OCCUPATIONAL AND ENVIRONMENTAL

WRHA OESH OP – Chemical Hazards Prevention May 2009 Page 1 of 6

SAFETY & HEALTH OPERATIONAL PROCEDURE

Subject: Chemical Hazards Prevention and Control Program (including WHMIS) Effective Date: May 2009 (version 1) Supercedes: New Review Date: 3 years or legislation or job changes Original Signed by: Diane Gantzel, Director, WRHA Occupational and Environmental Safety & Health 1.0 GUIDING PRINCIPLES

1.1 In keeping with the Winnipeg Regional Health Authority (WRHA) commitment to providing a safe and healthy workplace as noted in the WRHA ‘Workplace Safety and Health’ policy (20.10.080), the following Operational Procedure has been developed to ensure this policy is supported by ensuring that no WRHA staff or other person present on WRHA property is put at undue risk through working with, or in proximity to chemical substances.

1.2 This operational procedure is also designed to ensure that when followed the minimum

requirements of Manitoba Workplace Safety and Health legislation is complied with and where possible exceeded.

1.3 As with all matters relating to the Safety and Health of workers the Workplace Safety

and Health Committee should be consulted for their input. 2.0 DEFINITIONS

2.1 The Act: The Workplace Safety and Health Act W210 of Manitoba.

2.2 Committee: Means a workplace (occupational) safety and health committee established under section 40 of the Workplace Safety and Health Act.

2.3 Employer: 2.3.1 Every person who, by himself or his agent or representative employs or engages

one or more workers, 2.3.2 and The Crown and every agency of the government.

2.4 Supervisor: Means a person who has charge of a workplace or authority over a worker.

2.5 Worker: 2.5.1 Any person who is employed by an employer to perform a service whether for

gain or reward, or hope of gain or reward or not.

2.5.2 Any person engaged by another person to perform services, whether under a contract of employment or not

2.5.3 Any person undergoing training or serving an apprenticeship at an education institution or at any other place.

2.6 Director: means the person administratively responsible for the department or unit.

Director includes heads of departments. 2.7 OESH: means the Occupational and Environmental Safety and Health Unit

2.8 Chemical Hazards Prevention Program: comprehensive program document

developed by WRHA OESH to outline to the employer at all WRHA sites, the system to be developed, implemented and maintained to ensure worker safety when they produce, use, handle, store and dispose of chemical substances in the workplace.

2.9 SYMBAS: Symbol Based Chemical Storage System.

2.10 WHMIS trainer: means the individual selected by the facility/site/program management

and is responsible for education/training WHMIS and safe work procedures for chemical substances. The size of the facility/site/program may require departmental WHMIS trainers which necessitates a WHMIS Train the Trainer program.

2.11 MSDS: means Material Safety Data Sheets.

3.0 OPERATIONAL PROCEDURE

3.1 The facility/site/program WHMIS and Chemical Hazards Prevention Program will consist of:

3.1.1 A current written inventory of all controlled products.

3.1.2 Storage in accordance with the SYMBAS system.

3.1.3 A distribution and maintenance system for MSDS.

3.1.4 A labeling system which includes colour classifications

3.1.5 The provision of MSDS and labels where the facility/site/program acts as a supplier of controlled products.

3.1.6 Ongoing education and training on the purpose and significance of MSDS and labels and the safe work practices.

3.1.7 The evaluation of hazard information and work processes/practices to determine if a chemical or biological substance poses a risk to workers. (MSDS coversheet, label evaluation and prevention plans)

3.1.8 Occupational Exposure Limits and monitoring of work environment when appropriate.

3.1.9 Controlling Worker Exposure - Plans for chemical substances to identify control measures, including elimination or substitution with less hazardous products, engineering and administrative controls, personal protective equipment (PPE), spill containment cleanup and disposal methods

3.1.10 Personal Protective Equipment

3.1.11 Compilation, maintenance and storage of records.

WRHA OESH OP – Chemical Hazards Prevention May 2009 Page 2 of 6

3.1.12 An annual evaluation of the Program.

3.2 The WHMIS and Chemical Hazards Prevention Program will be in accordance with the WRHA

Chemical Hazards Prevention Program. 3.3 The WHMIS and Chemical Hazards Prevention Program will be specific to the facility/program.

I.e. size of facility/program, hazardous materials present, staffing levels, etc.

3.4 The WHMIS and Chemical Hazards Prevention Program will be developed in consultation with the Department/Facility/Program Safety and Health Committee.

3.5 The responsibility for providing central coordination, technical support and corporate

documentation of the program must be assigned. This assignment will be dependent upon the size of the facility/program, hazardous materials present, staffing levels, presence of OESH unit etc. Where an OESH unit is present the responsibility falls upon them. Other facilities/programs may assign these responsibilities to an individual(s).

4.0 RESPONSIBILITIES

4.1 Employer 4.1.1 Act in accordance with the objects and purposes of the Act by ensuring, so far as

is reasonably practicable, the safety, health and welfare at work of all his workers, and complying with the Act and regulations.

4.1.2 Ensure that all his workers, and particularly his supervisors, foremen, chargehands or similar persons, are acquainted with any safety or health hazards which may be encountered by the workers in the course of their service, and that workers are familiar with the use of all devices or equipment provided for their protection

4.2 Facility/Program Executive Team

4.2.1 Assign responsibilities to staff within the facility/program to ensure the implementation of this operational procedure.

4.2.2 Ensure resources (information, training, tool, equipment and time) are available to provide / maintain 4.2.1

4.2.3 Support the Operational Procedure throughout the facility/program.

4.2.4 Ensure that a record keeping system is in place to ensure that training records are kept.

4.3 OESH or Individual(s) Assigned as per 3.3 4.3.1 Consult with the facility/site/program on all aspects of this operational procedure.

4.3.2 Develop and maintain, in consultation with the Joint Workplace Safety and Health Committee, a WHMIS training program and if the size of the facility/site/program necessitates, a WHMIS Train-the-Trainer Program.

WRHA OESH OP – Chemical Hazards Prevention May 2009 Page 3 of 6

WRHA OESH OP – Chemical Hazards Prevention May 2009 Page 4 of 6

4.3.3 Assist departmental designates and trainers in the development of department specific education/training programs and prevention plans for controlled substances.

4.3.4 Provide ongoing expertise and assistance with respect to the regulations and workplace health and safety issues.

4.3.5 Maintain a current inventory of controlled products and their locations.

4.3.6 Maintains current MSDS for controlled products and develops/accesses and provides MSDS cover sheets.

4.3.7 Maintain a master record, compiled from departmental records, of all staff that have completed annual general WHMIS training and the dates of the training.

4.3.8 Evaluates complaints and concerns of chemical exposure from managers and workers and ensures environmental monitoring when deemed appropriate.

4.3.9 Conducts periodic literature reviews for monitoring of chemicals known to cause health hazards to workers in the healthcare industry.

4.4 Directors/Managers/Supervisors 4.4.1 Ensure compliance with all aspects of the regulations. The department director

is responsible for ensuring that their area of responsibility complies with all aspects of the regulations and this operational procedure.

4.4.2 Provide the OESH or Individuals assigned as per 3.3 with the names of all supervisors and the departments for which they are responsible.

4.4.3 Establish and maintain a current inventory of controlled products and MSDS’s in the work area and as changes occur regularly notify OESH or Individuals assigned as per 3.3.

4.4.4 Establish MSDS stations ensuring that MSDS are current and readily available to staff and external response agencies.

4.4.5 Ensure that all hazardous products are labelled appropriately.

4.4.6 Utilize the Job Hazard Analyses to determine if the chemical or biological substance creates a risk to workers and when required develop and implement safe work procedures.

4.4.7 Ensure that workers are not being over exposed to controlled products.

4.4.8 Ensure exposure control measures are implemented when necessary, to eliminate, reduce or control hazards from chemical or biological substances at the source, along the path, and the worker.

4.4.9 Provide personal protective equipment as required to employees and ensure that such equipment is worn when necessary.

4.4.10 Ensure that a department evaluates their risk of chemical spills and if required develop a specific spill control plan.

4.4.11 Select the department/program WHMIS trainer and ensures the selected individual(s) take the WHMIS-train-the-trainer workshop. (where applicable).

4.4.12 Develop, promote and monitor area specific WHMIS education and training in consultation with the WHMIS Trainer and the workplace safety and health committee.

