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 Chemical Fume Hood 

Testing Improvements Needed 

to Reduce Health and Safety 

Risk to EPA Employees 

Report No. 13-P-0363 August 28, 2013

 

 

U.S. ENVIRONMENTAL PROTECTION AGENCY

OFFICE OF INSPECTOR GENERAL
Report Contributors: Janet Kasper 

Michael Petscavage 

Melinda Burks 

David Penman 

Bruce Woods 

Abbreviations 

AI As Installed 

AU As Used 

EPA U.S. Environmental Protection Agency 

FAR Federal Acquisition Regulation 

fpm feet per minute 

NF not functioning 

OAM Office of Acquisition Management 

OIG Office of Inspector General 

RTP Research Triangle Park 

VAV Variable Air Volume 

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write: EPA Inspector General Hotline 

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 13-P-0363

August 28, 2013

Why We Did This Review

In response to a hotline 

complaint, we conducted an

audit of the U.S. Environmental 

Protection Agency’s acquisition 

of chemical fume hood 

retrofitting and testing 

contracts. Laboratory fume 

hoods minimize chemical 

exposure to laboratory workers. 

The fume hoods are 

considered the primary means 

of protection from inhalation of 

hazardous vapors, mists and 

particulate matter. The 

objectives of our audit were to 

answer the following questions:

1. Is the EPA complying with 

applicable procurement 

regulations and guidance 

regarding its purchases of 

chemical fume hood retrofit 

kits and procurement of fume 

hood testing contracts?

2. Do the chemical fume hood 

retrofit kits in question meet 

applicable safety standards 

and codes?

This report addresses the 

following EPA Goals or

Cross-Cutting Strategies:

Ensuring the Safety of 

Chemicals and Preventing 

Pollution.

Strengthening EPA’s 

workforce and capabilities.

For further information, contact 

our Office of Congressional and 

Public Affairs at (202) 566-2391.

The full report is at:

www.epa.gov/oig/reports/2013/ 

20130828-13-P-0363.pdf

Chemical Fume Hood Testing Improvements Needed

to Reduce Health and Safety Risk to EPA Employees

 What We Found

We found that the EPA complied with applicable regulations and guidance in 

procuring both the chemical fume hood retrofit kits and fume hood testing 

contracts. The EPA awarded both contracts using competition as opposed to 

using sole source procurement contracting methods. However, the same 

subcontractor, operating under the same prime contractor, is performing both the 

retrofitting of the chemical fume hoods and the annual testing of the hoods, which 

presents a potential conflict of interest. The agency already completed corrective 

action in response to our preliminary recommendation for this finding.

In addition, our technical expert’s review of a sample of testing results for the 

chemical fume hoods raises numerous concerns with the way the testing was 

performed at the EPA’s Research Triangle Park laboratories. The subcontractor 

rated the hoods as pass:

When not all of the EPA requirements were met.

When controllers or monitors were not functional.

When the testing results did not include all required documentation.

The agency’s 2009 testing protocol spells out the criteria for testing and 

evaluating the performance of fume hoods at the EPA’s laboratories, and would 

also be applicable to fume hood retrofitting. The EPA relied on the prime 

contractor to ensure the subcontractor’s fume hood testing met all requirements, 

and did not retest any of the hoods, without a user’s specific report of a problem. 

As a result, the EPA has limited assurance as to the safety of the chemical fume 

hoods, and there is a risk to the health and safety of the laboratory workers.

 Recommendations and Planned Agency Corrective Actions

We recommend that the director, National Exposure Research Laboratory,

require the Research Triangle Park Safety, Health and Environmental 

Management Office to:

Increase oversight and analysis of contractor testing results.

Ensure that when a monitor is reported as not functioning or inaccurate it is 

timely repaired or replaced.

Establish a practice of retesting a sample of the chemical fume hoods 

annually to verify the subcontractor’s testing results.

Work to revise and update the EPA’s 2009 testing protocol criteria.

The agency agreed to take corrective action for all four recommendations, and 

provided expected completion dates. The agency's proposed corrective actions 

and planned completion dates meet the intent of the recommendations.

U.S. Environmental Protection Agency

Office of Inspector General

At a Glance
August 28, 2013 

MEMORANDUM

SUBJECT: Chemical Fume Hood Testing Improvements Needed 

to Reduce Health and Safety Risk to EPA Employees 

 Report No. 13-P-0363 

FROM: Arthur A. Elkins Jr. 

TO: Dr. Jennifer Orme-Zavaleta, Director 

 National Exposure Research Laboratory 

 Office of Research and Develpoment 

This is our report on the subject review conducted by the Office of Inspector General of the 

U.S. Environmental Protection Agency. This report contains findings that describe the problems the OIG 

has identified and corrective actions the OIG recommends. This report represents the opinion of the OIG 

and does not necessarily represent the final EPA position. Final determinations on matters in this report 

will be made by EPA managers in accordance with established audit resolution procedures. 

In responding to the draft report, the agency provided a corrective action plan for addressing the 

recommendations with milestone dates. Therefore, a response to the final report is not required. The 

agency should track corrective actions not implemented in the Management Audit Tracking System. 

This report will be available at http://www.epa.gov/oig. 

If you or your staff have any questions regarding this report, please contact Richard Eyermann, acting 

assistant inspector general for the Office of Audit, at (202) 566-0565 or eyermann.richard@epa.gov,

or Janet Kasper, director, Contracts and Assistance Agreements Audits, at (312) 886-3059 or 

kasper.janet@epa.gov.

