Local Exhaust Ventilation (LEV) Policy

Michael Wraight

Duty Authorised Person for LEV

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Purpose

This policy has been created to assist in the management of processes in accordance with the duties set out in º¬Ðß²ÝÊÓƵ (LU) control of substances hazardous to health policy.

Specifically, this Policy provides guidance and control measures in the installation, operation, maintenance and annual examination of Fume Cupboards, Local Exhaust Ventilation and Microbiological Cabinets. Herein referred to as LEV systems.

Legal requirements are set out in Appendix 1.

Scope

This policy applies to all areas and installations on the º¬Ðß²ÝÊÓƵ site. Installations include Fume cupboards externally vented and recirculating types, all local ventilation control measures integrated into the building and freestanding.

References

  • º¬Ðß²ÝÊÓƵ Control of substances Hazardous to Health Policy
  • The Control of Substances Hazardous to Health Regulations (COSHH) 2002
  • EH40 Workplace Exposure Limits: Containing the list of workplace exposure limits for use with the Control of Substances Hazardous to Health Regulations 2002 (as amended); January 2020.
  • BS EN 14175 parts 1-7: Requirements for fume Cupboards
  • BS 7989:2001 Specification for re circulatory filtration fume cupboards
  • HSG 258 Controlling airborne contaminants at work – a guide to local exhaust ventilation (LEV).
  • INDG408 HSE guide to buying and using local exhaust ventilation (LEV).
  • INDG409 HSE workers guide to local exhaust ventilation (LEV).
  • BS 5726:2005 (replaces BS 5276 1992 2&4) Installation, selection, use Microbiological cabinets.
  • BE EN 12469:2000 Performance criteria and testing Microbiological cabinets.

Definitions

Local Exhaust Ventilation (LEV) – Engineering control system to reduce exposure to airborne contaminants such as dust, mist, fume, vapour, and gas. Including Microbiological cabinets.

Point – this is where the contaminated extract air is released to a safe place with no risk of re-entering the workspace.

Thorough examination and testing (TExT) – The procedures and methods with qualitative and quantitative methods as detailed in HSG 258- subsection ‘Carrying out thorough examination and testing.

Responsibilities

Duty Holder: VC / COO (senior person responsible)

The Vice Chancellor (VC) or Chief Operating Officer (COO) is the Statutory Duty Holder and, as the senior person responsible, has overall accountability for all aspects of the management of health and safety in the University organisation.

Designated Person: Dean of School / Director of Professional Service

A person appointed by º¬Ðß²ÝÊÓƵ who has managerial authority and responsibility for the control of health and safety legislation within the School / Professional Service.

Duty Authorised Person

A person, either employed by the University or another organisation, with the required knowledge, training, and experience, appointed by the Dean / Director in writing, to take managerial responsibility for the implementation of this policy and

procedures for a specific area of health and safety legislation.

Deputy Responsible Person

A person, either employed by the University or another organisation, possessing proficient technical knowledge and having received appropriate training, appointed by the Duty.

Authorised Person in writing to take responsibility for the implementation of policy and procedures as specified of a specific area of H&S legislation.

Competent Person

The operative / individuals, either employed by the University or another organisation, recognised by the Authorised Person as having the competence to undertake the task and follow the relevant process / procedure. This person undertakes the task at the place of work.

Individual Responsibilities

Director of Estates /Dean of School /Director Professional Service/ Designated Tenant will:

  • Appoint and ensure the competency of the Duty Authorised Person, by ensuring that the person has suitable ability, experience, training, and resources to enable them to carry out the duties defined in this policy.
  • Ensure arrangements are in place to fully discharge the requirements of this policy.
  • Ensure that the policy and guidance documents are available and accessible for all persons with responsibilities under this policy.
  • Receive reports on, and review effectiveness of this policy in consultation with the relevant Duty Authorised Person and the Health, Safety Manager.

Duty Authorised Person (DAP) will:

  • Review and propose updates to this Policy when appropriate.
  • Ensure that suitably competent advisors are available to support the design and selection of new local exhaust ventilation systems installations.
  • Appoint and ensure competency of AP’s by ensuring that the person has suitable ability, experience, training, and resources to enable them to carry out the role.
  • Communicate by whatever means suitable, information to the employees with regards to relevant information on the risks and control measures being undertaken.
  • Chairing appropriate reviews and forums and ensure that an audit of this policy and associated procedures are undertaken.
  • Undertake periodic review of the policy and procedures of tenants.