WRHA OESH OP – Chemical Hazards Prevention May 2009 Page 5 of 6

4.4.13 Provide trainers and others with sufficient training and time to satisfactorily fulfill their responsibilities under this procedure.

4.4.14 Ensure that all employees and other persons who work with or in proximity to chemical substances in the work area receive adequate WHMIS education and training and are competent to work safely and handle emergency situations.

4.4.15 Maintains records with the names of all workers who have completed WHMIS training as specified in 5.0 and the date that the testing was completed.

4.4.16 Receive, record and investigate all complaints and concerns involving controlled products. If the department management is unable to resolve the concern, it shall be referred to the Workplace Safety & Health Committee or Safety and Health representative.

4.4.17 As part of the annual evaluation of the Workplace Safety and Health Program, complete the section of the assessment on the department’s plan to control chemical hazards.

4.4.18 Ensure that contractors and/or sub-contractors comply with the regulations.

4.5 Worker 4.5.1 Take reasonable care in dealing with chemical substances to ensure both

individual and others safety and health.

4.5.2 Maintain product knowledge and follow all instructions listed on the label, MSDS and safe work practices.

4.5.3 Complete WHMIS training sessions as directed by the supervisor.

4.5.4 Apply WHMIS labels as directed by their supervisor. Inform their Supervisor of missing or damaged labels, incomplete or missing MSDS, chemical substances present in the area and not included in the program, or other violations of the regulations.

4.5.5 Report, to their Supervisor, any task or working condition(s), involving chemical substances, which the worker believes poses a danger to health and safety.

4.5.6 Follows the safe work practices for controlled products provided by the department and on the MSDS.

4.6 Department/Facility/Program Workplace Safety and Health Committees 4.6.1 Consult with the facility/site/program on the development and implementation of

this operational procedure.

4.6.2 Review and monitor the effectiveness of this operational procedure.

4.6.3 Facilitate cooperation and communication with staff, regarding safety and health issues or concerns involving controlled products and WHMIS/ Chemical Substances Program.

4.6.4 Ensure that there is departmental safety and health consultation, at least annually, regarding the education and training.

4.6.5 Provide information and recommendations to senior management and OESH with respect to any concerns regarding WHMIS/ Chemical Substances a program.

4.7 Contractor or Subcontractor

4.7.1 Ensure that any chemical or biological substance brought on site is labelled and MSDSs are available to staff.

4.7.2 Ensure their workers are properly educated and trained in WHMIS, and about the chemical substances that they will be using/handling on site.

4.7.3 Inform other contractors, sub-contractors and workers who may be affected about the hazards of the products they are bringing on site.

5.0 TRAINING REQUIREMENTS

5.1 The training program must be workplace specific, effective and updated annually or when changes which may affect the procedure are introduced in the workplace.

5.2 Training must involve understanding of:

• WHMIS Labels • WHMIS symbols • Classification • Material Safety Data Sheets • Storage • Use and handing of specific controlled products used at the workplace. • Precautions to be taken in case of an emergency such as a spill or a fire

5.3 All training must be documented. Records must be retained as required by the

Workplace Safety and Health Act and Regulations. 5.4 Retraining will be offered if necessary or upon request.

REFERENCES: Government of Manitoba. (2002). The Workplace Safety and Health Act – W210. Winnipeg: Queen’s

Printer. www.safemanitoba.com Government of Manitoba. (2006). The Workplace Safety and Health Regulation – 217/2006. Winnipeg: Queen’s Printer. www.safemanitoba.com

Part 35 Workplace Hazardous Material Information System (WHMIS) Part 36 Chemical Substances

APPENDIX: Appendix A – WRHA Chemical Hazard Prevention Plan Appendix B – SYMBAS (SYMbol BASed Chemical Storage System) – WRHA Guide

WRHA OESH OP – Chemical Hazards Prevention May 2009 Page 6 of 6

Chemical Hazards

Prevention Program

Prepared by: WRHA -Occupational and Environmental Safety & Health Preparation Date: January 2008

Copies to: WRHA Facilities - Workplace Safety & Health Committees

THE CHEMICAL HAZARDS PREVENTION PROGRAM Table of Contents

The Prevention Program will contain the following sections: Page 1.0 Purpose....................................................................................................................................................................................... ..3 2.0 Process ... ................................................................................................................................................................................... ...3 3.0 Definitions ... ................................................................................................................................................................................ ..3 4.0 Program Elements ....................................................................................................................................................................... .5

4.1. Consultation with the Workplace Safety & Health Committee(s): ... ................................................................ ...5 4.2. Inventory .................................................................................................................................................................... ...5 4.3. WHMIS ... ................................................................................................................................................................... ...5

4.3.1. Material Safety Data Sheets (MSDSs)................................................................................................... ...6 4.3.2. Labels ... ...................................................................................................................................................... .6 4.3.3. Workplace Label Colour Classification Code ... ......................................................................................... .6 4.3.4. WHMIS Education/Training Program ... ..................................................................................................... .6

4.4. Assessment of Chemical Hazards ... ........................................................................................................................ ...6 4.5. Occupational Exposure Limit (OEL) ........................................................................................................................... .7 4.6. Air Monitoring ... .......................................................................................................................................................... ..7 4.7. Controlling Worker Exposure ..................................................................................................................................... ..7 4.8. Personal Protective Equipment (PPE) ... .................................................................................................................. ...7 4.9. Compilation, Maintenance and Storage of Records... ................................................................................................ .7

5.0 Program Implementation... ........................................................................................................................................................... .7 5.1. Inventory: .................................................................................................................................................................... ..7 5.2. WHMIS ... ................................................................................................................................................................... ...8

5.2.1. Material Safety Data Sheets (MSDS(s) ... ............................................................................................... .8 5.2.2. Labels ... ...................................................................................................................................................... .9 5.2.3. Hazardous Waste ... ................................................................................................................................. ..9 5.2.4. WHMIS Education/Training .................................................................................................................. ..10

5.3. Assessment of Chemical Hazards... ..................................................................................................................... .11 5.4. Occupational Exposure Limits for Airborne Chemical Substances ....................................................................... ...12 5.5. Air Monitoring of Worker Exposure ... ..................................................................................................................... ...12 5.6. Implementation of Control Measures ... .................................................................................................................. ...13 5.7. Conducting Air Monitoring After Implementation of Control Measures: ... .............................................................14 5.8. Personal Protective Equipment ... ........................................................................................................................... ...14 5.9. Compilation, Maintenance and Storage of Records... ............................................................................................. ..14

Appendix A - MSDS Evaluation and Coding System... ....................................................................................................................... ..16 WHMIS Classifications: ... ....................................................................................................................................................... .16 Health Codes: .......................................................................................................................................................................... ..16 SYMBAS Group:... .................................................................................................................................................................... .16 Inclusion as Hazardous Waste: ... ........................................................................................................................................ ...16 WHMIS Workplace Label and Colour Classification System ... ...................................................................................... ...17 Safe Handling Symbols (WHMIS workplace label symbols):... .......................................................................................... .17 Chemical Evaluation/ Prevention Plan Forms...................................................................................................................... .17

Appendix B - Chemical Hazard Assessment ... .................................................................................................................................. ...18 Workplace Chemical Hazard Assessment Form................................................................................................................ ...19

Appendix C-Air Monitoring ... ................................................................................................................................................................. ..20 Monitoring Methods... .............................................................................................................................................................. .20 Annual Monitoring Plan... ........................................................................................................................................................ .22 Annual Air Monitoring Schedule for 200X ... ........................................................................................................................ .23

Appendix D-MSDS Coversheet Classifications ... ............................................................................................................................... ..24 Table 1 - WHMIS Classifications............................................................................................................................................ ..24 Table 2 - Health Effects............................................................................................................................................................ .25 Table 3 - Safe Handling Symbols (WHMIS workplace label symbols) ... .......................................................................... .26 Table 4 - SYMBAS GROUPS ... .............................................................................................................................................. ..27

Appendix E-Inventory Forms... .............................................................................................................................................................. ..29 WHMIS INVENTORY FORM ... ................................................................................................................................................. .29 WHMIS INVENTORY CHANGE FORM... ............................................................................................................................... ...31

2

1.0 Purpose

The purpose of this comprehensive Chemical Hazards Prevention Program is to outline to the employer at all WRHA sites, the system to be developed, implemented and maintained to ensure worker safety when they produce, use, handle, store and dispose of chemical substances in the workplace.