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, D.C. 20460

THE INSPECTOR GENERAL
The EPA Should Improve Chemical Fume Hood 13-P-0363 

Testing Oversight to Reduce Health and Safety Risk 

Table of Contents

Chapters

1 Introduction ...................................................................................................... 1

 Purpose ..................................................................................................... 1 

 Background ................................................................................................ 1 

 Scope and Methodology ............................................................................ 3 

2 Potential Conflict of Interest Identified ........................................................... 5

 FAR Requires Mitigation of Significant Potential Conflicts .......................... 5 

 Potential Conflict of Interest Identified ........................................................ 5 

 The EPA Did Not Identify the Potential Conflict .......................................... 6 

 Recommendation and Corrective Action Taken ......................................... 6 

3 Increased Oversight Needed to Ensure Chemical Fume Hood Safety.......... 8 

 EPA Performance Requirements for Laboratory Fume Hoods ................... 8 

 Technical Review Raises Fume Hood Testing Concerns ........................... 9 

 The Agency Does Not Independently Retest the Fume Hoods................... 11 

 The Agency Has Limited Assurance of Fume Hood Safety ........................ 12 

 Recommendations ..................................................................................... 12 

 Agency Response and OIG Evaluation ...................................................... 12

Status of Recommendations and Potential Monetary Benefits ............................. 15 

Appendices

A Sequence for Conducting AM and AI Performance Tests ............................ 16

B Sequence for Conducting AU Performance Tests ........................................ 17

C Agency Response to Draft Report .................................................................. 18

D Distribution ...................................................................................................... 23
13-P-0363 1 

Chapter 1

Introduction

Purpose 

In response to a hotline complaint, we conducted a review of the 

U.S. Environmental Protection Agency’s acquisition of two chemical fume hood 

retrofitting and testing contracts related to the EPA’s Research Triangle Park 

laboratories. The objectives of our review were to answer the following questions: 

1. Is the EPA complying with applicable procurement regulations and 

guidance regarding its purchases of chemical fume hood retrofit kits and

procurement of fume hood testing contracts? 

2. Do the chemical fume hood retrofit kits in question meet applicable safety 

standards and codes? 

Background 

Laboratory Fume Hoods 

Laboratory fume hoods minimize chemical exposure to laboratory workers. The 

fume hoods are considered the primary means of protection from inhalation of 

hazardous vapors, mists and particulate matter. Therefore, it is important that all 

potentially harmful chemical work be conducted inside a properly functioning 

fume hood. The EPA operates numerous laboratories across the nation and relies 

upon fume hoods to provide safe working conditions for laboratory workers.

Figure 1 is a diagram of a typical bench-top fume hood. 

Source: EPA Performance Requirements for Laboratory Fume Hoods. 
13-P-0363 2 

Hotline Complaint Allegations 

In July 2012, the EPA Office of Inspector General received a hotline complaint 

regarding the EPA’s procurement of chemical fume hood retrofit kits and related 

testing contracts. The complainant initially submitted the complaint in 

March 2012 to a U.S. senator. The complainant stated that the EPA has been 

awarding several hundred thousand dollars in no bid contracts to a contractor for 

chemical fume hood retrofit kits. 

The complainant alleged: 

The EPA unfairly used the sole source procurement method for the 

chemical fume hood retrofit kits as well as the fume hood testing 

contracts. 

The EPA unfairly allowed the sole source vendor to self-validate its 

equipment, inconsistent with the EPA’s previous positions requiring 

third-party independent testing for fume hood projects. 

The equipment does not meet applicable safety standards and codes. 

Chemical Fume Hood Retrofit Project 

The EPA contracted for the installation of chemical fume hood retrofit kits at its

RTP facility. The Safety, Health and Environmental Management staff responsible 

for the RTP laboratories are located within the National Exposure Research 

Laboratory organization. The retrofit kits were designed to operate at a lower face 

velocity of 70 feet per minute, versus a conventional fume hood, which operates at 

100 fpm. The reduced flow rate for the retrofitted fume hoods saves on heating and 

air conditioning costs because air in the laboratories is not recirculated. A pilot 

study estimated an annual energy savings of $62,500 per year due to reduced flow 

of air in the fume hoods. The same contractor also subcontracts the required annual 

testing of the chemical fume hoods under a separate contract.

Figure 2 illustrates the installation of a fume hood retrofit kit (sash handle, baffle, airfoil) 

redesigned to achieve containment at a 30 percent reduction in airflow. 

Source: EPA‐RTP Fume Hood Retrofits – FAQs document. 
13-P-0363 3 

While the chemical fume hood retrofit kits are primarily an energy saving 

measure, the hoods must operate properly at the lower flow rates to ensure the 

protection of laboratory workers from contaminants. As the face velocity drops,

contaminants can leak back at a low concentration from the hood. Because the 

face velocity of a hood can decrease over time for different reasons, the 

Occupational Safety and Health Administration recommends that hoods be 

equipped with a flow monitor to ensure the hood is operating properly. 

Scope and Methodology 

We conducted this audit from October 2012 to June 2013 in accordance with 

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. We believe that the evidence obtained provides a reasonable basis for 

our findings and conclusions based on our audit objectives. 

We focused our review on two contracts where the contractor in question is 

performing as a subcontractor. One contract is for the EPA RTP chemical fume 

hood retrofit project (contract no. GS-23F-0225M; task order no. EP09H001115), 

while the other is for the routine annual fume hood certification testing of the RTP 

fume hoods (contract no. EP-D-09-081). We reviewed relevant contracting 

criteria from the Federal Acquisition Regulations to assess whether the EPA 

followed applicable regulations and procedures in procuring both contracts. We 

obtained an understanding of internal controls related to the fume hood testing by 

interviewing program staff and reviewing relevant agency guidance. 

