MIT's Environment, Health and
Safety Management System is responsive to the overall structure and culture
that exist in the MIT community. Welcome to MIT's Environment, Health and Safety Management System Manual. This Manual is designed to serve as a comprehensive guide to the EHS Management System and all of its related components. It provides a detailed overview of the Management System's design and approach, and a summary discussion on all of the organizational components of the Management System. The Manual is an excellent source for obtaining a high-level and comprehensive perspective and understanding of the Institute's EHS requirements and the tools available to meet those requirements. All students, faculty, and staff should read the Manual to better assist in contributing to sound EHS practices.
The Manual is organized around the seven central components of the Management System:
The Manual can be used in two ways. Reading the Manual in its entirety will provide the most integrated and comprehensive perspective on the purpose, approach, and tools MIT has deployed to help the MIT community meet and surpass its EHS obligations. Also, the Manual can be used as a central reference source to access information on specific components of the Management System as needed. Simply click on the navigation area that addresses the desired topic.
Within the Manual are links to the multitude of essential procedures and tools that support the day-to-day demands of implementing the Management System and carrying out your EHS activities. These essential links are also provided on the homepage of the EHS Management System website.
Can't find what you are looking for? Please contact the EHS Office at 617-452-3477 or send us an e-mail at environment@mit.edu.
1.2 EHS Policy and Guiding Principles
1.3 Targets, Objectives, and Action Plans
MIT has a comprehensive and integrated Environment, Health, and Safety Management System (EHS-MS) that is sustainable for the long term within our academic research setting. A highly collaborative effort that draws on the leadership and expertise of faculty, researchers, students, administrators, and staff, the EHS Management System helped to reshape how all members of the MIT community view their environment, health, and safety responsibilities, carry out MIT's comprehensive and integrated environmental commitment in their day-to-day activities, and assess MIT's performance against our goals.
By creating a well-defined and structured EHS Management System embedded in the daily activities of the Institute, MIT has built an infrastructure that ensures long-term success and sustainability in meeting and surpassing its environment, health and safety obligations. Each component of the EHS Management System is designed to work interdependently in an integrated fashion that continually reinforces the common objective of improving EHS performance.
To ensure the organizational sustainability of the EHS Management System, all components of the Management System, such as Policy and Objectives, Planning, Training, and Inspections have been designed and established as formal systems, integrated into on-going academic and facilities operations, and evaluated on a regular basis to identify areas for continual improvement. It is these core systematic components that act both independently and cooperatively to form the backbone of the EHS Management System.
One of the central principles of this system and our EHS Policy is the commitment to reflect our long held values of excellence not only in our research and teaching, but also in our operations. This management system provides improved institutional capacity and accountability for achieving and maintaining compliance with MIT's high standards for EHS performance, and federal, state, and local EHS regulations in MIT's departments, laboratories, and centers (DLCs), while simultaneously retaining the independence of research and teaching. The EHS-MS also creates a more sustainable campus by encouraging the incorporation of positive initiatives into activities, such as reducing wastes and toxic materials, preventing pollution, and conserving and reusing resources. One of the defining features of MIT's EHS-MS is to integrate regulatory compliance with positive initiatives and educational programs in a decentralized academic research setting.
The EHS-MS operates in tandem with MIT's existing policies and procedures. This management system includes and implements MIT's EHS Policy which has the full authorization, approval and support of the MIT Academic Council, our highest policy-making council convened by the President and comprising the Institute's senior officers. MIT senior management has established and is committed to maintaining the EHS-MS.
This Manual describes the elements of MIT's EHS-MS; the established policies and procedures that MIT follows to meet applicable environment, health and safety performance and legal requirements; and policies and procedures to comply with other requirements to which MIT voluntarily subscribes.
MIT has adopted a comprehensive Environment, Health and Safety (EHS) Policy that describes and communicates the Institute's commitment to excellence in environment, health and safety stewardship. In particular, MIT's EHS policy commits the Institute to:
The Working Group and the Ad Hoc EHS Subcommittee of the Institute Council on Environment, Health and Safety, (co-chaired by the Vice President for Research and Associate Provost and the Managing Director for Environmental Programs, and comprising senior faculty and administrators), developed and endorsed the policy. The policy was then presented to the Academic Council, which is chaired by the Institute President and serves as the President's cabinet for Institute-wide policymaking. Following approval by the Academic Council, the policy was adopted by MIT on December 11, 2001.
The EHS Policy is communicated to the MIT community through a variety of means as described more fully in the EHS Communications Plan and outlined in Section 7, Communications. The EHS Policy is featured on-line through the Institute's Environment at MIT portal and is also provided to students, faculty, researchers, and staff during many orientation and training opportunities.
The EHS Policy is reviewed and modifications to the policy are considered periodically as part of the overall EHS-MS management review process as described in Section 6.1, Inspections.
MIT is committed to being at the forefront of large academic research institutes in measuring and continuously improving environment, health and safety performance. One way that MIT improves its EHS performance is through the implementation of action plans to meet specified objectives and targets. The objectives and targets are developed through a variety of processes as described in Section 3.9, Establishing and Updating Targets, Objectives, and Action Plans and progress is monitored on an ongoing basis.
MIT's Environment, Health and
Safety Management System is responsive to the overall structure and culture
that exist in the MIT community.
The EHS-MS Organizational Structure, shown in the chart, provides a framework that fosters communication and effective working relations among Departments, Laboratories, and Centers (DLCs), the Environment, Health and Safety (EHS) Office, the Environmental Programs/EHS Headquarters Office (EP/EHO) and MIT's senior officers (including the President, Provost, Chancellor, Executive Vice President, Vice Presidents, and Deans).
2.2 Departments, Laboratories, and Centers
2.3 EHS Programs Office and EHS Office
2.4 Incentives and Consequences
MIT's
Senior Officers include the President, Provost, Chancellor, Executive Vice President,
Vice Presidents, and Deans. This executive staff provides resources, including
human resources, specialized skills, technology, and financial resources, essential
to the implementation and control of the EHS-MS. (See Chart)
The organizational structure of the EHS-MS is designed to incorporate multi-disciplinary relationships to assure that EHS issues are addressed in a comprehensive and integrated fashion. These relationships are established through various committees whose functions are summarized below:
Institute Council on Environment, Health and Safety
The Institute Council on Environment, Health and Safety reports to the President and is responsible for coordinating policy development, the assessment of procedures of the Institute Committees concerned with specific areas of environment, health and safety, and overseeing the implementation and effectiveness of the EHS-MS. The Council serves as a forum in which shared concerns of these Committees are coordinated and where issues of individual Committees are resolved. The Council is also responsible for identifying new environment, health and safety issues that emerge as new activities are undertaken and new technologies evolve. In instances where such new activities do not fall within the purview of an existing committee, the Council may expand the area of concern of an existing committee or recommend the creation of a new committee.
The Council's membership includes:
MIT's Committee on Animal Care (CAC) reviews and approves all experiments involving animals to ensure that MIT researchers working with animals comply with federal, state, local and institutional regulations on animal care. To that end, the CAC inspects animals, animal facilities and laboratories, and reviews all research and teaching exercises that involve animals before approving experiments to be performed.
Committee on Assessment of Biohazards and Human Embryonic Stem Cell Research Oversight
The Committee on Assessment of Biohazards (CABESCRO) reviews and approves research involving potential health and safety problems associated with biological research.
Committee on Radiation Exposure to Human Subjects
The responsibilities of the Committee on Radiation Exposure to Human Subjects are to:
Committee on Radiation Protection
The Committee on Radiation Protection is responsible for developing and monitoring the Institute's radiation protection program. The Committee is also responsible for assuring the Institute's compliance with radiation protection regulations promulgated by state, federal, and local agencies.
