The Laboratory Biosafety Guidelines: 3rd Edition 2004

Chapter 5
Commissioning, Certification and Recertification for CL3 and CL4 Laboratories

5.1Introduction

For the purposes of this document, "commissioning" is defined as the verification of the physical construction and performance of critical containment components and is one part of the overall certification process. "Certification" is defined as the successful completion of commissioning and verification that the facility and operational protocols meet the requirements outlined in the current edition of the Laboratory Biosafety Guidelines. "Recertification" is verification that the facility continues to comply with the current edition of the Laboratory Biosafety Guidelines and has undergone a recommissioning process as outlined below.

5.1.1 Commissioning

Building systems commissioning is a process designed to ensure that the finished facility, equipment and systems will operate in accordance with the design intent and construction documents. It is recommended that commissioning be implemented early in the planning phase through to the construction and certification.

To ensure that the physical requirements for the intended containment level and use of the facility have been met, each laboratory must undergo a detailed commissioning regimen. This requires verification and documentation of critical containment components, equipment start-up, control system calibration, balancing and performance testing. A complete set of drawings and specifications, an understanding of the intended use and work to be performed, a list of equipment requirements, all test results, and an understanding of the intent of the systems' operation are all part of the commissioning process. Commissioning is a requirement for the certification of containment levels 3 and 4 laboratories.

5.1.2 Certification

A matrix of critical containment components to be verified during initial certification is provided below. Operational protocols must also be established before work with pathogens at the specified containment level can be carried out. Training of personnel is a critical aspect of this process and may involve initial work with pathogens normally requiring a lower containment level. Users must understand the containment systems and their operation in addition to scientific procedures. Detailed records of the certification process and test results must be maintained.

5.1.3 Recertification

Recertification of certain containment components should also be performed, the nature and frequency of which depend on a variety of factors. For example, verification of directional airflow, detection of any visual leaks in the room perimeter, recalibration of sensitive controllers and gauges, and monitoring of the efficacy of sterilization systems such as autoclaves can all be performed on a routine basis without disruption to the operation of the containment facility. Monitoring the resistance across a HEPA filter (i.e., using pressure monitoring devices) installed into air handling systems will provide information as to the necessity and frequency of replacing HEPA filters. Retesting the integrity of the room perimeter and ductwork is necessary after any structural change. Retesting of the HVAC control systems for fail-safe operation is not necessary unless the system has undergone logic changes or upgrades.

5.2 Room Integrity

Smoke testing the integrity of a containment room can be done to detect leaks in the room perimeter. All joints, corners and sealed penetrations should be surveyed for leaks. Pressure decay testing the integrity of the containment room provides an indication of the tightness of the room perimeter (i.e., the ability of gases and liquids to move through the perimeter membrane and service penetrations).

Matrix Legend: - mandatory - recommended

5.2.1 Matrix 6
Room Integrity

Matrix 6	Containment Level		Room Integrity
	3	4
1			Integrity of containment surfaces to be tested visually and with a smoke pencil or other visual aid. Inspect floors, walls, and ceiling for cracks, chips and wear. Verify integrity of wall/floor and wall/ceiling joints. Acceptance criteria: to confirm the integrity of all penetrations (i.e., equipment, services, etc.) and seals (i.e., around doors, windows, autoclaves, etc.) on the containment barrier.
2			Integrity of containment to be tested by pressure decay testing. Acceptance criteria: two consecutive tests with a minimum of 250 Pa (1 in. w.g.) loss of pressure from an initial 500 Pa (2 in. w.g.) over a 20 minute period(1). This test is not a mandatory requirement for recertification if no modification or changes have been made that will affect the integrity of the laboratory, and if a visual inspection of the containment barrier membrane indicates that the integrity has not been compromised; if the perimeter integrity is suspect upon visual inspection, the requirement for repeating the pressure decay test should be determined in consultation with the laboratory supervisor, Biological Safety Officer/Institutional Biosafety Committee.

