Interim Research Laboratory Safety and Accountability Policy

Rationale:

This policy governs the safety and accountability of all research laboratories at Syracuse University. All personnel in research laboratories are expected to be compliant with the University’s Environmental, Health and Safety (EHS) Policy and with all applicable laws and regulations. Safety is a shared responsibility, and all members of the research community at Syracuse University have a responsibility to ensure the safety of laboratory spaces and to evaluate if those spaces are running safely. If a safety incident does occur in a laboratory, prompt notification is essential. Since the University is ultimately responsible for the safety of all students, faculty, and staff in research laboratories, the University does not permit research to be conducted in a manner that could potentially harm students, faculty, staff, or University facilities.

Guiding principles:

  • Ensuring safety in research laboratory spaces requires close collaboration across academic units at Syracuse University. Deans of schools/colleges with research laboratory space must ensure that each laboratory has a faculty member overseeing the research laboratory as the principal investigator (PI). The Vice President for Research (VPR) will ensure that core facilities have a faculty director and that PIs are assigned for shared laboratories.
  • The laboratory PI plays a central role in ensuring safety in research laboratory spaces and is accountable for the immediate and continual care and safety of the laboratory activities The PI is also expected to proactively identify and address safety and compliance issues, in collaboration with the University.
  • The Environmental, Health and Safety (EHS) Organization also plays an important role in ensuring safety in research laboratory spaces. EHS collaborates with PIs to help them maintain safe and compliant laboratories and conducts periodic laboratory inspections to assist PIs in identifying and correcting safety and compliance issues and mitigate PIs are expected to address identified issues promptly, with support from EHS. This collaborative partnership will help ensure that research is conducted safely, that hazards are mitigated to the greatest extent possible, and that the next generation of scientists is trained in safe, compliant laboratory practices.

Notification of Incidents:

The notification procedure described below must be followed in the event of a serious incident in a research laboratory. A serious incident is any incident involving fire, explosion, personal injury, property damage, or release of hazardous materials or a “near miss” incident that had the potential to result in more than de minimis personal injury or property damage. Deans are ultimately responsible for ensuring that all faculty who have been assigned laboratory space are aware of this procedure. EHS safety trainings will include a review of this procedure.

Serious incident notification must be made by a phone call or text, followed by an email. Such notification should include details of when and where the incident occurred, details of any injury to persons, details of any immediate hazards, and a brief description of the incident. This notification should be sent according to the following procedures:

  1. Individuals present in the laboratory at the time of the incident or who discover the incident shall immediately notify the following individuals and offices:
    1. Department of Public Safety, which will dispatch public safety and fire and life safety officers to respond to laboratory; and
    2. Laboratory’s PI, as posted outside the laboratory. If the PI is unavailable, the department chair/school director and Associate Dean for Research (ADR) of the faculty member responsible for the laboratory.
    1. Department of Public Safety shall immediately notify the EHS Organization.
    2. The PI responsible for the laboratory shall immediately notify their department chair/school director, ADR, and EHS Organization.
    3. The department chair shall immediately notify the dean of their school/college.
    4. The school/college’s ADR shall immediately notify the VPR and relevant Dean.
    5. The dean shall immediately notify the Provost, VPR, and General Counsel.
    6. EHS shall immediately notify the Vice President of Facilities, VPR, and Director of Risk Management.
    7. The Vice President of Facilities and VPR (this may be a single, coordinated notification) shall immediately notify the Provost, the Chief Financial Officer, and the General Counsel.
    8. The Provost and Chief Financial Officer shall jointly notify the Chancellor and General Counsel.

    Violation and Mitigation of Compliance Incidents:

    Laboratory safety and compliance issues will be handled based on the violation risk level assigned to the laboratory, as defined in this policy. This policy also articulates the expectation for PIs to promptly address identified issues and the actions that departmental/school and research leadership will take when those issues are not addressed.  

    1. General Process for EHS Lab Inspections
    1.  EHS will perform periodic inspections of laboratory spaces, using a rubric developed to assess the safety of the laboratory space.
    2. Laboratories will receive written notification of any safety, compliance, or administrative issues, using the online lab safety management system. The PI is responsible for reading and responding to these electronic written communications.
    3. EHS will assign a violation level to a research laboratory with safety, compliance, or administrative issues, based on the criteria outlined below, and take additional actions, as applicable, based on the level assigned.
    4. PIs are required to address issues identified by EHS within the prescribed time period (generally 30 days) and respond, using the online lab safety management system.

    B. Laboratory Violation Levels

    Laboratories will be assigned a violation level based on the safety and compliance issues identified, the perceived risk level, the persistence of issues, and the judgement of EHS. A laboratory can be assigned any violation level from the initial EHS inspection. A laboratory’s violation level will be elevated to a higher level if their identified issues are not sufficiently addressed in the prescribed time.

    The following outlines the actions to be taken by EHS, the PI, and departmental and research leadership, depending on the violation level assigned. For all levels, the PI is expected to promptly acknowledge, address, and respond to the identified issue(s), seeking support from EHS, the department chair/school director, and/or ADR if needed.

    LEVEL 4 Violations – Critical Violations


    A Level 4 violation will be assigned to a laboratory when there is an area, activity, or condition observed that presents an immediate, confirmed, or perceived hazard to the health, safety or welfare of persons, property, or the environment and/or a clear or threatened serious violation of regulatory codes, laws, or requirements, or University policy. The VPR is authorized to immediately close a laboratory where a Level 4 violation has occurred.