Committee on Reactor Safeguard
The Committee on Reactor Safeguard is responsible for matters of nuclear safety related to the MIT Research Reactor, including the safety of personnel on and off site. The Committee reviews and approves all new operating plans and policies, including significant modifications, and all new experiments involving significant changes in procedure prior to implementation. The Committee verifies that nuclear reactor operation is consistent with MIT policy, rules, approved operating procedures, and license provisions.
The Committee on Toxic Chemicals is responsible for reviewing current practices with regard to the effects of toxic chemicals, including carcinogens, on human subjects. The Committee is also responsible for developing policies necessary to control the risks and exposure to personnel working with such agents, and for ensuring compliance with rules and regulations.
Committee on the Use of Humans as Experimental Subjects
The Committee on the Use of Humans as Experimental Subjects (COUHES) reviews and approves all research involving human subjects that is performed under the auspices of MIT in accordance with Federal regulations and MIT policy. Types of research that must be reviewed by the Committee include investigation of new drugs and medical, radiological, engineering, physiological, behavioral, sociological, and nutritional studies.
The
Departments, Laboratories and Centers (DLC) are the primary organizations that
implement and maintain sound EHS practices and that assure EHS compliance. (See
Chart)
The following sections explain roles and responsibilities for EHS activities within DLCs. A person in a specific role is responsible for certain EHS activities whether by performing those activities or overseeing other in performing those activities. This is intended to provide flexibility to each DLC and the central EHS office to operate in the most efficient and effective manner.
DLC Head/Director - has the primary responsibility of directing and managing the DLC and therefore has final responsibility for assuring sound EHS practices and compliance within the DLC. The DLC Head/Director is ultimately responsible for enforcing consequences arising from moderately serious and very serious incidents. The DLC's EHS performance evaluation is included in the annual report to the President of MIT and/or to the relevant Dean's Office.
Principal Investigator (PI)/Supervisor - is responsible for
compliance with EHS regulations and good practices in his or her laboratory
or non-research facility. The PI/Supervisor has the responsibility to appoint
an EHS Representative to assist in meeting his or her EHS responsibilities.
If an EHS Representative is not appointed, the PI/Supervisor also acts as the
EHS Representative. In the Department of Facilities and Division of Student
Life, the supervisor acts as the EHS Representative. In addition, the PI/Supervisor
is responsible for registering assigned spaces where hazardous and/or regulated
materials or equipments are used and stored, ensuring that all laboratory or
facility personnel under his or her supervision are trained, and that inspections
are conducted to meet EHS requirements. In some operational departments, the
EHS Coordinator may be responsible for registering spaces.
EHS Coordinator - receives authority from and acts on behalf
of the DLC Head/Director to carry out EHS programs. The EHS Coordinator provides
operational day-to-day oversight of the DLC's EHS-MS requirements. In addition,
the EHS Coordinator supports the EHS Representatives and PIs/Supervisors by
providing additional authority and resources to address EHS issues, including
regulatory deficiencies, training needs, and other EHS-MS needs. The EHS Coordinator
serves as Co-Chair, is a member of the DLC EHS Committee, and is responsible
for retaining a record of EHS Committee meeting. Please refer to EHS
Team List for your DLC EHS Coordinator. The EHS Coordinator is also responsible
for convening a meeting of the DLC EHS Representatives at least annually, and
for retaining a record of the meeting. An EHS Coordinator who prefers to meet
one-on-one, or with smaller groups of EHS Representatives instead of convening
the entire group must work with the EHS Office to determine a sustainable strategy
for including the EHS Lead Contact in these meetings.In some operational departments,
the EHS Coordinator may be responsible for registering spaces.
EHS Representative - reports to and assists the PI/Supervisor in identifying and addressing EHS issues. The EHS Representative initiates actions where appropriate, and brings issues to the EHS Coordinator and PI/Supervisor when his or her authority is required to address an EHS issue. The EHS Representative assists the EHS Coordinator in the maintenance of PI/Space registration data (as outlined in section 3.2) and emergency contact information. In the Department of Facilities and the Division of Student Life the Supervisor acts as the EHS Representative.
DLC EHS Committee - is a forum for single or multiple DLCs to review and discuss EHS regulations and practices and establish strategies to implement them in the DLC. This Committee is co-chaired by the EHS Coordinator and a senior faculty member, researcher or supervisor from within the DLC. The EHS Office Lead Contact and/or other EHS Team Members also participate in the committee in an advisory role. Each Committee meets annually at a minimum and keeps records of the meetings. In a DLC where the DLC Head / Director wishes to be actively involved with the DLC EHS Committee and act as the committee chair, the DLC's EHS Committee could consist of the DLC Head, DLC EHS Coordinator and EHS Lead Contact. Their meeting(s) that takes place during the course of inspections could be considered to satisfy the requirement for an annual committee meeting if a record is kept. In addition, the DLC EHS Committee provides guidance to the DLC EHS Coordinator and reviews operations within the DLC that may impact compliance with EHS requirements, EHS incidents and EHS-MS documents. DLC Heads/Directors have discretion to determine the extent to which they employ their DLC Committee to oversee EHS performance in their DLC.
Employees, students, contractors and visitors are responsible for compliance with EHS regulations and requirements in their research or work areas. (For more information, see EHS and Security Information for Visitor/Contractor (PDF)) They have the responsibility to complete required training prior to commencing their regulated or hazardous work and duties and perform inspections in their research or work areas as outlined in Section 6, Inspections of this Manual.
MIT's
commitment to an effective EHS-MS is demonstrated
through our documented policies and procedures that clearly define roles and
responsibilities. (See Chart)
EHS Programs Office (EPO) - is responsible for participating in the establishment of MIT's EHS vision and leadership, and coordinating collaborative EHS initiatives among all constituents of the MIT community. The EPO with support from EHS Office reviews DLC appointments of EHS Coordinators and reports on EHS matters to the Institute Council on EHS. EPO serves as MIT's senior administrative office for EHS affairs and has access to the senior management at MIT, including offices of the President, Provost, Chancellor, and Executive Vice-President on EHS issues. EPO is responsible to represent the administration of the EHS management system including the EHS Office to the Institute leadership for matters of policy, budget, organization, and major process and technology programs.
EHS Office - provides technical expertise and EHS advisory services to the MIT community that collaborate and support regulatory compliance and improved EHS performance at the DLC level. EHS Office is responsible for tactical and operational implementation of the EHS-MS. This includes providing interim support for DLC EHS-MS operations to those DLCs working with potential hazards or regulated activities that have an open position for the DLC EHS Coordinator. It also includes monitoring DLCs that do not have spaces identified in PI/Space Registration in order to add them to the system if they do begin to work with potential hazards or regulated activities. The EHS Office is responsible for implementing the programs identified in the overall vision and strategy set by the EPO, and to promote day-to-day good practices, compliance related activities, and initiatives that advance MIT’s commitment to environmental sustainability and health and safety excellence. These services are designed to fully support all aspects of the Institute’s EHS-MS and enable continuous improvement of the system. The EHS Office consists of five technical programs and eight functional areas, which are:
Programs
Service Teams
In addition, ongoing EHS staff development is a key component of the system and is monitored by the Director of the EHS Office and the Deputy Directors of the five EHS Programs. EHS Office services are further described in Section 5.2, EHS Office Programs, Services and Service Teams. EHS-MS is implemented and maintained by the Director of the EHS Office
EHS Office Lead Contact - is a representative from within the EHS Office who provides EHS expertise to an assigned DLC. The EHS Office Lead Contact partners with the DLC EHS Coordinator to deliver programs that meet EHS requirements applicable to that particular DLC. The EHS Office Lead Contact is also a member of the DLC EHS Committee. The EHS Office Lead Contact is supported by a team of experts from the EHS Office's areas of technical and functional expertise.
