CODE BROWN HAZARDOUS SPILLS. Purpose & Authority. Definitions. Reviewed and Approved by Covenant Health E/DM Jan 2016, Jan 2017 Page 1
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1 CODE BROWN HAZARDOUS SPILLS Purpose & Authority This plan addresses the procedures to be followed in the event of a spill involving a hazardous substance. All hazardous substance spills shall be reported in writing to the Joint Worksite Health & Safety Committee, regardless of size. The report shall include the date, time, location, chemical(s) and their volume, and names of all persons involved, including any visitors who were exposed and personnel involved in the clean up. A copy of this report shall also be kept by the JWHS committee. Hazardous substance spills are considered a workplace incident and must be reported to the Covenant Health OH&S Incident Reporting Line ( or ). Hazardous substance spills should be reported on the Employee Incident/Injury Reporting and Investigation Form and faxed to RLS may also need to be filled out if Patient Safety was an issue. Emergency spill responses shall be reported to Covenant Health Emergency/Disaster Management on-call ( and ask operator for E/DM on-call) Definitions Hazardous Substance A chemical, biological or radioactive material that may pose a threat to human health or the environment. Minor Spill Less than 9 inches in diameter, or 23 centimetres. Emergency Spill Equals or exceeds 23 centimetres in diameter, but less than 1.5 meters or 5 feet. Incident Commander Person assuming command and directing the response and cleanup. Page 1
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3 Upon Identification of a Spill All emergency operations shall be conducted in accordance with the following incident management procedure: Move people away from the spill area to prevent exposure Establish Incident Command Assume that the spill is hazardous. Assist any injured or contaminated persons. Isolate area / deny entry Close doors and windows, as necessary. Evaluate the hazard and risk: What spilled? How much? Hazards of the material Location of the spill. The need to shut down mechanical systems The potential for environmental contamination Determine if it is an Emergency Spill or a Minor Spill. Refer to the appropriate section below. Incident Command Upon determining the incident level, the Incident Commander (IC) will take reasonable measures necessary to ensure that the incident is appropriately contained, responded to, and cleaned up. These measures may include: Stopping operations Evacuating work areas or buildings Shutting down air handling systems Protecting nearby storm sewers Collecting and/or containing released wastes and removing containers Where necessary, the IC will direct the Emergency Response Team and Security to initiate evacuation of an area or building. The IC will direct the Emergency Response Team members to provide medical assistance, if necessary. The IC will assess available information, analyze potential hazards, and relay pertinent information to Emergency Response Team members at the scene. The hazard assessment will consider both direct and indirect effects of the release. Page 3
4 The IC may notify and request outside assistance as necessary. Emergency Spills A chemical spill is classified as an emergency spill whenever it: Causes personal injury or chemical exposure that requires medical attention; Causes a fire hazard or uncontrollable volatility; Requires a need for breathing apparatus of the supplied air or self-contained type to handle the material involved; Involves or contaminates a public area or an occupied patient room; Causes airborne contamination that requires local or building evacuation; Causes a spill that cannot be controlled or isolated by site personnel; Causes damage to property that will require repairs; Cannot be properly handled due to lack of local trained personnel and/or equipment to perform a safe, effective clean up; Requires prolonged or overnight clean up; Involves an unknown substance; or Enters the land or water. Although the following tactics are prioritized in terms of usual preferred action sequences, each spill incident is unique and involves persons with varying levels of spill expertise and experience. Thus, for any individual incident, isolation of the spill and/or securing the area might best occur prior to or simultaneously with contacting the Site Administrator/ Maintenance Department. Contact Camrose Fire Department dial 911. Notify the emergency response dispatcher of the location of the spill and, if known, the chemical spilled. Don t panic. Always send for help first, if possible. If the spill presents an immediate danger, leave the spill site and warn others. Control entry to the spill site, and wait for Camrose Fire Department response. Remove contaminated clothing. Flush skin/eyes with water for at least 15 minutes to 30 minutes or as recommended on the MSDS. Use soap for intermediate and final cleaning of skin areas. Protect yourself, and then remove injured person(s) to fresh air, if safe to do so. Notify nearby persons and evacuate as necessary. Prevent entry as necessary, by posting a guard in a safe area and/or shutting doors. If flammable vapours are involved, do not operate electrical switches unless to turn off motorized equipment. Try to turn off or remove heat sources where safe to do so. Page 4
