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Chapter 1

Neither the Chancellor’s Office Nor the Campuses We Reviewed Have Consistently Provided the Oversight and Training Necessary to Ensure the Safety of Employees and Students

Chapter Summary

The Chancellor’s Office has not provided effective leadership to its campuses to ensure that they address health and safety issues for managing hazardous materials. Although the University Auditor has raised concerns related to the campuses’ health and safety inspections and their employee and student trainings for at least two decades, the Chancellor’s Office has not held the campuses accountable for rectifying these issues. Further, the Chancellor’s Office has not ensured that campuses submit required annual reports on their health and safety programs, nor has it ensured that the reports that the campuses do submit identify risks to employees and students. As a result, issues regarding campuses’ compliance with health and safety standards have persisted.

In particular, we identified significant concerns related to oversight and training at the four campuses we reviewed. Specifically, these campuses do not have joint committees, as a bargaining agreement with a union requires, to solicit employee concerns about health and safety and to develop recommendations to the Chancellor’s Office. Further, although Sacramento’s and Sonoma’s chemical plans require their campuses to have committees to assist in evaluating the effectiveness of those plans, neither campus has ensured that its committee meets regularly and discusses chemical usage policies and issues. Moreover, none of the four campuses could provide documentation to demonstrate that they conducted annual reviews of their chemical plans’ effectiveness. In addition, the four campuses have not ensured that all relevant employees receive critical training on topics such as laboratory safety, hazardous waste, and hazard communication, as state regulations require. Similarly, they could not always demonstrate that they provided students with health and safety training before the students began working in laboratory environments. As a result of these deficiencies, the campuses have unnecessarily jeopardized the health and safety of employees and students.

The Chancellor’s Office Has Not Provided the Oversight Necessary to Ensure That Campuses Meet Health and Safety Requirements

The Chancellor’s Office has not ensured that it receives the information necessary to provide effective oversight of the campuses’ compliance with health and safety requirements. Although under state law a board of trustees administers CSU, state law also identifies the chancellor as CSU’s chief executive officer. The board of trustees has issued standing orders delegating to the chancellor the authority and responsibility to take whatever actions are necessary for CSU’s functioning. Thus, through his or her office, the chancellor is responsible for ensuring that CSU complies with EH&S laws and has the authority to require systemwide compliance with such laws. Further, state law requires the chancellor—as the individual responsible for CSU’s overall operations—to establish effective monitoring of the campuses’ health and safety programs. Receiving consistent information from the campuses regarding their health and safety programs is a critical component of ensuring that those programs align with expectations. The Chancellor’s Office appears to have recognized this need: Order 1039 requires campuses to submit to their respective campus presidents and to the systemwide Office of Risk Management at the Chancellor’s Office annual health and safety reports that could include reviews of significant events, program trends, status of key program areas, and performance data.

However, the systemwide Office of Risk Management has not ensured that the campuses report this critical information to the Chancellor’s Office. As a result, the Chancellor’s Office receives only limited information on relevant issues impacting employee and student health and safety. According to the Chancellor’s Office’s data, as of February 2018, 13 of the 23 campuses had not submitted the required annual reports within the last three fiscal years. In fact, four campuses had not submitted any reports since Order 1039 took effect in 2009. According to the director of systemwide risk management (risk management director), the Chancellor’s Office has not consistently contacted the noncompliant campuses regarding the reports. Although we believe this would be a small undertaking, he indicated that his office has not prioritized obtaining these reports from the campuses because, as discussed below, these reports do not frequently contain meaningful data. Without consistent and regularly reported information about campuses’ health and safety programs, the Chancellor’s Office cannot fully understand and take steps to mitigate issues that could pose risks to employees and students.

Further, the Chancellor’s Office has not established guidelines regarding the specific information the campuses should report, which makes the information it receives from campuses less useful. Order 1039 leaves the content of the reports to the discretion of the campuses. According to the risk management director, the campuses that do submit the reports appear reluctant to be openly self‑critical and identify areas for improvement. He indicated that instead they are more inclined to provide information about processes that enhance their health and safety efforts. For example, in one report, a campus mentioned improvements it had made to increase risk awareness and reduce risk exposures within different campus departments. However, it did not identify specific areas of risk, such as employee training efforts or inspections of laboratory safety equipment. Although information about improvements can be helpful, it does not enable the Chancellor’s Office to effectively identify and address health and safety‑related problems at the campuses. Further, because Order 1039 does not require campuses to provide uniform information, the Chancellor’s Office cannot identify trends and draw conclusions about systemwide health and safety. Finally, the lack of consistent and meaningful data negatively affects the risk management director’s ability to provide input to the University Auditor on potential areas of risk that could inform the systemwide audit plan.

The University Auditor’s work has also demonstrated the failure of the Chancellor’s Office to sufficiently oversee health and safety on the campuses. Over two decades, the University Auditor has repeatedly recommended that the Chancellor’s Office increase its oversight of employee and student health and safety training and inspections of laboratory safety equipment and workplace hazards. For example, nearly 25 years ago in a 1994 audit report, the University Auditor noted that the Chancellor’s Office had not made a concerted effort to ensure that all campuses had the procedures in place to provide applicable employees with timely and adequate required training. Further, that report found that select campuses did not always comply with regulatory requirements related to workplace inspections. Similarly, in a 1998 audit report, the University Auditor found that campuses did not adequately maintain individual health and safety training records for employees, did not have procedures in place to ensure that students formally acknowledged they had received laboratory safety training, and did not conduct inspections of laboratory safety equipment within established time frames or maintain evidence of inspections. The University Auditor recommended at that time that the Chancellor’s Office advise the campuses of the obligation to assure implementation of employee training guidelines and adopt systemwide policy and guidelines that specifically address occupational health and safety concerns related to students. It also recommended that the Chancellor’s Office direct the campuses about their responsibility to perform periodic occupational health and safety inspections.

Although that report noted that the Chancellor’s Office concurred with the findings and the related recommendations, Figure 2 shows that the University Auditor identified nearly identical findings related to trainings and inspections in its 2008 occupational health and safety audit and in its 2001 and 2014 hazardous materials management audits.

Figure 2
Timeline of Selected University Auditor Findings Related to Campus Health and Safety

With five reports over two decades identifying similar systemwide health and safety issues, we find it troubling that the Chancellor’s Office has not taken more action to require the campuses to improve their health and safety programs. As the University Auditor indicated in its 2008 and 2014 audit reports, a failure to conduct inspections and a lack of effective oversight of hazardous materials management activities, such as safety trainings, increase the risk of serious injuries and illness and expose CSU to potential litigation and regulatory sanctions. Nonetheless, as we describe later in this report, we found that campuses are still struggling to ensure and demonstrate that employees and students receive the necessary trainings, to conduct inspections of laboratory safety equipment, and to perform self‑audits of laboratories in which hazards exist.

The consistency of these audit findings demonstrates that the Chancellor’s Office’s approach to providing oversight is not adequate to resolve the shortcomings in the campuses’ health and safety programs. For example, the University Auditor noted in its 2014 report that the Chancellor’s Office did not have an effective process in place to monitor campus compliance with regulatory provisions for employee health and safety training and inspections. When we questioned the risk management director, he explained that the Chancellor’s Office does not see itself as the oversight entity responsible for ensuring health and safety on campus. Rather, he explained that it provides guidance, resource materials, and collaboration to the campuses and advocates for resources and causes that could better the health and safety condition for employees, students, and the public. He further stated that because the Chancellor’s Office does not have the resources needed to monitor all aspects of health and safety on the campuses, the campuses are better positioned to address specific daily and operational on‑site health and safety issues. However, we believe that the Chancellor’s Office’s failure to effectively hold campuses accountable for their actions may have enabled these issues to persist across the university system. In addition, because it has not created a meaningful structure for monitoring the campuses’ health and safety programs, the Chancellor’s Office lacks the information necessary to know whether its current direction and guidance are effective at addressing areas of risk.

The Chancellor’s Office has taken some recent steps to identify and address concerns regarding systemwide health and safety. For example, the systemwide Office of Risk Management has begun facilitating periodic meetings with working groups composed of relevant campus employees to address risk management items and environmental health and safety concerns. In addition, the Chancellor’s Office established a systemwide task force in January 2017 that is charged with addressing environmental health and safety issues, including laboratory safety and faculty training, determining how best to address these issues as a system, identifying where in the system other environmental health and safety areas may exist that could be candidates for improvement, and recommending to the chancellor strategies and options for addressing where such improvements can be realized. The Chancellor’s Office also contracted with a consultant in October 2017 to help develop a laboratory safety manual and to provide insight on the development, implementation, and tracking of faculty laboratory safety training. At the same time, CSU contracted with a different vendor to use risk management software to, among other things, conduct systemwide hazard assessments to ensure that laboratory personnel are properly protected in their work environment. Finally, in July 2015, the Chancellor’s Office created an EH&S manager position within the systemwide Office of Risk Management to, among other duties, obtain data from the campuses to evaluate and address systemwide health and safety concerns. The Chancellor’s Office filled this position in September 2016 for nearly a year; however, in August 2017 this position became vacant and is still vacant as of March 2018. The Chancellor’s Office hopes to fill the position by September 2018. Although these are positive steps, it is too soon to tell whether they will help the Chancellor’s Office sufficiently address health and safety concerns.