Dept. / School Deputy Responsible Person will:

  • Manage the day-to-day safe operation of the LEV system, ensuring regular checks are undertaken, that faults are acted upon. The logbook (Appendix 3 Logbook Contents and checklist) is completed, maintained, and retained with the LEV. Staff/students are trained.

Users will:

  • Use the equipment within its designed capabilities, highlight any problems to the AP. Follow training received and complete the logbook as required.

Organisational Responsibilities

LU User Department/School/Associated Company will:

  • Carry out risk assessment (including COSHH risk assessments) which identifies suitable control measures and to monitor the effectiveness of any control measure including the use of the LEV.
  • Ensure that the LEV is perating in such a way that adequate control is maintained. Allocate specific responsibilities for checks and maintenance, (these may overlap) for example:

Operator

Make daily checks, report faults

Safety/workers’ representative

Make weekly, monthly checks

Supervisor

Make weekly checks, arrange repairs, correct deviations from the correct way of working, record findings and actions

Section Manager/Technical officer

Identify problems, receive regular reports from the supervisor, be responsible for maintenance and testing

Facility Management Dept.

Repair faults, carry out maintenance, arrange annual thorough examination

 

  • If the LEV discharges and/or can become contaminated with toxic, infective, or otherwise harmful substances, put in place ‘permits to work’ and/or formal method statements for people to work on the system or adjacent to the discharge point(s).
  • Review the risk assessment and control measures in the event of any change of activity, or if there is suspicion that control of exposure is not being achieved.
  • Maintain a logbook for each LEV system, containing schedules and forms to keep records of checking, maintenance, and repair (Appendix 3 Logbook Contents and checklist)
  • Ensure that regular thorough examinations take place at least on an annual basis and carry out assessment of control effectiveness at least annually; carry out any corrective action.
  • Stop the work, if any examination and test or any assessment of control effectiveness shows that the LEV is not adequately controlling exposure to airborne contaminants. If it is determined that work can continue while repairs are arranged provide employees/students with protection.

 

Estates & Facilities Management will:

  • Appoint suitably qualified Maintenance Contract Service. Providers to undertake the annual thorough examination and test, to include thorough visual/structural examination and measure technical performance.
  • Receive the annual thorough examination test report/certificate and retain for 5 years.
  • Advise departments/schools on procedures/controls/supervision need improving whenever there is a reason to suspect that they are no longer valid. I.e., when an area of the building is taken out of use, exam and test results contain long lists of repairs and poor performance etc.
  • Ensure immediate action in response to out of specification results. Advise the department operating the system of the results and remedial actions to be undertaken.
  • Ensure that any remedial works undertaken is carried out on time, to specification and are recorded.

Contracted Annual thorough examination and test, Service Provider will:

  • Have a suitable and sufficient management structure to ensure professional competence at all times.
  • Ensure that all their personnel are competent, suitably trained, certificated, and experienced, and have the necessary equipment to carry out their duties.
  • Carry out the thorough examination and test against the required performance standard. For LEV systems with no documentation available, an adequate ‘thorough examination and test’ will take the form of an initial TExT report any subsequent tests will be carried out under the Routine TExT reports.
  • Provide a report/certificate of the examination to the department/school nominated deputy including prioritized action plan the dep’t/school needs to address.
  • Attach ‘tested’ label to the LEV, including the name of the examiner and the date of the next test, passed systems should include green pass labels on each extract point as a clear indication to users. If LEV has clearly failed then Attach red ‘failed’ label to the LEV, notify E&FM and the dept/school of urgent action. Inform the E&FM Contracts Supervisor if physical access or operations cannot be completed. Capture hoods shall also have a maximum safe working distance label attached to the extract point.
  • Produce and update a schedule of all LEV system and hoods tested, recording location, asset reference, fail/pass status, fault details, advisory items and action required.

E&FM Engineering, Maintenance and Sustainability will:

  • Support schools/departments by providing technical advice on plant etc. following a department/school risk assessment.
  • When completing new or modified installations, documentation is provided to the department/School and E&FM as specified within the º¬Ðß²ÝÊÓƵ Engineering Specification. A sample of this information is as follows:
    • A user manual with general specification of what the LEV system is designed to control, how it works, how to use it, maintenance, and spare parts.
    • A Logbook
    • An Initial TExT report or suitably detailed commissioning report, including system description, drawings, performance specification, results of tests carried out and correct usage.
  • Check any modifications or changes to existing installations are carried out under the site change control process and that all associated drawings, Risk Assessments, and testing schedules are updated.

