Health and Safety Program Manual

Health and Safety Program Manual Prepared by the Environmental Health and Safety Office November 2004 Version 1.1

Table of Contents I INTRODUCTION... 1 ENVIRONMENTAL HEALTH AND SAFETY OFFICE (EHSO)...1 Staff Overview...1 EHSO VISION & MISSION...2 EHSO PROGRAM OVERVIEW...2 STRATEGIC GOALS OF THE EHSO...2 EHSO WEB PAGE...3 EHSO LIBRARY...3 II HEALTH AND SAFETY POLICY AND RESPONSIBILITIES... 4 THE INTERNAL RESPONSIBILITY SYSTEM...4 DUE DILIGENCE...4 UNIVERSITY SAFETY AND HEALTH POLICY STATEMENT...5 University of Manitoba...6 Health & Safety Policy #512...6 PROCEDURES...8 Additional Information...8 III HAZARD IDENTIFICATION AND CONTROL... 9 MANAGEMENT OF CONTROLLED PRODUCTS...9 WHMIS...10 U of M Controlled Products Standard (CPS)...10 Centralized Controlled Products Database...10 Laboratory Audits and Signage...10 Management of Asbestos...10 Management of Hazardous Waste...11 Management of Radioactive Materials...11 OCCUPATIONAL HEALTH PROGRAM...12 Hearing Conservation Program...12 Respiratory Protection Program...12 Medical Surveillance-Asbestos...12 Ergonomic Evaluations...12 Immunization and Post-Exposure Program...12 Workers Compensation Program...12 Health and Wellness...13 SAFETY & HEALTH AUDITS...13 FIRE AND LIFE SAFETY PROGRAM...13 CRITICAL JOB INVENTORY...13

Additional Information...14 IV EMERGENCY RESPONSE... 15 CAMPUS EMERGENCY RESPONSE PLAN...15 HAZARDOUS MATERIAL SPILL CONTROL...16 FIRE WARDEN PROGRAM...16 FIRE AND FALSE ALARM INVESTIGATIONS...16 EMERGENCY FIRST AID...17 CARDIOPULMONARY RESUSCITATION (CPR LEVEL A)...17 Additional Information...17 V INSPECTIONS... 18 LOCAL AREA HEALTH AND SAFETY COMMITTEE (LAHSC) INSPECTIONS...18 CODE COMPLIANCE BUILDING INSPECTIONS...18 INSPECTION FOR FIRE SAFETY EQUIPMENT...19 ANIMAL CARE FACILITY INSPECTIONS...19 Additional Information...19 VI CHEMICAL, BIOLOGICAL AND RADIATION SAFETY PROGRAMS... 20 CHEMICAL SAFETY PROGRAM...20 WHMIS Coordinators...20 MSDS and WHMIS Handbook...20 Fume Hood Surveys...21 Biological Safety Cabinet Certification...21 BIOLOGICAL SAFETY PROGRAM...21 Biological Safety Advisory Committee...21 University of Manitoba Biosafety Guide...21 Biosafety Permits...22 RADIATION SAFETY PROGRAM...22 Types of Ionizing Radiation...23 Regulatory Requirements and References...23 Radiation Program Activities...23 Role of the Environmental Health and Safety Office...24 Responsibilities of the Users...24 Training Programs...24 VII ACCIDENT AND INCIDENT INVESTIGATION... 26 RESPONSIBILITIES AND DUTIES REGARDING ACCIDENT REPORTING AND INVESTIGATION..27 The Supervisor...27 The Employees...27 Members of Health and Safety Committees...27

PROCEDURE AND DOCUMENTATION REQUIREMENTS...27 Supervisor s Responsibilities:...27 Employee s General Responsibilities...28 Additional Information...28 VIII CONTRACTORS... 29 Contractor Pre-Qualification...29 Contractor s Safety and Orientation Manual...30 Contractor Orientation...30 Construction Projects on Campus...30 Additional Information...31 IX TRAINING... 32 GENERAL TRAINING...32 Asbestos Awareness...32 Basic Lab Safety...32 Cardiopulmonary Resuscitation (CPR)...32 Computer Ergonomics...32 Confined Space Entry Training...32 Fire Safety In-Service for Chief Fire Wardens and Fire Wardens...33 Hands-on Fire Extinguisher Training...33 Health and Safety Orientation...33 Indoor Air Quality...33 Radiation Safety Orientation Training (Self Study or Group Session)...33 Radiation Safety Workshop for Nuclear Gauges/Moisture Density Gauges...33 Radiation Safety Workshop for Radioactive Chemicals (1½ Day Workshop)...34 Radiation Safety Training Refresher...34 Supervisory Due Diligence...34 TDG Certification Training...34 WHMIS Train-the-Trainer...34 Workers Compensation at The University of Manitoba...35 CUSTOM AND SPECIALIZED TRAINING...35 GENERAL EDUCATION AND PROMOTION ACTIVITIES...35 Additional Information...35 X HEALTH AND SAFETY COMMITTEES... 36 WORKPLACE HEALTH AND SAFETY ADVISORY COMMITTEE (WHSAC)...36 LOCAL AREA HEALTH AND SAFETY COMMITTEES (LAHSC)...36 THE BIOLOGICAL SAFETY AND RADIATION SAFETY ADVISORY COMMITTEES...37 Additional Information...37 XI PROGRAM EVALUATION... 38 HAZARD IDENTIFICATION, RISK ASSESSMENT AND CONTROL PRINCIPLES... 1 DEFINITIONS...1 What is a hazard?...1 What is an occupational illness?...1