2.0 Process

Part of the Prevention Program process involves consultation with the facility’s joint workplace safety and health committee and an annual review of the Program. The Chemical Hazards Prevention Program is developed to meet or exceed the requirements of the Workplace Safety and Health Regulation 217/06, Part 35 Workplace Hazardous Material Information System and Part 36 Chemical and Biological Substances.

3.0 Definitions

“Air Monitoring” is the continuous or periodic sampling and analysis of air to measure the concentration of air contaminants. “Chemical inventory” is a list of chemicals substances produced, used, handled, stored and disposed of at the workplace. The inventory allows for the identification of chemicals present at the worksite, locations of chemicals that are used and stored in the facility, chemicals that may be present but not used, and storage requirements. "Chemical substance" means any natural or artificial substance, whether in the form of a solid, liquid, gas or vapour, other than a biological substance. “Control Measures” are actions taken by the employer to prevent workers from over exposure to control products/chemical substances. Control Measures may be implemented at the source of the hazard, along the path between the hazard and the worker, and/or at the worker level. Often, more than one control method needs to be implemented in order to protect the health and safety of workers. Strategies to control a hazard include:

Elimination (including substitution): remove the hazard from the workplace. Engineering Controls: includes designs or modifications to facilities, equipment, ventilation systems, and processes that reduce the source of exposure. Administrative Controls: controls directed by the employer that alter the way the work is done, including timing of work, policies and other rules. Administrative controls include safe work procedures, education/ training, housekeeping, and equipment maintenance, personal hygiene practices etc. Personal Protective Equipment: equipment worn by individuals to reduce exposure such as contact with chemicals or exposure to noise. These methods are also known as the "hierarchy of control" because they should be considered in the order presented (it is always best to try to eliminate the hazard first, etc).

3

"Controlled product" means any product, material or substance specified by the regulations made pursuant to paragraph 15(1)(a) of the Hazardous Products Act to be included in any of the classes listed in Schedule II of that Act and includes a controlled product in a fugitive emission or a hazardous waste. "Designated material" means a chemical or biological substance which meets the criteria as a carcinogen, mutagen, respiratory sensitizer, reproductive toxin, fetotoxin or teratogen under the Controlled Products Regulations. These products require special precautions and exposures must be kept a close to zero as possible. WHMIS classification for these products is Poisonous and Infectious materials - Materials Causing Other Toxic Effects -Very Toxic D2A. “Elimination” is the process of removing the hazard from the workplace. It is the most effective way to control a risk because the hazard is no longer present. It is the preferred way to control a hazard and should be used when ever possible. "Fugitive emission" means a gas, liquid, solid, vapour, fume, mist, fog or dust containing a controlled product. "Hazard information" means information on the proper and safe use, storage and handling of a controlled product and includes information relating to its toxicological properties. "Hazardous waste" means a controlled product that is intended solely for disposal or is sold for recycling or recovery. “Labels” on hazardous materials and their containers is a means to make a chemical substance identifiable with a marker. It t alerts employers and workers to the dangers of products and basic safety precautions. “Material Safety Data Sheet” (MSDS) means a document that provides information on the hazards of a controlled product and meets the requirements of the Controlled Products Regulations. A Material Safety Data Sheet (MSDS) is a document that contains information on the potential hazards (health, fire, reactivity and environmental) and how to work safely with the chemical product. It is an essential starting point for the development of a complete chemical safety program. It also contains information on the use, storage, handling and emergency procedures all related to the hazards of the material. “MSDS Coversheet” is a document that is attached to the front of the MSDS that summarizes the key information in the MSDS regarding the safe use, handing and storage of the product. “Occupational Exposure Limit (OEL)” are set as limits for concentrations of hazardous compounds in workplace air. OELs for hazardous substances represent an important tool for risk assessment and management. “Personal Protective Equipment (PPE)” includes all clothing and other work accessories designed to create a barrier against workplace hazards. Examples include safety goggles, safety glasses, gloves, respirators, aprons, and work boots etc. “Safe Work Procedures” (SWP) is a system of written practical instructions that must be followed by workers to reduce and control the hazards of specific work tasks. “Site Leadership” is the person administratively responsible for the departments or units at the facility. “Substitution” occurs when a new chemical or substance is used instead of another chemical. It is sometimes grouped with elimination because, in effect, you are removing the first substance or hazard from the workplace. The goal, obviously, is to choose a new chemical that is less hazardous than the original.

4

“WHMIS” is the Workplace Hazardous Material Information System and refers to Part 35 of the Workplace Safety and Health Regulation 217/2006. The Workplace Hazardous Material Information System (WHMIS) is a nationwide system to provide information on hazardous materials used in the workplace; identify hazards in the workplace, and; to ensure consistency of information about hazardous materials in all Canadian workplaces. “WHMIS Designate” is the individual in charge manager, supervisor, administrator, etc. with the responsibility for compliance related to Manitoba’s WHMIS and Chemical and Biological Substances regulations. While responsibility for compliance rests with designate tasks can be delegated to others in the workplace. “WHMIS Education/Training Program” The employer has a duty to train workers so that they understand the information on the labels and Material Safety Data Sheets of the hazardous materials/controlled products to which they may be exposed. The employer must also ensure that a worker comprehends the necessary procedures for the safe use, handling, storage and disposal of a material and possesses the required knowledge of emergency procedures. “WHMIS Trainer” is the person selected by the WHMIS Designate when necessary and is responsible for providing WHMIS education/training to staff at the facility.

4.0 Program Elements

The following program elements are required by WRHA, to meet or exceed the Workplace Safety and Health Act and the WHMIS and Chemical and Biological Substances Regulations. 4.1. Consultation with the Workplace Safety & Health Committee(s):

Occupational Environmental Safety and Health (OESH): ◊ Provides a copy of the Chemical Hazards Prevention Program to the WRHA Facilities Joint Workplace Safety and Health Committee (JWS&HC). The Joint Workplace Safety and Health Committee ensures: ◊ Ensures a copy of the program is available to the WHMIS Designate ◊ Reviews the facilities overall Chemical Hazards Prevention Program at least annually ◊ Consults with OESH on the training program and provides recommendations for improvement. Site leadership is responsible to ensure: ◊ The Chemical Hazards Prevention Program exists at their facility. The leaders may delegate the responsibilities to a designate (i.e. manager, supervisor, lead

technologist, administrator etc.). 4.2. Inventory

Chemical substances at the worksite must be identified on a written inventory. The chemical inventory must be maintained.

4.3. WHMIS WHMIS is, a system of communication with three key elements:

Material Safety Data Sheets (MSDS) - technical bulletins which provide detailed hazard and precautionary information on the product; and

Labels on hazardous materials and their containers that alert employers and workers to the dangers of products and basic safety precautions;

Worker Education Programs which provide instruction on hazards and training in work procedures.

5

4.3.1. Material Safety Data Sheets (MSDSs) ◊ MSDSs for controlled products (including those in hazardous waste) must: Be available at the worksite for all controlled products produced, used, handled, stored or disposed of at the worksite

Not be older than 3 years; Be readily available at the work site; Be provided to a medical professional for the purpose of making a medical

diagnosis or treating a worker in an emergency. 4.3.2. Labels

Labels are important because they are the first alert there may be hazards associated with using the product covered by WHMIS legislation. The labels also tell what precautions to take when using the product. ◊ Labels on containers of controlled products (including those in hazardous waste) will meet the following:

All containers of controlled products including those transferred in piping systems or vessels must be labelled to meet WHMIS requirements.

Supplier containers must have supplier labels. Workplace labels are required when the controlled product is produced and

used at the worksite, transferred from the supplier container to other containers or if the supplier label becomes damaged or illegible. When a controlled product is produced in the laboratory and is not removed from the laboratory, the product will be identified through a combination of a label.

When a controlled product is not in a container, the employer must fulfill the labeling requirement by posting a placard in a conspicuous place at workplace.

4.3.3. Workplace Label Colour Classification Code ◊ To provide additional information about the hazard associated with controlled products, the WHMIS program shall use coloured workplace labels. For additional information on the Workplace Label Colour classification system and MSDS coversheet see Appendix A.

