OSHA requirements are set by statute, standards and regulations. Our interpretation letters explain these requirements and how they apply to particular circumstances, but they cannot create additional employer obligations. This letter constitutes OSHA's interpretation of the requirements discussed. Note that our enforcement guidance may be affected by changes to OSHA rules. Also, from time to time we update our guidance in response to new information. To keep apprised of such developments, you can consult OSHA's website at http://www.osha.gov.

June 23, 2005

Dr. Paul Jonmaire, Ph.D.
Corporate Health and Safety Director
Ecology and Environment, Inc.
Buffalo Corporate Center
368 Pleasant View Drive
Lancaster, NY 14086

Dear Dr. Jonmaire:

Thank you for your January 18, 2005, letter to the Occupational Safety and Health Administration (OSHA) conveying your concern regarding the criteria for and training of the Safety Officer (Official) per the requirements of the Hazardous Waste Operations and Emergency Response (HAZWOPER) standard, 29 CFR 1910.120, and as discussed in OSHA's
Best Practices for Hospital-based First Receivers guidance document. This letter constitutes OSHA's interpretation only of the requirements discussed and may not be applicable to any situation not delineated within your original correspondence.

All hospital personnel who are expected to take part in emergency responses to releases of hazardous substances must be trained in accordance with 29 CFR 1910.120(q). HAZWOPER is a performance-based standard that allows employers flexibility in meeting the requirements of the regulation. The level and type of training that an employer is required to provide to employees under the standard is to be based on reasonably anticipated worst-case scenarios. The Safety Official's (SO) role and function and, therefore, their expected level and type of training, is largely dependent on whether the SO will be:

 

 

  • involved with only in-house releases of a hazardous substance (e.g., EtO); or
  • in addition to in-house releases, they will also be involved in community-wide emergency responses where the hospital is a Local Emergency Planning Committee (LEPC) designated facility for mass-casualty victims; or
  • if they will be involved in responses off-site (away from the hospital).

As you have indicated in your correspondence, there is significant difference between the roles of an SO at a hospital and an SO within an emergency response organization which actively responds to emergency incidents. First responders arriving at an emergency response site may face mass destruction, ongoing chemical releases, a wide range of physical and health hazards, and the possibility of secondary devices or incidents that would not typically be present at a hospital. Within a hospital, the SO's responsibility is typically limited to implementation of the hospital's emergency response plan and protection of the First Receivers. The knowledge base required of a hospital-based SO is typically less than that required for emergency response operations.

HAZWOPER paragraphs 1910.120(q)(3)(vii)-1910.120(q)(3)(viii) require that a SO designated by the incident commander be knowledgeable in the operations being implemented at the site; be able to identify and evaluate hazards; be able to provide direction with respect to safety of operations; and have the authority to alter, suspend, or terminate the response activity. From the standpoint of the hospital-based SO, their knowledge and training is generally limited to the potential hazards and operations at the facility. This knowledge may be gained from in-house training and/or from external training programs.

When the hospital is involved in community-wide emergency responses, the SO's training must be expanded to include the types of hazards in the community that First Receivers are more likely to encounter and what capabilities the First Receivers need to respond to those hazards. Subject areas that also must be covered include knowing the concerns involved in the set-up of a decontamination zone, controlling access to uncontaminated areas of the hospital, and understanding the minimum level of personal protective equipment for First Receivers. The SO does not need to be trained to the level of "first responder operations" unless his or her anticipated duties include taking a defensive action. If the SO is to be involved in decontaminating victims, all the competencies listed in 1910.120(q)(6)(ii) must be met for the first responder operations level. The competencies may be tailored to fit the tasks the SO is expected to perform. Similarly, the SO does not need to be trained to the level of "hazardous materials technician" unless the SO's anticipated duties include taking an offensive action.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires the SO be involved in in-house drills at least twice a year. These drills would also help the SO, as well as other hospital employees, maintain knowledge, skills, and expertise required during an emergency. These drills could include using an Incident Command System (ICS) based response structure that supports the National Incident Management System (NIMS), such as the Hospital Emergency ICS included in Appendix G of the First Receivers document. Additionally, an SO could attain and maintain a professional level of knowledge by, for example, being active on the LEPC and participating in mass-casualty community-wide emergency response exercises.

OSHA is in the process of revising its compliance directive on emergency response, CPL 02-02-059, Inspection Procedures for the Hazardous Waste Operations and Emergency Response Standard, 29 CFR 1910.120 and 1926.65, Paragraph (q): Emergency Response to Hazardous Substance Releases. Because the role of an SO is becoming ever more important in emergency response incidents, we plan to provide further guidance as it relates to the newly developed NIMS, and on what effective specific training, if any, a safety official should have to fulfill their responsibilities. The revised directive will be available on our public website when it is completed.

We hope you find this information helpful. OSHA requirements are set by statute, standards, and regulations. Our interpretation letters explain these requirements and how they apply to particular circumstances, but they cannot create additional employer obligations. This letter constitutes OSHA's interpretation of the requirements discussed. Note that our enforcement guidance may be affected by changes to OSHA rules. Also, from time to time we update our guidance in response to new information. To keep apprised of such developments, you can consult OSHA's website at
http://www.osha.gov. If you have any further questions, please feel free to contact the Office of Health Enforcement at (202) 693-2190.

Sincerely,


Richard E. Fairfax, Director
Directorate of Enforcement Programs