What is probability?...1 What is severity?...1 What is a risk?...2 What is risk analysis?...2 PRINCIPLES OF HAZARD IDENTIFICATION, ASSESSMENT AND CONTROL...2 Collect Information...2 Assess the Risk...2 Set Priorities...3 Communicate Information...3 Develop, Select And Implement Controls...3 IDENTIFYING AND ASSESSING SAFETY HAZARDS...4 IDENTIFYING AND ASSESSING HEALTH HAZARDS...4 How can health hazards be identified?...4 Prepare a list of known health hazards in the workplace...4 Review floor plans and work process diagrams...5 Interview workers, supervisors and managers...5 Be observant of conditions in the workplace...5 How can health hazards be assessed?...6 CONTROLLING HAZARDS...8 Technical steps in hazard control...8 1. Control At The Source...8 2. Control Along The Path From The Hazard To The Worker...9 3. Control at the level of the worker...9 JOB HAZARD ANALYSIS... 12 WHAT IS JOB HAZARD ANALYSIS?...12 WHAT ARE THE BENEFITS OF DOING A JOB HAZARD ANALYSIS?...12 WHAT ARE THE FOUR BASIC STEPS OF DOING A JHA?...13 WHAT IS IMPORTANT TO KNOW WHEN SELECTING THE JOB?...13 HOW DO I BREAK THE JOB INTO BASIC STEPS?...13 HOW DO I IDENTIFY THE POTENTIAL HAZARDS?...14 HOW DO I DETERMINE PREVENTIVE MEASURES?...15 1. Eliminate the hazard...15 2. Contain the hazard...15 3. Revise work procedures...15 4. Reduce the exposure...15 HOW SHOULD I MAKE THE INFORMATION AVAILABLE TO EVERYONE ELSE?...16 SAMPLE FORM FOR JOB HAZARD ANALYSIS WORKSHEET...17 PLANNING AND CONDUCTING INSPECTIONS... 18 GENERAL...18 INVENTORIES AND CHECKLISTS...18

WHAT TO INSPECT...19 1. People, including:...19 2. Vehicles, tools and equipment, including:...19 3. Chemicals and biological substances, including:...19 4. Work environment, including:...19 work area design...19 PRE-INSPECTION MEETINGS...19 WHAT TO DO DURING INSPECTIONS...20 HANDLING THE RESULTS...20 WHEN AN UNSAFE CONDITION IS FOUND...20 CONDUCTING ACCIDENT/INCIDENT INVESTIGATIONS... 22 DEFINITIONS AND REPORTING...22 CARRYING OUT THE INVESTIGATION...22 Secure the scene and report the incident...23 Notifications...23 Study the scene...23 Interview witnesses...23 Investigate the physical evidence...24 FINDING THE CAUSES...24 Task...24 Material...25 Environment...25 Worker(s)...25 Management...25 FIND THE INCIDENT CAUSES...26 The Direct Cause(s) (what caused the incident)...26 The Indirect Cause(s)...26 RECOMMENDATIONS...26 WHAT SHOULD BE DONE IF THE INVESTIGATION REVEALS HUMAN ERROR?...27 REPORT AND RECOMMENDATIONS...27

I Introduction This Manual has been developed to provide information and guidance on the University of Manitoba s Health and Safety Program. This Manual is also intended to meet the documentation requirements for the establishment of a written workplace safety and health program as required by Section 7.4 of the Workplace Safety and Health Act. ENVIRONMENTAL HEALTH AND SAFETY OFFICE (EHSO) The Environmental Health and Safety Office (EHSO) is a multi-disciplinary organization with each staff member having skills and experience in different and often overlapping areas. This allows the office to have a coordinated and multi-faceted approach and response to the many environmental health and safety issues that arise at the University of Manitoba. Each EHSO staff member is responsible for and has specific expertise in one or more of the key program areas. Some programs require a joint or team approach and the EHSO manages their activities accordingly. Staff Overview Grant McCaughey Danny Buksak Joey Bellino Richard Chaput Pauline Fortier Evelyn Froese Prabhat Goswami Paul Houle Pearl Novotny Terry Neufeld Leona Page Paul Richards Eva Sailerova Director Senior Program Coordinator Assistant Hazardous Waste Management Coordinator Asbestos Program Technologist Occupational Health Coordinator Assistant Biological & Chemical Safety Coordinator Biological & Chemical Safety Coordinator Hazardous Waste Management Coordinator Administrative Assistant Office Assistant Radiation Safety Coordinator Fire Marshall & Construction Safety Coordinator Assistant Radiation Safety Coordinator The EHSO has two Office locations and a Hazardous Waste Management Facility (Environmental Safety Building) at Fort Garry and Waste Management Facilities at Bannatyne. Fort Garry Campus - 191 Frank Kennedy Centre Eight staff are located at the Fort Garry Campus and expanded office space has been acquired to accommodate the increase in staff over the past two years. Bannatyne Campus T248/249 Basic Sciences Building Three EHSO staff members are located full time at the Bannatyne Campus to support the Faculties of Medicine, Dentistry, and the Manitoba Institute of Cell Biology (CancerCare). 1