4.3.4. WHMIS Education/Training Program Training shall be provided to workers who work with or near a controlled product or chemical substance or perform work involving the manufacturing of a controlled product or chemical substance in: ◊ The purpose and significance of WHMIS supplier and workplace labels ◊ The purpose and significance of Material Safety Data Sheets (MSDSs) ◊ Site specific safe work procedures for producing, using, handling, storing or disposal of a chemical substance ◊ Procedures to be followed in normal working conditions and in the event of an emergency

4.4. Assessment of Chemical Hazards Since employers must take all reasonable precautions, to prevent injuries or accidents in the workplace an assessment must be completed to identify chemical hazards and measures to control exposure from these hazards.

6

◊ To determine if the chemical substances (airborne and non-airborne) create a risk to workers at the worksite an assessment will be completed to evaluate the following: Frequency of use

Where and how the product is produced, used, handled, stored and disposed Physical hazards of the substance

Health hazards caused by the substance Possible routes of exposure

Measures used by the worksite to control exposure under normal and emergency circumstances

Review of worker complaints or concerns regarding exposure 4.5. Occupational Exposure Limit (OEL)

The employer must ensure that no worker is exposed to a substance that exceeds the occupation exposure limits ( ceiling limit, short-term exposure limit, or 8-hour TWA limit) prescribed by ACGIH.(American Conference of Governmental Industrial Hygienists). ◊ If an assessment determined that the presents of an airborne chemical substance creates a risk to a worker, an OEL will be established. The OEL will not exceed the threshold limit values by ACGIH.

4.6. Air Monitoring If workers may be exposed to an airborne chemical substance at a concentration in excess of the OEL, air monitoring will be conducted on a regular basis or control measures implemented to ensure that workers are not overexposed.

4.7. Controlling Worker Exposure If the assessment shows that a chemical substance (airborne and non -airborne) creates a risk to the health of a worker, control measures to eliminate, reduce or control exposure will be implemented at the worksite.

4.8. Personal Protective Equipment (PPE) Personal protective equipment shall: ◊ Only be used when no other control measures is reasonably practical. ◊ Meet the requirements of the Workplace Safety and Health Regulation Part 6 on Personal Protective Equipment.

4.9. Compilation, Maintenance and Storage of Records ◊ Records will be complied, maintained and stored for Inventories of controlled products

MSDS Education and Training Program

Training Records Assessments Safe Work Procedures Air Monitoring Reports

5.0 Program Implementation

5.1. Inventory: The employer must ensure that workers exposure to chemical substances is identified, assessed and controlled to ensure the workers safety. The first step is the identification of the chemical substances in the workplace. To assist in making a list as complete as possible, the employer must assign a WHMIS designate to complete a walk through of the

7

workplace to look for products being produced, used, handled, stored and disposed of. Each controlled product/ chemical substance at the workplace must be recorded on the inventory. WHMIS Designate ◊ Conducts a thorough inspection of all work areas of responsibility to determine the identity and location of controlled products/chemical substances including those in hazardous waste and fugitive emissions. ◊ Establishes and completes a WHMIS Inventory Form for all controlled products used, handled, stored or used at the worksite including those in fugitive emissions and hazardous waste. (Inventory forms are available in Appendix E) ◊ Places a copy of the inventory in MSDS binder at the worksite. ◊ Sends a copy of the inventory to OESH - HSC. ◊ Updates the inventory annually at a minimum and within 15 days of a new material arriving in the facility and within 60 days of a product being removed. ◊ Sends a notice of Change of WHMIS Inventory to OESH - HSC annually or whenever controlled products are added or deleted from the facility’s inventory. OESH - HSC: ◊ Provides electronic copies of the inventory of controlled products. The inventory is as reported from the WHMIS designates. The inventory is available via computer on the MSDS Online database. ◊ Receives notices of changes of inventory and process changes to reflect on the MSDS Online Database. ◊ Notifies the WHMIS designate of revised copies of the inventory and MSDSs available on the MSDS Online Database. ◊ Maintains hard copies of inventory and inventory changes in files.

5.2. WHMIS The second step is to ensure that the WHMIS requirements for MSDSs and labels are in place at the workplace for all the controlled products listed on the chemical inventory. This information is used to ensure that workers know about the hazards of the materials in the workplace. In addition, the employer must ensure training in WHMIS and safe work procedures is provided. 5.2.1. Material Safety Data Sheets (MSDS(s)

Refers to MSDS(s) for controlled products and those found in fugitive emissions and hazardous waste. Obtaining and Requesting MSDS(s) at the Facility: WHMIS Designate ◊ Prior to ordering a controlled product obtains MSDS(s) from the manufacturer /supplier and makes the MSDS available at the worksite. Obtaining and Managing MSDS(s) and Inventory at the Worksite WHMIS Designate: ◊ Maintains a copy of the MSDS at the worksite ◊ Completes a WHMIS Inventory Form and forwards a copy with the MSDS to OESH - HSC. ◊ Ensures that workers have access to the MSDS at the worksite by printing the MSDS and placing it in MSDS binders or providing workers computer access to the MSDS Online Database.

8

Maintaining Current MSDS(s) and Providing Electronic Copies of MSDS(s) OESH - HSC: ◊ Receives MSDS(s) and inventory notices from WHMIS designates. ◊ Provides electronic copies of the MSDS(s), and the MSDS(s) coversheets and makes them available by computer with access to the MSDS Online database. ◊ Notifies the WHMIS designate, as changes occur, of new or revised MSDS(s) on the database. ◊ Provides Updated MSDS(s):

• From the manufacturer/suppliers at the end of every three years. • When the manufacturer/suppler provides revised MSDS(s) with new hazard information. • When new hazard information becomes available as a result of literature reviews.

Workers ◊ Use the hazard information provided on the MSDS and coversheet to safety produce, use, handle, store and dispose of controlled products ◊ Reports to their WHMIS designate any task or working condition(s) involving controlled products, which the worker believes poses a danger to health and safety. ◊ Informs the WHMIS designate of incomplete or missing MSDS(s).

5.2.2. Labels OESH - HSC: ◊ Evaluates the MSDS and provides information on the Workplace Label Colour on the MSDS coversheet. WHMIS Designate: ◊ Ensures supplier labels are affixed on containers of controlled products. ◊ Uses the information on the coversheet and has the WHMIS workplace labels affixed on containers when required. ◊ Uses the label colour coding system to identify those products, which represent greater potential hazards. Worker: ◊ Applies WHMIS labels as directed by the designate. ◊ Informs the designate of missing or damaged labels.

5.2.3. Hazardous Waste OESH - HSC: ◊ Evaluates MSDS(s) and relevant regulations to determine if the material would meet the criteria of being a hazardous waste. ◊ Identifies those controlled products that should be treated as hazardous waste on the MSDS coversheet. WHMIS Designate: ◊ Determines if waste are hazardous by using the MSDS and MSDS coversheet and their knowledge and experience of processes or common practices in their field related to the use of controlled products. ◊ Identifies hazardous wastes with labels, which meet WHMIS workplace label requirements. ◊ Ensures hazardous wastes are picked up for disposal by the designated waste disposal department in the facility or waste management company.

9

◊ Provides the MSDS and coversheet for hazardous waste to the designated waste management department/company responsible for picking up the waste.

5.2.4. WHMIS Education/Training OESH in consultation with the joint workplace safety and health committee: ◊ Develops the content of basic WHMIS training and testing material ◊ Develops the WHMIS Training course for the WHMIS designates\trainers ◊ Develops training for WHMIS designates on the preparation of departmental/unit spill plans. ◊ Consults with WHMIS designates in the development and delivery of education/training programs. WHMIS Designate: ◊ Determines the need for specific WHMIS and spill control training/education relevant to their area and ensures it is provided to workers ◊ Consults with the departmental Safety and Health Committee and OESH on WHMIS related education/training. ◊ Identifies the need for a WHMIS trainer, who will attend the WHMIS Train-the- Trainer Course Delivery and Evaluation: OESH: ◊ Provides at corporate orientation for new employees: ◊ Provides a WHMIS booklet ◊ Delivers the WHMIS training to WHMIS designates ◊ Delivers the WHMIS Train-the-Trainer course ◊ Delivers training on the preparation of spill plans to WHMIS designate\trainer WHMIS Designate: ◊ Ensures WHMIS training records are kept. ◊ If necessary, identifies the need for a site WHMIS trainer. WHMIS Designate or WHMIS-Trainer: ◊ Attends the WHMIS Train-the-Trainer course ◊ Orientates new employees to WHMIS ◊ Delivers general WHMIS education annually to all workers that include education and training on the spill plan. ◊ Provides site-specific training to workers who produce, use, handle, store or dispose of hazardous chemicals. ◊ Tests workers annually to ensure they can demonstrate competency by:

◊ Successfully completing the annual WHMIS test provided by OESH. ◊ Knowing the hazards of the chemicals they are required to use or handle. ◊ Knowing the safe work procedures when using or handling a controlled product. ◊ Knowing where the MSDS(s) are for any controlled product they may be required to use. ◊ Knowing what to do in an emergency situation involving a chemical substance

◊ Maintains records with the names of all workers who have successfully completed the basic WHMIS test and the date that testing was completed.