To answer objective 1, we interviewed the contracting officers for both contracts 

reviewed to gain an understanding of the rationale for the procurement method 

used. We also obtained and reviewed relevant contract file documentation. 

To answer objective 2, we interviewed program staff knowledgeable about the 

fume hoods to obtain an understanding of the retrofit project, applicable safety 

standards and codes, internal controls related to the fume hood testing, and 

relevant agency guidance. We obtained and reviewed testing results performed on 

a random sample of 12 retrofitted fume hoods from three different RTP laboratory 

buildings. Specifically, for each of the 12 fume hoods in our sample, we obtained 

and reviewed both the testing results performed immediately after retrofit 

installation as well as the latest routine annual testing results. We also obtained 

assistance from an OIG chemist who holds a Ph.D. with technical expertise and 

experience working with chemical fume hoods in an EPA laboratory to fully 

evaluate those results. Specifically, the assistance entailed performing a technical 

analysis of the results to determine whether the tests were performed in 

accordance with applicable EPA standards, and whether the chemical fume hoods 

meet those standards based on the testing results. The technical expert reviewed 
13-P-0363 4 

tests for a total of 76 fume hoods1. The sample reviewed included and expanded 

upon our original sample of 12 fume hoods. The resulting technical report dated 

March 20, 2013, was provided to the agency for comment. This technical report is

the basis for the finding in chapter 3. 

 

1

 RTP has more than 500 laboratory modules spread across five laboratory buildings. 
13-P-0363 5 

Chapter 2

Potential Conflict of Interest Identified

We found that the EPA complied with applicable regulations and guidance in 

procuring both the chemical fume hood retrofit kits and fume hood testing 

contracts. Specifically, the EPA awarded both contracts using competition, as 

opposed to using sole source procurement contracting methods. However, the 

same subcontractor, operating under the same prime contractor for two contracts, 

is performing both the retrofitting of the chemical fume hoods and the annual 

testing of the hoods, which presents a potential conflict of interest. FAR 9.5 states 

that contracting officers shall analyze acquisitions to identify and evaluate 

potential organizational conflicts of interest, and mitigate significant potential 

conflicts. The EPA did not consider that there might be a conflict of interest. As a 

result, there is a risk that the subcontractor could make the annual testing results 

look better by adjusting the results to show increased energy efficiency for the 

retrofitted hood in order to get more retrofitting work.

FAR Requires Mitigation of Significant Potential Conflicts 

The testing contract includes conflict of interest clauses requiring the contractor to 

disclose to the EPA contracting officer any actual or potential conflicts of interest, 

and these requirements also flow down to any subcontracts. The contract also 

requires the contractor to provide annual certifications regarding conflict of 

interest. These contract clauses reference FAR 9.5. The contract for the 

retrofitting of the chemical fume hoods also includes conflict of interest clauses. 

FAR 9.504 states that contracting officers shall analyze planned acquisitions in 

order to: 

(1) Identify and evaluate potential organizational conflicts of 

interest as early in the acquisition process as possible; and 

(2) Avoid, neutralize or mitigate significant potential conflicts 

before contract award. 

FAR 9.505 states that each individual contracting situation should be examined on 

the basis of its particular facts and the nature of the proposed contract. The 

exercise of common sense, good judgment and sound discretion is required in 

both the decision on whether a significant potential conflict exists and, if it does, 

the development of an appropriate means for resolving it. 

Potential Conflict of Interest Identified 

The same subcontractor, operating under the same prime contractor for two 

contracts, is performing both the retrofitting of the chemical fume hoods and the 
13-P-0363 6 

annual testing of the hoods, which presents a potential conflict of interest. 

A potential conflict of interest exists because the subcontractor who assembled 

and installed the retrofit kits was also conducting the annual testing. 

The EPA has compensating controls in place but does not utilize all of them. 

For example, the agency’s 2009 testing protocol criteria, EPA Performance 

Requirements for Laboratory Fume Hoods, states that the EPA reserves the right 

to double-check the testing of the hoods, but the EPA has chosen not to. Rather, if 

there is a problem with a fume hood, the EPA addresses it at that time with 

testing/troubleshooting. For the annual certifications, the on-site prime contractor 

reviews the subcontractor’s work. One compensating control is that the fume 

hoods are all required to be equipped with monitors, sensors and alarms, which 

should alert laboratory personnel if there is a safety problem.

The EPA Did Not Identify the Potential Conflict 

The contractor did not notify the EPA of the potential conflict of interest. In 

addition, the EPA’s 2009 testing protocol criteria does not address whether the 

same contractor can perform the installation of the retrofit kits as well as the 

annual testing. EPA officials believed it was a good idea to have the contractor do 

the testing rather than the EPA, and did not consider that there might be a conflict 

of interest. 

The potential conflict of interest creates a risk that the subcontractor could make 

the testing results look better in order to get more retrofitting work. For example, 

if testing results show increased energy efficiency for retrofitted hoods, the EPA 

would be more likely to increase the number of retrofits it requests the contractor 

to perform. 

Recommendation and Corrective Action Taken 

In a preliminary finding outline issued to the agency, we recommended that the 

assistant administrator for the Office of Administration and Resources 

Management, in accordance with FAR 9.5, require the EPA contracting officers 

for both the retrofitting of the chemical fume hoods and the routine annual testing 

of the hoods to analyze the situation to determine whether a significant conflict of 

interest exists, and if so, establish controls as necessary to mitigate the risk.

In its response to our finding outline, the agency analyzed the situation and stated 

that as the work being performed under each contract has no impact or affect on 

the other, and since contractor performance on each task is easily objectively 

confirmed and monitored by the EPA, the contractor saw no conflict of interest 

with these tasks, and the EPA concurs. 