EHSO VISION & MISSION VISION The learning, research and workplace environment at the University of Manitoba shall be such that there will be no losses through occupational injury, illness or property damage and no harm shall be done to the physical environment. MISSION The Environmental Health and Safety Office supports the continuous improvement of a safety culture at the University by providing advice, guidance, training, and technical support to the campus community. The safety culture encompasses a healthy and safe environment achieved through everyone's understanding of their related responsibilities and compliance with all regulatory requirements and University safety policies. EHSO PROGRAM OVERVIEW The Environmental Health and Safety Office (EHSO) provides a number of essential programs which contribute to creating a safe and healthy working and learning environment at the University of Manitoba. These include the following; General Safety Biological Safety Chemical Safety Fire & Life Safety Radiation Safety Hazardous Waste Management Occupational Health Office Safety & Ergonomics Workers Compensation Accident Investigation Indoor Air Quality Asbestos and Mould Management Confined Space Entry Transportation of Dangerous Goods Personal Safety Hearing Conservation Program Emergency Planning and Response Safety and Health Committees Traffic Safety Construction and Contractor Safety RED and Laser Safety STRATEGIC GOALS OF THE EHSO There are a number of strategic goals which are central to the mission and activities of the EHSO and link to the overall strategic goals of the University, as follows: Creating a Safe and Healthy Environment - Facilitating the provision of a safe and healthy environment for all staff, students and visitors to the University of Manitoba. Compliance with Legislation Ensuring compliance with provincial and federal legislative requirements and research agency directives. This includes providing evidence to external funding agencies that the University is in compliance with safety, health and environmental legislation. Education and Training Providing orientation, training and awareness courses to University staff and students regarding hazards and risks to personal safety and the environment. This is one of the key components towards ensuring a safe and healthy environment and legislative compliance. 2

Risk Management Establishing a risk management process which identifies and controls the hazards posed to the safety and health of staff, students and visitors from activities in the University environment. Emergency Management In cooperation with Security Services, establish and maintain a system for the management and control of emergency incidents at the University. EHSO WEB PAGE The Environmental Health and Safety Office has established an information website which is regularly updated and is a source of information on EHSO Programs. The website address is http://www.umanitoba.ca/campus/health_and_safety/index.shtml. EHSO LIBRARY The EHS Office maintains a small but significant library that contains legislative and safety information that is not normally available anywhere else on campus. This library forms a valuable resource on a wide variety of safety and health issues and is available for perusal by people within the University community. A large number of training and awareness videos on a variety of disciplines are also available. 3

II Health and Safety Policy and Responsibilities THE INTERNAL RESPONSIBILITY SYSTEM The Workplace Safety and Health Act supports every worker s right to a safe and healthy workplace. The duty for creating and maintaining a safe and healthy workplace falls on every person in the workplace, to the degree they have the authority and ability to do so. Whether they are the President of the University or the newest staff or Faculty member, everyone has a personal and shared responsibility for working together co-operatively to prevent injuries and occupational illnesses. Because employers have the greatest degree of control over the workplace, they also have the greatest degree of legal responsibility for safety and health. But this does not relieve supervisors and workers from their duty to co-operate in controlling workplace hazards and to take the necessary precautions to protect themselves and others from hazards. The Workplace Safety And Health Act also recognizes that only workers who are adequately informed and empowered can effectively fulfill their responsibilities. The Workplace Safety And Health Act grants four important rights to workers: Right to Know about workplace hazards, including how to identify hazards and protect themselves from those hazards, and about the rights afforded to workers under the Act. Right to Participate in decisions related to workplace safety and health, free of reprisal for their participation. Participation, in part, is achieved through consultation with the committee or representative. Right to Refuse dangerous work. Right to Protection from Discrimination protects these rights by prohibiting employers from imposing discipline or other sanction on workers for fulfilling their responsibilities or exercising their rights. The goal of an internal responsibility system is to get people working together to identify and control situations (hazards) that could cause harm. Its ultimate objective is to ensure everyone integrates safety and health into their work. DUE DILIGENCE Due Diligence means everyone with responsibility for safety and health must take every precaution reasonable in the circumstances to avoid a work related injury or illness. This concept of reasonable care holds individuals accountable for their acts (what they do) and omissions (what they fail to do). It goes beyond simple regulatory compliance. The term reasonably practicable used in Safety and Health Legislation What is reasonably practicable is determined by asking what a reasonable person, in the same position and circumstance, would have done to prevent the incident. When making that determination, three main factors need to be taken into account; foreseeability, preventability and control. 4