EHS Team - is a group of EHS professionals representing each of the five EHS Office programs that provide expertise and consultation in EHS matters to their assigned DLC. The EHS Lead Contact is the primary contact on the EHS Team for the DLC.
MIT has established incentives and consequences to support EHS performance.
MIT's faculty, researchers, staff, and students are all responsible individually for implementing the EHS Management System, and for complying with MIT's high EHS standards as well as federal, state, and local EHS regulations, and other requirements. In addition, faculty, researchers, students and staff are expected to employ best feasible management practices to ensure a safe, healthy and environmentally sustainable campus.
The responsibility for satisfying MIT's EHS Requirements is designed to flow through the supervisory chain:
MIT has two recognition programs, "Appreciation" (spot) awards and "Infinite Mile" awards, to recognize excellent performance of academic and administrative employees in a particular area or a project to supplement the Periodic Performance Review process.
Appreciation awards are small awards - such as thank-you notes, gift certificates, lunches and other small prizes - given at the time of a specific achievement to provide immediate and spontaneous recognition of an exceptional contribution by an individual and team.
Infinite Mile awards are larger financial or non-financial awards that recognize excellent contributions to the objectives of each strategic area within the Institute. The Institute has been organized into a number of clustered groups to enable each area to customize and implement an Infinite Mile Awards program that reflects the work, values and/or behaviors specific to that area. DLCs include EHS performance as one of the criteria for determining these awards.
MIT also has an Institute-wide Rewards and Recognition Program (MIT Excellence Awards) to recognize excellent contributions to the values and goals of MIT's mission statement.An appointed Selection Committee chooses these awards annually with award categories such as "Making a Difference...in the Workplace. " EHS contributions qualify for this award as well.
MIT has a specific Institute-wide EHS Performance Award which is given to a particular DLC. EHS training and Level II Inspection metrics are reviewed over the previous year to determine the highest performing large and small DLC. For training, a rolling average of completion rates for core courses is calculated. To be considered, a DLC must have no core courses below 90% completion. For inspections, having inspected at least 80% of the total DLC spaces during the last round is used as the performance metric.
MIT has established an organizational structure with designated staff such as DLC EHS Coordinators and EHS Office Lead Contact to support DLCs in complying with EHS regulations and good EHS practices.
Members of the MIT community, including faculty members, researchers, staff,
and students, are responsible for complying with MIT's high EHS standards
as well as federal, state, and local EHS regulations and good EHS practices.
In the event any member of the MIT community fails to fulfill his or her responsibility,
appropriate consequences, as described in the Corrective
Actions and Consequences Framework / Guideline (PDF) document, apply.
Consequences in all departments, labs or centers will be applied in a way
that is consistent with MIT’s human resources or academic disciplinary
procedures. Starting in May of 2008, EHS coordinators recieved an email with
performance metrics attached if either or both of the following
There are a number of environmental, health and safety (EHS) issues to consider in establishing a new laboratory or workspace at MIT. The following sections describe EHS Rules and regulations and MIT's requirements and provide guidance on meeting these requirements while getting started doing research or work at MIT.
3.3 Potential Hazards Identification
3.4 Potential Hazards Assessment
3.5 Emergency Preparedness and Response
3.7 EHS Planning and Integration with Operations
3.8 Integrating EHS Into Operations
3.9 Establishing and Updating Targets, Objectives, and Action Plans
MIT's Environment, Health & Safety (EHS) Office manages environment, health, and safety programs and supports EHS performance including sustainability, good practices, and legal compliance throughout the MIT community. The EHS Office's Compliance Management Plan (PDF) identifies and interprets the laws, regulations, and other requirements that apply to MIT facilities and operations; describes the requirements of these regulations as applicable to MIT; and establishes a process for assigning an EHS Office staff member support and oversight responsibility to help ensure compliance with each requirement.
MIT's EHS standards and regulatory requirements are also communicated directly to affected parties through training, inspections, and audits. Education and training, addressed in Section 4, Training of this Manual, is an integral component of the EHS Management System and is a significant tool for introducing and reinforcing MIT's regulatory requirements and MIT compliance programs to individual faculty, researchers, staff, and students.
Inspections and audits, discussed in Section 6, Inspections and Audits of this Manual, further serve to communicate and reinforce regulatory requirements that are applicable to each laboratory or facility space. As each Principal Investigator/ Supervisor registers space under his or her supervision in a central database and a hazard assessment is completed, and MIT's standards and regulatory requirements that apply to each space are identified. The inspections and audits then help to ensure that the appropriate requirements are being met.
MIT's regulatory requirements are communicated to contract service providers at the time of engagement through the provision of the Contractor EHS Handbook (pdf).
Other mechanisms for ongoing communication include an EHS newsletter, the EHS website, http://web.mit.edu/environment/, campus newspapers, such as Tech Talk and The Tech, an EHS Annual Report, and DLC meetings.
Communicating with Regulatory Agencies
MIT, as a complex, diverse organization, must communicate with a multitude of federal, state, and local regulatory agencies on
a wide variety of topics and issues.
Any communications with regulatory or law enforcement agencies that concern environment, health and safety issues, or impact the whole Institute, including MIT policy, legal requirements, regulatory compliance, or the Institute's EHS performance, must be coordinated through the Environmental Programs/EHS Headquarters Office (EP/EHO) and the EHS Office. These procedures are described more fully in the EHS Communications to External Parties SOP (pdf).
Communications with regulatory agencies that are of a routine nature, such as those that occur as a normal part of the Institute operations, and that are not precedent-setting or do not impact Institute-wide policies or issues, typically are conducted directly by employees with the relevant regulatory agency personnel.
The EHS Office has established an internal SOP for Regulatory Agency Visits. The SOP describes procedures for communications with federal, state, and local agencies, such as Environmental Protection Agency, Occupational Safety and Health Administration, Nuclear Regulatory Commission, Department of Environmental Protection, Department of Public Health, Cambridge Fire Department, and Cambridge Inspectional Services.
The PI/Space Registration Process (pdf) is the primary point of entry into the EHS Management System for faculty and supervisors, and their associated use of potentially hazardous and/or regulated materials. This Process is the fundamental building block upon which the major system components of hazard/ regulatory identification and assessments, training, inspections, inventory, and emergency preparedness are based. The PI/Space Registration database is updated at least annually.
The registration process creates an entry in the PI/Space Registration database for each laboratory or other facility space and associates with that space the names of the PI or supervisor (PI/Supervisor) and the EHS Representative, a description of the type of space (lab, storage, etc.), emergency contact information, and the core hazard/regulatory types found in that space, such as chemicals, biological materials, ionizing radiation sources, non-ionizing radiation sources, flammable liquids, highly reactive materials, and large oil volumes. The emergency contact "Green Cards" that are posted outside lab spaces are generated from the information contained in the PI/Space Registration database.
The Potential Hazards Assessment SOP (pdf) is closely associated with the PI/Space Registration Process and is often completed simultaneously. The process results in a database called the Potential Hazards Inventory.
During the Potential Hazards Identification Process, the DLC EHS Coordinator and the EHS Office Lead Contact evaluate the space and activities conducted in that space to more specifically identify the various hazard types and safety equipment contained within. This process is grouped into seven categories (chemicals, chemical wastes, biological, radiation sources, non-ionizing radiation sources, safety equipment, and other) to determine where potential hazards/regulations are present in or applicable to the space. The information from this process assists the EHS Office in developing and implementing appropriate programs for periodic assessments and control of hazards, training, inspections, and prevention activities.
In addition to the Potential Hazards Identification Process, the EHS Office coordinates the annual Environmental Protection Agency (EPA) mandated SARA Title III inventory and periodic "Chemical of Interest (COI)" survey for the Department of Homeland Security (DHS). The inventory of chemicals tracked is outlined in the federal regulations, and DLCs are required to keep records of the regulated chemicals and quantities used within their spaces. .