◊ Provides training to workers who are required to obtain MSDS(s) using the MSDS Online Database from computer terminals

10

Workers: ◊ Complete all WHMIS training and testing provided by the WHMIS designate\ trainer and, if unable to pass the tests, take additional instruction and training and be retested. ◊ Complete any other education and training related to controlled products as instructed by management.

5.3. Assessment of Chemical Hazards The third step involves looking at the product or substance itself in terms of physical hazards and its health effects on the body. Equally important are where the product is located, number of workers with potential of exposure, how it is produced or used, stored and disposed of, and the types of exposure that may occur. This evaluation must include consideration of the measures currently being used to control worker exposure under normal and emergency circumstances. The conditions found in the workplace are compared with recommendations found in the reference information (MSDS) to determine if measures are adequate. (For information on Chemical Hazard Assessment see Appendix B) The following must be completed to evaluate if a chemical substance presents a risk to workers. OESH - HSC: ◊ Evaluates and codes MSDS(s) to provide a MSDS coversheet to supplement and compliment the information provided on the MSDS. Controlled products are evaluated using the follow categories:

WHMIS classification OSHA Health Codes SYMBAS Group Inclusion as Hazardous Waste Colour Classification (WHMIS workplace label colour) Safe Handling Symbols (WHMIS workplace label symbols)

◊ A brief description of each of these criteria is presented in Appendix A. ◊ Distributes the MSDS coversheet to WHMIS designates for attachment to the front of every MSDS on the MSDS Online database. ◊ Identifies on the MSDS coversheet if the controlled product contains a designated material WHMIS Designate: ◊ Uses the information provided on the MSDS and MSDS coversheet and their knowledge (or that of an experienced worker) on the tasks and process used at the worksite to completes a Chemical Evaluation/Prevention Plan form for each chemical substance used at the worksite ◊ Completes an annual review of the worksite and the Chemical Evaluation/Prevention Plan forms to ensure the control measures are effective in reducing and controlling worker exposure. ◊ For the following chemicals know to be airborne hazards in health care:

• Ethylene Oxide • Formaldehyde • Glutaraldehyde • Methyl Methacrylate • Mercury • Nitrous oxide and other anaesthetics agents • Solvents (i.e. toluene, xylene, acetone, alcohols etc.) 11

Notify OESH when: ◊ There is a change in conditions in the workplace that may affect work exposure. ◊ There is a change in the health or physical condition of a worker. ◊ Non air-borne exposures such as dermal contact and ingestion indicate a risk to workers.

OESH: ◊ Investigates management & worker complaints and/or concerns related to chemical substances and provide recommendations to eliminate or control exposure levels. ◊ Conducts an annual database analysis to identify chemical hazards and makes recommendations to reduce or eliminate the risk. ◊ Completes annually the Workplace Chemical Hazard Assessment Form for the following chemicals know to be airborne hazards in health care:

• Ethylene Oxide • Formaldehyde • Glutaraldehyde • Methyl Methacrylate • Mercury • Nitrous oxide and other anaesthetics agents • Solvents (i.e. toluene, xylene, acetone, alcohols etc.)

◊ When there is a change in conditions in the workplace that may affect work exposure. ◊ When there is a change in the health or physical condition of a worker. ◊ When non air-borne exposures such as dermal contact and ingestion indicate a risk to workers.

◊ Provides assistance to WHMIS designates to help the facility achieve compliance and eliminate or reduce exposure to hazardous materials.

5.4. Occupational Exposure Limits for Airborne Chemical Substances Occupation Exposure Limits (OEL) are used when an airborne chemical may pose a health hazard to a worker. An OEL is a maximum allowable limit of a worker’s exposure to that chemical. Workers must not be exposed to airborne concentrations above the OEL. The OEL must not exceed the most current threshold limit values by ACGIH (American Conference of Governmental Industrial Hygienists). OESH: ◊ Uses the Occupational Exposure Limits (OEL) for airborne exposure of chemical

substances set by the ACGIH (American Conference of Governmental Industrial Hygienists) and/or other organizations (i.e. NIOSH).

◊ In the case of an airborne designated material, establishes an occupational exposure limit for the material that is as close to zero as possible and does not exceed the threshold limit value established by the ACGIH, where one exists. ◊ In the case of an airborne substance for which the ACGIH has not established a threshold limit value establishes an occupational exposure limit for the substance.

5.5. Air Monitoring of Worker Exposure For some airborne substances, it is may be necessary to conduct air monitoring to determine the concentration of the substance in the air at the worksite. Exposure to dusts, fumes,

12

gases and vapors can cause long-term health effects or short-term acute nuisance or irritation. Measurement and assessment of pollutant concentrations is therefore, essential to ensure worker protection and show compliance with legislation and/or to identify if there is deterioration in the controls in the workplace environment. Dependent of the workplace chemical assessment air monitoring may be undertaken: ◊ To determine a risk to health of workers, ◊ To determine the exposure levels if a control measure was to fail or deteriorate (or if they are absent); ◊ To ensure that a particular control measure is working properly and is reducing exposure concentration below the OEL. OESH: ◊ Determines the air monitoring method. ◊ Prepares and coordinates an annual monitoring plan for WRHA facilities. ◊ Prepares an annual monitoring schedule. ◊ Consults with WHMIS designates regarding the purchasing or rental of monitoring equipment including any monitoring badges with lab analysis, when necessary. ◊ Coordinates the monitoring schedule with the WHMIS designate. ◊ Conducts monitoring. ◊ Provides an occupational hygiene reports with recommendations to eliminate or control the exposure (elimination, substitution, engineering controls, work practices, PPE) to the workplace WHMIS designate. WHMIS Designate: ◊ Purchases or rents monitoring equipment including any monitoring badges with lab analysis, when necessary.

5.6. Implementation of Control Measures The next step is to ensure that worker exposure is controlled to prevent adverse health affects. For airborne chemicals exposure must be kept below the OEL. For designated materials the exposure limit must be kept as close to zero as possible. WHMIS Designate: When the assessment has determined a chemical creates or may create a risk to the safety or health of a worker ◊ Develops and implements safe work procedures in conjunction with workers in the area. ◊ Train workers in the safe work procedures. Airborne Exposures: When ever any airborne exposure monitoring results indicate that the exposure limit of chemical substances has been exceeded or: ◊ Follows-the recommendations in the occupational hygiene reports and implements control measures and ensuring consideration is given to:

Eliminating the hazardous products or substituting hazardous products with less hazardous ones whenever possible.

Implementing engineering controls to eliminate worker handling. Establishing administrative controls including developing and implementing the use

of safe work procedures and site worker education and worker training. Enforcing the use of PPE as required and as identified on the MSDS and/or MSDS

coversheet. ◊ Implements interim control measures to eliminate or reduce exposure such as administrative controls and/or PPE if necessary. ◊ Forwards the report to the management, and any affected worker.

13

◊ Advises OESH and affected workers of the measures taken to reduce exposure. Non-Airborne Exposures The nature of non airborne exposures to chemical substances is by dermal contact and ingestion. The following control measures will be implemented to eliminate non-airborne exposures. ◊ Ensures worker use PPE (such as gloves, goggles, face shields, gowns or labs coats), personal hygiene (hand washing) and good housekeeping practices are utilized to prevent exposure from such routes.

5.7. Conducting Air Monitoring After Implementation of Control Measures: When control measures are implemented or modified to control the concentration of an airborne chemical substance air monitoring will be conducted to: ◊ To ensure that a particular control measure is working properly and is reducing exposure concentration below the OEL OESH: ◊ Conducts air monitoring after control measures are implemented. ◊ Provides an occupational hygiene follow-up report to the WHMIS designate with recommendations to eliminate or control exposure. WHMIS Designate: ◊ Follows the recommendations in the report to modify control measures. ◊ Forwards the report to the safety and health committee and any affected worker.