The agency’s response also stated the following: 
13-P-0363 7 

With regard to internal Office of Acquisition Management 

requirements management, while the primary intent of the Centers 

of Expertise Study is to identify both organizational and process 

improvements to increase procurement quality and efficiency, 

OAM anticipates another outcome of such improvements will be 

better alignment of these types of similar and related requirements 

among the EPA contracting offices. Accordingly, if requirements 

such as chemical fume hood retrofit and testing are better planned 

and coordinated, OAM will be better positioned and able to 

recognize and address such potential appearances of conflict of 

interest. As a result of implementing this new acquisition process, 

as well as the Balanced Scorecard self-assessment and peer review 

oversight programs, OAM believes the guidance and processes are 

in place to address and manage such situations in the future. 

In response to our recommendation, the EPA analyzed the situation and 

determined a significant conflict of interest did not exist. In accordance with 

FAR 9.5, this determination involves contracting officer judgment. Therefore, the 

agency’s action addressed the recommendation, and we consider the corrective 

action completed. 
13-P-0363 8 

Chapter 3

Increased Oversight Needed to Ensure 

Chemical Fume Hood Safety

Our technical expert’s review of a sample of chemical fume hood testing results 

raises numerous concerns with the way the testing was performed on the EPA 

RTP chemical fume hoods. For example, the subcontractor rated the hoods as pass 

when not all of the EPA requirements were met or when controllers or monitors 

were not functional. The testing results did not include all required 

documentation, and the EPA’s testing protocol document did not include 

appropriate criteria for the fume hood retrofits. The agency’s 2009 testing 

protocol spells out the criteria for testing and evaluating the performance of fume 

hoods at the EPA’s laboratories, and would also be applicable to fume hood 

retrofitting. The EPA relied on the prime contractor to ensure the subcontractor’s 

fume hood testing met all of the requirements, and did not retest any of the hoods 

without the prompting of a user’s specific report of a problem. As a result, the 

EPA has limited assurance as to the safety of the chemical fume hoods, and there 

is a risk to the health and safety of the laboratory workers. 

EPA Performance Requirements for Laboratory Fume Hoods 

The agency’s 2009 testing protocol criteria, EPA Performance Requirements for 

Laboratory Fume Hoods, spells out the criteria for testing and evaluating the 

performance of fume hoods at the EPA’s laboratories. These requirements are 

also applicable to fume hood retrofitting. The EPA operates numerous 

laboratories across the nation and relies upon fume hoods to provide safe working 

conditions. In addition to As Manufactured Performance tests, this document 

includes criteria for the following types of tests: 

As Installed tests, which the fume hood manufacturer or a third-party, 

independent testing agency conducts immediately following installation 

and after the testing and balancing report has been reviewed by the EPA’s 

Safety, Health and Environmental Management Division. These tests: 

(1) verify proper performance integration with mechanical heating, 

ventilating and air conditioning systems; and (2) establish a benchmark for 

the performance of the fume hood system. These AI tests also apply to the 

retrofitted fume hoods, and are performed immediately following the 

retrofitting. 

As Used tests, which EPA laboratory personnel or qualified contractors 

conduct annually to ensure long-term sustainable performance of the fume 

hood systems. These tests verify the continued long-term performance of 

the fume hood system. 
13-P-0363 9 

The EPA’s 2009 testing protocol includes multiple criteria for both the AI and 

AU tests, such as: 

Differential Pressure and Temperature Test. 

Cross-Draft Velocity Test.

Face Velocity Test.

Hood Monitor Test.

Dynamic Variable Air Volume Response and Stability Test.

Airflow Visualization (smoke) Test. 

Tracer Gas Containment with Manikin Test (not required for AU tests). 

Sash Movement Effect or VAV Tracer Gas Containment Test.

The document states that the results of each test shall be recorded on the EPA’s 

performance test data sheets or equivalent. The EPA reserves the right to verify 

calibration of test equipment, photograph or videotape the tests, or take 

independent measurements before, during or after the routine tests. 

See appendix A and B for diagrams illustrating the sequence of conducting the 

performance tests. 

Technical Review Raises Fume Hood Testing Concerns 

Our technical expert’s review of a sample of chemical fume hood testing results 

raises numerous concerns with the way the testing was performed on the EPA 

RTP chemical fume hoods, which are outlined in the resulting technical report 

dated March 20, 2013. For example: 

The subcontractor rated the hoods as pass when not all of the EPA’s

requirements were met. 

The subcontractor rated the hoods as pass when controllers or monitors 

were not functional. 

The testing results did not include all required documentation.

The EPA’s testing protocol document did not include criteria for hoods 

operating at average face velocities of 70 fpm, which is the design face 

velocity for the retrofit kits.

Hoods Rated as Pass When Not All EPA Requirements Met 

The contracts require the fume hoods to be certified in accordance with the EPA 

Performance Requirements for Laboratory Fume Hoods document, which lists 

several requirements. However, based on the technical review of a sample of 

testing results for both the AI testing of the retrofit kits and the AU annual testing, 

the subcontractor rated the hoods as pass when not all criteria or requirements 

from the EPA’s 2009 testing protocol document were met. 
13-P-0363 10

Based on the retrofitted and annual hood test reports reviewed, the hoods failed 

some of the requirements the EPA has established in their testing procedures, 

such as lab differential partial pressures not met, cross-draft velocity not met, and 

face velocity not met. Overall, the technical expert’s review found one or more 

deviations for 71 out of 76 fume hoods tested. Therefore, about 93 percent of the 

fume hoods rated as pass did not meet all criteria or requirements from the EPA’s 

2009 testing protocol document. 