There are a number of other specific EHS programs at MIT that identify potential hazards and regulatory requirements, such as the Occupational Safety & Health Administration (OSHA) driven Chemical Hygiene Plan Program and the Hazard Communication Program, authorizations on the use of radioactive materials, and a registration program for the use of biological agents and select agents.
The Potential Hazards Inventory is used by the DLC in coordination with the EHS Office as a starting point for identifying where hazard/regulatory assessments may be needed. Hazard/regulatory assessments are performed to determine what controls are needed to reduce, eliminate or mitigate a hazard, and comply with regulatory requirements. Hazard/regulatory controls are addressed in Section 5.1, Hazard Assessment and Control.
EHS Coordinators make initial hazard/regulatory assessments using guidance provided by the EHS Office. The EHS Lead Contact assists the EHS Coordinator as necessary, and generally takes primary responsibility for more complex hazard/regulatory assessments. If the assessment determines that controls are needed to reduce or eliminate the hazard or to meet MIT's EHS standards and/or regulatory requirements, recommendations are made to the appropriate parties, such as the DLC EHS Coordinator, PI/Supervisor, and/or Department of Facilities to address the hazards and requirements.
In some cases, a hazard assessment may determine that a Standard Operating Procedure (SOP) is needed to prevent potential regulatory violations or EHS incidents. This process of determining when it is necessary to create an SOP is, itself, documented in an SOP. In addition to SOPs, EHS has developed Standard Operating Guidelines (SOGs) and fact sheets to help guide the program.
MIT EHs Office has also defined a uniform format and procedure for developing, approving, and implementing SOPs/SOGs/fact sheets to ensure consistency and quality across all efforts.
The standard format and a list of EHS-related SOPs, SOGs and other documents are available online at mit.edu/environment/ehs/topic/sops.html
MIT conducts a variety of monitoring and measurement activities of workplace conditions to sustain compliance, protect student, staff, employee, and community health and safety, and to safeguard the environment. Because monitoring is often conducted to measure exposure to a hazard, monitoring and measurement activities are an important part of the hazard assessment process. Different groups at MIT perform monitoring and measurement activities, as described below.
The Department of Facilities conducts or oversees monitoring performed to assure compliance with some environmental regulations that relate to facilities operations such as:
The technical programs and service teams within the EHS Office conduct a wide variety of initiatives and programs that involve monitoring and measurements to sustain regulatory compliance and protect human health and the environment. These are described below:
Continuous monitoring systems are also in place where certain toxic gases are in use. If measurements exceed a pre-determined level, an alarm is triggered and the building is evacuated. There is a set procedure to follow to evaluate the situation before re-entry is permitted.
Noise monitoring is performed under MIT's Hearing Conservation Program.
IHP conducts a laboratory ventilation monitoring program for fume hoods and local ventilation systems. This program includes both an initial evaluation and ongoing measurements to assure systems are operating as designed, and their operation is sufficient to control the hazards.
This team provides oversight to assure EHS-MS organizational structure is implemented and maintained, and facilitates the DLC EHS Coordinator and EHS Lead Contact relationship through periodic meetings and communications. This team also oversees the PI/Space Registration process. This team also provides advice and direction regarding professional development needs of the EHS Office Staff and EHS Coordinators.
This team provides oversight to implementation and maintenance of the inspection and audit program.
This Team provides oversight for all EHS training needs, assists in the development of new EHS training courses, assists in the development and update of the Training Needs Assessment, and tracks the maintenance of the database used for managing official training records.
This Team provides oversight for the 24-hour emergency response services provided by the EHS Office; the coordination of the EHS responses with MIT's Emergency Response Group, and oversight of the emergency response follow-up process.
This Team formally collaborates with the Department of Facilities and DLCs to assure that EHS requirements and concerns are addressed systematically in new construction and renovation projects at MIT.
This Team has oversight for the development and maintenance of the technology needed to support EHS activities, including EHS web resources, the EHS Office intranet, and all databases associated with the EHS-MS. This team may continue in the EHS Office or its service maybe provided by a central Information Services and Technology group or a contractor over time.
This Team works to promote effective and timely communication among all the EHS stakeholders across the Institute and MIT community to improve EHS performance. Central to this objective is the development and oversight of the EHS Communication Plan and EHS Office Newsletter.
When the hazard assessment process indicates a potential EHS regulatory impact, an evaluation to implement engineering controls to prevent or reduce workplace exposures or minimize compliance issues is conducted. These controls are designed to be part of the space (for new spaces) or retrofit (for existing spaces). Examples of engineering controls include: fume hoods, secondary containment for tanks and containers, neutralization systems for wastewater discharges, and others. These controls are typically implemented or overseen by the Department of Facilities, the EHS Office, or both, in conjunction with external consultants and/or contractors.
MIT has an Emergency Preparedness and Response Program to respond to EHS emergencies on campus. The Program is integrated into the overall structure and culture of the MIT community. A key component of this program is the Emergency Operations Plan.
The EHS Office provides full-time, around-the-clock emergency response support and service to the MIT community. Emergency EHS services can be obtained by calling the EHS Office at 617-452-3477 (2-EHSS) during business hours or by dialing 617-253-1500 off hours. The EHS emergency response system consists of a primary on-call point person and, as needed, assistance from team members from the Biosafety, Environmental Management, Industrial Hygiene, Radiation Protection, and Safety Programs to address the issues of concern during an emergency. Refer to the MIT EHS Response System SOP.
MIT's EHS Office has developed standard procedures for responding to spills of hazardous materials. The Spill Response Procedures SOP provides guidance on how to differentiate minor spills and major spills, and defines each type of spill to clarify response procedures. Major spills require immediate notification to the MIT Police or the MIT Operations Center, or both, who are then required to contact the EHS Office or the Cambridge Fire Department. The Environmental Management Program in the EHS Office determines whether external reporting is necessary.
MIT has a robust agenda of positive environmental initiatives to make our campus more sustainable and to reduce pollution. Please see The Environment at MIT's Commitment Section for details.As part of its commitment to excellence in environment, health, and safety stewardship on our campus, MIT adopts and implements policies and practices that reduce or eliminate the use of hazardous materials and the generation of waste streams (both hazardous and non-hazardous) whenever possible. The EHS Office is responsible for programs of regulatory compliance and sustainability (including Pollution Prevention) and approaches this work in a comprehensive and integrated manner. The Environmental Programs/EHS Headquarters Office (EP/EHO) and EHS Office actively collaborates with DLCs and student groups to reduce the volume and toxicity of the Institute's waste streams. This approach and the following goals frame MIT's Pollution Prevention Plan:
MIT implements a broad spectrum of pollution prevention projects in support of these goals (see Also of Interest). Members of the EP/EHO and Departments, Labs, and Centers comprise teams that develop and steer pollution prevention efforts, engage stakeholders from DLCs and other groups who are potentially affected by or may bring expertise to the project, and determine metrics to assess the project's success in meeting pollution prevention goals. MIT's commitment to pollution prevention both contributes to and draws from the enthusiasm and momentum of groups within the Institute as well as the greater Cambridge/Boston community. A partial listing of these groups and their respective projects can be found at http://web.mit.edu/environment/commitment/involved.html.
MIT's EHS Policy describes and communicates the Institute's commitment to excellence in environment, health, and safety stewardship. Consistent with this objective, the Institute directly considers and seeks to mitigate the EHS impacts of its operations by integrating EHS criteria into its planning and decision-making processes.