The Chancellor’s Office and Campuses Could Further Improve the Health and Safety of Employees and Students on Campuses

The Chancellor’s Office and the four campuses we reviewed could do more to further improve health and safety of employees and students on campus. The Chancellor’s Office and the four campuses have not convened systemwide and campus‑level joint university safety committees as outlined in the bargaining agreement with the State Employees Trade Council (union). Such committees could enable them to receive employee feedback that could improve their health and safety practices and their work environments. Further, although Sacramento’s and Sonoma’s chemical plans require the campuses to have committees to assist in the process of evaluating their chemical plans, neither campus has ensured that its committee meets regularly and discusses chemical usage policies and issues.

State law requires employers to establish and maintain effective injury and illness prevention programs to, among other things, communicate with employees on matters relating to occupational safety and health. Employers can facilitate this communication by establishing labor and management health and safety committees. Toward this end, CSU and the union agreed as part of their bargaining agreement dating back to at least September 2012 to continue a joint health and safety committee (joint committee) at the systemwide level consisting of 12 members, with equal representation from CSU management and employees. Members of the systemwide joint committee are to meet as mutually agreed. The systemwide joint committee’s purpose is to gather and analyze data to identify systemwide trends that it can use to make recommendations of corrective actions, including those related to campus or systemwide training, to the Chancellor’s Office. Although the campuses have other committees that may discuss health and safety issues, the agreement also requires that each campus have a joint committee consisting of an equal number of management and employee representatives. The campuses’ joint committees are to meet on a monthly basis or by mutual agreement. The purpose of the campuses’ joint committees is to recommend safety regulations, guidelines, training programs, and necessary corrective actions concerning conditions associated with the work environment to campus officials, including those in the campuses’ Environmental Health and Safety offices (EH&S offices). According to the agreement, the campus committees should provide copies of meeting minutes to the systemwide joint committee upon request, as well as information regarding injuries, illnesses, accidents, training needs, and any other topics that the systemwide joint committee feels would be helpful.

However, despite the agreement, we found no evidence that the Chancellor’s Office or the four campuses we reviewed made efforts to convene the joint committees during our audit period. The associate vice chancellor, chief negotiator and senior labor relations advisor (associate vice chancellor) at the Chancellor’s Office stated that the systemwide joint committee has not met for roughly seven years because there has been no mutual agreement to do so, nor has the union asked for such meetings. As part of the most recent negotiations, the associate vice chancellor stated that the parties have mutually agreed to reconstitute the systemwide joint committee, which is scheduled to meet in early May 2018.

Three of the four campuses could not provide documentation to demonstrate that campus joint committees have ever existed. Sacramento explained that one of the reasons they have not held campus joint committee meetings is that the campus joint committees cannot fulfill their responsibilities that involve interacting with the systemwide joint committee because the systemwide joint committee does not exist. The bargaining agreement requires the union to designate its representatives who will serve on the campus joint committee; however, officials at Sacramento explained that the union has not done so. According to Channel Islands’ senior director of facilities services, the campus had a joint committee that met regularly and kept minutes up until about 2013; however, he could only provide minimal documentation indicating the committee met twice more than 10 years ago and struggled with attendance. Nevertheless, he explained that in 2013 the campus combined its monthly managers meeting with the joint committee to openly discuss any safety concerns and union related issues. However, the senior director of facilities services explained that although this committee meets on a monthly basis, it does not maintain meeting minutes and, therefore, could not provide documentation to demonstrate the committee has met. He also acknowledged that the committee was not aware of all of the requirements of the joint committee, but he said that the campus will take steps to achieve compliance with the various requirements, including ensuring that the required committee membership is met and maintaining meeting minutes. Officials at Sonoma and San Diego explained they were not aware of the specific requirements for a campus joint committee, but stated they will work on forming the committee by the end of April 2018 and May 2018, respectively.

Because it has not ensured that the systemwide joint safety committee convene, the Chancellor’s Office has not taken advantage of the opportunity to obtain and analyze data on issues affecting multiple campuses. Consequently, it cannot ensure that it identifies systemwide trends and makes appropriate recommendations to address health and safety issues. Similarly, the campuses could do more to ensure they receive feedback from employee representatives on conditions associated with the campuses’ work environments. The campuses could use this feedback to more effectively recommend interventions—such as specific training based on recent incidents—to relevant stakeholders on campus.

Although two of the four campuses we reviewed require the establishment of chemical hygiene committees (chemical committees) in addition to joint committees, these committees do not appear to have served their intended purposes. State regulations require any campus engaged in the laboratory use of hazardous chemicals to have a chemical plan. This plan must include, among other things, the operating procedures that the laboratory workers must follow when using hazardous chemicals and the standards that the campus will use to determine and implement measures to reduce employee exposure to such chemicals. The plan must also designate the personnel responsible for implementing the provisions of the chemical plan, including the establishment of a chemical committee, if appropriate. Of the four campuses we reviewed, the chemical plans of two—Sacramento and Sonoma—require chemical committees. However, the two campuses could not provide any evidence that they have such committees that are fulfilling the responsibilities outlined in their respective plans. These chemical committees have important responsibilities, which include assisting with reviewing or updating the chemical plans; when they do not meet those responsibilities, it can have consequences for chemical safety on their campuses.

In 2006 Sacramento combined its chemical committee with its Campus Safety Advisory Committee to form a campuswide safety and environmental health committee. However, the new committee does not meet regularly and the meeting minutes do not reflect meaningful and regular discussions on chemical hygiene. Sacramento’s EH&S director, who is a member of this committee, confirmed that the committee rarely discusses issues related to the chemical plan. Further, according to the EH&S director, Sacramento has not had a campuswide chemical committee for more than 10 years. In the absence of a committee of this type, Sacramento could not demonstrate that the campus had fulfilled key responsibilities that its chemical plan has assigned to its chemical committee, including making recommendations to the campus president about the use of chemicals. In addition, as we discuss later, the campus has not substantially updated its chemical plan in 15 years—a task that the chemical committee should have overseen. In fact, the laboratory safety task force (task force)—which the campus created in the fall of 2016 to address concerns arising from a laboratory incident in the spring of 2016 and a subsequent report produced by the University of California’s Center for Laboratory Safety—recommended the creation of a chemical committee in order to better ensure the safety of employees and students.

Similarly, Sonoma’s chemical plan states that a chemical team, which includes a chemical officer and a chemical committee, is responsible for reviewing the campus’s chemical plan annually and updating it as necessary. However, the committee had only two documented meetings—one in 2015 and another in 2017—and based on the minutes, these meetings seemed perfunctory in nature and reactive in their discussion of chemical hygiene concerns. Moreover, after its last meeting in 2017, the committee’s chair informed the campus’s EH&S director that the committee agreed that having regularly scheduled meetings might be unnecessary and instead proposed that committee members discuss departmental safety concerns each semester over email and meet only if emergency issues arise. The committee has not met since March 2017, and Sonoma has also not updated its chemical plan since 2011.

The Four Campuses Could Not Demonstrate That They Consistently Assessed Their Chemical Plans Annually as State Regulations Require

Although all four campuses we reviewed have developed chemical plans as state regulations require, none of the campuses could demonstrate that they consistently conducted annual reviews of these plans for effectiveness. The chemical plan is a critical component of a campus’s oversight because it enables the campus to specify the operating procedures that laboratory workers must follow when using hazardous chemicals as well as the standards campuses will use to determine and implement control measures, such as fume hoods or safety goggles, to reduce employee exposure to such chemicals. Consequently, state regulations require campuses to review and evaluate the effectiveness of their chemical plans at least annually and to update them as needed. Nonetheless, although Channel Islands and San Diego revised their plans more frequently and recently than Sacramento and Sonoma, none of the four campuses could provide documentation to demonstrate that they conducted annual reviews of their plans’ effectiveness. As a result, particularly as it relates to Sacramento and Sonoma, certain information in their chemical plans may be outdated and may not align with their current practices or environments, increasing the risk to health and safety of employees and students.

The chemical plans of three of the four campuses—Channel Islands, San Diego, and Sonoma—clearly specify the campus entities or individuals responsible for overseeing or implementing all the plans’ provisions. For example, both Channel Islands and San Diego have assigned their EH&S offices the responsibility for developing and implementing their chemical plans. On the other hand, Sonoma has designated responsibility for the overall management and administration of its chemical plan to its program administrator, whom the plan identifies as the dean of the School of Science and Technology (dean). Although the EH&S office is only responsible for certain elements under Sonoma’s chemical plan, the dean stated that she partners with the EH&S office in a fully integrated manner to implement the chemical plan.