5.8. Personal Protective Equipment PPE may only be used if no other control measure such as substitution, engineering controls is reasonably practical. The use of PPE can also is to be used in conjunction with other control measures and safe work practices. OESH: ◊ Ensures assessments are conducted to ensure the selection and use of PPE is appropriate and adequate to eliminate or reduce worker exposure. ◊ Provides reports to the WHMIS designate as it relates to the selection, use and maintenance of PPE. ◊ Provides education and training in the selection, use and maintenance of PPE. WHMIS Designate: ◊ Consults the MSDS, MSDS coversheet and or OESH in the selection, use and maintenance PPE used to reduce worker exposure to controlled products/chemical substances. ◊ Participates in educational sessions provided by OESH on PPE. ◊ Enforces the use of required PPE at the worksite. WHMIS Trainers: ◊ Participates in educational sessions provided by on PPE. ◊ Delivers education/training to workers on the selection, use and maintenance of PPE. Workers: ◊ Wears and maintains all PPE as directed and trained.

5.9. Compilation, Maintenance and Storage of Records In order for the employer to document the plan implemented to identify, assess and control chemical hazards the following records must be kept. WHMIS Designate:

14

◊ Maintains and ensures copies of the following records are sent to OESH - HSC: Material Safety Data Sheets required for a controlled product used at the worksite

including those in fugitive emissions or hazardous waste. Inventory of controlled products used at the worksite, revisions to the inventory. ◊

Maintains the following records at the worksite: The site-specific worker education/training program developed and implemented for

controlled products. Records of site-specific education, training and testing results.

Records of assessment. ◊ Prevention Plans. ◊ Occupational hygiene reports of the worksite. ◊ Provides copies of records to the safety and health committee for review. OESH ◊ Maintains and makes available copies of records related to the WHMIS program sent by WHMIS designates. ◊ Maintains records of the WHMIS Train-the-Trainer program, the WHMIS Booklet, and the general WHMIS test. ◊ Keeps MSDSs, inventory and Occupational Hygiene Reports, for 30 years. ◊ Makes available the WHMIS training program and the Chemical Substance Prevention Plan on the internal intranet website.

15

Appendix A - MSDS Evaluation and Coding System An Occupational Hygienist, who is familiar with government legislation evaluates and codes MSDS(s).

WHMIS Classifications: WHMIS Classifications are based on criteria in Part IV of the Controlled Product Regulation. The criteria for classification are published by Manitoba Labour Workplace Safety and Health Division called the “WHMIS Core Material” document (MG #384) (see Table 1). OESH - HSC uses these criteria to classify controlled products into the following classes: A) Compressed Gas B) Flammable and Combustible Material C) Oxidizing Material D) Poisonous and Infectious Material E) Corrosive Material F) Dangerously Reactive Material Health Codes: The MSDS were coded on the basis of the health effect that they could potentially cause. The coding criteria used involved a set of 22 health effects adapted from a health code system developed by the Occupational Safety and Health Administration (OSHA) in the United States. The health codes are provided in Table 2.

MSDS reporting health effects are assigned the appropriate health code based on the above table. Chemicals may produce a number of different health effects at different doses. For example, acetone is considered to be a simple irritant and would be assigned health code 15 or 16. However, at very high concentration that could occur in an emergency discharge, acetone could cause central nervous system depression. Chronic long-term exposure may produce dermatitis. As exposures should be reduced to control the most restrictive health effect, an effort was made to include health effects that would arise from extreme exposures.

SYMBAS Group: The SYMBAS group is a chemical storage tool based on the WHMIS and TDG symbols. This system separates chemicals on the basis of their chemical and physical properties into 10 groups of compatible chemicals for storage purposes. This system is an option available to departments/units where hazardous chemicals are stored. Each of the products coded is assigned a SYMBAS group. (See Table 4 for details.)

Based on the review of the individual MSDS, the product is coded into the best SYMBAS group. This tool is used in helping to determine the appropriate storage conditions. However, the MSDS should also be consulted for high hazard materials because it contains specific storage and compatibility information.

Inclusion as Hazardous Waste: The coding system also identifies those controlled products that should be treated as hazardous wastes. All controlled products are treated as hazardous waste unless they are irritants (WHMIS classification D2B, Health Codes 14, 15, 16) and do not violate any criteria of the Winnipeg Civic Bylaw on discharges to sewers. For example, a product may have a pH of 4 so that it is likely a mild irritant but it still has a pH too low for discharge to sewer under the civic bylaw. Thus, the product will be classified as a hazardous waste.

16

WHMIS Workplace Label and Colour Classification System To provide additional information on the hazards associated with controlled products, coloured workplace labels are used. WHMIS covers potential hazards ranging from products that cause eye irritation to products that will explode on mechanical impact. To address this broad range of potential hazards, the colour coding system is used to identify those products, which represent greater potential hazards and require additional care in their use and storage. The colors range from white, to yellow, to pink, with increasing potential hazard and increasing need for additional handling precautions.

White These controlled do not pose an immediate or long-tem health hazard. Normal safe work procedures are required such as wearing PPE for the hazard represented, following good housekeeping practices using safe work procedures and ensuring proper storage. Yellow These controlled products may contain a designated material or produce one or more of the following health effects: cancer, mutation, reproductive effects, and sensitization (respiratory and dermal). Additional safe work procedures are required and workers may require additional health monitoring (depending on exposure levels). Pink These controlled products have serious or immediate hazards and require special work procedures, engineering controls, and highly trained workers.

Safe Handling Symbols (WHMIS workplace label symbols): The information on the cover sheets attached to the front of every MSDS includes safe handling symbols. The symbols alert the user to the hazards of the material and what they should do to protect themselves. See Table 3 for details. This information is also used to produce workplace labels for decanted products.

Chemical Evaluation/ Prevention Plan Forms The Chemical Evaluation/ Prevention Plan form must be completed by the WHMIS designate for all controlled products at worksite and reviewed periodically. The purpose of the form is to document the assessment including the identification of existing control measures and training to protect workers at the worksite. When it is necessary, ensure that any additional measures that are needed are implemented to ensure workers protection. The form may also be utilized during worker training to summarize measures in please to protect workers from exposure.

17

Appendix B - Chemical Hazard Assessment What is a Chemical Hazard Assessment? A Chemical hazard assessment involves:

• identifying the substances used or produced or released in an activity; • gathering information about the hazards (MSDS), the harmful or adverse effects of the substances; • considering whether and how harm or adverse effects could actually arise from the way the substances are used or produced, the risk to health and safety; • identifying the people whose health and safety may be endangered; • considering what methods of prevention or control and any other measures are needed; • identifying the need for monitoring;

o performance of control measures; o workplace condition.

Many of the substances that we encounter in our work, not only in laboratories but also in offices and other not so likely places, can cause ill-health or fire and even explosion. The properties that cause these effects are called hazards. In some activities we do not start with a hazardous substance but one is produced from the process as a fume or residue.

In order to determine whether an unsafe condition may arise and what to do about it, we need information about both the substances and the processes involving them. That is, we need to do a hazard assessment of the activity. The assessment must also consider:

• any potential for change in the activity that would alter the risk; • what could go wrong.

Unsafe conditions include: ◊ An atmosphere contaminated with gas, dust,

vapour, fume, aerosol; ◊ Oxygen deficiency; ◊ Spills or splashes of liquids; ◊ Mixing of incompatible substances; ◊ Overheating, excess pressure, exposure to source

of ignition. ◊ Incorrect storage

Criteria for determining excessive personal exposure:

An unsafe condition may cause: ◊ Personal exposure by inhalation or eye or skin contact; ◊ Asphyxiation; ◊ Violent reaction and/or release of further hazardous substances; ◊ Ignition or detonation leading to fire or explosion.

Harm to health can only arise if the exposure or contact to a substance could lead to its absorption into the body. Is the substance likely to be present in a form in which it could be?