The Environmental Programs/EHS Headquarters Office (EP/EHO), through the Managing Director for EHS Programs, participates in Institute-wide EHS planning and policy-making, and together with the EHS Council is responsible for overseeing overall EHS policy implementation, including regulatory compliance, and EHS initiatives. Members of the EP/EHO and EHS Office conduct internal management review of the EHS Management System. In addition, theEP/EHO is responsible for developing, implementing, and managing the vision, strategic direction, and oversight of the EHS Office. The creation of a high-level EP/EHO, overseen by a senior administrator reporting directly to the Executive Vice President, with dotted line reporting to Provost, and Chancellor, demonstrates the Institute's commitment to environmental stewardship and compliance. This organizational structure effectively leverages MIT's resources to have lasting, Institute-wide impact, and is consistent with the objectives set out in the EHS Policy.
Further integration of EHS issues into MIT planning, decision-making, and operations is achieved through the use of specialized EHS Councils and Committees as outlined in Section 2, Roles and Responsibilities of this Manual.
EHS considerations are integrated into Institute-wide operations at two levels. One level addresses existing physical spaces or buildings, and operations; the other addresses new or modified buildings and operations.
Existing Buildings and Operations. The process for ensuring that EHS requirements are integrated into existing buildings and operations involves several linked components. These include EHS training; PI/Space registration; hazard/regulatory identification, assessment, and control; incident and non-compliance investigations; inspections and audits; and the EHS Office communications activities.
Through the corrective action process, EHS issues are identified, communicated, tracked, and remediated. This integrated and on-going process allows for identifying and acting upon opportunities for continual improvement of EHS performance. When a potential problem or opportunity for improvement is identified, the EHS Office conducts an investigation resulting in a communication or report to the DLC with findings and recommendations.
New and Modified Buildings and Operations. EHS requirements and considerations are integrated into the planning, design, and construction of new and renovated buildings and operations through the Laboratory and Facility Design and Construction Review Process. For new spaces (including new construction, renovations, and space changes), the EHS Office works closely as a member of the design and construction project team with the Department of Facilities, the client DLC, and external designers and construction firms. EHS Office participation on the project team is through the auspices of the EHS Laboratory and Facility Design and Construction Review Services (pdf). Once a project is identified, the team leader assembles an EHS Project Review Team and assigns an EHS Point Person.
The EHS Laboratory and Facility Design and Construction Review Services team leader provides direction and oversight to the review process and to the EHS Office Construction Safety Program; works with the overall Project Manager to resolve issues and report significant impacts to MIT management; and coordinates the transfer of EHS responsibility to the EHS Lead Contact and DLC EHS Coordinator following building commission and occupancy.
Taking MIT's EHS Policy to a greater level of specificity, Institute-wide EHS objectives are established in the MIT EHS Policy, and focus on EHS stewardship, sustainability, compliance, accountability, opportunity, and performance. The EHS Policy is reviewed periodically and modified, as needed, by the Institute Council on Environment, Health and Safety and approved by the Academic Council of MIT, if required.
The Environmental Programs/EHS Headquarters Office (EP/EHO) sets vision and
high-level environment, health and safety objectives and goals for the central
administration of MIT and brings Institute-wide goals and objectives to respective
Institute Committees for endorsement.
In addition, if systemic compliance problems are identified within any DLC or
contractor operations, the EHS Management Systems requires the development of
an action plan to address the problem. The action plan must include steps to
be taken to investigate and remedy the problem, including tracking and reporting
status. The EHS Office and DLC EHS Coordinators and Committees monitor the implementation
and effectiveness of these additional action plans.
The Deputy Director for Sustainability Programs in the EP/EHO works with
key Institute administration to establish Institute-wide sustainability goals.
The Pollution Prevention
Plan helps establish
interim performance targets and provides a general framework for developing
sustainability action plans, setting targets and establishing timeframes for
meeting P2 and sustainability goals.
Refresher training, also called retraining, may be required periodically if the trainee is engaged in specific activities. The EHS Office and DLC EHS Coordinators track the required training and retraining, and MIT personnel are informed when their retraining is due. A training needs assessment pairs regulated activities to training requirements. An expiration date is listed for those trainings where refresher training is required.
Individuals who intend to engage in EHS-regulated activity at MIT must register for training via the web-based EHS Training Needs Assessment. This includes MIT faculty, employees, researchers, students, and visiting scientists. Training needs for operational employees in the Department of Facilities, the Division of Student Life, the Division of Comparative Medicine, and some sub-groups at Lincoln Laboratory are determined by their job title or function instead of the Training Needs Assessment.
4.1 Determining Training Needs
The Training Needs Assessment is a web-based tool used by MIT to identify individuals engaged in regulated activities; assess the types and levels of EHS risks they may encounter and regulations that apply to their activities; and create and track a customized training program for each individual. The assessment creates and tracks individual training programs based on different criteria such as departmental or EHS activity or job title.
The EHS Coordinator may assist a PI in completing the Training Needs Assessment. That assistance should be provided as follows:
An employee with a designated role within the EHS Office must receive training appropriate to that role. For example, EHS Office Lead Contacts must complete the training program designed to give the Lead Contacts the tools necessary to carryout that function. A list of training requirements for EHS Office roles can be found in the EHS Cross Training Table.
The training system has the ability to link training requirements for students registered in an undergraduate academic lab course. The new capability provides instructors with the ability to monitor and run reports on the group of students enrolled in their courses. EHS Office personnel work with instructors to determine which EHS training modules are required for their courses. The training rules are then added to the training needs assessment so that when students who are registered for that course go to their EHS Training summary page, the requirements are listed automatically without the need for doing the self assessment. The EHS training modules completed from enrollment in an academic course are added to those required by completing a self assessment in the training needs assessment so they do not need to be repeated, which is a common experience for UROP students.
The special group-based training requirements can be used when none of the other methods for determining EHS training requirements such as self-assessment, department-specific training requirements, job title-based requirements, or academic course-based requirements are appropriate.
There are certain regulated activities that require a participating individual to have specific training before engaging in that regulated activity. A few examples of these regulated activities and their training requirements are outlined below. A complete list of regulated activities can be found at http://web.mit.edu/environment/pdf/TrainNeedsAssess.pdf.
| Regulated Activity | Required Training Course | Retraining |
|---|---|---|
| Working with chemicals in a laboratory | General Chemical Hygiene | Initial Only |
| Lab-Specific Chemical Hygiene | Annual | |
| Managing Hazardous Waste | Annual | |
| Working with Class 3b or 4 lasers | Laser Safety Training | Initial Only |
| Working with radioactive materials | Radioactive Materials Safety Training | Biennial |
| Handling human materials | Bloodborne Pathogen Training | Annual |
In addition to providing the regulatory-driven required EHS training, MIT's goal is to promote good practices to advance overall excellence in the workplace and learning environment. To this end, the Institute actively promotes training and awareness in elective practices that support implementation of the EHS Management System; the Institute's EHS policy; and MIT's goals for a sustainable campus. The Institute's general environmental web portal showcases all the resources available for implementing the Institute's EHS Policy and promoting good practices.
MIT has developed an EHS-MS awareness program that focuses on Institute EHS Policy and management system implementation roles for different groups within the Institute.
MIT has several mechanisms through which the required EHS training can be received. The course content in each of the methods remains the same for each required course. If only a classroom-based course is available to a trainee, then the trainee is directed via the web to the on-line class registration tool, or directed to a contact person to coordinate the training.
If a web-based training course is available and allowed by their DLC(s), the trainees can proceed directly to the course(s) after the Training Needs Assessment is completed. Some DLCs require live training as well as permitting web-based training. The core content is consistent in each method. When the web-based training course is successfully completed, the results of the training are automatically captured in the EHS Central Training Records Database.
After the Training Needs Assessment is completed, the trainees can access the schedule for classroom-based training courses offered by both the EHS Office and specific DLCs. The content for these classes is broadly applicable throughout DLCs and is the same as the web-based training, but delivered in a classroom format where the trainee can interact with the instructor. The instructor is responsible for submitting training attendance documentation to the EHS or DLC Training Registrar for uploading to the Central Training Records Database.