In contrast, Sacramento’s chemical plan does not clearly identify the entity responsible for its implementation or oversight. Sacramento’s senior director of risk management services stated that despite the missing information, he believes that the EH&S office has this responsibility. However, unless Sacramento clearly identifies the entity responsible for implementing and overseeing the chemical plan, it risks that its plan may not adequately safeguard the health and safety of employees and students.

In general, we found that the four campuses have otherwise appropriately ensured that they identify the individuals responsible for implementing aspects of the chemical plans. For example, all four campuses’ chemical plans clearly define the roles and responsibilities of various employees working in campus laboratories, including laboratory supervisors and principal investigators. In addition, Channel Islands, Sacramento, and Sonoma have designated chemical officers during our audit period—July 1, 2014, through June 30, 2017—in compliance with state regulations. Although San Diego did not establish the chemical officer position until November 2016 and did not fill it until June 2017, the associate director of its EH&S office stated that she was the functioning chemical officer without that specific title.

Although the campuses’ chemical plans may appropriately assign most responsibilities, we found that the campuses have not been able to demonstrate that they consistently performed one critical task. Some of the campuses’ chemical plans assign responsibility for annually evaluating the plans’ effectiveness as regulations require, and two campuses had recently updated their plans, but none could demonstrate that they had consistently done so for each year in our audit period. For example, Channel Islands, Sacramento, and Sonoma have assigned the responsibility for reviewing and updating their chemical plans to various campus entities but could not provide documentation—such as decision points and recommended revisions in their committee meeting minutes or memos to their campus communities—to demonstrate that they conducted the evaluations annually. San Diego had not assigned responsibility for the annual evaluations of its chemical plan at all and could not provide evidence that it had performed such evaluations. However, Channel Islands and San Diego had revised their chemical plans at least once during our audit period, July 1, 2014, through June 30, 2017, indicating that they had conducted a more recent review of the effectiveness of their plans.

Both Sonoma and Sacramento acknowledged that they had not performed the annual evaluations of their chemical plans. Sonoma’s chemical plan designates responsibility to the chemical officer for reviewing and updating the chemical plan annually, with input from the chemical hygiene team, which includes the chemical officer, associate chemical officer, chemical committee, and environmental safety director. However, Sonoma’s chemical officer stated that he has not reviewed the chemical plan annually and that he has not seen any indication that the chemical plan needed additional revisions. In contrast, and an indication that Sonoma needs to more effectively oversee and communicate about its chemical plan, the campus’s EH&S director stated that the chemical plan is due for an update, and he plans to update it by the end of June 2018 to incorporate, among other things, any recommendations from our audit. Sacramento’s chemical plan states that the chemical officer will review and evaluate the effectiveness of the plan at least annually and submit a report with recommendations to the campus’s University Environmental Health and Safety committee, if necessary. Although EH&S office and Risk Management Services representatives, including the chemical officer, stated that there is no formal report from the chemical officer evaluating the effectiveness of the chemical plan, the campus has used the lack of chemical incidents and other compliance‑related activities to gauge the plan’s effectiveness.

In contrast, both Channel Islands and San Diego asserted that their campuses had conducted these annual reviews; however, they were unable to produce evidence to support their claims. Channel Islands’ EH&S director stated that it has conducted frequent reviews of the effectiveness of the campus’s chemical plan, primarily through the formal audits the campus conducts for compliance with the chemical plan. However, we found that although these audits may demonstrate the campus’s compliance to its own policies, they do not evaluate the campus’s chemical plan itself. Although San Diego’s chemical plan does not clearly assign responsibility for the annual evaluations, the EH&S director stated that the chemical officer is responsible. San Diego’s EH&S office’s associate director claimed that she had conducted the annual reviews during our audit period. However, she could not provide documentation of such reviews. She stated that the chemical officer and EH&S office will document the reviews in the future.

The fact that the campuses lacked evidence that they had evaluated their chemical plans’ effectiveness is especially concerning given that two of the campuses have not fully updated their chemical plans in at least six years. Although campuses are not required to revise their chemical plans annually, some campuses have not updated their chemical plans with as much frequency as others and certain information may be out of date and therefore may not reflect current campus practices. Specifically, Channel Islands revised its chemical plan in 2014, while San Diego revised its chemical plan in both 2015 and 2017. However, Sonoma has not updated its chemical plan since December 2011, more than six years ago. In fact, Sonoma’s EH&S director acknowledged that some areas of the plan require updates, and we also identified processes and terms in the campus’s chemical plan that do not accurately reflect the campus’s current practices, such as chemical procurement, documentation of student training records, chemical committee responsibilities, and EH&S office inspections. We discuss a number of these processes in this report.

Similarly, Sacramento has not substantially revised its chemical plan in approximately 15 years. Specifically, the EH&S director explained that his office and the chemistry department began discussing revisions to the 2003 chemical plan in 2015, but they did not decide on any proposed changes to the plan, and therefore, there was no need to make any proposed policy recommendations to the campus president. However, this is not consistent with the concerns of the task force that Sacramento created in the fall of 2016 to address issues related to a laboratory incident earlier that year. For example, the task force highlighted its concern that the campus needed to review and update a number of its policies related to laboratory safety to reflect current best practices and changes in how the business of the university has evolved. Demonstrating the need for such revisions, the task force oversaw a complete update of the campus’s chemical plan and provided a draft of the plan to the campus president in May 2017.

However, according to the EH&S director, the revised chemical plan included challenges that prevented it from being adopted by the faculty and employee unions in its entirety. In particular, because the chemical plan includes policies regarding union‑represented employees’ safety and possibly discipline, state law requires campuses to meet and confer with the respective unions. The EH&S director explained that as a result of concerns raised by the unions, the campus is in the process of revising the existing chemical plan in sections. He stated that Sacramento determined that the section related to accidents and chemical spills was the most critical to update and, as of March 2018, this section is pending final approval. The remaining 17 sections, the director explained, will be revised through a collaborative effort between the EH&S office and the College of Natural Sciences and Mathematics, to be followed by a process to meet and confer with the affected unions. When we asked him when he anticipated the completion of the chemical plan to occur, he said there was no formal date at that time.

The Campuses We Reviewed Have Not Ensured That All Employees and Students Receive Proper Health and Safety Training

The four campuses we reviewed have not ensured that all employees and students receive critical health and safety trainings. State regulations require that employers provide different trainings to employees who work with hazardous materials to ensure their safety and well‑being, and the four campuses we reviewed have developed trainings to comply with these requirements. However, all four campuses failed to ensure that all employees receive the required training. Specifically, a significant number of the employees we reviewed had not received training in the areas of laboratory safety, hazardous waste, or hazard communication. Similarly, the campuses could not demonstrate that all students who worked with hazardous materials or equipment received training and information on safety procedures and protocols. The campuses either did not ensure that the responsible departments trained students as required or did not require the departments to document that students received the appropriate training. Without documenting training, CSU cannot effectively ensure or demonstrate that those trainings have occurred and that students have received important safety information.

The Campuses We Reviewed Did Not Ensure That All Employees Received Required Trainings Related to Laboratory Safety, Hazardous Waste, and Hazard Communication

State regulations require campuses to provide their employees with training that is specific to their working conditions, as the text box describes. Because regulations allow employers to determine the frequency of refresher laboratory safety training, the campuses have set these trainings at various frequencies ranging from not providing the refresher training at all at Channel Islands to once every five years at Sacramento. Further, campuses have also set different frequencies for providing subsequent hazard communication training to nonlaboratory staff. All four campuses require subsequent hazard communication training as new hazards are introduced. Sacramento’s Hazard Communication Program also requires subsequent hazard communication training at least once every three years for these staff.

Nonetheless, the four campuses we reviewed have not always ensured that their employees receive all required trainings as frequently as either their policies or state regulations require. We reviewed training records for five employees, including faculty and support technicians, who worked in laboratory settings at each campus for the three‑year period from July 1, 2014, through June 30, 2017. We also reviewed training records for two employees who worked in each of the four campuses’ art departments, which are not considered laboratory settings, yet who should have received hazardous waste and hazard communication trainings because they interacted with chemicals and temporarily stored hazardous waste. As Table 2 shows, the four campuses did not always ensure that employees received these trainings as required.

The level of noncompliance with training regulations varied from campus to campus. Of the seven employees we reviewed at Sacramento, the campus did not ensure that four received the hazardous waste training as frequently as required and another did not receive hazard communication training during our review period as frequently as required. For example, a part‑time faculty member in Sacramento’s chemistry department did not receive the training on hazardous waste during our three‑year review period until February 2017. Six of the seven employees we reviewed at both San Diego and Sonoma also did not receive hazardous waste trainings as frequently as required. The same six employees at these two campuses also did not receive laboratory safety or hazard communication trainings as frequently as required. Channel Islands made the hazardous waste training available to all staff; however, it did not always ensure that the employees we reviewed consistently received the required training.