• inhaled; • swallowed (either directly or by settling on food or from putting contaminated fingers to the mouth); • absorbed through the skin or eyes (either directly or from contact with contaminated surfaces or clothing); • in contact with skin or eyes; • injected into the body by high pressure, equipment or contaminated sharps objects

18

Workplace Chemical Hazard Assessment Form (Complete one form per product)

Facility Name: Name of WHMIS Designate Date Completed: √ Indicates the chemical

Ethylene Oxide Glutaraldehyde Formaldehyde Methyl Methacrylate Mercury Nitrous Oxide

Halogenated Anaesthetic Agents Solvents Other Chemicals Isoflurane Xylene { specify name} Desflurane Toluene Sevoflurane Methanol, (other) Ethyl Ether

{ specify name} (other) { specify name}

Name of the product: (which contains the chemical) Department/Unit Name: Name Dept./Unit Manager: Phone # Dept. Manager: Describe how is the product is No. or workers Area/Room Amount Frequency of use used/handled Number (daily/weekly

monthly_ Have workers reported any adverse symptoms as a result of their exposure? Area/Room Number Concern

Describe the Exposure Control Strategies (specify Area/Room) Elimination (including substitution): Describe plans to remove the hazard from the workplace. Engineering Controls: Specify the design, (or modifications made to equipment), the ventilation systems (general exhaust, local exhaust), and processes that reduce the source of exposure Administrative Controls: specify the controls that alter the way the work is done, including timing of work, policies and other rules, and safe work practices such as standards and operating procedures (including training, housekeeping, and equipment maintenance, and personal hygiene practices Personal Protective Equipment: specify the equipment and when it is worn by individuals to reduce exposure √ Indicates the air monitoring

Base Line Air Monitoring Periodic Air Monitoring (Every 3 years) Annual Air Monitoring Required as a result of exposure concerns

19

Appendix C-Air Monitoring

Monitoring Methods Chemical /CAS# Physical/Health Hazards* Occupational Exposure Sampling Methods Reference information on

Limit** monitoring badges Ethylene Oxide Flammable gas 1 ppm TLV-TWA ACGIH Miran SapphIRE Ambient Monitoring Badges (75-21-8) Acute Toxicity Air Analyzers http://www.assaytech.us/

CNS Impairment ChemDiskTM Monitor badge Analytical Methods: Carcinogen, Mutagen, for Ethylene Oxide No. 555 ASTM D5578-94, Similar to Reproductive toxin OSHA 50 Corrosive to skin Reactive

Formaldehyde solution Combustible Liquid 0.3 ppm TLV -C ACGIH Miran SapphIRE Ambient (50-00-0) Acute Toxicity Air Analyzer

Irritant Drager CMS Analyzer Carcinogen, Mutagen Skin Sensitizer Corrosive to skin

Glutaraldehyde solution Acute Toxicity 0.05 ppm TLV -C ACGIH Glutaraldemeter®3 (111-30-8) Irritant

Skin Sensitizer Corrosive to skin (dependent on concentration) Limited evidence of Respiratory Sensitizer

Methyl Methacrylate Flammable liquid 50 ppm TLV-TWA ACGIH Miran SapphIRE Ambient Monitoring Badges (80-62-6) Eye irritation 100 ppm TLV-STEL ACGIH Air Analyzers http://www.assaytech.us/

Skin Sensitizer ChemDiskTM Monitor badge Analytical Methods: Reactive for Organic Vapour OSHA 7, NIOSH 1500

No.541/546

20

Chemical /CAS# Physical/Health Hazards* Occupational Exposure Sampling Methods Reference information on

Limit** monitoring badges Mercury (Vapour) Acute Toxicity 0.025 mg/m3 “Skin “ TLV- Mercury Vapour Indicator Monitoring Badges (7439-97-6) CNS Impairment TWA ACGIH ChemDisk IITM Monitor for http://www.assaytech.us/

Kidney Damage Mercury No. 593 Analytical Methods: Teratogen and Embryotoxin OSHA 140 Skin Sensitizer

Nitrous Oxide Nonflammable gas 50 ppm TLV-TWA Miran SapphIRE Ambient Monitoring Badges (10024-97-2) CNS Impairment Air Analyzers http://www.assaytech.us/

Hematological effects ChemDiskTM Personal Analytical Methods: Teratogen and Embryotoxin Monitor for Nitrous Oxide Modified OSHA 166

No. 575 Halogenated Agents CNS Impairment OEL not established by Miran SapphIRE Ambient Monitoring Badges Isoflurane (26675-46-2) ACGIH Air Analyzers http://www.assaytech.us/ Sevoflurane (28523-86-6) Recommended 25ppm TLV- ChemDiskTM Monitor Analytical Methods: Desflurane (57041-67-5) TWA badges for Halogenated Modified OSHA 103

2 PPM Ceiling NIOSH Anesthetic Gases No. 574 recommended (60 minutes)

Solvents Hazards vary according to Vary review the most Miran SapphIRE Ambient Monitoring Badges solvent - review the MSDS current TLV booklet from Air Analyzer http://www.assaytech.us/ for specific hazards ACGIH Drager CMS Analyzer Analytical Methods:

ChemDiskTM Personal OSHA 7, NIOSH 1500 Monitor for Organic Vapour No. 541/546

The Threshold Limit Value - Time Weight Average (TLV-TWA) is the average concentration for a normal 8-hour workday and a 40-hour work week, to which nearly all workers may be repeatedly exposed without adverse effect. Threshold Limit Value - Short Term Exposure Limit (TLV-STEL) which is a 15 minute time weight average that should not be exceeded at any time during a working day. Exposures up to the STEL should be less than 15 minutes and not more that four times per day. Threshold Limit Value - Ceiling (TLV-C) which is the exposure limit that should not be exceeded at any time.

"SKIN" notation: Contact with skin, eyes, mucous membranes can contribute to the overall exposure and may invalidate the TLV. Consider measures to prevent absorption by these routes. 21

Annual Monitoring Plan

200? AIR MONITORING PLAN for (Facility Name)

The 200x priority chemicals were assessed to determine if they were still priority chemicals, and what further action was required. The following is the result of that assessment:

Priority Chemicals

Ethylene Oxide Formaldehyde Glutaraldehyde Methyl Methacrylate Mercury Anesthetic Gases - Nitrous Oxide and halogenated anesthetic agents Solvents Xylene Toluene Other Chemicals assessed as a priority for 200x

Example -Findings of the Assessment

This material could be dropped from the 200x priority list. New equipment was installed to sterilize materials within the Centre. The new equipment contains the ethylene oxide within a closed system discharging through the roof. This material will remain on the 200x priority list. It is a toxic material that is widely used in the facility. This material will remain on the 200x priority list. It is a toxic material that is used in the facility. This material will be dropped from the 200x priority list. Monitoring done in past revealed exposure levels were considerably below TLV and control measure are in place. Monitoring can be conducted upon a request bases. This material could be dropped from the 200x priority list. Most of the equipment and processes that used mercury have been phased out. A small number of units remain with mercury in them. These materials will remain on the 200x priority list. It is widely used in the facility operating rooms.

These materials will remain on the 200x priority list. As a class they are widely used throughout the facility by many people. Xylene and Toluene are used extensively in Pathology Laboratories - Histology,

To assess the potential risk presented by the materials, a risk assessment was carried out. Worker exposures will be estimated for tasks that are deemed to have the highest potential risk within the facility

The following air monitoring to carried out: Chemicals

Formaldehyde Glutaraldehyde Anesthetic Gases - Nitrous Oxide -halogenated anesthetic agents Solvents Xylene Toluene

Action Plan Formaldehyde samples will be collected in areas of highest use. Areas identified are: Pathology Laboratories - Areas that use Glutaraldehyde will be contacted by OESH and assessment will be completed. Based on the assessment if necessary monitoring will be done. Areas identified are - Endoscopy GA1, MDR, Fetal Assessment. N2O and halogenated anesthetic samples will be collected in the operating rooms.

Solvent Monitoring will be collected in the following areas: Pathology Laboratories -

The exposures of the highest exposed workers in each identified area will be assessed.