A major expansion of corporate liability was taken by the Federal Government when Bill C- 45, amending the Criminal Code of Canada, came into force March 31, 2004. The amendments hold directors, officers and organizations criminally liable for workplace safety and health. Bill C-45 included the following provisions: imposition of legal duties on employers and those who direct work to take reasonable measures to protect employee and public safety; if this duty is carelessly disregarded and bodily harm or death results, an organization could be charged with criminal negligence; organizations may be found guilty of negligence if a representative is a party to the offence, or a senior officer (or officers) who is (are) responsible for the aspect of the organization s activities that is relevant to the offence departs markedly from the standard of care to prevent a representative of the organization from being a party to the offence. every one who undertakes, or has the authority, to direct how another person does work or performs a task is under a legal duty to take reasonable steps to prevent bodily harm to that person, or any other person, arising from that work or task. The fine for a summary conviction has been increased from $25,000 to $100,000. There is no ceiling for fines on indictable or more serious offences. UNIVERSITY SAFETY AND HEALTH POLICY STATEMENT A Safety and Health Policy statement recognizing duties and responsibilities of all the workplace participants was prepared by the Environmental Health and Safety Office (EHSO), reviewed by the Workplace Health and Safety Advisory Committee (WHSAC), and was adopted by the Board of Governors, effective January 1, 2003 meeting. This policy clearly establishes the roles and responsibilities of all parties and sets the framework for continued development of the program at the University. The Policy is available on the University Governance Website at http://www.umanitoba.ca/governance/policies/section_500/512.shtml. The Safety and Health Program Policy Statement includes statements of responsibility and duties for Deans, Directors, Department Heads, supervisors, staff and students. These responsibilities are included in training and awareness sessions that are provided by EHSO to the University community and constantly emphasized when inspections, audits and investigations are conducted. 5

University of Manitoba Health & Safety Policy #512 Effective Date: January 1, 2003 Review Date: February 1, 2006 1.0 Reason for Policy The reason for the Policy is to identify the University s commitment to, and responsibility for, the safety and health of academic and support staff, students and visitors to the campus. 2.0 Policy Statement The safety and health of all academic and support staff, students and visitors to the University campus is a priority for the University. The University shall, so far as is reasonably practicable, provide a safe and healthy environment in which to carry on the University's affairs. All reasonable measures shall be taken to prevent and eliminate accidental injuries and illnesses. The Environmental Health and Safety Office and the University Workplace Health and Safety Advisory Committee shall work to achieve the objective set out in this Policy. The University seeks to ensure that health, safety and accident prevention form an integral part of the design, construction, purchase and maintenance of all buildings, equipment and work processes under control of the University. Local Area Safety Committees shall monitor the safety and health programs within their areas and make recommendations to improve their effectiveness. The University will meet the minimum legal standards and, where reasonably practicable, will strive to exceed the minimum legal standards set out in The Workplace Safety and Health Act (Manitoba) and other such applicable safety and health legislation, as amended from time to time. 2.1 Application The successful application of this Policy will be achieved by everyone exercising their responsibilities for safety and health as follows: 2.1.1 The University It is the responsibility of the University acting through Deans, Directors and Department Heads to: provide a safe and healthy working environment. provide such information, supervision and instruction to students and employees as may be reasonably required to allow them to conduct their activities in a safe and healthy manner. ensure regular inspections are made and take action as required to improve unsafe conditions. support supervisors and safety committees in the implementation of an effective accident prevention program; and establish and support a Department or Local Area Safety Committee. take all reasonably practicable measures to ensure compliance with applicable regulations passed under the Workplace Safety and Health Act (Manitoba) and other applicable safety and health regulations as amended from time to time. 2.1.2 The Supervisor (Note: A supervisor means a person who has charge of a workplace or authority over a worker) It is the responsibility of supervisory staff to: formulate specific rules and safe and healthy work procedures for activities falling under their areas of supervision. ensure that all employees under their supervision are made aware of safe and healthy practices 6

and that employees follow the procedures. provide training in the safe use and operation of tools, machinery and equipment. regularly inspect their areas for hazardous conditions. promptly correct unsafe work practices or hazardous conditions. ensure that any accidents that occur in their area of responsibility are properly investigated in conjunction with the Environmental Health and Safety Office and to implement procedures that will minimize the re-occurrence of a similar accident. immediately report any accidents using the appropriate form as provided for by The Workplace Safety and Health Act (Manitoba) as amended from time to time; and 2.1.3 The Employee It is the responsibility of all employees to: use reasonable care so as to protect their own safety and health and the safety and health of others affected by their actions. conduct all activities in accordance with safety and health rules and procedures established by the supervisor, Department Head and the University. take an active part in practicing safe and healthy work habits. immediately report any accident, injury or unsafe conditions to the appropriate supervisor. properly use and adequately care for personal protective equipment that is required for their activities. consult and cooperate with the Department or Local Area Safety Committee. 2.1.4 Students It is the responsibility of all students to: use reasonable care so as to protect their own safety and health and the safety and health of others affected by their actions. conduct all University activities in accordance with the University's safety and health policies and procedures. seek guidance from their instructors or supervisors concerning safety-related knowledge and skills required to ensure the safe and healthy performance in their University-related activities; properly use and adequately care for any personal protective equipment that is required for their University activities. immediately report any accident, injury or unsafe conditions to the appropriate supervisor. 3.0 Accountability 3.1 The University Secretary or the President is responsible for notifying the contact person for this policy that a formal review of this Policy and Secondary Documents is required. 3.2 The Executive Director of Human Resources is responsible for the communication, administration and interpretation of this Policy. The Environmental Health and Safety Office is responsible for providing advice, guidance, technical support and ensuring that department and administrative units are made aware of their responsibilities to comply with the Policy and all Secondary Documents. 3.3 All employees, supervisors, and students will be accountable for complying with the Policy and all Secondary Documents. 4.0 Secondary Documents 4.1 The Vice-President (Administration) or the President may approve Procedures which are secondary to and comply with this Policy. 5.0 Review 5.1 Formal Policy reviews will be conducted every three (3) years. The next scheduled review date for this Policy is February 1, 2006. 7