In addition, although Channel Islands provided documentation demonstrating that the five employees who worked in a laboratory setting received laboratory safety training, because it does not provide refresher laboratory safety training, some of these employees had not received the training for several years. For example, one employee had not received the training since 2003. According to Channel Islands’ EH&S manager, the campus does offer other trainings that cover some topics related to laboratory safety. Further, she explained that the former EH&S director, who retired in 2017, met with employees on a periodic basis to discuss issues surrounding laboratory safety and that this is a practice that EH&S staff have continued. Although state regulations do not specifically require campuses to provide refresher laboratory safety training, we believe it is a good practice to ensure that employees working in laboratories are familiar with any new requirements or changes in their work environments so that they can respond appropriately to any health and safety issues that might arise. Channel Islands’ EH&S manager acknowledged that it would be a good practice going forward to provide refresher laboratory safety trainings.

Further, three of the four campuses have not adequately ensured that employees are trained on exposure to bloodborne pathogens. Specifically, state regulations require all campuses that have employees with occupational exposure to blood and other potentially infectious materials to create and maintain an effective exposure control plan designed to eliminate or minimize employee exposure. The regulations require that employers provide training to relevant staff on preventing exposure to bloodborne pathogens at the time the employee is first assigned to work with them and at least annually thereafter. Although all four campuses have developed bloodborne pathogen exposure control plans, three did not ensure that all relevant employees received training on the respective plans as required. For example, only one of the three Sonoma employees we reviewed had completed each of the annual trainings during the three years of our audit period. We found similar lapses at Sacramento and San Diego.

The problems we found at the four campuses appear to exist throughout the CSU system. Specifically, of the 193 support technicians who work in the types of departments in which we conducted audit work at our four selected campuses and who responded to our survey, 69—or 36 percent—across 21 campuses reported that they did not receive training on laboratory health and safety protocols before starting their work. Further, 14 of these 69 individuals—across 10 campuses—reported that they never received any training on laboratory health and safety. These survey responses suggest that campuses need to do more to ensure that employees receive required trainings.

All four campuses we reviewed are aware that they are out of compliance with the training requirements, and each offered different reasons. For example, San Diego’s EH&S director stated that he would need to notify the associate vice president of administration, and that notification would be relayed through the chain of command from the vice president of business and financial affairs to the vice president of academic affairs, in order to address concerns related to employee failure to complete required training. However, he could not provide evidence that he had done so for the employees we reviewed. Sonoma’s EH&S director told us that due to limited resources, the EH&S office placed less focus on reviewing training records to verify employees consistently completed required safety training. Further, he claimed that the campus’s EH&S office provides a general overview of hazardous waste training during the campus’s new employee orientation, but he was unable to provide documentation that training occurred. He explained that staff often forgot to document when they provided this one‑on‑one training because they were busy. However, failing to retain training documents is a violation of state regulations, which require that an employer keep hazardous waste training records for current employees until a facility closes and training records for former employees for at least three years from the date they last worked at the facility.

In addition, in September 2017, the county of Sacramento’s Environmental Compliance Division within the Environmental Management Department (county) issued an administrative enforcement order against Sacramento for, among other things, failing to adequately train employees in the handling and management of hazardous waste to ensure that personnel are able to respond effectively to emergencies. According to the documents the county provided, Sacramento has since corrected this violation. However, because some employees did not receive the required trainings, the four campuses may place their staff, and ultimately their students, at risk of injury.

The Four Campuses Could Not Consistently Demonstrate That They Adequately Prepared Students to Safely Participate in Laboratory Courses

The four campuses could not consistently demonstrate that they had trained students in laboratory safety. At each of the four campuses, we reviewed six laboratory classes that campus officials told us required students to wear PPE because of laboratory hazards. We expected that faculty or other appropriate personnel would be able to demonstrate that they had provided laboratory safety information to the students before they interacted with chemicals or hazardous materials. Some academic departments that are responsible for the classes we reviewed require students to sign forms that outline the necessary safety information and indicate that the students have received the appropriate training. Nonetheless, as Table 3 shows, the departments could not provide these signed safety acknowledgement forms for a number of the classes we reviewed. For example, although San Diego campus officials explained that students were required to wear PPE in the classes we tested there, the responsible departments could not provide safety acknowledgement forms for selected students from four of the six classes we reviewed.

Some department officials explained they could not provide these forms because of their document retention practices. However, in February 2008, the Chancellor’s Office issued Executive Order 1031 (Order 1031), which includes a record retention and disposal schedule that indicates campuses should retain student training records for at least three years. Although each of the campuses we reviewed has documentation retention policies for student training that generally reflect this schedule, actual document retention practices related to student safety acknowledgement forms varied across the departments at the four campuses. The departments’ practices ranged from returning the forms to students at the end of a semester to retaining the forms for up to three years after the conclusion of a class. For example, San Diego’s College of Sciences’ associate dean for resources indicated that the chemistry department—which was responsible for two of the six classes we reviewed—returns the safety acknowledgement forms to students at the end of the semester to indicate that the students have returned any laboratory equipment they received. According to an instructional support technician in Sacramento’s chemistry department, some chemistry department employees retain safety acknowledgement forms for at least three years; however, for one class we reviewed, she explained that a student assistant had destroyed the forms after one year. Retaining student training acknowledgement forms for three years after the conclusion of a class would not only satisfy the Chancellor’s Office’s expectations but would also demonstrate that students have received critical safety information.

In addition, some of the campuses could not provide us with safety acknowledgement forms because certain departments do not require documentation to demonstrate that students were trained. As Table 3 shows, three campuses had at least one class that did not require students to sign safety acknowledgement forms. As a result, although some department officials indicated that students were provided with this information, they could not confirm this through documentation. For example, two of the six classes we reviewed at Sonoma did not require students to sign a form to acknowledge that they received the safety training. An instructor for one of these classes told us that he requires students to wear PPE and instructs students on the necessary safety precautions in the laboratory; however, students in his class do not sign safety acknowledgement forms.

The absence of acknowledgement forms can be attributed to inadequate policies and processes to ensure that departments document student training. Specifically, Sacramento lacks policies on training students. Sonoma and San Diego have policies requiring their employees to provide students with health and safety training and to document those trainings; however, neither campus has a verification process to ensure that departments adhere to the policy. Channel Islands has a policy requiring documentation of student training, and its EH&S office staff told us that the campus reviews whether departments follow the policy as part of the EH&S office’s annual laboratory self‑audits. However, its physics department staff told us that it does not always document student training. For example, the campus was unable to provide student acknowledgement forms for a class we reviewed in the physics department. According to the physics department staff, the department did not require students to sign acknowledgement forms because the experiments in this class occurred infrequently throughout the term. However, because the instructor required students to wear PPE in the laboratory to protect themselves from hazards, we believe that the physics department should have required these students to submit forms. Without signed acknowledgment forms, campuses cannot be assured and cannot demonstrate that students have received the necessary safety training.

The University Auditor has identified similar concerns in four audit reports since 1998 of various campuses’ health and safety practices and procedures, and it has acknowledged the importance of documenting that students receive health and safety training. For example, in its April 2008 audit report focused on eight campuses, including San Diego, the University Auditor noted the need for significant improvement in the biology, chemistry, and art departments’ processes for tracking and providing health and safety trainings to students. Further, the University Auditor found that some of the campuses’ departments were unable to demonstrate that they had updated their health and safety policies and communicated them to students. In 2014 the University Auditor also identified problems with the provision of student training at six campuses it reviewed, including Channel Islands and Sonoma. In the 2008 and 2014 audits, the University Auditor concluded that the lack of effective oversight of student safety training increases the risk of serious injuries and exposes the campuses to potential litigation and regulatory sanctions.

Recommendations

Chancellor’s Office

To ensure that it provides effective oversight of health and safety issues on the campuses, the Chancellor’s Office should do the following:

• By September 2018, review and identify all recommendations issued to the Chancellor’s Office and the campuses from the University Auditor’s systemwide audits of campus health and safety practices since 1994. Using this information, develop and implement a plan by January 2019 to ensure that the campuses have taken appropriate actions to comply with health and safety requirements.
• By November 2018, develop a uniform health and safety reporting template and require the campuses to use it to annually report information related to campus health and safety, including data regarding employee and student training and any other areas the Chancellor’s Office considers critical to its oversight of health and safety compliance. In developing this reporting template, the Chancellor’s Office should consider the information from its own health and safety‑related audits as well as the findings and recommendations of this audit.

Once it has developed the health and safety reporting template and campuses have used it to submit their reports, the Chancellor’s Office should do the following:

• Assess the data and information in the reports to identify trends, risks, and best practices.
• Develop recommendations for improving campus health and safety and follow up on the campuses’ implementation of any corrective actions related to these recommendations.
• Incorporate the risks identified in its assessments into the University Auditor’s audit plan to ensure that the University Auditor evaluates problem areas related to campus health and safety.
• Follow up with campuses that fail to submit the required annual health and safety reports and take appropriate steps to ensure compliance with this requirement.