5.2.2 Room Pressure Decay Testing

The basic procedure for room pressure decay testing under negative pressure is as follows:

• Isolate the area by closing and securing all doors, valves and bubble tight dampers at the containment barrier (avoid temporary sealing measures in doors, windows and services that would cover permanent seals and not permit their testing for leakage); plug all pressure sensor lines, e.g., magnehelic gauges.
• Install a calibrated inclined manometer across the containment barrier such that it is not affected by air distribution. Manometer to have minimum accuracy of 10 Pa (0.05 in. w.g.) and capable of reading pressure up to 750 Pa (3 in. w.g.)⁽¹⁾.
• Install a ball valve in the piping between the vacuum pump/fan and the room to allow the room to be sealed once the test pressure has been attained.
• Connect a vacuum source to the room and create a 500 Pa (2 in. w.g.) negative pressure differential; allow room to stabilize and close the valve between the vacuum pump/fan and the room to seal room at 500 Pa (2 in. w.g.).
• Dynamically trend pressure loss starting at 500 Pa (2 in.   w.g.) negative pressure differential; record the differential pressure at 1 minute intervals for 20 minutes.
• If repeat test is required, allow 20 minute wait period.
• Disconnect the vacuum pump/fan and open the ball valve slowly to allow room pressure to return to normal condition.
• If leak rate exceeds the acceptance value:
  • pressurize the room to a pressure adequate to locate leaks;
  • with the room under continuous pressure, apply bubble solution to areas to be tested (joints, corners, sealed penetrations, etc.) or, by using audible leak location method, locate audible leaks (electronic sound detection equipment option);
  • identify places where bubbles are found;
  • after repair of leak, retest as required.

5.3 Air Handling Systems

Various components of a containment room's air handling system require commissioning. Manufacturers' requirements for airflows for BSCs must be met. Integrity testing of HEPA filters must be performed to ensure that they do not contain leaks in the filter media, the gasketing or the seal to the filter housing. This filter housing test is performed by challenging with a known particulate concentration and scanning for percentage of penetration downstream of the filter. Ductwork systems should be pressure decay tested to confirm that specified leakage rates are not exceeded. The American Society of Mechanical Engineers (ASME) Standard N510 Testing of Nuclear Air Treatment Systems , 1989, reaffirmed 1995⁽²⁾ , gives procedures for testing the leak-tightness of ducts and plenums. The performance of room pressure control systems must meet the design intent (e.g., negative pressures must be maintained).

The following testing requirements and acceptance criteria must be satisfied for certification of laboratories.

5.3.1 Matrix 7
Air Handling Systems

Matrix 7	Containment Level		Air Handling Systems
	3	4
1			Classes I and II BSCs to be tested in situ in accordance with NSF/ANSI 49-2002(3) or CSA Z316.3-95(4).
2			Class III BSCs to be tested in situ in accordance with the Laboratory Safety Monograph, NIH 1979(5) and BS EN 12469-2000(6).
3			Interlocks (i.e., Class II Type B2 BSC internal cabinet supply fan and exhaust fan) to be tested in accordance with NSF/ANSI 49:2002(3) to ensure that internal supply fan shuts off whenever exhaust fan fails.
4			Alarms to be tested for detection of BSC and/or exhaust fan failure by simulation of alarm conditions.
5			Integrity of HEPA filters installed into supply as method of backdraft protection and exhaust ductwork to be tested in situ by particle challenge testing using the scanning method according to IEST-RP-CC-006.2 (section 6.2)(7). Acceptance criteria: particle penetration not to exceed 0.01%. Small in-line filters need not be in situ scan tested – maintenance program to include visual inspection and regular replacement.
6			Integrity of HEPA filter housings with inlet and outlet bubble tight dampers installed into supply ductwork, where HEPA filters are used as backdraft protection, and exhaust ductwork to be tested in situ by pressure decay testing in accordance with ASME N510(2). Acceptance criteria: rate of air leakage not to exceed 0.1% of housing vol/min at 1000 Pa (4 in. w.g.) minimum test pressure. This test is not a mandatory requirement for recertification if no physical modification or changes have been made. If modifications have been performed then the laboratory supervisor, in consultation with the Biological Safety Officer/ Institutional Biosafety Committee, shall determine the degree of change and whether this test is subsequently required.
7			Supply ductwork, where backdraft protection is required on supply, and exhaust air ductwork located between containment perimeter and HEPA filter or bubble tight backdraft damper to be tested in situ by pressure decay method in accordance with ASME N510(2). Acceptance criteria: rate of air leakage not to exceed 0.1% duct vol/min at 1000 Pa (4 in. w.g.) minimum test pressure.
8			Supply and exhaust air ductwork between containment perimeter and HEPA filter or bubble tight backdraft damper to be tested in situ by pressure decay method in accordance with ASME N510(2). Acceptance criteria: rate of air leakage not to exceed 0.1% duct vol/min at 1000 Pa (4 in. w.g.) minimum test pressure.
9			All supply and exhaust air ductwork is not required to be tested for pressure decay for recertification if no physical modifications have been done. If modifications have been performed then the laboratory supervisor, in consultation with the Biological Safety Officer/Institutional Biosafety Committee, shall determine the degree of change and whether this test is subsequently required.
10			Pressurization relationships across adjacent areas to be verified (i.e., clean change to dirty change, dirty change to laboratory). Acceptance criteria: inward directional airflow (under normal operations) to be visually demonstrated (e.g., by holding a smoke pencil at each door leading to adjacent areas).
11			Control systems to be tested for fail-safe operation by failure of system components, (i.e., exhaust fan failure, supply fan failure, power failure [where possible], Class II B2 BSC exhaust failure). This is to include audible/visual alarm testing. Acceptance criteria: inward directional airflow. The sustained reversal of airflow across containment barrier is to be prevented. This test is not a mandatory requirement for recertification if no control system hardware or logic changes or upgrades have been done; if modifications have been performed, or if frequent control system problems or failures have been encountered, then the requirement for retesting should be determined in consultation with the Biological Safety Officer/ Institutional Biosafety Committee. Note, this may necessitate the need for decontamination. While not required annually, control systems should be retested periodically. Consult Manufacturer's specifications.

