Standard Operating Practice for Servicing Exhaust Systems in Research Facilities

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Standard Operating Practice for Servicing Exhaust Systems in Research Facilities


The following procedure was developed to protect maintenance personnel and laboratory workers from potential exposure to hazardous materials while servicing exhaust systems.


This policy applies to all Facilities Management maintenance employees who perform work that requires entering or removing duct work, entering the fan housing, changing filters, shutting off fans or any other maintenance that requires entering the inside of the exhaust system. Special precautions are not required when servicing equipment which is outside of the hood cabinet and/or outside of the potentially contaminated air stream. For example, belts and pulleys may be serviced, vibration isolators may be caulked and lamps may be replaced on many fume hoods without entering the interior of the hood or exhaust duct.

Program Components

1. Responsibilities

2. Pre-maintenance Activities

3. Maintenance Procedures

General Practices for Working Inside of Exhaust Systems

Special procedures

4. Routine Leak Inspection

5. Appendices

1. Responsibilities

Operations Supervisors:

  1. Assure that employees assigned to work in potentially contaminated systems are adequately trained and utilize the appropriate personal protective equipment.

  2. Assure that maintenance work requiring the shut-down of the system is coordinated with the customer.

  3. Assure that inspection checklists are submitted to the Occupational Health and Safety Administrator upon completion.

Maintenance Employees:

  1. Perform work in a manner consistent with this policy utilizing the appropriate personal protective equipment.

2. Pre-maintenance Activities

  1. Whenever service requires that a fumehood, biological safety cabinet or other local exhaust system be shut down, the designated laboratory supervisor must be informed of the time and duration of the shut down.

  2. Whenever work must be done inside of the exhaust system, laboratory staff must confirm that hazardous materials have been secured. Laboratory staff are also responsible to assure that a work area in laboratory space is cleared of laboratory equipment; maintenance staff need room to place their tools and may occasionally need room to place a ladder. NOTE: Facilities Management maintenance employees shall not remove alter or move laboratory equipment or chemicals. Laboratory staff are responsible these items.

  3. Immediately before an exhaust system will be shut down, the sign shown in Appendix A must be placed on the sash of the fumehood. If the exhaust system being serviced, provides ventilation for an entire room, this sign must also be placed on the door to the room.

  4. Some work inside an exhaust system may be accomplished without shutting it down. However, hazardous chemicals must be secured and the fumehood cleared so that work can be safely performed. Some examples of work inside the exhaust system which can be done while the fumehood is running include: replacing lamps, cleaning behind fumehood baffles or replacing airflow sensors.

3. Maintenance Procedures

  1. General Practices for Working Inside of Exhaust Systems

    1. Wear the following personal protective equipment: minimum respiratory protection of a 3M 9913 dust mask, plastic or rubber gloves, chemical goggles or face shield and coveralls.

    2. Perform necessary maintenance

    3. Dispose of coveralls and wash the outside of gloves or dispose of gloves.

    4. Remove mask and gloves; then wash hands and face.

  1. Special Operating Procedures

Radioisotope Hoods

    1. Whenever working on the inside of a fumehood cabinet posted with a "Caution Radioactive Materials" sign, contact the Department of Environmental Health and Safety, Radiation Protection Division (RPD) and request a survey to certify that hood contamination is below applicable standards. Use the flowchart (Appendix B) to determine if RPD should be contacted to perform a survey. Following the survey, RPD staff will post the hood with the notice shown in Appendix B.

    2. When working inside of duct work or fan systems that serves a radioisotope hood, the RPD need not be contacted except in the following locations: W-41 Boynton, 338 An Sci/Vet Med, V73 VFW Bldg., 1-274 U Hospital, and 2nd Floor Hosp Nuc Med Hood. A survey is necessary for these hoodsbecause they are the only locations where volatile radioisotopes are used which might contaminate an air stream.

    3. If contamination is below applicable standards the general practices outlined above shall be used.

    4. If contamination is above applicable standards, special procedures will be specified by the RPD representative.

Perchloric Acid Hoods

    1. Contact the Department of Environmental Health and Safety (DEHS). The hood will be tested for the presence for perchlorates.

    2. If perchlorates are not present, proceed under general practices as outlined above in 3.A.

    3. If perchlorates are present, the hood must be washed down with water until the levels are acceptable. After safe levels are reached, proceed under general practices as outlined above.

Biological Safety Cabinets

    1. Follow the general practices discussed in 3.A. when servicing building HVAC equipment serving a biological safety cabinet. Particulate contaminants originating inside the cabinet are filtered out by the biological safety cabinet filters system before reaching the building HVAC system.

    2. Contact the Department of Environmental Health and Safety before working inside contaminated spaces of the biological safety cabinet such as the plenum, blower or HEPA filter compartment.

Replacement/Repair of HEPA or Charcoal Filters

    1. Follow the general practices as outlined above.

    2. For removal of these filters, follow the precautions and procedures listed below:

      1. At least the following equipment will be required: ladder, duct tape, large U of MN #21058 poly bag, + and - screwdrivers, pliers and adjustable wrench.

      2. Notify lab of required maintenance, tag out hood then turn off the fumehood fan.

      3. Put on protective equipment.

      4. Remove the filter access panel and place in a bag. Verify that filter locking devices are loosened.

      5. Attach the large #21058 bag around the filter access panel opening in a manner that seals the filter access opening using duct tape or elastic cord.

      6. Remove the prefilter by grasping the filter from outside the bag (with the bottom of the bag) and pull it into the bag.

      7. Pull the HEPA filter into the bag in the same manner. NOTES: a) Charcoal filters are heavy when compared to a HEPA filter. Because a used charcoal filter can weigh 100 pounds, you may require assistance to remove it. b) In some cases, it may be necessary to remove the bag with the prefilter and tape a second bag to the access panel for removal of the HEPA filter.

      8. Remove the bag from the duct work, then seal the bag shut with tape, leave the bag on the lab floor near the fumehood.

      9. Replace the access panel(s).

      10. Restart the fumehood fan.

      11. Reassemble the fumehood.

      12. Any tools that have had contact with the interior of the filter enclosure should be placed in a bag by filter and RPD will survey them.

      13. Clean up any dust or debris outside of the fumehood with wet paper towels and place them in a bag. Then remove coverall, respirator, glove and place them in a bag. Wash hands when job completed.

      14. Contact the RPD of the Department of Environmental Health and Safety to clearance check the filters which were removed from the fumehood.

      15. RPD will contact FM to have them remove the filters to a dumpster if the item was cleared for disposal. If not cleared for general disposal, RPD staff will remove the filters for special disposal.

      16. The fumehood system must be rebalanced to assure that face velocities are between 90 and 110 feet per minute. When completed, the mechanic will advise an operations supervisor. The Operations Supervisor will notify DEHS that the system has been balanced. Also, notify lab staff and remove tag out posting upon completion of the job.

    1. Do not replace filters in fumehood ducts unless directed to do so by DEHS staff.

Repair of Heat Recovery Coils

    1. Follow the general practices as outlined in above.

    2. Prefilters must be carefully removed and placed into heavy polyethylene bags. The bags must be taped shut and placed in the general waste stream.

4. Routine Leak Inspection

  1. Inspect the fan housing, vibration isolator and the positive pressure duct work for leaks.

  2. Seal minor leaks that have been identified NOTE: If you are not able to seal the leaks, notify your operations supervisor and note the duct work condition.

5. Appendices

  1. Appendix A:

    • Health and Safety Notice for Fume Hoods (PDF)

    • Fume Hood Out-of-Service Notice (PDF)

  2. Appendix B:

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