To ensure that it identifies systemwide trends and makes appropriate recommendations to address health and safety issues, the Chancellor’s Office should do the following:

• Work with the appropriate union to form a systemwide joint committee, as agreed upon in its bargaining agreement with the union, by September 2018.
• Ensure that the systemwide joint committee meets and fulfills its responsibilities in accordance with the bargaining agreement by actively working with the union on an ongoing basis.

To ensure the health and safety of employees working with hazardous materials, the Chancellor’s Office should prescribe the frequency for which the campuses provide refresher laboratory safety training to employees.

Campuses

To ensure that they receive feedback from employee representatives on conditions associated with their work environments and that they develop appropriate interventions, the four campuses should do the following:

• Ensure that their joint committees meet and fulfill their responsibilities in accordance with the bargaining agreement. If such committees do not exist, they should work with the union to form them by September 2018.
• Ensure that their joint committees record meeting minutes and provide copies of the minutes and other information to the systemwide joint committee, as requested.

To increase its oversight of chemical safety, Sacramento should do the following:

• Establish a chemical committee consistent with its chemical plan requirements.
• By June 2018, specify how often the new chemical committee should meet and then ensure that it meets as frequently as required and that it proactively addresses issues related to chemical hygiene and safety on campus.
• Ensure that the new chemical committee records its meeting minutes and makes those minutes available to all employees.

To increase oversight of chemical safety, Sonoma should do the following:

• By June 2018, specify in its chemical plan how often its chemical committee should meet.
• Ensure that its chemical committee meets as frequently as required and that it proactively addresses issues related to chemical hygiene and safety on campus.
• Ensure that its chemical committee records its meeting minutes and makes those minutes available to all employees.

To more effectively provide oversight of their chemical plans, the four campuses should annually evaluate those chemical plans for effectiveness and document the results of those evaluations, including their discussions of any recommended revisions.

To ensure that it has a chemical plan that is up to date and reflects current campus practices, Sacramento should develop and implement a revised chemical plan by January 2019.

San Diego should ensure that its chemical plan clearly defines the campus entity or individual who is responsible for reviewing and evaluating the effectiveness of its chemical plan at least annually.

To ensure that its chemical plan is updated to reflect current practices and changes to how the campus may have evolved, Sonoma should immediately update its chemical plan.

To ensure the health and safety of employees working with hazardous materials, the four campuses should do the following:

• By June 2018, review the training records of all employees who are required to take trainings related to laboratory safety, hazardous waste, hazard communication, or bloodborne pathogens and identify those who have not taken these trainings.
• By December 2018, make the required trainings available to these employees and establish procedures for ensuring that the employees have received all required trainings.
• Going forward, regularly monitor employee training records to ensure that all employees have received the required trainings.

To ensure that employees working in a laboratory setting receive current information regarding laboratory safety, Channel Islands should provide periodic refresher laboratory safety training to these employees beginning in the Fall 2018 semester.

To ensure the health and safety of students in a laboratory setting, the four campuses should do the following:

• By June 2018, Sacramento should develop campuswide policies to ensure that its departments are accountable for providing student training on laboratory safety.
• Channel Islands, Sacramento, and Sonoma should work with appropriate faculty to develop student safety training acknowledgement forms by June 2018.
• Beginning in the Fall 2018 semester, all four campuses should require departments to have those students required to wear PPE sign the student safety training acknowledgement forms to demonstrate that they have received proper laboratory safety training.
• By May 2018, Sacramento and San Diego should remind all departments to retain student training acknowledgment forms for at least three years after the end of classes.
• Beginning in the Fall 2018 semester, Sacramento, San Diego, and Sonoma should perform reviews at least annually to ensure that all departments are using the student training acknowledgement forms and are complying with the retention requirement.

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Chapter 2

The Campuses We Reviewed Have Not Always Taken Critical Steps to Maintain Safe Environments for Their Employees and Students

Chapter Summary

Numerous state regulations require employers, including the CSU campuses, to take actions to maintain safe environments for their employees. By completing such actions, campuses can also protect the health and safety of their students. Among other requirements, regulations require CSU to inspect the functionality of laboratory safety equipment, conduct periodic inspections to identify hazards in the workplace, and notify employees about the presence of certain hazardous materials. We found varying levels of compliance with the requirements at the four campuses we reviewed. For example, state regulations require campuses to regularly monitor the proper working conditions of critical safeguards, which include emergency eyewashes and showers that enable employees and students to quickly rinse away hazardous substances in an emergency. However, only Channel Islands complied with this requirement for the items that we reviewed. Without consistent inspections of safeguards and other safety equipment, campuses cannot know whether the equipment will function properly to help prevent injuries to students and employees.

We found other instances in which the four campuses did not take actions that would ensure the safety of their work and classroom environments. For example, although all four have procedures for conducting inspections as state regulations require, none have consistently adhered to their procedures. In another example, not all of the campuses we reviewed complied with a state regulation requiring that they post warning signs about the presence of asbestos. Without this signage, employees may inadvertently expose themselves to this hazardous substance, which can have serious or even fatal consequences.

In Violation of State Regulations, Some Campuses Have Not Adequately Monitored the Proper Working Conditions of Critical Safeguards

Three of the four campuses we reviewed have neglected to adequately monitor the proper working conditions of critical safeguards as state regulations require. A safeguard, as we discuss in the Introduction, is a method of mitigating or preventing the effects of a person’s exposure to dangerous substances. Many of the laboratories we reviewed contained showers and eyewash stations—two examples of safeguards—to enable individuals to rinse off hazardous substances in an emergency such as a chemical spill. According to state regulations, eyewash and shower equipment must be activated—or flushed—at least monthly in order to verify it is operating properly. Similarly, state regulations require campuses to manually inspect fire extinguishers at least monthly and to record the dates of the inspections. As Figure 3 shows, despite the regulatory requirements, we determined that three of the campuses we reviewed—Sacramento, San Diego, and Sonoma—failed to flush showers and eyewash stations monthly, and Sonoma failed to inspect fire extinguishers monthly. Only Channel Islands conducted the required flushes and inspections of all safeguards we reviewed. When they do not conduct required flushes or inspections, campuses have less assurance that critical safeguards will function properly and help prevent injuries to employees and students during emergencies.

Figure 3
Three of the Four Campuses We Reviewed Did Not Always Complete Safeguard Inspections and Flushes Monthly

Sacramento and San Diego both acknowledged that they could improve the timeliness of their safeguard flushes and inspections. For example, Sacramento’s EH&S director agreed with our findings and said there was no systemic cause for why Sacramento did not consistently flush its eyewashes and showers monthly. To improve oversight of these flushes, he stated that Sacramento created a standing work order to flush showers as of January 2018 and that the campus was working to implement a new oversight tool for eyewash flushes. As Figure 3 shows, San Diego allowed even more time to pass between flushes of its showers and eyewash stations than Sacramento: the average time between eyewash flushes was nearly nine months. The director of facilities services at San Diego acknowledged that eyewashes and showers should be flushed monthly but stated that the flushes have occurred sporadically since the employee previously responsible for conducting them retired in early 2016. This timing aligns with our finding that between May 2016 and April 2017, San Diego did not flush three of the four shower and eyewash stations we reviewed. Those same three showers had not been flushed since April 2017 when we observed them in October 2017, indicating that San Diego has inconsistently conducted the flushes for about 18 months.

Sonoma also failed to flush shower and eyewash stations as required and additionally failed to consistently inspect other equipment, such as fire extinguishers. Our review found that Sonoma allowed an average of nearly two years to pass between shower flushes and more than 18 months to pass between eyewash flushes. In one extreme example, Sonoma failed to flush the only shower in a chemistry stockroom for more than six and a half years. Additionally, we found that Sonoma allowed an average of three months to elapse between inspections of the fire extinguishers we reviewed—triple the one‑month requirement. In one instance, we found that it had been eight months since Sonoma had inspected the sole fire extinguisher in a biology lab. When we asked Sonoma’s vice president of administration and finance about the campus’s failure to inspect safeguards monthly as required, she acknowledged the shortcomings but did not offer an explanation for why the failure had occurred. We additionally determined that Sonoma had not inspected two biosafety cabinets—containment devices for work involving biohazardous materials—annually as required. The vice president of administration and finance provided evidence that Sonoma is working to develop a process to ensure that it completes preventative maintenance, including inspections of fire extinguishers and biosafety cabinets and flushes of eyewash stations and showers, within required intervals. She anticipated that this process would be completed by summer 2018.