5.2 In the interim, this Policy may be revised or rescinded if: (a) the Approving Body deems necessary; (or the President, where the approving body is the Administration); or (b) the relevant Bylaw, Regulations or Policy is revised or rescinded. 5.3 If this Policy is revised or rescinded, all Secondary Documents will be reviewed as soon as reasonably possible in order to ensure that they: (a) comply with the revised Policy; or (b) are in turn rescinded. 6.0 Effect on Previous Statements 6.1 This Policy supersedes the following: Policy 503 Safety Wearing Apparel and Personal Protective Equipment Policy 505 Disposal of Hypodermic Syringes Policy 506 Biological Hazards Control Policy 507 Procedure for Handling Workplace Health and Safety Concerns Policy 511 Controlled Products PROCEDURES Specific Procedures have been adopted under the Health and Safety Policy #512. Procedures adopted as of October, 2004 include; Use of Safety Footwear Procedure Fall Protection Procedure Radiation Safety Policy and Procedures Additional Information The latest Procedures are available on the University Governance web page at http://www.umanitoba.ca/governance/policies/section_500/index.shtml. 8

III Hazard Identification and Control A fundamental component of a successful Health and safety Program is the effective identification and control of hazards in the workplace. The University has taken action to identify and control workplace hazards at the University by; establishing centralized programs to deal with recognized hazards that apply across the University (i.e. radiation, chemical, biological, waste control and disposal, fire and building life safety, occupational health services, contractor safety, asbestos, etc.) providing program development, advice, training and consultation to Faculties, Departments and Administrative Units in order to deal with site specific hazards and programs unique to their areas of responsibility. The Workplace Health and Safety Advisory Committee (WHSAC), Local Area Health and Safety Committees (LAHSC) and Hazard Specific Committees (Radiation and Biological Safety) play an integral role in hazard evaluation and control and bring issues and concerns forward for the University to consider and take action upon. Resulting recommendations often result in Policies or Procedures. The following is a description of the primary centralized programs at the University. More details on some of these programs are included in the Appendix. (NOTE: Specific Details on the Chemical, Biological and Radiation Safety programs are included in the section of this manual entitled Chemical, Biological and Radiation Programs ) MANAGEMENT OF CONTROLLED PRODUCTS Controlled products include any materials or chemicals that are regulated by the Transportation of Dangerous Goods Act, Canadian Nuclear Safety Regulations, Explosive Act, Pest Control Products Act and Workplace Hazardous Materials Information System including: Radioactive Materials Explosive Materials Pesticides Compressed Gases Flammable or Combustible materials Oxidizing Materials Poisonous or Infectious Materials Corrosive Materials Dangerously Reactive Materials 9

WHMIS WHMIS has been implemented in each of these Departments/Units through WHMIS Departmental Coordinators appointed by the Department Heads/Directors at the request of the Vice President (Administration). The EHSO provides an advisory role, resource base and central coordination for WHMIS in the University. It also provides a Train the Trainer type WHMIS training to the WHMIS departmental Coordinators. Details on the WHMIS Program are found in the WHMIS Handbook on the EHSO web page at http://www.umanitoba.ca/campus/health_and_safety/ U of M Controlled Products Standard (CPS) The Controlled Product Standard is a University of Manitoba Policy document. Part A describes Design Standards for Facilities containing Controlled Products (as defined in the document) for new building construction and renovations. Part B, contains Standard Practices for the Use of Controlled Products EHSO works in close cooperation with Physical Plant on renovations, upgrades and new construction projects to ensure that the design meets the University Controlled Products Standard (CPS). A copy of the CPS is found on the EHSO web page at http://www.umanitoba.ca/campus/health_and_safety/cps97/index.html) Centralized Controlled Products Database The University is in the process of implementing a web-accessible Controlled Products Inventory Database for biological, chemical and radioactive materials, to allow for a centrally administered hazardous materials inventory. Laboratory Audits and Signage EHSO has completed a comprehensive environmental audit of an estimated 382 laboratories in 2003 and plans to continue monitoring the status of these labs. EHSO has established a new laboratory signage protocol and is in the process of finalizing the design and piloting the system at selected laboratories. This system will link to the new controlled products database inventory of controlled products. Management of Asbestos The University is responsible to protect staff and students from exposure to asbestos, which is a controlled product and a designated material (potentially cancer-causing) under WSH legislation. The University of Manitoba is continuing to take action to ensure that asbestos containing materials (ACM s) are managed in a safe and effective manner. Detailed information on the University program is available on the EHSO website at http://www.umanitoba.ca/campus/health_and_safety/asbestos/index.shtml The University of Manitoba s Asbestos Management Program (AMP) has been very effective in dealing with asbestos on campus. The AMP details safe work practices and quality control protocols to ensure due diligence. The success of the program relies on all parties involved (workers, supervisors and managers) following procedures and ensuring that maintenance, renovation and construction work is done in accordance with the established requirements. 10