Control Principles

The control principles listed below are written to match the lifecycle of the LEV systems, starting with design / installation, and finishing with decommissioning and removal. Due to the LEV system types and range of complexity used by º¬Ðß²ÝÊÓƵ in controlling airborne contaminants detail Specification within this policy will not be inclusive; Appendix 2 Checklist and Technical guidance will be used as LU standard of good practise.

Legal requirements and duties placed on those concerned with LEV (including manufacture, design, supply, commissioning, use, maintenance, testing etc.) are detailed in Appendix 1.

Risk Management

It is the user department/ school responsibility for the COSHH risk assessment that identifies suitable control measures and to monitor the effectiveness of any control measure including the use of LEV.

Risk assessments shall identify the required performance of the LEV system to ensure effective containment of any hazardous substance. The COSHH risk assessment shall be reviewed whenever there is reason to believe that it is no longer valid (e.g., due to changes in plant, equipment or new information about risks or control measures).

LU Control of Substance hazardous to health policy defines the operational duty in broader detail.

Departments/Schools will assess a benchmark for the specification of the LEV; Control specification COSHH E-Tool (hse.gov.uk) can identify a control solution.

Additional standards should be reviewed to ensure that the system complies with the standards set down relating to in biological containment.

Design and Installation

All design and installation works are to be managed by an engineering representative of E&FM (E&FM Engineering or appointed specialist/consultant).

The installation or refurbishment of any LEV system should be undertaken in accordance with Latest HSE guides, relevant University Engineering standards, Professional bodies such as British Occupational Hygiene society, institution of Occupational safety and Health, Heating, and ventilating contractor’s association. Particular attention is to be paid to the appointment of suitable contractors, the design in accordance with regulations & guidance, appropriate installations for the contaminants identified to be used, the co-ordination of the works between E&FM, Schools/Dept, and contractors to ensure the Health, Safety & Welfare of building users.

Appendix 2 identifies good practise and standards LU will meet.

Commissioning

On completion of the installation the system must be commissioned prior to handover. The trained commissioning engineer will take measurements in accordance with relevant guidance and compare with design intent. The commissioning engineer will attend to non-compliances. The results are to be recorded within the LU Initial TExT report or an equally detailed commissioning report and presented to the E&FM LEV DAP for review and sign off. A copy is then given to the School/Department and a record kept within E&FM, as part of the Operating and Maintenance (O&M) manuals. Any O&M manual shall also include the COSHH risk assessment, schematic, and layout drawings of the system in AutoCAD format, records of installation and details of maintenance procedure.

When the equipment has been commissioned and is ready for operational use, E&FM shall ensure that suitable and sufficient training is given to the receiving School/Dept by the installer of the equipment. This training will involve the School Senior Technical Officer (STO), or school safety officer (SSO) being briefed by the installer on the equipment, including what to do in the event of an emergency. Any relevant documentation, including drawings, capabilities of the system etc. shall also be provided to the School STO and it will be their responsibility to store this in a retrievable format.

Operation, Checks and Maintaining the LEV's

There are different types of LEV systems in use throughout LU. Any subsequent training of end users (students, researchers, and technical staff etc.) in how to safely use the LEV system shall be the responsibility of the School/Dept, and they shall induct / train end users accordingly and give people responsibility for: -

  • Maintaining a LEV logbook
  • Producing the schedule of in year checks
  • Daily, weekly, monthly checks as scheduled in the LEV Logbook
  • Record findings and actions in the LEV logbook
  • Identify problems, arrange repairs
  • Correcting deviations from correct way of working
  • Scheduling Maintenance and testing in year
  • Assessing control effectiveness in year

The Environment Agency has not produced any guidance specifically for the operation of LEV as “it is unlikely that laboratory scale operations produce sufficient fume discharge to merit inclusion in environmental regulations”. Therefore, the use of fume cupboards for day-to-day laboratory experiments is not controlled by environmental legislation, however under no circumstances LEV’s should be used for the large scale “disposal” of volatile compounds or substances. Guidance on the disposal of Hazardous Waste is provided by LU Environment policies and guidance notes.