Hoods Rated as Pass When Controllers or Monitors Not Functional 

Based on the technical review of a sample of testing results for both AI and AU 

tests, the subcontractor rated the hoods as pass when the VAV controllers or fume 

hood monitors were reported as not functioning. For example: 

All of the retrofitted chemical fume hoods did pass the tracer gas 

containment test, even though the subcontractor reported hood monitors 

and some VAV controllers as NF. The hood monitor is the primary 

feedback mechanism to the users regarding the safety of the hood. If the 

monitor is NF, this important control is useless. 

The EPA requires accurate hood flow monitors, but in the annual test 

reports, the subcontractor reported hood monitors as being unplugged, NF, 

or the flow rate on the monitor did not accurately measure the flow of air 

in the hood. After installation testing and acceptance, the hood flow 

monitor is the primary indicator to laboratory workers that the fume hood 

is working properly. In one example, the hood monitor read a flow of 

102 fpm but the measured flow was only 35 fpm. Although the 

subcontractor correctly rated the hood as Fail in this case, this raises a 

concern about how long this hood monitor, with its inaccurate reading,

was providing a false sense of security to the laboratory staff who may 

have needed to use this fume hood. 

Overall, the technical expert’s review found one or more deviations for 44 out of 

76 fume hoods tested. Therefore, about 58 percent of the fume hoods rated as pass 

had VAV controllers or fume hood monitors that were reported as NF. 

Table 1 illustrates the deviations discussed above for hoods rated as pass when 

not all EPA requirements were met and when controllers or monitors were not 

functional. 

Table 1: Deviations identified by technical review 

Hoods passed when:

Number of fume 

hoods tested

Number of 

deviations

Deviation 

percentage

Not all requirements met 76 71 93

Controllers or monitors not functional 76 44 58

Source: Technical review of a sample of testing results. 
13-P-0363 11

Testing Results Missing Required Documentation 

According to the technical analysis, the testing results did not include all 

documentation required by the EPA’s 2009 testing protocol document. Based 

upon the documents provided for review, the tracer gas manikin tests were passed 

for the retrofitted fume hoods, but the subcontractor presented insufficient 

information to verify if the sash movement2effect test with tracer gas was 

acceptable. In addition, the EPA requires calibration information for all test 

equipment to be included with each testing report. However, calibration 

information could not be located in the reports for the following equipment: 

Micromanometer used to measure differential pressures. 

Smoke generator. 

Tracer gas sensor. 

Data logger/computer used to acquire flow measurements. 

EPA’s Testing Protocol Document Did Not Include 

Appropriate Criteria for Retrofits 

The EPA Performance Requirements for Laboratory Fume Hoods document

includes criteria for chemical fume hoods operating at an average face velocity of 

100 fpm for typical chemical fume hoods, and 60 fpm for low-velocity chemical 

fume hoods. However, it does not include specific criteria for fume hoods or the 

retrofit kits operating at an average face velocity of 70 fpm, which is the design 

face velocity for the retrofit kits. The EPA testing protocol document should be 

updated with criteria for chemical fume hoods operating at an average face 

velocity of 70 fpm. 

The Agency Does Not Independently Retest the Fume Hoods 

The EPA relied on the prime contractor to ensure the subcontractor’s fume hood 

testing met all requirements, and did not retest any of the hoods, without a user’s 

specific report of a problem. Safety, Health and Environmental Management 

Division personnel also stated that the retrofits “got ahead of them” when trying 

to order appropriate hood monitors for the retrofits. Safety, Health and 

Environmental Management Division staff stated that all chemical fume hoods are 

required to be equipped with monitors, sensors and alarms, which would alert 

laboratory personnel if there is a safety problem. The agency relied on this 

compensating control to help ensure safety of the fume hoods.

 

2

 The sash movement effect test is conducted to determine the potential for escape from the hood following 

movement of the sash from closed to open. 
13-P-0363 12

The Agency Has Limited Assurance of Fume Hood Safety 

The EPA has limited assurance as to the safety of the chemical fume hoods. 

Agency safety personnel are relying on the compensating control of the monitors 

alerting staff to problems, but we found this is not a reliable control because of the 

monitors being not functional or inaccurate. In addition, for one fume hood, a 

testing report stated that a hood monitor needed to be installed; however, a 

subsequent test report indicated the monitor still had not been installed 10 months 

later. Therefore, there is a risk to the health and safety of the laboratory workers. 

In light of this risk, it would be a good internal control and business practice for 

the EPA to retest some of the hoods periodically, in order to protect the 

government’s interests. Such retesting would verify the subcontractor’s testing 

results to ensure the hoods meet all applicable standards, as allowed for by the 

EPA’s testing protocol criteria.

Recommendations 

We recommend that the director, National Exposure Research Laboratory, require 

the RTP Safety, Health and Environmental Management Office, to: 

1. Increase oversight and analysis of contractor testing results to ensure that 

all the EPA’s requirements are met when a hood is rated as pass, and that 

all the EPA’s required documentation is included. 

2. Take steps to ensure that when a monitor is reported as not functioning or 

inaccurate it is timely repaired or replaced as necessary. 

3. Establish a practice of retesting a sample of the chemical fume hoods 

annually to verify the subcontractor’s testing results.

4. Work with the Safety, Health and Environmental Management Division at 

headquarters to revise and update the EPA’s 2009 testing protocol criteria, 

EPA Performance Requirements for Laboratory Fume Hoods, to add 

criteria for chemical fume hoods operating at an average face velocity of 

70 fpm, which is the design face velocity for the retrofit kits. 