Our findings regarding the failure of campuses to conduct monthly flushes of showers and eyewash stations are similar to previous findings by the University Auditor. Specifically, in 2001, the University Auditor issued a report on its review of the effectiveness of policies and procedures for hazardous materials management and found that six of the nine campuses it reviewed did not flush showers and eyewashes monthly as required. In its response to this finding, the Chancellor’s Office stated that it would issue a directive to the campuses to inform them that noncompliance with the monthly flush requirements was an unacceptable risk for the campuses to assume. When we asked the risk management director at the Chancellor’s Office for a copy of this directive, he stated that he was unable to locate it. Our review demonstrates that some campuses still do not consistently conduct flushes as required 17 years after the University Auditor issued its report. The Chancellor’s Office could better monitor campuses’ compliance with the inspection requirements if it required campuses to report on the timeliness of their safeguard inspections in the annual reports that we discuss in Chapter 1.

In addition, we determined that Sonoma also failed to inspect fume hoods—a type of engineering control—as required. As we indicate in the Introduction, engineering controls are methods of protecting campus employees and students from exposure to injurious substances. Specifically, Sonoma did not inspect fume hoods—enclosed ventilated devices designed to draw air inward to control exposure to hazardous substances into which individuals insert only their hands and arms so that they can work with hazardous substances—as often as state regulations require. State regulations require that fume hood inspections occur every year. Sonoma’s EH&S director agreed that fume hood inspections are designed to ensure that an individual working at a fume hood has the appropriate air flow to protect him or her from substances in the fume hood. However, at the time of our review in September 2017, Sonoma had not inspected any of the 17 fume hoods we selected for more than three years. If it conducted inspections of fume hoods as required, Sonoma would decrease the risk of failing to address problems with critical safety equipment. According to Sonoma’s EH&S director, Facilities Services staff were confused about how often they needed to inspect fume hoods. He explained that when he reviewed the campus’s work order system, which the campus uses to track preventative maintenance work orders, he could not find any work orders to inspect fume hoods in the building that he stated houses the most fume hoods. After we shared the significant shortcomings we identified, the campus’s vice president of administration and finance showed us documentation demonstrating that Sonoma hired an outside company to inspect fume hoods beginning in December 2017. If Sonoma were to include preventative maintenance work orders for fume hood inspections in its work order system, it could better ensure that it completes fume hood inspections annually as required.

Sonoma’s failure to conduct required inspections of any of the fume hoods we reviewed was markedly different from what we found at the other campuses. Channel Islands and San Diego had inspected all of the fume hoods we reviewed within one year, as required. Also, Sacramento generally complied with the fume hood inspection requirements. For the 20 fume hoods we reviewed in Sacramento, we found that three had one late inspection each, and those three inspections were only about one month late.

Finally, while conducting our audit work at Sacramento, we observed that its safeguards were not always readily accessible. State regulation requires that emergency eyewashes and showers be in accessible locations that require no more than 10 seconds for an injured person to reach. However, when we visited a Sacramento art sculpture lab in which students could use potentially dangerous materials, we found that if someone required an eyewash, he or she would need to go down a flight of stairs and through a bathroom in order to access that equipment. Further, if the bathroom door was locked, the person would need to go outside of the building, traverse two additional flights of stairs, and use another entrance in order to access an eyewash. When we discussed this situation with the EH&S director, he agreed that an eyewash was not sufficiently accessible for those in the upstairs area of the art sculpture lab and that he would start working with the Facilities department to install an eyewash as soon as practicable. We also observed at Sacramento that should an individual require an emergency shower while working in the solvent room of the printmaking area in an art department building, the individual would need to leave the room, cross a common area, and use the shower in a room in which individuals work with acids. When we spoke to the EH&S director about those concerns, he explained that solvents that could cause someone to require an emergency shower will not be used in the future in that area, which would eliminate concerns about the accessibility of the shower.

Our survey of support technicians whose work exposes them to hazardous materials suggests that the problems we identified are not isolated to the four campuses we reviewed. Most significantly, 18 of the 193 support technicians and assistants who worked in the same kinds of departments as those where we conducted audit work reported experiencing a situation in which they needed safeguards or engineering controls but the equipment was either unavailable or malfunctioning. These responses were not isolated to a few campuses but rather reflected the answers of employees from 13—more than half—of the campuses. Furthermore, more than half of the safeguards that the support technicians reported as malfunctioning in laboratory areas were either eyewash stations or showers. These responses underscore the need for campuses to conduct inspections as required to ensure that safeguards and engineering controls will work properly in emergency situations to protect the health and safety of the employees and students who use them.

Campuses’ Average Time to Repair Engineering Controls Has Varied

The Audit Committee requested that we determine the average repair time for engineering controls. Examples of engineering controls include fume hoods and cabinets for storing flammable materials. Although the campuses we reviewed have work order management systems that can track requests for repairs to engineering controls as well as the length of time it takes to complete those repairs, we encountered various challenges in calculating the average repair times at the four campuses we reviewed.

One of the challenges was that the campuses did not always separately track the dates that repairs were completed and the dates for the final administrative review of work orders. For example, Sonoma’s work control system administrator indicated that its work order system’s closure date reflects the date the repairs were completed. In contrast, an assistant director of logistical services and maintenance at Channel Islands explained that the campus’s work order system closure date reflects the date when the technician completed the repair work and when supervisory review of the work order was final; he said, the campus did not track the interim dates of when repairs were completed. Although a Facilities Services administrator in Sacramento explained that its work order closure date also accounted for when both the necessary repair work and associated administrative review—such as finalizing purchases and waiting for invoices—was complete, he indicated that Sacramento had a field in its work order system that reflected when the work was completed; however, the administrator stated that this field was inconsistently used. Furthermore, although San Diego’s current work order management system separately includes a date on which repair work was completed, the service center manager with San Diego’s Facilities Services stated that the campus did not use the date the work was completed in its prior work order system and indicated that the older system was in use during one year of our audit period. However, Sacramento, Channel Islands, and San Diego generally explained that the time between the repair date and administrative closing should be relatively short. We therefore used the dates between when the work order was opened and when it was closed at all of the campuses we reviewed.

An additional challenge we encountered was that in order for campuses to locate the work orders for engineering controls, they needed to search their work order systems for key words. We requested work orders containing the key phrases of fume hood and the name of another type of engineering control—snorkel. However, we only identified two work orders—which were closed in nine and 14 days—for snorkels across all four campuses we reviewed. Therefore, due to the limited population, we do not present calculations for snorkels in Table 4. We present calculations only for fume hoods because it was a unique phrase that campuses could identify using a key word search. However, because this approach depends on a work order containing a key phrase, we do not have assurance that we identified all the work orders for fume hoods. Although it likely affected our ability to identify all work orders related to engineering controls, we do not believe that this issue is a limitation for campus management. Most of the campuses explained that they generally use their work order systems to run reports by “shop”—for example, reports on the timeliness of all work orders completed by the plumbers in Facilities Services rather than by type of equipment, such as fume hoods. This appears to be a reasonable manner in which to use the work order data.

Given these challenges, the data we present in Table 4 are the best available calculations of the average length of time campuses took to repair the engineering controls that we reviewed. In presenting these data, we note that the existence of a work order does not necessarily mean that the engineering control was entirely nonoperable. For example, a work order to replace a light bulb in a fume hood does not indicate that the fume hood was not ventilating properly and thus not protecting the user from hazardous substances. We further note that because of the different types of work needed, there is not a standard, average time frame within which we expected campuses to complete these work orders. For example, even though a work order requesting an evaluation of fume hoods at Channel Islands was open for nearly 60 days, the assistant director of facilities explained that the campus was likely waiting to receive the necessary parts to complete the repair. In contrast, Sacramento took eight days to close a work order that involved replacing light bulbs in a fume hood. Although both of these work orders were for repairs to an engineering control, the scope of the repairs—and thus the time needed to complete them—was significantly different. Finally, although we identified a work order for a fume hood that took Sacramento 352 days to close, the manager of engineering services explained that it stayed open that long because Facilities Services was waiting to receive an estimate and approval for a budget to replace the fume hood even though the fume hood was working to its full capacity. However, he further explained that the requester ultimately decided not to replace the fume hood.

We further note that the University Auditor has found problems with San Diego’s management of its work order data. Specifically, in a June 2017 audit of San Diego’s Facilities Services, the University Auditor identified a concern regarding work orders erroneously remaining open. The University Auditor found that of 10 work orders it reviewed that were open for more than 120 days, San Diego completed nine of the repairs but failed to update its data. This finding mirrors one of the work orders for a fume hood repair that we identified at San Diego, which was open for more than 530 days. When we requested an explanation for why it took nearly a year and a half to close this work order, the campus explained that the work order appeared to take so long to close because it was closed incorrectly within 25 days and the error was corrected over a year later.