Laboratory and/or workplace-targeted EHS training is provided directly by the PI/Supervisor, EHS Representative or other designated individual to meet these specialized training needs and requirements. The EHS Coordinator submits the training attendance documentation to the EHS Office for inclusion in the EHS Central Training Records Database.
Information captured by the EHS Central Training Records Database includes, but is not limited to:
MIT uses a central 'roles' database to administer authorizations for access to secure information across the Institute. For the EHS Central Training Records Database, DLC Heads/Directors, DLC EHS Coordinators, EHS Coordinator administrative designees, and DLC PIs/Supervisors, have roles recognized by the system that enable them to access training information for their specific DLC. EHS Office Lead Contacts have access to the entire training records database. The roles database also designates different access permissions that can be granted to a person in a role, such as "view only", "run reports", or "maintain information". Having a flexible set of roles and permissions enables the system to be optimized to the work requirements in each DLC. To ensure proper controls, Department Heads/Directors, PIs/Supervisors, and EHS Representatives are not granted permission to update training records in the EHS Central Training Records Database. DLC EHS Coordinators and their administrative designees are granted permission to update records for their DLCs.
The ability to generate specific reports on training status is available via the EHS Central Training Records Database. Authorized DLC personnel can access training status information via a set of standard reports about trainees; trainee needs assessments; courses that have not been completed; and courses that have been completed. These standard reports have been designed based on the needs and inputs of the following data users: EHS Representatives, PIs/Supervisors, DLC EHS Coordinators, EHS Office Lead Contacts, and other EHS Office personnel. DLC personnel can submit requests for additional types of training reports to the EHS Office Lead Contact via their DLC EHS Coordinator, who will then queue the request for future system development.
Trainee data generated by the EHS training program is routinely archived and purged of outdated information to ensure a robust and accurate dataset. The periodicity of archiving and purging is determined by the EHS Office to foster accurate information and to the extent feasible takes into consideration the annual academic year cycles for students and staff appointments, and the need for regular purging of inactive students, staff, and employees from the system. Up to twice a year, the EHS Training Services Team will facilitate training affiliations data clean up by contacting the PI and EHS Representatives for lab groups to have them validate the list of people working in their lab and then to have them de-affiliate those who are no longer working in their lab. EHS training records are archived and will be retained for a to-be-determined period according to regulatory requirements or MIT determined best practice, and then purged.
Training Reconcilers, most often EHS Coordinators and EHS Representatives, can directly confirm and update the list of those who work in their labs and work areas who require EHS training. Twice a year the system emails the "Training Reconciler" for a PI or DLC to remind them to complete training reconciliation for their lab groups within 30 days. The Training Reconciler goes into the on-line Training Reconciliation system to confirm and update the accuracy of those who are affiliated with their PI(s)/Supervisor(s) during the TNA, adding anyone missing from the database and inactivating anyone no longer working in the area. When a person is added to the list, the system sends the new person an email as a reminder to immediately complete their Training Needs Assessment. The default months for training reconciliation reminders are October and June. A DLC may change the months to the two best that fit their calendar. Training reconciliation can be done at any time but the default reminder cycle is as described above.
For those who still have active Kerberos usernames, their training records can be found through the normal EHSWEB or BrioQuery training reports. Once a person’s Kerberos username is retired, their records can be found through an archive report on EHSWEB training administrator’s page. A snapshot of the system is taken on a regular basis and those are the records that are available.
The Environment, Health and Safety (EHS) Office develops and delivers EHS services to ensure compliance and promote best management practices throughout all the Institute's day-to-day operations. The services provided include: EHS program development and implementation; technical consultation and advice; and tactical and operational implementation of the EHS Management System (EHS-MS). Central to the EHS Office's function to ensure sound environmental practices, and a safe and healthy campus, is a focus on identifying, assessing, mitigating, and controlling the potential hazards and regulatory requirements associated with all the academic and operational activities of the Institute.
5.1 Hazard Assessment and Control
5.2 EHS Office Programs, Services, and Service Teams
5.3 Documentation, Records, and Data Management
An essential component of the EHS Management System is the ongoing processes and procedures for identifying, assessing, mitigating, and controlling potential EHS hazards and identifying EHS regulatory requirements that exist throughout the MIT campus. These systems for identifying hazards and regulatory requirements include the PI/Space Registration Program described in Section 3, Getting Started, and the Inspection and Audit Program described in Section 6, Inspections and Audits.
Hazard/regulatory assessments are performed within MIT spaces when:
Assessments are done by PI/Supervisors, EHS Representatives, DLC EHS Coordinators, or EHS Office professional staff. The objective of an assessment is to determine if improvements are needed in: guidance, procedures, training, engineering or administrative controls, facility or equipment maintenance, or enforcement of policies to reduce or eliminate EHS impacts.
Hazard/regulatory assessments by EHS Office staff are initiated through four primary channels:
When a hazard/regulatory assessment results in a determination that improved controls are needed, a report is written that includes recommendations for the type of controls needed. The report is sent to the affected party, (usually a PI/Supervisor), with a copy sent to the DLC EHS Coordinator. Controls may involve a need for action by the DLC, a need for EHS Office services, or a combination of both. When the DLC must take action, it is the responsibility of the affected party to ensure the controls are implemented. The DLC EHS Coordinator is responsible for providing assistance to the affected party and tracking action to ensure the controls are implemented. When there is a need for EHS Office services, the Director of the EHS Office ensures appropriate follow-up action is initiated.
The services provided by the EHS Office promote day-to-day good practices, compliance-related activities, and initiatives that advance MIT's commitment to environmental sustainability and health and safety excellence. These services are designed to fully support all aspects of the Institute's EHS-MS.
EHS Office services are delivered to DLCs through teams of specially chosen professionals from each technical program area to create a customized service team for each DLC. The EHS Office is organized around five technical programs: Biosafety, Environmental Management, Industrial Hygiene, Radiation Protection, and Safety. The DLC can request services by contacting their EHS Lead Contact, contacting a member of the DLC EHS Team, or by calling the EHS Office (617-452-3477) during office hours. Off hours, EHS services are available for emergencies and can be obtained by calling the campus emergency numbers: 100 or 617-253-1500. For details regarding the EHS programs and EHS services see: EHS brochure.
The EHS Office has also established cross-functional service teams to better leverage the diverse technical expertise of the EHS Office and address the requirements of the EHS-MS. The service teams include:
This Team provides oversight to ensure EHS-MS organizational structure is implemented and maintained and facilitates DLC EHS Coordinator and EHS Lead Contact relationship through establishing periodic meetings and communications. This team also oversees the PI/Space Registration process. This team also provides advice and direction regarding professional development needs of the EHS Office Staff and EHS Coordinators.
This Team provides oversight for the implementation and maintenance of the inspection and audit program.
This Team provides oversight for all EHS training needs, assists in the development of new EHS training courses, assists in the development and update of the Training Needs Assessment, and tracks the maintenance of the database used for managing official training records.
This Team provides oversight for the 24-hour emergency response services provided by the EHS Office; the coordination of the EHS responses with MIT's Emergency Response Group; and oversight of the emergency response follow-up process.
This Team formally collaborates with the Department of Facilities and DLCs to ensure that EHS requirements and concerns are addressed systematically in new construction and renovation projects at MIT.
This Team has oversight for the development and maintenance of the technology needed to support EHS activities, including EHS web resources, the EHS Office intranet, and all databases associated with the EHS-MS.
This Team works to promote effective and timely communication among all the EHS stakeholders across the Institute and MIT community to improve EHS performance. Central to this objective is the development and oversight of the EHS Communication Plan and EHS Office Newsletter.