Annual Thorough Examination and Testing

Annual thorough examination and testing will be considered in three stages:

  1. Thorough Visual and structural examination
  2. Measure technical performance
  3. Assess control effectiveness, the LEV is protecting operators from contaminants

To carry stage 1 and 2 E&FM will set up and manage a contract with an independent Service Provider experienced in the testing of such equipment.

The schedule of inspection and testing is to comply with the reference documents within Section 3, with additional requirements as specified by º¬Ðß²ÝÊÓƵ in the contract document.

Where appropriate a specific inspection and testing schedule will be individually designed for complex systems.

The Service Provider will issue air velocity test certificates and test reports for each LEV system and fit test labels to the system/hood indicating test date, next test, and examiner. Fail labels will be fitted when there is inadequate control. The system will carry the green “pass” or red “fail” label until it has been repaired.

Appendix 2 Table 1 shall be used for LEV performance criteria unless specific risk requirement is identified and recorded in the LEV logbook.

Stage 3 will be carried out by the school/dept. authorised/responsible persons and will include:

  • Observation of the work processes requirements
  • Observation of the way operators work,
  • Source of contaminant cloud size, speed, and direction
  • LEV hood type, size, and airflow

In the event of inspection/testing being required on either a LEV system or near its discharge point or on the roof generally, FM would contact the STO/DSO in advance (i.e., the day before in the event of planned works) to inform them of the works. The STO/DSO would have a responsibility to manage the risk of exposure to persons on the roof. This may involve either ceasing the operation of the LEV system or agreeing with E&FM a rescheduled date for the works. A formal handover of the system from the School to E&FM shall be made, and the equipment isolated from use.

Alterations

If the School wishes to alter any part of the LEV system, the STO/DSO shall contact E&FM and request a meeting to discuss their requirements. The School is not authorised to make any alterations themselves. Alterations are to be undertaken in accordance with section 6.1, 6.2 and 6.3 of this policy to ensure a safe and compliant system.

In the event of the LEV being taken out of use to enable alterations by E&FM to take place, a formal handover of the system from the School to E&FM shall be made, and the equipment isolated from use. The School is responsible for briefing the normal end users that the equipment will be out of use for the agreed time. When the alterations have been completed, E&FM will be responsible for the installer to train the STO and handing over any documentation in the established manner, and then the STO is subsequently responsible for briefing the end users and safe operation, again in the established manner.

Following any alteration, a thorough examination and test will be carried out as per section 6.5.

Decommissioning & Removal

At the end of the lifespan of the LEV system, or when repairs / alterations to the system are prohibitively expensive, the STO/DSO shall agree a system closure date with E&FM and end users informed when the last operation date will be. Once operation of the LEV system has ceased, the system shall be isolated and works undertaken to remove the system or render it inoperable. This de- commissioning work shall be undertaken by specialists under the management of E&FM, and all materials disposed of correctly, with particular focus given to the correct disposal of hazardous materials.

Audit and Review

The process shall be reviewed by the team on a regular basis. A periodic independent audit shall be undertaken by LU HSE dept. Any discrepancies will be highlighted, and actions identified to address the issues, including making improvements to the process where necessary.

LEV Document Management

This policy is to be made available via LU H&S website.

Changes to the documents are to be made only by the Duty Holder and under approval of the Health and Safety Committee.

The test reports are to be kept in electronic format on the E&FM workspace and a copy provided to the user dept/school.

The test reports may also be kept on a web-based system as provided by the competent persons undertaking the contract to provide thorough examination and testing.

Reports will be kept for at least 5 years.

The routine checks, maintenance and assessment of control effectiveness are to be kept in the LEV systems LEV logbook. Logbooks need to be kept for at least five years.

For LEV systems with no or incomplete logbook, user manual or commissioning report, the school/dep’t may need help from the supplier or from an expert, e.g., a consultant engineer or occupational hygienist specialising in LEV to prepare suitable documentation.

The methods used to judge whether the LEV system continues to achieve the required performance and provide adequate control will depend on the assessment of the system but would normally include visual, pressure measurements, airflow measurements, dust lamp and air sampling tests, as appropriate.

Where the LEV appears to be working to be effective the annual inspection competent person will make measurements of pressure and airflow data for the logbook. Section 5.4

Where the control also depends on operator behaviour and how it is used, the correct ways of working are to be recorded. The procedure and practise should appear in the logbook for the LEV system.