To address these inaccuracies in the system data, the University Auditor recommended that San Diego revise its procedures to enhance oversight of work orders, including a review and analysis of aged work orders. In response, in December 2017, San Diego’s director of Facilities Services issued a memo requiring Facilities Services to conduct a weekly review of all open work orders and to close any work orders that the review identified should be closed. In addition, in March 2018 an associate director of Facilities Services said that she was working to implement new processes to improve the efficiency of Facilities Services’ use of the work order system, such as an automated reminder to contact work order requesters when work orders become overdue. If San Diego consistently follows its new process to review open work orders, we believe that it will help Facilities Services maintain more accurate data on how long it takes to close work orders for repairing engineering controls.

Some Campuses Did Not Consistently Complete Annual Inspections of Key Ventilation Equipment in Science Buildings

To ensure that the condition of ventilation equipment is regularly checked, state regulations require that employers inspect mechanically driven heating, ventilating, and air conditioning (HVAC) systems at least annually and that they document, among other things, the specific findings of the inspection and the actions they take during the inspection. The regulations also require employers to correct problems found during an inspection within a reasonable time. An integral component of an HVAC system is the air handler unit, which serves to regulate and circulate fresh air. Because a properly functioning air handler unit is critical to ensuring good indoor air quality and because state regulations establish minimum HVAC systems standards to prevent harmful exposure of employees to dusts, fumes, mists, vapors, and gases, we assessed whether the four campuses had completed routinely scheduled preventative maintenance inspections of this component of the HVAC systems located in science buildings on their campuses within annual intervals.

San Diego did not conduct timely annual inspections in 2017 on some of the air handler units we selected for review. We reviewed the inspection records for the selected air handler units from each campus’s work order system expecting to see inspections on each unit conducted within 12 months of each other for all three years. However, we found that San Diego did not inspect three of the eight air handler units that we selected at any time in 2017, and it did not inspect one of the five remaining air handler units within 12 months of the previous inspection. San Diego’s associate vice president of business operations stated that due to limited resources, Facilities Services was unable to complete all of the scheduled inspections. Without conducting regular inspections of air handler units, campuses risk that this critical ventilation equipment will not operate effectively, which could be detrimental to the health and safety of employees and students working in science buildings.

Sonoma could not demonstrate that it completed preventative maintenance inspections since 2016 on any of the four air handler units we reviewed. Further, it completed three of the four 2016 inspections 13, not 12, months after the previous inspection. Sonoma’s associate vice president for administration and finance, facilities operations and planning (associate vice president) believed, based on conversations with campus engineers, that the air handler units were inspected in 2017 and that the campus’s work order system just does not demonstrate those inspections. Sonoma also provided evidence that it had responded to requests for repair of some of the air handler units during 2017. In addition, the campus’s current interim associate vice president for facilities services stated that he is assured that the employees and students working in campus buildings will be healthy and safe because campus engineers conduct ongoing visual inspections on the HVAC systems multiple times a week. However, this is different from ensuring that regular preventative maintenance occurs. Sonoma’s work control system administrator confirmed that the campus does not currently have preventive maintenance work orders set up in the campus’s new work order system. The associate vice president expects that the new system will be fully implemented by about the end of summer 2018. Until it adds preventative maintenance work orders to its new work order system, Sonoma will continue to be at a higher risk of not completing regular maintenance on its air handler units.

Unlike San Diego and Sonoma, Sacramento and Channel Islands have corrected the issues we observed in our review of their records. Each campus had missing records for at least one inspection in the years of our review, although both campuses asserted that the missing inspections had been conducted. At Sacramento, facilities management’s customer service center administrator explained that one of the five air handler units we reviewed was not included in the campus’s preventative maintenance schedule until 2016, which meant that the campus had not documented any inspections for that unit before it included this missing information. Additionally, Channel Islands has two science buildings on campus. The three air handler units in one of these buildings were consistently inspected within the annual requirement for the three years of our review. The other science building was first opened in 2015, and the campus’s work order system shows that the building has three air handler units. The campus was unable to provide documentation that inspections on these units occurred in 2016 and 2017 after the building’s opening. The assistant director of logistical services and maintenance stated that maintenance was recorded on a blanket work order because the campus had not finished setting up the preventative maintenance in its system. However, as of November 2017, the preventative maintenance work orders have been added to the campus’s work order system. We believe that both Sacramento and Channel Islands are likely to consistently conduct these inspections in the future because our review showed that they conducted timely inspections of the other air handler units when they had maintenance work orders in their work order systems.

Most Campuses We Reviewed Did Not Follow Their Policies for Conducting Health and Safety‑Related Audits of Laboratories

State law requires every employer to establish and implement a program for effective injury and illness prevention. As a part of that program, state regulations require an employer to include procedures for identifying and evaluating workplace hazards, including scheduled, periodic inspections (self‑audits). For laboratories and other locations on campus where hazardous chemicals are stored, these self‑audits can include checking the accessibility of key safety equipment, the proper functioning of engineering controls, the proper labeling of chemicals, and the proper design of shelving, among other activities. Although all four campuses we reviewed have procedures for conducting self‑audits of laboratories and have identified who is responsible for such reviews, we found that Sonoma, Sacramento, and San Diego did not consistently adhere to their procedures, and Channel Islands had not established an expectation for how often self‑audits should be performed.

Despite its plan to conduct regular self‑audits of its laboratories, Sonoma’s chemistry department did not conduct regular self‑audits in the two rooms we selected during the three‑year period we reviewed. However, we found that its biology department did conduct self‑audits in the two rooms we selected during the same period. Sonoma’s injury and illness prevention program plan states that inspections of the laboratories, shops, and hazardous material and equipment use areas will occur twice per year. A chemistry support technician stated that he did not know why the department had not completed laboratory inspections for the past three years. However, he stated that the campus’s chemical hygiene officer prioritized and created a plan for completing these inspections in Fall 2017.

Although Sonoma’s biology department completed self‑audits in the rooms we reviewed, these self‑audits did not include a step for verifying whether fume hoods had been inspected and eyewashes and showers had been flushed as frequently as state regulations require. The biology instructional support technician explained that she developed the self‑audit checklist for use in the biology department, which was then approved by the EH&S director. However, because engineering controls and safeguards are critical to ensure the safety of employees and students working in laboratory settings, we believe a key component of laboratory self‑audits should include steps for verifying whether the campus inspected fume hoods annually and flushed eyewashes and showers monthly as state regulations require. If Sonoma’s biology department included this key step when conducting self‑audits and if its chemistry department had conducted similarly thorough self‑audits, the campus would more likely have identified some of the shortcomings that we found during our review and that we describe in this chapter. Earlier in this chapter, we noted that Sonoma had failed to meet both (1,2) of these requirements for the laboratories we reviewed.

Further, Sonoma’s EH&S office was not adequately ensuring that departments were performing self‑audits. Sonoma’s injury and illness prevention program establishes procedures for the EH&S office to verify that these self‑audits occur and to maintain documentation of its verification. However, its EH&S director stated that the EH&S office does not expect the departments to submit these completed self‑audits and that the office has not had the resources to monitor the departments to ensure the self‑audits happened. Had Sonoma’s EH&S office regularly verified the self‑audits, it would have been in a better position to remind the chemistry department to conduct them.

We found that Sacramento and Channel Islands adhered to some, but not all, of their procedures for conducting self‑audits. Both campuses expected the departments that use laboratories–such as the chemistry or biology departments—to perform self‑audits of those laboratories. However, the departments in question did not all regularly conduct self‑audits of the laboratories and chemical stockroom areas we selected for review. Channel Islands’ chemical plan does not specify a frequency with which departments must conduct self‑audits. When we reviewed the self‑audits of selected biology and chemistry stockrooms—where safeguards and engineering controls are present—we found that each room had at least one inspection during the three‑year period we reviewed. However, three of the four rooms we reviewed had gaps of at least one year during which Channel Islands completed no self‑audits. Channel Islands was the only campus we reviewed that did not specify in its policies an expectation for how often self‑audits should be conducted by either its departments or, as we discuss next, its EH&S office. When we discussed expectations about the frequency of self‑audits with Channel Islands, the campus indicated that it would consider adding more specific expectations about self‑audit frequency when it next updates its chemical plan.

Similarly, Sacramento’s chemical plan requires its departments to complete self‑audits once every semester, but this did not occur for the biology laboratories we reviewed. The biology department chair could not explain why the department did not complete self‑audits consistently. Although the chemistry department conducted more frequent reviews of the rooms we selected than Sacramento’s chemical plan requires, its self‑audits for one of the rooms did not identify that the showers were not always flushed in accordance with state regulation, as we discussed earlier. When departments do not complete self‑audits in accordance with their own policies, department officials cannot be sure that they are addressing the safety hazards in their laboratories or areas where chemicals are stored.