Activities undertaken include; The AMP undergoes review and continuous improvement to ensure it is meeting the current needs and is revised as required. Orientation for all staff and students is available through regular EHSO seminars and hands-on training of Physical Plant and other University staff continues to be delivered. The campus community is advised of asbestos project activities and precautions to be taken through e-mails and direct notification by Project Coordinators. Incidents involving asbestos are investigated to identify failures and any necessary improvements that require implementation. In accordance with the recommendations of the August 9, 2002 report by Pinchin Environmental Asbestos Building Assessment Of The University of Manitoba, comprehensive building assessments are being undertaken. These surveys provide detailed information on the location and condition of all asbestos containing materials in buildings and are available to all staff or students for review if requested. Medical surveillance of staff working with asbestos has been conducted in April 2002 and 2004 in accordance with the AMP and provincial legislation. Management of Hazardous Waste All hazardous chemical, biological and radioactive waste at the University is collected and removed from each generation area by the EHSO and ultimately transported to the Fort Garry Waste Management Facility. At this facility, it is consolidated and packaged for removal by a commercial waste disposal company. This is an extremely efficient and cost effective activity for the University. A procedures manual outlining safe work procedures for labpacking, bulking, handling potentially unstable chemicals, using the Mobile Thermal Destruction Unit, disposal of potentially unstable chemicals by detonation and a working alone policy for the hazardous waste facility have been completed. EHSO has acquired a new Hazardous Materials Vehicle to deal with waste and to respond effectively to emergency situations involving controlled products. EHSO has also acquired a Mobile Thermal Destruction Unit (MTDU) to safely dispose of potentially unstable chemicals in a safe and cost effective manner. Management of Radioactive Materials The Canadian Nuclear Safety Commission (CNSC) has issued a consolidated license to the University of Manitoba to allow the University to possess, use and store radioactive materials for research purposes. The license requires a Radiation Safety Committee to oversee and advise on the Radiation Safety Program. The University formally adopted a new Radiation Safety Policy and Procedures, effective April, 2004. The Environmental Health and Safety Office provides staff and resources for the day to day operations of the Radiation Safety Program, including: the development of the Radiation Safety Manual, general radiation safety training, inspections, centralized inventory in cooperation with the Purchasing Department, disposal of radioactive wastes and liaison with the CNSC. EHSO is developing a program to deal with laser safety and is in the process of organizing a Laser Safety Committee to develop and review procedures. 11

OCCUPATIONAL HEALTH PROGRAM The University has developed a number of programs dealing with occupational health issues, including the following; Hearing Conservation Program A comprehensive program has been developed to prevent hearing loss to staff and meet requirements of Workplace health and safety. Education, training and annual hearing testing is conducted for all staff exposed to greater than 80dB of noise. Noise monitoring is conducted and areas requiring hearing protection are identified for posting with signage. Follow-up and medical referrals are made as per the WSH Regulations, including an annual report that is forwarded to the Chief Occupational Medical Officer at the WSH Division. Respiratory Protection Program Medical evaluations and fit testing is done for workers required to wear respirators for their work. Medical Respiratory Capabilities form has recently been incorporated to assist with compliance with fit testing requirements. Medical referrals are conducted as required. Job site assessments are conducted on request to ensure air quality meets safe standards and proper respirator protection is recommended based on the findings. Medical Surveillance-Asbestos A program for asbestos exposure follow-up has been implemented in accordance with the WSH Guidelines and the University Asbestos Management Program. The program is being offered to all employees meeting criteria established by the University occupational health physician consultant. Surveillance is conducted bi-annually. Ergonomic Evaluations Individual evaluations of work stations are done on request to assess risks associated with repetitive strain injuries. Written reports of recommendations are sent to managers and supervisors. Worker s Compensation claims are filed, if appropriate. Group training sessions are offered to all staff. Safety posters are offered to Libraries and Student Services. Special instructional courses are conducted as part of the curriculum for Faculty of Arts and Agriculture for students. Immunization and Post-Exposure Program A new immunization program protocol has been developed for laboratories and animal care facilities. A post exposure treatment protocol for exposure to human blood/body fluids for both Bannatyne and Fort Garry has been developed and posted. Coordination has been obtained for assistance from community based resources for treatment and follow up. Workers Compensation Program The management of claims requires prompt and accurate reporting of accidents and injuries. A database information system has been developed to assist with identification of trends and high risk areas. Regular statistical data is presented to the Workplace Health and Safety Committee for analysis and risk identification for the purpose of developing safer work practices. 12

Incident Investigation procedures and forms have been developed for all accidents/incidents/near miss events. Forms and reporting information are posted on the EHSO website at http://www.umanitoba.ca/campus/health_and_safety/occhealth/index.shtml Return to Work assistance is given on request to assist long term or acute illness/injuries develop successful job reentry plans. Health and Wellness InfoSafe Bulletins and Hazard Alerts information bulletins are posted on the EHSO website for the general public and our staff. http://www.umanitoba.ca/campus/health_and_safety/infobulletins/index.shtml A bi-yearly Newsletter identifying the various programs and initiatives offered by our office is published and distributed to all staff supervisors and managers for posting to improve general staff awareness of EHSO services. http://www.umanitoba.ca/campus/health_and_safety/newsletter/index.shtml SAFETY & HEALTH AUDITS A comprehensive, all campus, personal safety audit was conducted in 2001, that looked at such issues as lighting, blind spots, personal security, etc and many of the recommendations have been addressed through building improvements and upgrades since that time. EHSO will conduct comprehensive safety and health audits to assist Departments with identifying problem areas and recommend safety & health improvements. FIRE AND LIFE SAFETY PROGRAM The Fire and Life Safety program includes the following activities: Providing fire safety training to staff Conducting building inspections (in conjunction with the City of Winnipeg Fire Department), Identifying hazardous activity as it relates to fire and life safety and advise Departments and Physical Plant Oversee compliance to the Manitoba Fire Code, Manitoba Building Code and other regulatory requirements. Investigate fires and false alarms, Review renovation and new construction drawings to ensure the needs of the University are met and there is compliance with the University of Manitoba Control Products Standard and applicable codes and regulations. CRITICAL JOB INVENTORY In consultation with the Workplace Health and Safety Advisory Committee (WHSAC), work has begun on establishing a process for identifying hazardous work activities and maintaining a Critical Job Inventory. 13

