The Office of the Vice Chancellor Safety Oversight Committee (OSOC) is charged with promoting a safe work environment for all staff working in research and teaching laboratories on campus. In an effort to ensure that issues identified during lab safety inspections are adequately addressed and corrected within a timely matter, the committee established a 3-tiered Laboratory Safety Compliance Procedure (LSCP).

In order to provide a highly responsive process, the OSOC has delegated administration of the first two tiers of the procedure to be overseen by the campus Chemical & Physical Safety Committee (CPSC). Both the OSOC and CPSC are faculty-led committees. While the 3-tiered procedure is designed to provide a progressive compliance process, it may be by-passed in the event of significant disregard for safety by a PI or the PI’s associated group that results in a condition that is immediately dangerous to life and health (IDLH).

Any egregious findings will be reported to the OSOC immediately for review at the discretion of EH&S. This may result in suspension of the PI’s laboratory activities, in whole or in part, by EH&S in accordance with UCLA Policy 811, with concurrence of the OSOC or appropriate Subcommittee and the Director of Environment, Health & Safety, without instituting the LSCP. Should this occur, the PI will be required to appear before the OSOC or an appropriate Subcommittee before laboratory activities may resume.

The tiers are defined below.

Questions can be sent to: cpsc@research.ucla.edu

Tier One

When a repeat issue of noncompliance by a group has been identified by EH&S during an inspection, a Tier One Memorandum may be issued.

The campus EH&S Chemical Hygiene Officer (CHO) will provide the Chair of the CPSC with a report indicating which operations have safety findings that qualify as a repeat issue. Repeat issues that require consideration by the Chair must include, but are not limited to the following:

  • All findings which have not been corrected within 90 calendar days of the initial inspection report issuance
  • Any serious findings which have not been corrected within 3 business days of the initial inspection report issuance

Note: Corrections that require infrastructure upgrades will be considered on a case-by-case basis and alternative risk mitigation strategies may be approved by the CPSC (or a subcommittee consisting of at a minimum, the Chair, the CHO, and a third committee member to be appointed by the Chair) and the EH&S Director.

Once a report has been issued to the CPSC, the committee may move to issue a Tier One Memorandum or defer issuance of the memorandum. If the committee wishes to defer, it must establish a rationale for deferring issuance and set a time for re-evaluation.

A Tier One Memorandum will be sent to the PI and their Department Chair informing them of the noncompliance issue(s) and of the potential for suspension of operations. The memorandum will indicate the item(s) of noncompliance and indicate a new timeframe for implementing corrective action.

A written response to the Tier One Memorandum is required. The response should contain details regarding either the corrective action taken or plans to take corrective action. Failure to respond within the stated time period (for non-serious issues, 15 calendar days from the date of issue will be used as a standard but this can be changed as determined by the sub-committee) may escalate the memorandum level to Tier Two. Lack of corrective action within the prescribed problem-resolution peri¬od following a Tier One Memorandum may result in the issuance of a Tier Two Memorandum. If the committee wishes to defer issuance of a Tier Two Memorandum, it must establish a rationale for deferring issuance and set a time for re-evaluation.

Should the item(s) of noncompliance be corrected within the specified timeline the CPSC will issue a Resolution Memorandum indicating that corrective action has been taken and verified by EH&S. Since corrective action must be verified by the EH&S, labs should provide sufficient time for EH&S to respond to claims of corrective action (one business day).

Tier Two

A Tier Two Memorandum will be sent to the PI and the Department Chair informing them of the noncompliance issue(s) and of the potential for suspension of operations. This notice will be sent to the PI informing him/her that this is a repeat item of noncompliance that was not resolved in response to the Tier One Memorandum. The PI, or their designee, must provide a formal written response to the CPSC and EH&S as to the reasons for a second instance of non-compliance and/or why the previous corrective action(s) was/were ineffective and what further corrective action(s) will be implemented to prevent recurrence. In addition, the Principal Investigator (or other responsible manager) will be asked, along with the Department Chair, to appear before a sub-committee of the CPSC to discuss the proposed corrective action plan. The Committee will offer recommendations and/or additional requirements to the Principal Investigator to ensure future compliance.

Failure to respond within the stated time period (for non-serious issues, 15 calendar days from the date of issue will be used as a standard but this can be changed as determined by the sub-committee) may escalate the memorandum level to Tier Three. Lack of corrective action within the prescribed problem-resolution period following a Tier Two Memorandum will result in the CPSC sending a report to the OSOC detailing the issues related to repeat non-compliance and recommending issuance of a Tier Three Memorandum. If the committee wishes to defer its recommendation to the OSOC for escalation to Tier Three, it must establish a rationale for postponement of a recommendation and set a time for re-evaluation.

Should the item(s) of noncompliance be corrected within the specified timeline the CPSC will issue a Resolution Memorandum indicating that corrective action has been taken and verified by EH&S. Since corrective action must be verified by the EH&S, labs should provide sufficient time for EH&S to respond to claims of corrective action (one business day).

Tier Three

Upon recommendation of the CPSC, the OSOC will review cases where safety issues are not resolved following a Tier Two Memorandum. Should the OSOC agree with CPSC regarding non-compliance, they will issue a Tier Three Memorandum.

This notice will be sent to the Principal Investigator, the Department Chair, and the Vice Chancellor for Research informing them of the continuing noncompliance and recommending that the Principal Investigator’s operations be suspended until corrective action is taken. The Vice Chancellor for Research will decide on the course of action following consultation with the OSOC and the Director of EH&S and will provide authority and instruction on enacting suspensions. During the suspension period, the Principal Investigator and Department Chair will be instructed to appear before the OSOC to explain why the operation should be reinstated and concurrently present a formal written corrective action plan.

Revised 12/17/2014