintenance |
Decommissioning #
Decommissioning activities (waste removal, cleaning, etc.) must be performed prior to vacating any departmental space. All chemicals for disposal must be properly labeled, manifested and packaged for EHS HMM pickup. In the event there are unusually large amounts of chemical waste, EHS HMM may be able to provide additional assistance, as necessary, to expedite the process. EHS strongly recommends disposing of all unwanted chemicals at least 14-days prior to the actual move date.
Utilities and Infrastructure Modification #
Modification of facilities can have a serious impact on health, safety, and the environment. Modifications may also involve building code restrictions, fire safety, and life safety compliance. Any modification involving any utilities, ventilation, building equipment, fixtures, structural
components, or egress changes must be reviewed by appropriate U-M personnel in
Facilities & Operations. This includes functional or operational changes related to new equipment, hazardous materials, or processes.
The review process is initiated by contacting your building or facilities manager with any
proposed changes.
1.8 Resources #
The University of Michigan provides health, safety, and environmental resources to the campus community through the Department of Environment, Health & Safety (EHS). Technical assistance regarding research material risks, method refinement, equipment specifications and training, hazard containment, protective equipment, and hazardous waste disposal is available from EHS. The EHS web page is a readily available resource for initial query into these areas.
EHS representatives are a phone call away and will provide personalized service for specific challenges.
1.9 Exclusions #
This CSP does not cover work in locations where a more in depth or detailed plan or program already exists to achieve the same goals as this CSP (e.g., laboratory safety, radiation safety, biosafety, etc.). Procedures for work in these situations are addressed via the University’s Radiation Safety Service website, Biosafety Manual, Exposure Control Plan, Chemical Hygiene Plan, etc.
1.10 EHS Document Binder (the blue binder) #
While this CSP is the core compliance document for many safety regulations, the decentralized nature of the University demands that most subunits (e.g., departments) maintain separate specific information and documentation at their individual locations. To better facilitate this necessary documentation, EHS has created a modular mechanism for maintaining this documentation, the EHS Document Binder, or the BLUE BINDER.
Each chapter of the CSP that requires specific department documentation will include a reference to supplemental departmental documentation which should be completed and maintained by each department, when applicable. This supplemental documentation should be kept and maintained in each department’s Blue Binder.
Blank copies of supplemental documentation for each CSP chapter can be obtained from EHS, as needed.