The EHS Office currently has several systems for managing documents, records, and other data. The EHS Office in conjunction with the DLCs is continuously assessing and upgrading its information management systems to improve efficiency, accuracy, and the delivery of services. The EHS Office is also progressing towards the conversion of paper-based systems to more effective electronic systems that allow for better integration and accountability.
Core to the implementation of the EHS-MS is the concerted effort across the Institute to capture, codify, and disseminate written documentation on the EHS programs, services, and standard operating procedures available for addressing MIT's high EHS standards, EHS hazards and regulatory requirements, communicating regulatory requirements, and promoting the adoption of good EHS practices. The process for determining what written documentation is needed is described in Section 3.4.1, SOP Assessment. Once the need for documenting a procedure, activity, program or issue is established, there is a process in-place for determining the most appropriate type of document, and a process for planning the writing, reviewing, communicating, implementing, and updating the document. The different types of documentation include written program descriptions, standard operating procedures, standard operating guidelines, and fact sheets. The primary means of making these documents available to the MIT community is by posting them to the EHS Office web site. They are linked in a multiple fashion so that individuals searching for information can readily find what they are looking for.
Appropriate records are maintained to ensure compliance with EHS regulatory requirements, MIT's high EHS standards and good practices. Records may be maintained as either paper files or electronic files. The EHS Office recognizes that it is good business practice to retain records in a consistent, systematic and reliable manner so that they can be retrieved promptly when required for legal, regulatory or operational reasons. The EHS Office has determined the types of records that must be maintained, and the time period over which the records must be available. The EHS Records Management Program has been developed to provide management direction and support throughout the records lifecycle. The objectives and details of this program are covered in the EHS Records Retention Standard Operating Procedure, and Records Retention Schedule.
Currently, there are several database components that support EHS activities on campus. They are the PI/Space Registration Database, described in Section 3, Getting Started, the Training Database, described in Section 4, Training, the Inspections Database, described in Section 6 Inspections and Audits, and the Incidents Database, described in Section 6.2 EHS Incident and Non-Compliance Investigations. The PI/Space Registration, Training, and Inspections databases can be accessed by DLC staff providing EHS support, such as DLC EHS Coordinators, and DLC EHS Representatives; and by EHS Office staff for purposes of entering information, viewing information, and reporting information. The Supervisor's Injury Report system is accessible to supervisors to report injuries via the web, while the Non-injury Incidents database is maintained by EHS Office Staff.
Using the EHS Roles and Responsibilities Database, the EHS Office maintains a database of all regulatory program areas that clearly identifies the individual assigned to oversee that program. The EHS Office also has a number of databases that support the specific programmatic area activities, such as hazardous waste manifests, biological research protocols or authorizations for working with ionizing radiation. The purpose of these databases is to manage the information required to deliver the program-specific core services.
The inspection, audit, and incident investigation programs provide a coordinated and consistent mechanism across the MIT campus for both local and central MIT EHS staff to assess performance, correct problems, and prioritize areas for improvement with respect to environment, health and safety. These programs also serve as an essential conduit for educating the MIT community in EHS issues, requirements, and good practices.
6.1 Inspection and Audit Program
6.2 EHS Incident and Non-Compliance Investigations
At MIT, the Inspection and Audit Program consists of a three-tiered system for inspection and evaluation targeting all levels of organization throughout MIT for EHS concerns.
The first tier (Level I) is a self-inspection program consisting of weekly inspections conducted by DLC EHS Representatives or their designees. Level I Inspections must be conducted in those areas which contain Satellite Accumulation Areas (SAA) while inspections of other labs or facilities will occur on a schedule determined by the EHS Office and DLC. A Level I Inspection Checklist has been developed for laboratories that includes sections on environmental management, including satellite accumulation areas; health; safety; and emergency response. The EHS Office manages the Institute's "less than 90 day" hazardous waste storage areas that are also inspected on a weekly basis. If a problem is identified in this level of inspection action can be taken to correct the problem at the time of the inspection. For those findings not readily correctable, the PI or Supervisor must develop and initiate an action plan to correct the problem. The inspection process is designed to ensure that DLCs make consistent checks of key components in their work areas essential for maintenance of the EHS program, and foster good working habits with respect to the environment, health and safety. A review of the self-inspection system is performed when the more comprehensive Level II inspections are carried out. Records of these Level I inspections are not required to be kept, although some DLCs may elect to do so.
The second tier is a DLC-wide inspection, called Level II Inspections, performed twice a year by a team consisting of the DLC EHS Coordinator and other parties selected by the EHS Coordinator. For some operational areas within the Division of Comparative Medicine, Division of Student Life and Department of Facilities inspections are done on an appropriate periodic basis as determined by the DLC and the EHS Office. At least once a year, one member of the team will be the EHS Lead Contact or other EHS office representative. A Level II Inspection SOP has been developed and must be followed when conducting this inspection. The DLC EHS Coordinator will provide a comprehensive report on findings and recommendations to the appropriate parties for action. In addition, as part of Level II Inspections, EHS Office staff will be reviewing some specific supplemental topics. These supplemental review components will be developed to assess different local program effectiveness. This may be done at the time of joint Level II Inspections with the EHS Coordinator, or independently. EHS Office staff will be responsible for compiling a report on these supplemental inspection topics.
The third tier is an Institute-wide or targeted systems or compliance audit examining the overall implementation and effectiveness of the EHS Management System. The MIT Audit Division and/or an outside consultant will audit MIT's EHS-MS biennially. A level III SOP has been developed and is followed when conducting these audits. A summary of the audit results will be included in the annual Environmental Programs/EHS Headquarters (EP/EHO) and EHS Office report to the President and will be distributed to the Institute Council on EHS and all DLCs. The EHS Office oversees implementation of the recommendations emanating from the systems audit. In addition, as part of the process for evaluating the EHS Management System, there will be an internal management review conducted by members of the EP/EHO, EHS Office and the EHS-MS Leadership Committee at least annually. At the time of the management review, the review team will:
When accidents or incidents occur, or events of non-compliance are observed, it is important to investigate to determine the root cause or causes, and to initiate and confirm completion of appropriate corrective action.
Accidents or incidents involving injuries, and illnesses to employees, are part of the OSHA reporting and record keeping procedures, as described in the Injuries and Illnesses OSHA Reporting SOP.
Incidents involving potential harm to the environment, such as a major chemical or oil spill, are to be reported to the EHS Office immediately. Please see Spill Response Procedures SOP for definition of major spills. The EHS Office has in place procedures for emergency response and for notifying the appropriate agencies regarding such incidents. Procedures for contacting regulatory agencies are described in the EHS Communications to External Parties SOP.
Accidents and incidents are investigated at different levels of detail, depending on their severity. Emergencies are investigated by the EHS Office and selected DLC representatives to determine the cause of the emergency, equipment malfunction, or operating procedure problem. A Root Cause Analysis is completed to determine root causes or contributing causes of the incident, underlying factors, and the roles that design, skills, maintenance, and procedures played in the occurrence of the incident. The EHS Office develops a report with recommendations for corrective action, and coordinates with the affected parties to ensure that the corrective measures are carried out. When corrective action is required by the DLC, the EHS Coordinator is responsible for initiating and confirming completion of the corrective action. When corrective action is required by the EHS Office, or by the MIT administration, EHS Office management initiates and confirms completion of the corrective action.
For employee injury and illness, the DLC PIs/Supervisors investigate the accidents and complete the Supervisors' Report of Occupational Injury/Illness. The EHS Office and the DLC may investigate certain accidents in greater detail if needed.