22

Annual Air Monitoring Schedule for 200X Month Grace 2007 Hospital

January February March

April May

June July Glutaraldehy

de Ultrasound CSR OR Endoscopy (June Trottier/ Ethelinda Padua)

August September

October November

December

HSC Victoria

Hospital

Oaks Hospital Centre

Formaldehyde /Solvents Pathology MS4

Nitrous Oxide/Halogenated agents CH PACU

Nitrous Oxide/Halogenated agents CH OR/ ADULT OR./WOMEN’S OR

Glutaraldehyde GA1 endoscopy (June Trottier)

Med. Devices (Ethelinda Padua) Ultrasound Fetal Assessment Com. Disorders (June Trottier) GA1 endoscopy (June Trottier)

Seven Concordia Deer Lodge

23

Pan Am Community St. Boniface Clinic Health Hospital

Services

Appendix D-MSDS Coversheet Classifications

Table 1 - WHMIS Classifications The products are classified based on their WHMIS Classification

WHMIS Class. Code WHMIS Class Description

A Compressed Gas B Flammable and Combustible

Material C Oxidizing Material

D1A Acute - Very Toxic Material D1B Acute - Toxic Material D2A Chronic - Very Toxic

Material D2B Chronic - Toxic Material D3 Biohazardous Infectious

Material E Corrosive Material F Dangerously Reactive

Material NW Non-WHMIS R Radioactive

24

Table 2 - Health Effects The products were evaluated based on their health effect. Health Effect

Cancer Chronic Toxicity - suspected carcinogen or mutagen Chronic Toxicity - long-term organ toxicity other than nervous system Acute Toxicity - short term high hazard effects Reproductive hazards - fertility impairment or teratogenesis CNS disturbances - cholinesterase inhibition CNS disturbances - nervous system effects other than narcosis CNS disturbances - narcosis Respiratory effects - respiratory sensitization, asthma Respiratory effects - cumulative lung damage Respiratory effects - acute lung damage / edema Haematologic disturbances - anemias Haematologic disturbances - methaemoglobinaemia Marked irritation - eye, nose, throat, skin Moderate irritation - eye, nose, throat, skin Mild irritation - eye, nose, throat, skin Asphyxiants Explosive, flammable, no effects when good housekeeping practices followed Low risk health effects - nuisance particulates, vapours or gases Low risk health effects - odours Dermal Sensitization Bioinfection N/A

HEALTH EFFECTS, Principal effect(s) of exposure to each substance, listed by OSHA Health Code and Health Effects. {Link to website: http://www.osha.gov/dts/chemicalsampling/field.html#healthcode )

25

Table 3 - Safe Handling Symbols (WHMIS workplace label symbols) WHMIS Handling Symbol means

Symbol May harm eyes May be liquid or solid May harm skin May be absorbed through the skin Usually in liquid form May harm the digestive track Can be a risk in all forms May be harmful if inhaled Gases, vapors or aerosols can be a hazard

26

You are required to:

Use proper work procedures Avoid splashes Use engineering controls Use protective eye wear

Use proper work procedures Use gloves, aprons, boots or other equipment as needed Use barrier cream Wash immediately

Do not smoke, eat or drink in area Wash after use or if in contact

Use ventilation or other engineering controls Use respirator

Table 4 - SYMBAS GROUPS SYMBAS Physical/Chemical GROUP SYMBAS Description Properties

1 Explosives Explosives 2 Flammable Gas Flammable Gas 3 Non Flammable Gas Non Flammable Gas 4 Dangerously Reactive Dangerously

When Wet Reactive When Wet 5 Dangerously Reactive Dangerously

When Dry Reactive When Dry 6 Oxidizers Oxidizers

Definition -

Capable of self-sustained chemical reaction, of producing gas at such temperature, pressure speed as to damage surroundings; or is mfg. for the purpose of producing explosion. A compressed gas (WHMIS Class A) and forms a flammable mixture at normal atmospheric pressure over a significant range of concentration.

A compressed gas, dissolved gas, or liquefied by compression or refrigeration.

When in contact with water or water vapor emits a flammable or toxic gas; becomes spontaneously combustible under conditions of shock or increased temperatures or pressure or can undergo hazardous decompositions. Liable to spontaneous heat under normal conditions or shock or increase in temperature or pressure or is liable to heat in contact with area to the point where it begins to burn. Liable to cause or contribute to the combustion of other materials by yielding oxygen or other oxidizing material; or is an organic peroxide that contains the bivalent o-o structure

Incompatibilities

WHMIS Class E Corrosives- ; Class B - Flammables; Class F - Reactive, Ignition sources, Heat

WHMIS Class C Oxidizer; Class F Reactive; Explosives; Ignition Sources; Elevated Temperatures

WHMIS Class B Flammables, Excessive Heat

WHMIS Class E Corrosives that are Aqueous acids and bases; Class B Flammables, Water and water solutions, Dangerous Reactive when Dry; Ignition sources WHMIS Class B Flammables, Class C Oxidizers, Class E Corrosives, Heat, Physical Shock

WHMIS Class B Flammables, Class E Corrosives, Heat, Organic Material

27

Storage Conditions Required

Cool, dry area protected from shock, elevated temperatures, or rapid temperature changes. Site should be remote from other storage/activities. Magazines should be heavily constructed. Cool, dry ventilated area away from heat and ignition sources. Cylinder temperature should never exceed 51C (125F). Stored secured in an upright position and care taken to avoid damaging valves. Full containers should be separated from empty ones. Cool, dry ventilated area away from heat and ignition sources. Cylinder temperature should not be elevated. Stored secured in an upright position and care taken to avoid damaging valves. Full containers should be separated from empty ones. Cool, dry ventilated waterproof area - no water sprinkler system should service the area. Alternative fire fighting system (e.g. Halon suppression) is advisable. Containers should be raised above possible flood levels.

Cool, dry area. Great care should be taken in handling containers. Store only one high.

Cool, dry ventilated area out of direct sunlight. Protect from temperature extremes or rapid temperature changes. Fire fighting procedures should be reviewed as normal procedures are not particularly effective with oxidizers.

SYMBAS Physical/Chemical GROUP SYMBAS Description Properties

7 Flammable/Combustible- Flammable Liquids Liquids and Solids and Solids

8 Acids Acids 9 Bases Bases

10 Toxics Toxics

Definition -

Can be ignited at normal temperatures; or can cause a fire through friction or retained heat.

Can significantly corrode steel or aluminum; or is corrosive to skin and has a pH<=2.0.

WHMIS Class D Toxic Materials, Class B Flammables, Class C Oxidizers, Organic materials

Can significantly corrode steel or aluminum; or is corrosive to skin and has a pH>=12.5.

WHMIS Class D Toxic Materials, Class B Flammables, Class C Oxidizers, Organic materials

Is poisonous, and/or radioactive, and/or infectious, and/or hazardous to the environment, and waste materials may be hazardous..

Incompatibilities

WHMIS Class C Oxidizers, Class F Reactive, Ignition Sources

WHMIS Class E Corrosives, Class F Reactive, Class B Flammables, Heat, Moisture

28

Storage Conditions Required

Cool dry area. Eliminate all ignition sources. Provide adequate ventilation to prevent build-up of vapours. Proper fire fighting equipment should be available. Storage area should be of fireproof construction and comply with existing Fire Code.

Cool, dry ventilated area out of direct sunlight in approved containers. Storage area should not be subject to rapid temperature changes. Structural and stacking material should be non-corroding or metal covered with acid fume resistant paint. Cool, dry ventilated area out of direct sunlight in approved containers. Storage area should not be subject to rapid temperature changes. Structural and stacking material should be non-corroding or metal covered with acid fume resistant paint. Ensure containers are secure, closed and properly labelled.

Appendix E-Inventory Forms WHMIS INVENTORY FORM

Name of Facility: Department/Unit: {i.e. housekeeping} Department/Unit Mailing Address: Director Name: Phone # Room #: Manager Name: Phone # Room #: Name of WHMIS Room #: Designate: Phone # Designates e-mail address:

Designates Fax #

Room Locations of MSDS Binders:

29

WHMIS INVENTORY FORM

Controlled Product Name Product Code/ Room Numbers Manufacturer Name, Supplier Name Current MSDS

Catalogue # - Location of Address, Phone, Fax# Address, Phone, Available? Products Fax#

Yes No

After completing this form, please e-mail to OESH-HSC ayoung@exchange.hsc.mb.ca Thank you. Phone # 787-7242 Fax# 787-1172

30

Estimated Maximum Quantity Present at any one time

Qty.# Container size (ml, g, L, kg, ug, ul)

WHMIS INVENTORY CHANGE FORM

Date: Facility Department/Unit: Location: Mailing Address: Contact Person: Phone: Inventory is complete and accurate as is: YES /NO : ADDITIONS: MSDS MUST BE SENT TO OESH-HSC Full Name of Product Product Manufacturer Local Supplier Product Labeled Phone # Current Estimated

Code With WHMIS Labels? MSDS Max. Qty. Yes / No

DELETIONS: Full Name of Product Manufacturer Local Supplier After completing this form, please e-mail to OESH-HSC ayoung@exchange.hsc.mb.ca Thank you. Phone # 787-7242 Fax# 787-1172

31