    The process for laboratories assigned a Level 4 – Critical Violations includes the following:

    1. EHS will immediately inform the VPR, the affected school/college’s ADR and department chair/school director of the identified critical violation. EHS has the authority to immediately close a laboratory prior to informing the VPR, ADR, or chair if the issues are an immediate threat to life and property.
    2. The VPR, ADR, and/or department chair/school director will take immediate actions to notify the PI, suspend the activity, and isolate and restrict access to the location causing the critical violation. This action may include changing the lock core on the laboratory to restrict anyone, including the PI, from entering the laboratory until the critical violation is corrected.
    3. The relevant university-level safety committee(s) will be notified (e.g. Lab Safety, IBC, IACUC, Radiation Safety, etc.) of the situation. The PI will not be confidential, as the safety committee must be able to assess the PI’s expertise to perform the research in the manner described and engage with the PI to review and discuss mitigation actions.
    4. EHS will record the violation(s) in the online software system.

    Mitigation and Recovery from LEVEL 4 critical violations include the following:

    1. The department chair/school director and ADR will work with the PI and EHS to develop a plan to correct the critical violation(s). The corrective actions plan will be reviewed with the relevant safety committee, if applicable.
    2. The PI will log the corrective actions taken in the online lab safety management system.
    3. Once the corrective action plan has been implemented and all actions have been taken, the location, activity, or condition will be reassessed by EHS.
    4. EHS will convey the findings of the reassessment to the VPR, ADR, department chair/school director (if applicable), and relevant safety committee.
    5. If all parties listed in Point 4 agree that the critical violation has been corrected, the location/area will be re-opened and/or the activity will be allowed to resume, and the research laboratory and PI will be returned to compliant status.
    LEVEL 3 Violations

    Level 3 violations will be assigned to any laboratory where the following conditions are found:

    • An unsafe condition or action, which, in the judgement of EHS, has the potential to quickly become a critical violation.
    • Previously assigned Level 2 Violation issues have not been addressed in 30 days to the ADR’s satisfaction.

    The process if a laboratory is assigned Level 3 Violations include the following:

    1. EHS will log the issue(s) the online lab safety management system to inform the PI.
    2. EHS will inform the VPR, the affected school/college’s ADR, and department chair/school director of the identified issue(s).
    3. The VPR, ADR and/or department chair/school director will notify the PI, suspend research activity, and restrict student access to the laboratory. This action may include all or partial activities and/or laboratory areas, depending on the nature of the issues.
    4. The relevant university-level safety committees will be notified (e.g. Lab Safety, IBC, IACUC, Radiation Safety, etc.) of the situation. The PI name will not be confidential, as the safety committee must be able to assess the PI’s expertise to perform the research in the manner described and engage with the PI to review and discuss mitigation actions.

    Mitigation and Recovery from LEVEL 3 violations include the following:

    1. The department chair/school director and ADR will work with the PI and EHS to develop a plan to correct the identified issue(s) within 30 days.
    2. he corrective actions plan will be reviewed with the relevant safety committee, if applicable.
    3. The ADR will keep the PI accountable to the mitigation plan and work with EHS to check after 30 days.
    4. The PI will log the corrective actions taken in the online lab safety management system.
    5. Once the corrective actions plan has been implemented and all actions are completed, EHS will reassess the laboratory. The ADR and department chair/school director may accompany EHS for the reassessment, if warranted.
    6. EHS will convey the findings of the reassessment to the VPR, ADR, department chair/school director, and relevant safety committee.
    7. If all agree that the issue(s) has been corrected, the laboratory will be re-opened to students, the research will be allowed to resume, and the research laboratory and PI will be returned to compliant status.
    LEVEL 2 Violations

    Level 2 violations will be assigned to any laboratory where the following conditions are found:

    • Several issues involving unsafe and/or noncompliant conditions or actions are identified.
    • Persistent issues, repeating from past inspections, are identified.
    • Previously assigned Level 1 violation issue(s) has not been addressed in 30 days to the satisfaction of EHS.

    The process if a laboratory is assigned Level 2 violations include the following:

    1. EHS will log the issues in the online lab safety management system to inform the PI.
    2. EHS will inform the school/college ADR and department chair/school director of the identified issues.
    3. The ADR and/or department chair/school director will notify the PI. Activity will not be suspended, but the PI and laboratory are responsible for mitigating the risk.
    4. The fact that the PI is non-compliant will be reported to the relevant university-level safety committee(s) (Lab Safety, Biosafety, IUCAC, ORIP, Radiation Safety) at the regularly scheduled meeting time. The PI name will not be confidential, as the safety committee must be able to assess the PI’s expertise to perform the research in the manner described.

    Mitigation and recovery from LEVEL 2 Violations include the following:

    1. The department chair/school director and ADR will work with the PI and EHS to develop a plan to correct the identified issue(s) within 30 days.
    2. The ADR will keep the PI accountable to the mitigation plan and work with EHS to check after 30 days.
    3. The PI will log the corrective actions taken in the online lab safety management system.
    4. Once the corrective actions plan has been implemented and all actions are completed, the EHS will reassess the laboratory. The ADR and department chair/school director may accompany EHS for the reassessment, if warranted.
    5. EHS will convey the findings of the reassessment to the ADR and department chair/school director. The relevant safety committee will have a report from EHS of compliance at their regular meeting.
    6. If all agree that the identified issue(s) has been corrected, the research laboratory and PI will be returned to compliant status.
    LEVEL 1 Violations

    Level 1 violations are the most common violation level assigned. This violation level will be assigned to a laboratory where issue(s) are identified other than described above.

    The process if a laboratory is assigned Level 1 Violations include the following:

    1. EHS will log the issue(s) in BioRaft to inform the PI.
    2. The PI will be expected to correct the issue(s) within 30 days and log the corrective actions taken in BioRaft.
    3. EHS will reassess the laboratory to confirm that corrective actions taken address all identified issues. EHS will contact the PI if additional actions are needed.
    4. The research laboratory and PI will be returned to compliant status.

    Date: April 2025