Agency Response and OIG Evaluation 

In response to recommendation 1, the agency stated it will ensure all health and 

safety requirements are met, and that the RTP Safety, Health and Environmental 

Management Office will continue to provide feedback to the facilities engineering, 

operations and maintenance staff when an EPA energy efficiency requirement or 

other requirements are not met. The RTP campus has multiple laboratories 

undergoing renovation to accommodate a move of personnel from the 

consolidation of another building expected to be vacated in April 2014. Any fume 
13-P-0363 13

hoods installed will be commissioned, with attention to complete documentation as 

the laboratory is inspected for occupancy and usage. All fiscal year 2013 data to 

date will be re-examined for completeness. The expected completion date to ensure 

complete documentation for fiscal year 2013 fume hood annual testing is 

August 30, 2013. 

In response to recommendation 2, the agency stated that when a fume hood’s face 

velocity monitor is reported as not functioning, as a temporary measure, a 

vaneometer will be issued to the laboratory occupants to visually verify adequate 

face velocity flow rates. At the RTP main campus, buildings A and B have had all 

the non-functioning monitors repaired or replaced. Non-functioning monitors in 

buildings D, E and the High Bay building are being prioritized based on laboratory 

utilization and future occupants. The expected completion date for replacement of 

any non-functioning monitors is September 30, 2013.

In response to recommendation 3, the agency proposed retesting one fume hood 

from each building within 30 days of delivery of passing fume hoods in a given 

building. If the random fume hood fails reinspection, two additional fume hoods 

from the building batch submitted as passed will be retested. The estimated 

completion date for retesting building by building random fume hoods is July 2014. 

In response to recommendation 4, the agency stated that since revision to the 

EPA’s testing protocols is the responsibility of the Safety, Health and 

Environmental Management Division at headquarters, which is in the Office of 

Administration and Resources Management, the agency suggested recommendation 

4 be reassigned to the Director of the Safety, Health and Environmental 

Management Division.3The consensus decision with the details on how to annually 

recertify fume hoods operating at 70 fpm for retrofitted fume hoods can reasonably 

be expected to be in place prior to the RTP campus annual fume hood 

recertification cycle which begins in fiscal year 2014. The estimated completion 

date for revising the testing protocols is October 31, 2013.

As a general narrative comment, the agency stated it disagrees with the assertion 

that the agency has “limited assurances of fume hood safety”, as stated on page 12 

of the draft audit report. The agency outlined various controls in place, and stated 

its back-up practices do not show exposure above action levels or health effects. 

Nevertheless, the agency recognized that the fume hoods are the primary 

engineering control used to minimize exposure and will receive improved oversight 

as outlined in the agency's responses to the recommendations. 

The agency agreed to take corrective action in response to all four 

recommendations, and provided expected completion dates for all corrective 

 

3

 Since the Director, National Exposure Research Laboratory, agreed to work with the Office of Administration and 

Resources Management, Safety, Health and Environmental Management Division on this recommendation we did 

not change the action official. We did speak with staff that are revising the testing protocol criteria and they plan to 

incorporate the recommendation into the revision. 
13-P-0363 14

actions. The agency's proposed corrective actions and planned completion dates 

meet the intent of the recommendations. The complete agency response to the draft 

audit report is attached at appendix C. 
13-P-0363 15

Status of Recommendations and 

Potential Monetary Benefits 

RECOMMENDATIONS

POTENTIAL MONETARY 

BENEFITS (in $000s)

Rec. 

No.

Page 

No. Subject Status1 Action Official

Planned 

Completion 

Date

Claimed 

Amount

Agreed-To 

Amount

1 12 Require the RTP Safety, Health and Environmental 

Management Office to increase oversight and 

analysis of contractor testing results to ensure that 

all the EPA’s requirements are met when a hood is 

rated as pass, and that all the EPA’s required 

documentation is included.

O Director, National Exposure 

Research Laboratory

8/30/13

2 12 Require the RTP Safety, Health and Environmental 

Management Office to take steps to ensure that 

when a monitor is reported as not functioning or 

inaccurate it is timely repaired or replaced as 

necessary.

O Director, National Exposure 

Research Laboratory

9/30/13

3 12 Require the RTP Safety, Health and Environmental 

Management Office to establish a practice of 

retesting a sample of the chemical fume hoods 

annually to verify the subcontractor’s testing 

results.

O Director, National Exposure 

Research Laboratory

7/31/14

4 12 Require the RTP Safety, Health and Environmental 

Management Office to work with the Safety, Health 

and Environmental Management Division at 

headquarters to revise and update the EPA’s 2009 

testing protocol criteria, EPA Performance 

Requirements for Laboratory Fume Hoods, to add 

criteria for chemical fume hoods operating at an 

average face velocity of 70 fpm, which is the 

design face velocity for the retrofit kits.

O Director, National Exposure 

Research Laboratory

10/31/13

1

 O = recommendation is open with agreed-to corrective actions pending 

C = recommendation is closed with all agreed-to actions completed 

U = recommendation is unresolved with resolution efforts in progress 
13-P-0363 16

Appendix A 

Sequence for Conducting AM and AI Performance Tests

Conduct Inspections Laboratory Hood Test Laboratory Ventilation System

Verify Instrument

Function and Calibration

Velocity Probes 

Pressure Meter 

Flow Sensor 

Tracer Gas Detector and Ejector 

Conduct Hood Tests Establish Test Configuration

Sash Opening, Baffle Setting, etc.

Test Procedures Measure Cross Draft Velocities 

(Exhaust Fan On) 

NO 

Acceptable

YES 

Adjust 

Supply/Diffuser Flow 

Measure Face Velocity 

Measure Exhaust Flow and 

Hood Static Pressure 

Analyze and Adjust 

(flow, baffles, bypass, etc.) 