These two campuses’ EH&S departments performed inspections of the departments in question. Specifically, in addition to the department‑level self‑audits, Sacramento’s injury and illness prevention program states that the campus’s EH&S office will conduct annual inspections of departments that use hazardous materials. We found that Sacramento’s EH&S office conducted inspections of the biology and chemistry departments at or near the beginning of each school year from 2014–15 through 2016–17. Similarly, although its policy does not specify a frequency, Channel Islands expects its EH&S office to audit compliance with its chemical plan. The EH&S office conducted reviews of laboratory health and safety in each of the three years we reviewed. Although these inspections can serve as a quality control step to ensure that departments are not overlooking critical problems in laboratory settings, we found that these EH&S offices do not conduct these inspections as frequently as the department‑level inspections occur and therefore those audits cannot fully substitute for the important inspections that the campuses expect their departments to complete.

San Diego was unable to demonstrate that it completed self‑audits as regularly as it expects to. San Diego’s chemical plan states that EH&S is responsible for performing laboratory inspections, and other department policies state these inspections must be performed on a semiannual basis. However, for the rooms we selected for review, the EH&S compliance specialists at San Diego were not always able to provide documentation that demonstrated they conducted the self‑audits. In one case, the specialists were not able to provide records of having audited one of the rooms at any point during the three‑year period we reviewed. According to San Diego’s EH&S director, San Diego only documents the violations it finds during its self‑audits and if no documentation exists, there were no violations observed during the audit. However, San Diego’s injury and illness prevention program states that San Diego should keep records of the periodic inspections it conducts. Without such documentation, San Diego is less able to demonstrate that it proactively conducts inspections to identify unsafe working conditions.

Further, San Diego’s self‑audits did not include a review of whether it flushed key safety equipment in laboratories as frequently as state regulations require. As a result, during these self‑audits, San Diego’s environmental health and safety compliance specialists would not have identified Facilities Services’ failure to complete monthly flushes of eyewash stations and showers, a deficiency we discussed earlier. The EH&S associate director noted that because the campus did not document the dates of flushes on physical tags at each piece of equipment, the compliance specialists would have needed to take additional steps to determine when Facilities Services last flushed each eye wash station and shower. To better facilitate reviewing compliance, in November 2017, San Diego’s chemical officer recommended to Facilities Services that the flushing date be documented at the eyewash stations and showers by writing the flushing date on the attached tag. In early March 2018, the director of San Diego’s EH&S office indicated that the campus planned to have this process fully implemented by the end of the month. Implementing this process will better assist San Diego in reviewing the frequency of eyewash and shower flushes when it conducts self‑audits.

The Campuses We Reviewed Have Not All Consistently Followed State Requirements Regarding Notifications of the Locations of Asbestos

Three of the campuses we reviewed have not consistently notified employees of the locations of asbestos as state law and regulations require. According to the U.S. Occupational Safety and Health Administration, asbestos—the name given to a group of minerals that are resistant to heat and corrosion—has been used in various building materials, such as insulation for pipes. However, it is a health hazard and can cause fatal lung diseases. Accordingly, state law requires owners of buildings constructed before 1979 to provide notice to employees working in that building about the presence of asbestos upon learning of it and then annually thereafter. State regulations also require employers to post signs at the entrances of mechanical rooms that contain asbestos or material presumed to contain asbestos. Mechanical rooms are located in multiple buildings on campuses and can include rooms for elevator machines and boilers. Both Sonoma and San Diego complied with state law by providing annual notices to employees regarding the presence of asbestos, but Channel Islands and Sacramento could not locate the documentation for one of the years we reviewed. To gain assurance that those two campuses consistently provide annual notices to employees, we requested documentation for two years prior. Because both campuses were able to provide documentation for the two additional years, we do not believe the lack of documentation was a systemic problem.

However, three campuses—Sacramento, San Diego, and Sonoma—did not consistently comply with the requirement to post warning signs at the entrance of mechanical rooms. This signage is critical because employees may enter mechanical rooms that might contain asbestos. State regulations specify that the signage at the entrance of these rooms must identify the material that is present, its location, and appropriate work practices that, if followed, will ensure that employees do not disturb the material. Without this signage, employees may inadvertently expose themselves to asbestos.

In August 2017, Cal/OSHA issued a citation to Sonoma with several findings related to asbestos, including that Sonoma did not post required signage at the entrance to its mechanical rooms. Initially, Cal/OSHA expected Sonoma to address this violation by September 2017; however, due to reasonable delays, it granted Sonoma several extensions to address this citation and Sonoma informed Cal/OSHA that it had finished addressing it in January 2018, as required. As part of our audit work, we reviewed a selection of five mechanical rooms at Sonoma in January 2018 and found that the campus had posted the required warning signs regarding asbestos at the entrances of the rooms.

Similar to Cal/OSHA’s finding at Sonoma, our review of mechanical rooms at San Diego and Sacramento found that these campuses did not consistently post signs at the entrances. We initially identified a mechanical room at Channel Islands on its annual notice list that did not have warning signs at the entrance. However, subsequent to its 2017 annual notice, the campus received test results indicating that no asbestos‑containing material was present in the room. The health and safety manager stated that she would remove this room from the annual notice list. We also reviewed two mechanical rooms that San Diego identified as containing asbestos in its annual notice to employees and found that the campus had not posted the required signage at the entrance of either room. When we discussed this with the EH&S director and the facilities services’ director, both stated that they were not aware of the requirement to post signs at the entrance of mechanical rooms. The director of the EH&S office stated that EH&S will work with facilities services to begin affixing asbestos warning signs on mechanical room doors, and the EH&S office will assist in selecting the proper signage in order to comply with state requirements. Similarly, we reviewed three mechanical rooms that Sacramento identified as containing asbestos and determined that two did not have the required signage at the entrances. Sacramento’s EH&S director agreed that the two rooms required signage at the entrances and subsequently posted signs.

Recommendations

Chancellor’s Office

As part of the uniform health and safety‑reporting template that we recommend in Chapter 1 that it develop, the Chancellor’s Office should require campuses to annually report on the timeliness of their inspections of safeguards, engineering controls, and ventilation systems and identify the reasons for any delays. The Chancellor’s Office should follow up with campuses that report untimely inspections and should require that the campuses develop action plans to ensure that they complete inspections as often as state regulations require.

To ensure compliance with state requirements to notify employees about the presence of asbestos, the Chancellor’s Office should immediately remind all of its campuses that state regulations require posting signage at the entrances to mechanical rooms that contain asbestos. By September 2018, it should ensure that campuses are compliant with that requirement.

Campuses

Sacramento should monitor the implementation of its new processes for inspecting safeguards to ensure that it completes monthly flushes of eyewashes and showers as state regulations require.

Sacramento should immediately assess the health and safety risks in its art sculpture lab and take action to ensure that safeguards are readily accessible as state regulations require.

San Diego should immediately develop and implement a plan to ensure that it consistently completes its flushes of eyewashes and showers monthly as state regulations require.

Sonoma should continue to implement and adhere to its plan to ensure that it flushes showers and eyewashes and that it inspects fire extinguishers monthly as state regulations require.

Sonoma should add preventative maintenance work orders to its work order system by September 2018 to ensure that it completes fume hood and biosafety cabinet inspections annually as state regulations require.

San Diego should continue to implement its new policy to regularly review open work orders to ensure that it closes work orders in a timely fashion.

San Diego should immediately develop and implement a plan to ensure that it consistently completes its inspections of air handler units at least annually.

By September 2018, Sonoma should begin using its work order management system to track and ensure preventative maintenance inspections of air handler units are completed at least annually.

Channel Islands, Sonoma, and Sacramento should immediately begin following their policies to conduct departmental self‑audits to identify and address safety concerns in their laboratories. Channel Islands should amend its chemical plan to include specific expectations about how often departments and its EH&S office will conduct self‑audits. Sacramento and Sonoma should ensure that their self‑audits review whether timely flushes of eyewashes and showers have occurred. Further, Sonoma’s departments should ensure that fume hoods have received annual inspections, and Sonoma’s EH&S department should regularly review whether departments are conducting self‑audits.

San Diego should ensure that it documents all self‑audits it conducts, including when it does not identify any violations during the audit. Additionally, San Diego should continue to implement and follow its new process to include reviews of safeguard inspections as a part of its self‑audits.

San Diego and Sacramento should immediately ensure that the entrances to all mechanical rooms with asbestos or material presumed to contain asbestos have signage to inform employees about the presence of the hazardous substance.

We conducted this audit under the authority vested in the California State Auditor by section 8543 et seq. of the California Government Code and according to generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives specified in the Scope and Methodology section of the report. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Respectfully submitted,

ELAINE M. HOWLE, CPA
State Auditor

Date:
April 24, 2018

Staff:
Bob Harris, MPP, Audit Principal
Laura G. Kearney, Audit Principal
Kris D. Patel
Katrina Solorio
Jillien Lee Davey
Ryan Grossi, JD
Patrick Malloy, MPA
Lindsay Maple, MPP
Alejandro Raygoza, MPA
Kelly Reed, MSCJ

Legal Counsel:
Heather Kendrick, Sr. Staff Counsel

For questions regarding the contents of this report, please contact Margarita Fernández, Chief of Public Affairs, at 916.445.0255.

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