Chapter 41
VENTILATION, HOODS, AND HEPA FILTERS

Contents

Approved by Laurel Davis
Revised 11/13

 

NOTE:
new section flagnew section flag . . . . . Denotes a new section.
start section flag . . . . . . . . Denotes the beginning of changed text within a section.
end section flag . . . . . . . . Denotes the end of changed text within a section.

___________________

41.1 Policy

The Berkeley Lab Ventilation Program protects workers and the environment by reducing airborne concentrations of contaminants through the following work-process requirements:

  1. The Environment/Health/Safety (EHS) Division must be consulted to determine applicable design, construction, and performance standards for new ventilation systems used for contamination control, and must be notified of the purchase of hoods, glove boxes, filtering equipment, emissions-collection equipment, and other relevant ventilation items. (See Work Process B).
  2. New and relocated ventilation systems may not be used for contamination control until installation and performance have been evaluated and labeled by EHS and verified to meet application standards (See Work Process B).
  3. Line management must ensure that ventilation systems that do not meet performance standards (i.e., are deficient) are repaired, and are used within safety limits (if allowed) until repaired (See Work Process C).
  4. Performance of ventilation systems, including HEPA-filtered units, must be periodically evaluated (See Work Process C).

41.2 Scope

The Ventilation Program includes:

41.3 Applicability

Berkeley Lab employees, casual and participating visitors, affiliates, and subcontractors who work with hazardous substances

41.4 Exceptions

None

41.5 Roles and Responsibilities

Role

Responsibilities

Facilities Division

  • Ensures that newly installed or refurbished ventilation systems are designed, installed, commissioned, and function-tested in accordance with applicable codes and guidance provided by the EHS Division
  • Maintains a proactive preventive-maintenance program to ensure that ventilation systems are in proper operating condition in accordance with applicable codes and guidance that it has provided

Industrial Hygiene Group

  • Ensures that performance standards are identified for ventilation systems and that periodic surveillance is performed
  • Ensures the development, approval, revision, and administration of this policy and its implementing documents

Line Managers

  • Ensure that persons within their areas of responsibility comply with this policy and its implementing documents

Supervisors and Work Leads

  • Ensure that persons within their areas of responsibility comply with this policy and its implementing documents, and have completed any required training prior to beginning work

Ventilation System Users

  • Follow all guidance provided in training, as well as this policy and its implementing documents

41.6 Definitions

HEPA filters

High-efficiency particulate air (HEPA) filters, used to filter hazardous chemical, biological, or radioactive particles. A HEPA filter has a minimum efficiency of 99.97% when challenged with an aerosol containing 0.3 micron particles.

Fume hood

A box-like structure with a sash or sashes that move vertically and/or horizontally across the front opening. Fume hoods are designed to contain and exhaust airborne contaminants generated inside its enclosure.

41.7 Required Work Processes

Work Process A. Ventilation Program Flowchart
Work Process B. New or Modified Ventilation Systems
Work Process C. Surveillance

Work Process A. Ventilation Program Flowchart

Work Process B. New or Modified Ventilation Systems

  1. The Environment/Health/Safety (EHS) Division must be consulted to determine applicable design, construction, and performance standards for new ventilation systems used for contamination control. EHS must be notified of the purchase of hoods, glove boxes, filtering equipment, emissions-collection equipment, and other relevant ventilation items. EHS may review the use of such ventilation systems with the requestor.
  2. New systems for contaminant control — including local exhaust ventilation systems, hoods, and in-place filters — must meet the requirements of applicable codes including California Building Code, the California Mechanical Code, and the California Fire Code. In addition, applicable industry standards must be consulted for guidance. These standards include those promulgated by the American Conference of Governmental Industrial Hygienists; the American Society of Heating, Refrigerating and Air-Conditioning Engineers; the American Industrial Hygiene Association; and the American National Standards Institute. EHS must be consulted to determine the applicable design, construction, and performance standards applicable to a project.
  3. Responsibility for assuring code compliance and conformance with applicable standards and requirements rests as follows:
    1. For projects executed by the Facilities Division, the Project Manager is responsible.
    2. For projects not executed by Facilities, the activity line manager responsible for the activity is responsible.
  4. New or relocated fume hoods and gas cabinets must be provided with electronic flow meters to indicate the velocity of air flowing into the hood, and to sound an alarm when the velocity falls outside permissible range. Other new or relocated exhaust systems used for contaminant control must have a visible means of indicating that the system is operating properly, such as a pressure gauge or manometer. These indicators are in addition to any monitoring devices installed as part of building operations.
  5. New fume hood systems, including those involving fume hoods relocated from another location, must be tested in accordance with applicable tests contained in ASHRAE 110-1995 as a condition of acceptance. The tracer gas containment test must conform to the 4.0 AI 0.1 criteria contained therein. This testing is performed by a third party, is paid for by the project, and must be validated (generally by witnessing) by EHS.
  6. New systems may not be used for contaminant control until their installation and performance have been evaluated and verified to meet applicable standards established by EHS, and they have been labeled as such.