Acceptable NO

YES 

Conduct VAV Response and 

Stability Tests (if applicable) 

NO 

Acceptable Adjust/Tune Controls

YES 

Conduct Smoke

Tests

Conduct Static Sash

Tracer Gas Test

Conduct VAV 

Tracer Gas Test

Source: EPA Performance Requirements for Laboratory Fume Hoods.
13-P-0363 17

Appendix B 

Sequence for Conducting AU Performance Tests 

Source: EPA Performance Requirements for Laboratory Fume Hoods. 

 
13-P-0363 18

Appendix C 

Agency Response to Draft Report 

July 25, 2013 

MEMORANDUM

SUBJECT: Response to “The EPA Should Improve Chemical Fume Hood Testing Oversight to 

Reduce Health and Safety Risk” || OA-FY-13-0013 Dated June 25, 2013 (506 KB) 

FROM: Jennifer Orme-Zavaleta, PhD

Director, National Exposure Research Laboratory 

Mail Code D305-01 

TO: Richard Eyermann 

 Acting Assistant Inspector General for Audit 

 

 Janet Kasper 

 OIG, Office of Audit 

 Director, Contracts and Assistance Agreement Audits 

The purpose of this memorandum is to respond to the draft report transmitted in the e-mail sent 

by Janet Kasper on June 25, 2013 entitled: “The EPA Should Improve Chemical Fume Hood 

Testing Oversight to Reduce Health and Safety Risk.” This response is provided in accordance 

with EPA Manual 2750. Specific recommendations are individually addressed as enumerated in 

the report. No specific enumerated findings were found in the draft report, therefore, a general 

response to the draft report’s question about health and safety risk will be addressed in a 

narrative. 

For reference, the four recommendations appearing on page 12 of the report are reiterated before 

each response. 

Recommendation: 

1. Increase oversight and analysis of contractor testing results to ensure that all the EPA’s 

requirements are met when a hood is rated as pass, and that all the EPA’s required 

documentation is included. 

Response 1: The EPA-RTP SHEM office will ensure all legal Health and Safety requirements 

are met. The EPA-RTP SHEM office will continue to provide feedback to the facilities 

engineering, operations and maintenance staff when an EPA energy efficiency requirement or 

other requirements are not met. Some of EPA’s internal requirements, such as the operation of a 

variable air volume (VAV) box do not jeopardize safety and are only necessary to optimize 

energy conservation and efficiency. A VAV control box which is not functioning in the variable 

mode is essentially a constant air volume valve maintaining a set-point for exhaust. In order for 
13-P-0363 19

the fume hood to pass annual testing, a VAV box set to a constant flow would have to be set to 

the flow rate demanded by an “as used” chemical fume hood condition. Additionally, some 

fume hoods can fail EPA’s requirement tolerances for cross drafts but pass face velocity 

averages and demonstrate capture and containment when challenged with a smoke test as part of 

the annual recertification testing. 

Please be advised the EPA-RTP campus has multiple laboratories undergoing renovation to 

accommodate a move of personnel from the consolidation of another building expected to be 

vacated in April 2014. Any fume hoods installed will be commissioned, with attention to 

complete documentation as the laboratory is inspected for occupancy and usage. All FY 2013 

data to date will be re-examined for completeness. The main omission found previously was 

calibration data for the contractor’s instrumentation used to make measurements of the fume 

hoods. The contractor is required to provide instrument calibration data with each monthly or 

periodic report. They may have in some instances provided the instrument calibration data with 

a prior deliverable and failed to include it with subsequent submittals. Therefore, when a batch 

of fume hoods in a specific building location is completed as they are scheduled on a rolling 

basis to manage work flow, the instrument calibration documentation for the batch of fume 

hoods certified by the instruments for each building will be included with each batch of fume 

hoods tested. This will result in some duplication of documentation in the annual fume hood 

certification but allows each buildings report to stand alone as a complete documentation 

package. 

Expected completion date to ensure complete documentation for FY2013 fume hood annual 

testing: August 30, 2013. 

Recommendation: 

2. Take steps to ensure that when a monitor is reported as not functioning or inaccurate it is 

timely repaired or replaced as necessary. 

Response 2: When a fume hood’s face velocity monitor is reported as not functioning, as a 

temporary measure, a vaneometer will be issued to the laboratory occupants to visually verify 

adequate face velocity flow rates. EPA requirements are for a visual and audible alarm. No 

regulatory requirement exists for an audible alarm. Laboratory occupants are trained to report 

fume hood performance deficiencies or suspected malfunctions. Face velocity monitors are 

important and do serve as the primary indicator to laboratory workers that a chemical fume hood 

is working correctly. When face velocity monitors are not functioning and the fume hood is 

providing capture and containment, interim procedures allow researchers to use a portable 

vaneometer and/or have the EPA-RTP SHEM office perform “on demand” checks for any 

chemical fume hood prior to daily usage. Without these interim measures, research work would 

have to be suspended interrupting work when the fume hood is otherwise fully operational. At 

the EPA-RTP main campus, buildings A and B have had all the non functioning monitors 

repaired or replaced. Non functioning monitors in building D, E and the High Bay building are 

being prioritized based on laboratory utilization and future occupants. Please recall that multiple 

laboratories are under renovation in building D and E and therefore, not every fume hood is in an 

occupied laboratory during the renovation/construction phase. 

Expected completion for replacement of any non functioning monitors: September 30, 2013. 
13-P-0363 20

Recommendation: 

3. Establish a practice of retesting a sample of the chemical fume hoods annually to verify the 

subcontractor’s testing results.

Response 3: Currently the EPA-RTP SHEM Office personnel routinely respond to chemical 

fume hood trouble calls or other deviations in ventilation controls to assess safe operations. A 

performance work statement and quality assurance monitoring requirement with penalty fees 

could establish acceptable sample sizes in future contracts. 