5 If the substance involved is an unknown, then emergency spill response procedures are limited to self-protection, notification of supervisor or Site Executive Lead Director/Maintenance Department, isolation of the chemical, and evacuating and securing the area involved until assistance arrives from Camrose Fire Department. Obtain Code Brown Spill Kit for clean up procedures, Personal Protective equipment and supplies. Code Brown Spill Kits are located in Emergency, Laboratory, Unit One Sterilizing room, MDRD, Materials Management. Blood and Body Fluid Spill kits on all units Do not touch the spill without protective clothing. Where the spill does not present immediate personal danger, try to control the spread or volume of the spill. This may mean shutting a door, moving nearby equipment to prevent further contamination, repositioning an overturned container, or one that has a hole in the bottom or side, creating a dike by putting an absorbent around a spill or opening the sashes on the fume hoods to facilitate removal of vapours. Never assume gases or vapours do not exist or are harmless because of lack of odour. Use absorbents to collect substances. Reduce vapour concentrations by covering the surface of a liquid spill with absorbent. Control enlargement of the spill area by diking with absorbent. Refer to the Material Safety Data sheet or area/chemical specific spill response procedures for information on handling spills of a specific chemical. Page 5
6 Minor Spills - Minor spills are those spills that do not fit the requirements for Emergency Spills. The following general procedures should be used for all minor spills Attend to any persons who may have been contaminated. If these persons require medical attention, this is an emergency spill (see above). Notify persons in the immediate area about the spill. Evacuate all non-essential personnel from the spill area. If the spilled material is flammable, turn off ignition and heat sources. Avoid breathing vapours of the spilled material. If respiratory protection is necessary it is an emergency spill (see above). Leave on or establish exhaust ventilation if it is safe to do so. Secure Code Brown Spill Kits to effect clean up. Spill kits are kept at: Emergency Laboratory Unit One Scope Cleaning room Materials Management Medical Device Reprocessing Department (MDRD) Environmental Services Main Room Level One Blood and Body Fluid spill kits are in all nursing areas house keeping rooms Don appropriate personnel protective equipment. Confine or contain the spill to a small area. Do not let it spread. Follow clean up directions given in Code Brown spill Kit. If in doubt, refer to Material Safety Data Sheet (MSDS) Or Area/Chemical specific spill response procedures for further information. Sop up the spill, with absorbent pads or carefully scoop up solid mass with dustpan and dispose of in bag provided. Carefully pick up and clean any cartons or bottles that have been splashed or immersed. If needed, vacuum the area with a HEPA filtered vacuum cleaner approved and designed for the material involved If the spilled material is extremely volatile, let it evaporate and be exhausted by the laboratory hood (provided that the hood is authorized for use with the spilled chemical Page 6
7 Solid Spills Generally sweep low toxicity spilled solids into a dustpan and place them into a container suitable for that chemical. Additional precautions, such as the use of a vacuum cleaner equipped with a HEPA filter, may be necessary when cleaning up spills of more highly toxic solids. Dispose of residues according to safe disposal procedures, remembering that personal protective equipment, brooms, dustpans, and other items may require special disposal procedures. Refer to the Material Safety Data sheet or Area/Chemical specific spill response procedures for further information. Clean Up Responsibility Department where spill occurred: Initiate immediate clean up and / or response procedures Provide trained personnel and clean up procedures Occupational Health and Safety: Department staff assist in clean up or advise as appropriate Incident Termination The Incident Commander or designate shall determine when an emergency incident is over. This decision may be based on input from the Emergency Response Team and / or outside emergency responders. When determining an emergency has ended, the Incident Commander will consider: Remaining potential threat to human health and the environment Whether the incident has ceased or is under control Whether it is safe for workers to enter evacuated areas Clean up of site Radiation Decontamination Initiation of radiation decontamination procedures is the responsibility of the Provincial Radiation Safety Officer. Page 7
8 Preparation for Radiation Decontamination General Precautions Inform persons in the area that a spill has occurred. Keep them away from the contaminated area. Cover the spill with absorbent material to prevent the spread of contamination Minor Spills (Typically less than 100 exemption quantities of a nuclear substance) Wearing protective clothing and disposable gloves clean up the spill using absorbent paper and place it in a plastic bag for transfer to a labelled waste container. Avoid spreading contamination. Work from the outside of the spill towards the centre. Wipe test or survey for residual contamination as appropriate. Repeat decontamination, if necessary, until contamination monitoring results meet the Nuclear Substances and Radiation Devices licence criteria. Check hands, clothing, and shoes for contamination. Report the spill and cleanup to the person in charge and, if necessary, to the Radiation Safety Officer. Record spill details and contamination monitoring results. Adjust inventory and waste records appropriately. Major Spills (Major spills involve more than 100 exemption quantities, or contamination of personnel, or release of volatile material) Clear the area. Persons not involved in the spill should leave the immediate area. Limit the movement of all personnel who may be contaminated until they are monitored. If the spill occurs in a laboratory, leave the fume hood running to minimize the release of volatile nuclear Substances to adjacent rooms and hallways. Close off and secure the spill area to prevent entry. Post warning sign(s). Notify the Radiation Safety Officer or person in charge immediately. The