Work Process C. Surveillance

  1. Surveys
    1. EHS must conduct periodic surveys of the performance of contaminant-control systems on the following schedule:
      1. Laboratory fume hoods have electronic flow monitors that continuously indicate the velocity of air flowing into the hood. The calibrations of these monitors are checked on a nominal one-year (for radiation-use hoods identified by the EHS Radiation Protection Group) or nominal two-year (all other laboratory fume hoods) rotation.
      2. Biological safety cabinets used for personnel protection are certified by an external vendor on a nominal one-year rotation. EHS verifies that the certifications have been performed by checking that the certification sticker is current.
      3. Vacuum cleaners equipped with HEPA filters and used for personnel protection are tested on a nominal one-year rotation.
      4. Other contaminant-control ventilation systems, including those with in-place filters, are surveyed for proper operation on a nominal two-year rotation.
      5. Nonspecific systems such as general laboratory or shop exhaust, equipment (e.g., vacuum pump) exhaust, mechanical room exhaust, and the like are monitored by the Facilities Division — Facilities Management and Control System (FMCS) — and are not surveyed by EHS.
    2. Surveys are scheduled so that all hoods in a given building are due on the first day of a particular month, and are past due three months after that date.
    3. The results of all calibration, certification, and other checks are recorded in a database on Berkeley Lab’s network, which is considered the point of record. Additionally, most systems have stickers that indicate when the last check was performed.
    4. Some HEPA filter-equipped systems are used for product protection only (e.g., as “clean benches” for maintaining sterility of non-infectious organisms;  for clean assembly of optical or vacuum systems; as supply HEPA filters in semiconductor or nanomaterials fabrication rooms). EHS can assist in setting up testing of these systems, but the responsibility and expense for the testing belong to the research program.
  2. Hoods and Local Exhaust Points
    1. EHS establishes minimum standards of performance for each hood or system based on code requirements, nationally recognized standards, and good professional judgment. The performance standard for each hood is listed in the computerized record for that hood. If a hood fails to meet the minimum performance standard, it is considered deficient.
    2. Line management must ensure that ventilation systems that do not meet performance standards (i.e., are deficient) are repaired. Until repairs are completed, line management must also ensure that deficient systems are not used (if tagged “out of service”) or are used within safety limits (if allowed and tagged as such).
  3. Recordkeeping Requirements
    1. The results of all calibration, certification, and other checks are recorded in the Berkeley Lab Ventilation Database and maintained by the EHS Division.
    2. Ventilation systems are marked with stickers that indicate when the last surveillance check was performed.
  4. Additional Information
    1. For questions about the database or to have the performance of local exhaust systems evaluated, call the EHS Ventilation Program Coordinator at ext. 2324.
    2. For information regarding the testing of HEPA vacuums and HEPA filtering systems, contact the EHS HEPA Filter Program Coordinator at ext. 7609.

41.8 Source Requirements

In addition to this document, the following regulations contain applicable information:

41.9 Reference Documents

Document Number

Other Reference

Title

Type

N/A

PUB-5341

Chemical Hygiene and Safety Plan, Hazard Controls section

Procedure

N/A

PUB-3435E

Biosafety Manual, Section 5.6.4, Ventilation and Hoods

Procedure

N/A

PUB-3140

Integrated Environment, Safety & Health Management Plan

Procedure

N/A

PUB-3000 Chapter 4, Section 4.15

Procurement

Procedure

12.01.002.000

 

Procurement of Goods and Services

Policy

 

 

In-Place HEPA Filter Leak Testing Procedure

Procedure

 

 

Restricted Items List

Form

_____________________

<< Chapter 40 || Table of Contents || Chapter 42 >>