5.4 Matrix 8
Laboratory Equipment and Services

Matrix 8	Containment Level		Laboratory Equipment and Services
	3	4
1			Operation of water supply backflow preventers to be verified in accordance with CAN/CSA-B64.10-01/ B64.10.1-01(8).
2			Backflow prevention for other services (e.g., gases) to be verified to ensure that system will operate as specified.
3			Compressed breathing air and systems to be verified in accordance with CAN/CSA-Z180.1-00(9). Systems to be verified for switchover to backup system and to test the response of the alarm.
4			Operation of positive-pressure personal protective equipment (i.e., suit) to be tested to ensure that the suit will operate as specified.
5			Water and chemical shower systems to be tested to ensure that systems will operate as specified and to test the response of the (CL4) disinfectant tank low level alarm.
6			Standby power and UPS systems to be tested under appropriate load conditions to ensure that the systems will operate as specified.
7			Operation of interlocking doors to be verified to ensure that doors cannot be opened at the same time.
8			Operation of security systems (e.g., controlled access, closed circuit TV) to be verified to ensure that the system will operate as specified.
9			Operation of communication and electronic paper transfer systems (e.g., intercom, telephone, fax) to be verified to ensure that the system will operate as specified.
10			Operation of decontamination systems (e.g., autoclaves, fumigation chambers, liquid effluent) to be verified for operation as specified and microbiologically tested using representative loads; resistance of test organism to be representative of organisms likely to be encountered.
11			For containment level 4 laboratories, drains and associated piping leading to liquid effluent treatment systems (including associated vent lines) to be tested in accordance with Section 3.6 of the National Plumbing Code of Canada (1995)(10) ; pressure for air test on drainage system shall be at standard code requirements of 35 kPa (14 in. w.g.).

References

1. ARS facilities design standards. 242.1M-ARS. Facilities Division, Facilities Engineering Branch AFM/ARS, United States Department of Agriculture, 2002.

2. Testing of nuclear air treatment systems. ASME N510. New York, NY: American Society of Mechanical Engineers, 1989 (reaffirmed 1995).

3. Class II (laminar flow) biohazard cabinetry. Standard 49. Ann Arbor, Michigan: NSF International, 2002.

4. Biological containment cabinets: installation and field testing. CSA Z316.3-95. Toronto, ON: Canadian Standards Association, 1995.

5. National Cancer Institute Office of Research Safety and the Special Committee of Safety and Health Experts. Laboratory safety monograph: a supplement to the NIH guidelines for recombinant DNA research. Bethesda, MD: National Institutes of Health, 1979.

6. Biotechnology – performance criteria for microbiological safety cabinets. BS EN 12469:2000. European Committee for Standardization (CEN), 2000.

7. Testing cleanrooms. IEST-RP-CC006.2. Rolling Meadows, IL: Institute of Environmental Sciences and Testing (IEST), 1997.

8. Manual for the selection and installation of backflow prevention devices/manual for the maintenance and field testing of backflow prevention devices. CAN/CSA-B64.10-01/B64.10.1-01. Toronto, ON: Canadian Standards Association, 2001.

9. Compressed breathing air and systems. CAN/CSA-Z180.1-00. Toronto, ON: Canadian Standards Association (approved 2001).

10. National plumbing code of Canada. Ottawa, ON: Canadian Commission on Building and Fire Codes, National Research Council, 1995.

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