An After Action Review can be initiated by the Managing Director of Environmental Programs/EHS Headquarters Office (EP/EHO), EHS Office Director, or Emergency and Business Continuity Planner for the Security and Emergency Management Office (SEMO) after an incident to determine the level and quality of response from the DLCs involved. The After Action Review report is completed by a team assembled by the EHS Office after the incident and includes:
Where corrective actions (including non-compliance or non-conformance items) are identified through the After Action Review, the After Action Review team and the DLC representatives are responsible for:
Effective communication is an important part of the EHS Management System (EHS-MS). MIT has developed comprehensive communication mechanisms within the EHS-MS to ensure that the information needed to implement MIT's EHS Policy reaches the MIT community. The ultimate objective of these communication mechanisms is to promote the full integration of the MIT EHS Policy and EHS Management System into research and work processes to ensure compliance and promote achievement of MIT's high EHS standards. Clear and effective channels for communication are essential to ensure awareness and understanding of EHS regulatory requirements, the components and operation of the EHS-MS, and of the supplemental programs, plans, and procedures established at MIT to address EHS issues.
As a leading educational institution, MIT strives to serve as a role model for other institutions and the community at large. MIT is an incubator of ideas, including ideas regarding improved systems or technologies that may protect the environment or reduce the negative human impact on the environment. Communicating these new MIT ideas and approaches related to environment, health, and safety is one component of the EHS-MS communication system that can serve other institutions, neighboring communities, and beyond.
As an institution subject to EHS regulatory requirements, another important component of the communication program is to ensure MIT has well-defined procedures in place for communicating with the regulatory community. These procedures address communicating both compliance problems and achievements, as well as obtaining information for interpreting regulations or guidelines.
7.1 EHS-MS Organizational Structure and Communications
7.2 Communications Service Team (CST)
7.4 Communications with Regulatory Agencies
7.5 Community Involvement and Outreach
The MIT EHS-MS organizational structure was designed with the importance of effective communications in mind. A key aspect of the organizational structure is the EHS Coordinator and Lead Contact relationship. This relationship was created to facilitate important communications from the EHS Office to the DLC community, and vice versa. Another important aspect of the organizational structure is the creation of both MIT-wide and DLC-specific EHS committees. Each DLC must establish an internal EHS Committee, and the Institute has several key EHS committees, as outlined in Section 2, Roles and Responsibilities. These Committees provide an opportunity for the EHS Office to communicate EHS concerns, programs, projects, and regulatory updates, as well as provide an opportunity for DLCs to provide feedback regarding the impacts, effectiveness, and problems with both the EHS-MS and specific programs established to assure EHS compliance.
To ensure effective communication as part of the EHS-MS, the EHS Office has established a "Communications Service Team." The purpose of this team is to identify and plan for EHS-MS communication needs, and to initiate action or provide assistance to ensure these needs are met.
The Communications Service Team determines the EHS communication needs for the MIT community based, in part, on input from the program groups within the EHS Office, and input from the DLCs, and develops a comprehensive Communications Plan for meeting those needs. The Plan identifies the stakeholders or target audience of the communicated information, and the responsible parties within the EHS Office or the MIT community charged with ensuring the communication is carried out. The Plan is reviewed and updated routinely during the year to ensure communication needs are addressed in a timely and effective manner.
The Communications Service Team is also responsible for the periodic newsletter EHS News and Views that provides information on various EHS topics and activities, and is distributed to key personnel on campus via printed copy and the World Wide Web. EHS News and Views also serves as a vehicle for communication of MIT EHS activities to the wider community, other universities, and outside organizations through the use of an extensive mailing list.
The Communications Service Team initiates and maintains ties to other communication resources on campus such as the MIT News Office weekly newspaper, Tech Talk, and the twice-weekly student newspaper, The Tech. Periodically, the Communications Service Team will submit information or articles for publication in these campus newspapers to enhance understanding of EHS issues. The Communications Service Team also maintains linkages with communications personnel in other departments and offices on campus, such as the Department of Facilities.
In addition, the Communications Service Team coordinates EHS Office participation in campus wide fairs and activities such as the annual Vendor Fair in September, the Events Fair in November, The Transportation Fair in March, and the Earth Day Fair in April. Generally, the EHS Office has a booth at these fairs with activities and information to promote awareness of the EHS Office, the EHS Management System, and EHS issues.
Periodically, the Communications Service Team coordinates EHS Office participation in special community wide events such as the Cambridge Science Festival, an annual festival established in 2007. In addition, the EHS Office holds special events such as open houses and outreach surveys that are led or supported by the Communications Service Team.
Personal communication between EHS Office staff and EHS clients is recognized as the most effective form of communication. A variety of tools are also available through the EHS Office to promote effective communication and information sharing. These tools include:
The Environment at MIT Web Site
Within the EHS-MS and Environment
at MIT web site,
comprehensive information is posted regarding the EHS-MS, MIT EHS-related
programs, documents, and positive initiatives. It is a significant
and strategic vehicle for communicating with the MIT community. The web site
reinforces the comprehensive and integrated approach that MIT takes to EHS
stewardship. The web site is also used as a mechanism for soliciting and collecting
comments, questions, and service calls from the MIT community through the use
of automated e-mail and feedback forms.
The EHS Office Intranet
The EHS Office intranet (EHSNet) is a mechanism for information sharing and
management, and communicating among EHS Office personnel. EHSNet provides
controlled access to shared EHS electronic files, databases, contact information,
mailing lists, and calendar information.
The EHS newsletter
For EHS News and Views see section 7.2.2
Calendars Several calendars are maintained to track EHS activities. The Environment at MIT web site has a Calendar of Events noting special seminars and lectures on EHS topics. The EHSNet intranet has an EHS Events Calendar noting meetings and events for the EHS Office as well as for the communications plan calendar.
Meetings
Routine meetings are held for EHS Coordinators and EHS Lead Contacts to facilitate their interaction and share information.
Other meetings are organized, as needed, when there is an important matter to communicate.
The EHS Office phone number
There is a single phone number (617-452-3477) through which all personnel at the EHS Office can be contacted during regular
work hours. As outlined in Section 3, Getting Started, the EHS Office also provides 24-hour emergency response services.
Effective communication with regulatory agencies is a critical component of implementing the EHS-MS. The Management System is designed to accommodate and facilitate two-way communications between MIT EHS personnel and local, state, and federal regulatory authorities. Open and clear channels of communication are important to convey information on compliance-related issues, good practices, and regulatory questions and interpretations.
Because timely and effective communication with regulators is crucial for effective EHS performance, communication requirements have been included in key standard operating procedures (SOPs) to clarify roles and responsibilities, and thresholds for contacting regulatory authorities. Communications for regulatory agent visits are addressed in SOP EHS-0006, "Regulatory Agent Visits". Communications with the Occupational Safety and Health Administration (OSHA) to report serious injuries or fatalities are addressed in SOP EHS-0008, "Reporting Work Related Injuries and Illnesses". Communications to appropriate regulatory agencies to report spills or releases to the environment are addressed in SOP EHS-0004, "Spill Response and Release Procedures". In addition, to enhance the effectiveness of regulators contacting MIT personnel, SOPs have been developed to ensure that regulators who call on MIT are quickly and efficiently routed to the appropriate personnel or resources. More detailed information on managing communications with regulators can be found in EHS Communications to External Parties SOP.
MIT's EHS Policy clearly articulates the Institute's commitment to the well-being of the community in which it operates. Acting on this commitment, MIT participates in numerous community-focused activities that promote sound EHS practices and performance. The following select examples showcase the variety of MIT community-focused EHS activities:
Other recent activities have included:
* This project was undertaken by MIT in connection with the settlement of an enforcement action brought by the U.S. Environmental Protection Agency and the U.S. Department of Justice for alleged violations of the Federal Clean Water Act, the Clean Air Act, and the Resource Conservation and Recovery Act. There was no actual harm to the environment.
Printed on Mon Nov 23 04:58:05 2009
Document URL: http://informit.mit.edu/ehs-ms/home.html