A question exists as to how much retesting is required to demonstrate statistical significance? 

The RTP-SHEM office proposes retesting one fume hood from each building within 30 days of 

delivery of ‘passing’ fume hoods in a given building. If the random fume hood fails reinspection, two additional fume hoods from the building batch submitted as passed will be 

retested. 

Expected Completion: As this will be a new practice, completion will occur with the next set of 

annual fume hood re-certifications beginning in FY 2014 where the current cycle completes all 

campus building fume hoods by the following June 2014. 

Estimated Completion of re-testing building by building random fume hoods: July 2014. 

Recommendation: 

4. Work with the Safety, Health and Environmental Management Division at headquarters to 

revise and update the EPA’s 2009 testing protocol criteria, EPA Performance Requirements 

for Laboratory Fume Hoods, to add criteria for chemical fume hoods operating at an average 

face velocity of 70 fpm, which is the design face velocity for the retrofit kits. 

Response 4: The actual performance standard for retrofitted fume hoods applied at the EPARTP campus was the same as for any other fume hood, namely an onsite ASHRAE 110 test 

confirming containment performance of an average tracer gas concentration of less than or equal 

to 0.1 ppm. Before the retrofitted fume hoods were ‘delivered’ as operational the ASHRAE 110 

test was performed on every retrofitted fume hood under the EPA RTP chemical fume hood 

retrofit project (contract no. GS-23F-0225M; task order no. EP09H001115.) 

Revision to EPA’s testing protocols for an average face velocity of 70 fpm is the responsibility 

of the Safety, Health and Environmental Management Division (SHEMD) at Headquarters which 

is in OARM/Office of Administration. Therefore, I suggest this fourth recommendation be reassigned to the Director, Safety, Health and Environmental Division who is better positioned to 

address EPA’s 2009 testing protocol criteria. As a combined EPA-OARM and EPA-ORD 

facility at the RTP North Carolina campus, the RTP SHEM office commits to work with 

SHEMD at Headquarters to provide review and comment for any updated testing protocols for 

retrofitted chemical fume hoods to explicitly state ASHRAE 110 testing for newly installed or 

retrofitted fume hoods. The RTP-SHEM office understands the SHEMD HQ is currently 

revising its 2009 testing protocols. Therefore the consensus decision with the details on how to 
13-P-0363 21

annually recertify fume hoods operating at 70 fpm for retrofitted fume hoods can reasonably be 

expected to be in place prior to the EPA-RTP campus annual fume hood recertification cycle 

which begins in FY 2014. 

At the EPA-RTP campus, I disagree with the assertion the Agency has “limited assurances of 

fume hood safety” as stated on page 12 of the report. The facility has two full time Federal 

industrial hygienists who can perform on demand fume hood verification testing and additional 

chemical specific monitoring. The research staff community at the RTP campus is one of the 

most highly trained. Researchers are constantly evaluating environmental and health effects 

from various toxicants. This same research staff has a keen focus on their own individual work 

place exposure. The training delivered initially and on an annual basis to research staff 

communicates the correct usage of fume hoods and when to suspect a malfunction. The RTP’s 

campus Chemical Hygiene Plan further classifies laboratories according to the risk posed by the 

chemicals used in each laboratory setting and requires additional levels of personal protective 

equipment in addition to engineering controls in higher hazard level laboratories. Finally, 

personnel are enrolled in the occupational medical surveillance program to monitor their fitness 

for duty, potential exposures and health effects. All these back-up practices do not show 

exposure above action levels or health effects. Nevertheless, the fume hoods are the primary 

engineering control used to minimize exposure and will receive improved oversight as outlined 

in my responses. 

Thank you for the opportunity to respond to the report. 

Should you have any questions, please contact Jewel Morris, ORD’s designated Safety Health 

and Environmental Management Official at 919-541-2292; morris.jewel@epa.gov or Todd 

Baker, Acting Director ORD Safety, Health and Environmental Management at 919-541-4307; 

baker.todd@epa.gov. 

Summary of Planned Actions 

Rec. 

No.

Action

Planned

Completion

Date

1 Ensure complete documentation for FY2013 fume hood annual testing. Aug. 30, 2013

2 Replacement of any non functioning monitors. Sep. 30, 2013

3 Re-testing building by building random fume hoods.

(As this will be a new practice, completion will occur with the next set of annual fume 

hood re-certifications beginning in FY 2014 where the current cycle completes all 

campus building fume hoods by the following June 2014.)

Jul. 31, 2014

(Begins FY 

2014)

4 Review and comment for any updated testing protocols for retrofitted chemical fume 

hoods in coordination with SHEMD-HQ.

Oct. 31, 2013

CC: Jewel F. Morris

Todd Baker

Wesley Carpenter
13-P-0363 22

Howard Wilson

Dave Gibson

John Bashista

Lisa Maass

Bruce Woods

Melinda Burks

Michael Petscavage
13-P-0363 23

Appendix D 

Distribution 

Office of the Administrator 

Director, National Exposure Research Laboratory, Office of Research and Development 

Principal Assistant Deputy Administrator, Office of Research and Development 

Agency Follow-Up Official (the CFO) 

Agency Follow-Up Coordinator 

General Counsel 

Associate Administrator for Congressional and Intergovernmental Relations 

Associate Administrator for External Affairs and Environmental Education 

Director, Office of Acquisition Management, Office of Administration and 

Resources Management 

Director, Facilities Management and Services Division, Office of Acquisition Management, 

Office of Administration and Resources Management 

Audit Follow-Up Coordinator, Office of Research and Development