Radiation Safety Officer or person in charge will direct personnel decontamination and will decide about decay or cleanup operations. In general, decontaminate personnel by removing contaminated clothing and flushing contaminated skin with lukewarm water and mild soap. Follow the procedures for minor spills (if appropriate). Record the names of all persons involved in the spill. Note the details of any personal contamination. The Radiation Safety Officer or person in charge will arrange for any necessary bioassay measurements. If required, submit a written report to the Radiation Safety Officer or person in charge. The Radiation Safety Officer or person in charge must submit a report to the CNSC. Major spill procedures should be implemented whenever minor spill procedures would be inadequate. If an exposure may have occurred that is in excess of applicable radiation dose limits, the CNSC shall be contacted within 24 hours of the occurrence under Section 16 of the Radiation Protection Regulations For more information, contact: Directorate of Nuclear Substance Regulation, Canadian Nuclear Safety Commission, P.O. Box 1046, Station B, Ottawa, ON K1P 5S9. Telephone: Fax: (613) Page 8
9 SITE COMMAND POST Tentative Designated Location: Boardroom Chemical Inventory Product WHIMS Classification Location Total Volume Volume of Single Largest Container Page 9
10 Incident Commander / Executive on-call / Designate Sets the incident objectives, strategies, and priorities and has overall responsibility at the incident. Decides which command positions will be manned and by whom. Personnel assigned by the Site Commander have the authority of their assigned positions, regardless of the rank they hold within their respective agencies. Makes decisions about level of evacuation and establish Emergency Operation Centre. Makes decision regarding evacuation Appoints command chiefs, officers and deputies as required per flowchart. Liaises with the senior officers of the : Covenant Health Senior leadership Covenant Health Emergency Disaster Management Office /9099 (office) or / after hours (as per E/DM on-call roster) Alberta Health Services Emergency Contact Camrose Fire Department Appoint assistant to record or log all actions taken. When incident is complete, direct the Planning Section Chief to implement demobilization as appropriate. Public Information Officer Advises Site Commander on issues related to information dissemination and media relations. Is the primary contact for anyone seeking information about the incident and the response. Works closely with the designated section chiefs. Safety Officer / HazMat Branch Director Works closely with the Operations Section Chief. Is responsible for ensuring that job safety standards are upheld during the incident. Ensures responders have access to protective apparel and equipment. Conducts risk analyses and implement safety measures to eliminate hazards Page 10
11 Is responsible for detection and monitoring of spills, responses, victim/facility/ equipment decontamination Maintains a log of actions taken. Liaison Officer Serves as the primary contact for supporting agencies assisting with and incident but are not participating within the incident command system structure. Medical / Technical Specialist Emergency Dept Physician on shift Coordinates physician services and resources. Works closely with Operations Section Chief and Medical Care Branch Director. Operations Section Chief Develops and manages the Operations section to accomplish the incident objectives set by the Incident Commander. Oversees tactical fieldwork and assigns incident resources. Divisions of the Operations Section include; Staging Manager Medical Care Branch Director HazMat Branch Director Security Branch Director Business Continuity Branch Director. Infrastructure Branch Director if sufficient staff available otherwise Operations Section Chief role Reports to the Operations Chief. Is responsible for provision of essential equipment and utilities (water, sewer, medical gases, biomedical equipment, etc). Maintains a log of actions taken. Page 11
12 Security Branch Director if sufficient staff available otherwise Operations Section Chief role Reports to the Operations Chief. Is responsible for access control, crowd control, traffic control, search unit and law enforcement interface unit. Maintains a log of actions taken. Business Continuity Branch Director if sufficient staff available otherwise Operations Section Chief role Reports to the Operations Chief. Is responsible for patient care record preservation and information systems accessibility (IT). Maintains a log of actions taken. Planning Section Chief The Incident Commander determines whether there is a need for a Planning Chief. Key roles of the Planning Chief may include: collecting, evaluating, and displaying incident intelligence and information preparing and documenting Incident Action Plans conducting long-range and/or contingency planning developing plans for demobilization maintaining incident documentation tracking resources assigned to the incident. assisting to ensure that resources are released from the incident in an orderly, safe, and cost-efficient manner. Divisions of the Planning Section include; Resources Unit Leader Situation Unit Leader Documentation Unit Leader Page 12
13 Logistics Section Chief The Logistics Section Chief is responsible for all of the services and support needs, including: ordering, obtaining, maintaining, and accounting for essential personnel, equipment, and supplies providing communication planning and resources setting up food services setting up and maintaining incident facilities providing support transportation providing medical services to incident personnel. Divisions of the Logistics function include; Service Branch Director, and Support Branch Director Page 13
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