At the April 14, 2004 meeting of the WHSAC, a master list of job classifications was reviewed and position descriptions will be studied to determine the type of activities that require JHA and SWP s. Individual Departments will be responsible to ensure that the assessments are undertaken, safe work procedures developed and the necessary training has been undertaken. This will be a long term project that will require significant resources and commitment to complete. The Physical Plant Department has been undertaking the development of JHA s and SWP s, concentrating on Grounds, Caretaking and General Services. Additional Information The Appendices include more details on the following topics; Appendix A Hazard Identification, Risk Assessment and Control Principles Appendix B Job Hazard Analysis More Information is available on the EHSO website on the following topics; Asbestos Management at the University of Manitoba University Controlled Products Standard University WHMIS Handbook Indoor Air Quality 14

IV Emergency Response CAMPUS EMERGENCY RESPONSE PLAN The Emergency Response Steering Committee completed the development of comprehensive Emergency Response Policy in the fall of 1999. This Policy and Operation Plan was formally adopted by the Board of Governors in December 1999. The complete Plan can be found on the Environmental Health and Safety Office page on the University of Manitoba Web Site at http://www.umanitoba.ca/campus/health_and_safety/erp/index.html. The Campus Emergency Response Plan has several objectives. A large focus of the plan is outlining the role administration will play in managing the emergency itself. As well, the Plan addresses campus wide issues to ensure the entire community is equipped to respond. The Plan objectives include the following: 1. Education & Awareness - About emergency events that can occur in a University setting and what managing them may entail, including their risks, ramifications and response requirements. At a community level this includes raising awareness about the procedures to be followed in specific situations such as a power outage or blizzard. 2. Emergency Preparedness -- To ensure that a systematic plan exists that can quickly mobilize University resources and effectively coordinate them. This involves the activities and programs by which emergency responders are supported and trained in quickly assuming specialized roles. It also involves evaluating the Plan and actions taken under it to obtain feedback on possible problems. 3. Emergency Management - Includes identifying the participants, their roles and duties and the way they might operate together. It also includes the responsibilities those individuals and groups can be expected to assume during a disruptive event. 4. Damage Mitigation - To ensure that any harm incurred is minimized, that event-related needs are properly addressed and that normal operations are quickly restored. This Plan is intended to guide the University s response to everything from a disruptive or disturbing incident through to a community-wide disaster. It is also intended to function as the umbrella plan for all University locations, as well as all departments. Four stages of emergency management are addressed in this plan. 1. Assessment & Notification -- Is the process by which the event is assessed for its response requirements and the necessary personnel and resources are summoned. 2. Resource Mobilization -- Is the activating of University personnel and resources, including departmental emergency plans, staff notification lists, etc. Situation reports are gathered to further define the event and determine the scale of response required. Briefings with emergency leaders then determine the response priorities and the deployment of resources begins, including establishing an Emergency Control Centre (ECC) or Site Command Post (SCP) if required. 3. Resource Coordination -- Is the deployment of resources to event needs. This involves the activation of roles, area teams and communication networks which can report on and 15

modify their activities as required. This occurs once the necessary emergency management roles and centres are ready for overseeing this function. 4. Recovery & Restoration -- Involves the restoration of normal operations following a disruptive incident, particularly where critical services are concerned. This also includes the long-term resumption of full operating capacity and evaluating the actions taken under the plan. The Plan identifies individuals and Departments responsible for specific activities. An initiative was taken in 2003 to offer workshops to all Departments to review the Plan and assist Departments in preparing their own specific response mechanisms. An Emergency Response Core Group, made up of EHSO, Security Services, Physical Plant, Public Affairs, IST and Student Affairs has been organized to deal with communication and first response issues. An Emergency Manager is identified at all times and the position is rotated between managers at EHSO, Security Services and Physical Plant HAZARDOUS MATERIAL SPILL CONTROL The EHSO Hazardous Waste Program has a large inventory of spill control equipment available to respond to emergencies. This inventory includes 55 gallon recovery drums, granular absorbents and pads, neutralizers and various tools. The hazardous materials response unit is kept stocked with enough spill response equipment to deal with most emergencies. The hazardous waste program is an in-house Level C response capable team. Training follows the NFPA 472 matrix. FIRE WARDEN PROGRAM The Fire Marshall from Environmental Health and Safety Office is responsible for ensuring the development of a functional fire safety plan. The Fire Marshall provides direction, training support, and assist in the coordination of Fire Wardens in each area to ensure the building fire safety plan functions effectively. The Dean, Director, Department Head or Unit Administrator is responsible for ensuring that a Chief Fire Warden and appropriate number of Fire Wardens and alternates are appointed and given the necessary authority to ensure the functional operation of the area fire safety plan and in the event of a fire emergency, delegate the authority to the Chief Fire Wardens and Fire Wardens to implement the fire safety plan. The authority will include issuing work orders relating to regular building maintenance. One Chief Fire Warden and a designated alternate are required per department and a minimum of two Fire Wardens and two alternates are required per floor. Physical Plant is responsible for the installation and maintenance of fire safety equipment and for ensuring compliance with all buildings and fire safety codes. FIRE AND FALSE ALARM INVESTIGATIONS The Campus Security at the Fort Garry campus monitors all the buildings for fire alarms as well as the Bannatyne campus, the Carman Facility and 3 buildings at Delta Marsh. The Powerhouse engineer responds to alarms at the Fort Garry and Bannatyne campuses and fills out a report on the cause of the fire alarm. This report is sent to EHSO for review or further investigation and for 16

serious events, a comprehensive investigation is conducted to determine the cause and identify necessary improvements. A detailed report of the fire/false alarms is available from the Environmental Health & Safety Office. EMERGENCY FIRST AID The University is in compliance with the Workplace Health & Safety Regulation by providing training in the one day Emergency First Aid Course to identified First Aiders across campus. It covers CPR plus first aid for shock, bleeding, stroke, and first aid for injuries unique to the university setting such as post-exposure to human blood/body fluids, exposures to chemicals and radiation, animal and reptile bites. Re-certification is required every 2 years. Departments are asked to solicit staff volunteers to be an area first aid provider. Each department is responsible to provide a current first aid kit and restock it on a regular basis. Departments whose locations are more than 30 minutes from a medical facility, such as Glenlea, Carman and Delta Marsh are provided with the Standard First Aid level training, which is a twoday course. The material taught is Emergency First Aid plus spinal injuries, transporting casualties, heat stroke, severe bleeding, anaphylactic shock, fractures and diabetic emergencies. CARDIOPULMONARY RESUSCITATION (CPR LEVEL A) This 4 hour course, taught by the Occupational Health Coordinator, is available free for staff, students and retirees and was offered throughout the year as a service to the University community. Additional Information More information is available on the EHSO website on the following topics; Fire Warden Program at University of Manitoba Hazardous Materials Emergency Response Procedures (http://www.umanitoba.ca/campus/health_and_safety/) 17

V Inspections The University has established an on-going safety and health inspection program with many elements and components. The following is a list of various inspection activities on-going at the University of Manitoba; Fire and life safety inspections related to Building and Fire Codes. Routine and special inspections of radioisotope permitted areas (including CNSC inspections). Routine and special inspections of laboratories using controlled products and biohazardous materials. Fume hood surveys (face velocity checks, containment checks via smoke tests). Biosafety Cabinet inspection and certification. Personal safety audits and inspections. Construction site safety inspections. Safety survey program to improve the storage, use and handling of chemicals and biohazardous materials and to evaluate compliance with legislation and guidelines. The Asbestos Management Program includes documented monitoring and inspection protocols for working with and for the removal of asbestos containing materials. Inspection of safety equipment, including eyewash stations and safety showers. Inspections in response to specific concerns and requests from staff and students on safety and health matters. LOCAL AREA HEALTH AND SAFETY COMMITTEE (LAHSC) INSPECTIONS The University is encouraging the Local Area Health and Safety Committees (LAHSC) to conduct routine safety inspections. For example, Physical Plant has initiated a building inspection program. An inspection team of members of the LAHSC completes a walkthrough inspection of the identified building areas and a report is produced, with concerns and recommendations identified. This report is forwarded to the appropriate managers for follow-up action. CODE COMPLIANCE BUILDING INSPECTIONS To meet the intent of the Manitoba Fire Code, all University Buildings must be inspected on a regular basis to ensure the life safety systems, exits, access to exits (corridors) are operational and there are no hazardous activities going on to which the building was not designed for. These inspections are shared between the Buildings Fire Wardens, Physical Plant Personnel and the Fire Marshall. An undertaking started this year is conducting Buildings Life Safety Audits. These audits not only identify fire safety deficiencies but non-compliance to the most recent Manitoba Building code and hazards inherent in the construction of the building (i.e. asbestos). Building inspections are classified at one of three levels. Level one inspection is a partial inspection of the building by the EHSO Fire Marshall. Level two inspection is a thorough inspection by the ESHO Fire Marshall. Level three inspection involves the City of Winnipeg Fire Prevention Officer. 18

INSPECTION FOR FIRE SAFETY EQUIPMENT The University of Manitoba Physical Plant has an on-going program for the annual testing of fire extinguishers, fire hose, fire pumps, emergency generators and fire alarm testing. ANIMAL CARE FACILITY INSPECTIONS The biosafety staff from EHSO participate in animal facility inspections annually with the Campus Protocol Management Review Committees (PMRC). EHSO staff also undertake site visits for special animal projects involving hazards at the request of the Facility manager or the PMRC. Additional Information The Appendices include more details on the following topics; Appendix C Planning and Conducting Inspections 19