28 July 2011

What you must know with regards to each audit element

How to respond to auditors to show that you comply to each of those elements

Positive Aspects – “Good job!”

Areas for improvement (AFIs) – will need to be addressed by labs and improvements shown at the next surveillance audit

Category A findings – non-compliance to the SMS that might result in accidents or incidents in the laboratories

Category B findings –non-compliances to legal and other

requirements

For non-compliance findings, PI must inform OSHE of corrective actions to be taken. Follow-up audit within one month to verify.

1. Occupational Health and Safety Policy2. Risk Assessment3. Legal and Other Requirements4. Objectives and Programmes5. Roles and Responsibilities6. Training 7. Communication8. Documentation and Document Control9. Operational Control 10.Emergency Preparedness and Response 11.Performance Measurement and Monitoring/Internal Audit 12.Incident Reporting

Defined by management and shows commitment to the SMS Are all lab members familiar with department’s OSH Policy? Is the hardcopy filed together with your other SMS documents?

The policy consists of 3 principles (‘pillars’)

Legal Complianc

e

Legal Complianc

e

Prevention of Ill-Health and Injury

Prevention of Ill-Health and Injury

Continual Improvemen

t

Continual Improvemen

t

Every routine and non-routine activity must have a risk assessment Lack of risk assessment for any lab activity/experiment immediately

gets a non-compliance finding The lab member who conducted the risk assessment and even those

users of the experiment/lab activity can be ‘interviewed’ on its contents Must be familiar with Severity and Probability rankings:

Why is severity 2 and not 3? Must be able to explain to

auditors

Note: The aim of a risk control measure should be to either reduce the likelihood of occurrence (probability) and/or the severity of potential injury

or damage (severity).

Why do you implement additional risk controls?

Your lab is a ‘workplace’ Everyone has the responsibility to ensure a safe

workplace

Housekeeping in order?

Any dangerous practices or arrangements observed?

Are safety signages prominently displayed?

All lab members aware of safe handling of hazardous substances?

Accidents/incidents must be reported by law

Do you know who the first aiders are?

Risk assessments to be carried out for every routine and non-routine activity

Petroleum And Flammable Materials (PFM) Regulations Chemical Weapons Convention (NACWC) Poisons Act Environmental Protection & Management Act Environmental Public Health Act Sewerage and Drainage Act Misuse of Drug Act Arms and Explosives (Amendment) Act

General Requirements: Maintain and update Inventory List with inventory check every 6

months. Maintain, update and make available Safety Data Sheets. Ensure

validity of SDS within 5 years. Liquid chemical must be stored within a secondary containment tray

that can capture 20% of the total chemicals stored in a tray. All chemicals to be disposed through toxic industrial waste collector.

Where do you keep your PFM and how much do you keep?◦ Maximum allowable quantity of PFM: (0.8 litres/m2)

500 litres max for MD7 1, 3, 4, 5400 litres for MD4A Level 2 and MD7 Level 2200 litres for MD4A Level 1including amount in flammables cabinets (170 litres) and

solvent wastes

Are all stock bottles of flammable liquids kept in the flammables cabinet?

Is the flammables inventory list updated?

Annual declaration of amounts to OSHE Licence to store PFM held at the University level and

administered by OSHE. Note: Glacial acetic acid has a flash point of 40°C and thus

is considered a Class III PFM – storage in flammables cabinet with plastic secondary container

The only chemical that falls under this act in the department is Triethanolamine

◦ Must be locked and logged. Disposal must be declared to OSHE.

Annual declaration to OSHELicence to store CWC chemicals held at the University level and administered by OSHE

All regulated poisons to be locked and logged, including freezers and fridges. If stored in cold room, then it must be lockable as well.

Annual declaration to OSHE Licence is held by SoM Safety Office. However, Poison Licence shall not be required if the poisons are

purchased from local vendors.

As an additional measure, keep chemicals with prominent toxicity symbols together with your other poisons. Some, like beta-mercaptoethanol, APS, are used daily and can be kept inside the fume hood with a secondary container (small beaker etc. Good practice to label the container ‘Caution: Toxic’)

Applies to:◦ Hazardous Substances - Includes concentrated acids and bases, phenols,

formaldehyde ◦ Ozone Depleting Substances – department does not use these substances

For Hazardous Substances◦ Lab members can be asked to describe health hazards of a specific

chemical in the lab◦ Stored separately from incompatible substances and with secondary

containment ◦ Good practice to label ‘Hazardous’ on storage areas or individual bottles

All personnel handling the hazardous substance must have received training to:◦ Know the hazards involved (risk assessment), ◦ Handle safely so as not to affect people and environment◦ Deal with spills and leakage.

Annual declaration to OSHE Licence is held by SoM Safety Office. Local vendors will require a

copy of the licence.

Applies to waste disposal

All Toxic Industrial Waste (includes lab chemicals and biohazard waste) must only be collected by NEA-licensed waste collectors

Are biohazard and chemical/cytotoxic waste disposal procedures adhered to (refer to respective SOPs)?

Are bottles of liquid waste properly labelled and stored with secondary containment?

Be aware of chemical incompatibilities (tables of incompatible chemicals can be found on the departmental safety website)

No licence requirement

Good practice: Waste bottle affixed with both departmental waste disposal and hazard warning labels.

Regulates the discharge of effluent into public sewer.

Only buffers of pH 6 – 9 and10% bleach.

All solvents or buffers containing solvents must be collected and disposed by TIW contractors.

No licence requirement

Regulates the use of controlled drugs (check against Regulated Chemicals Identifier). Even includes chemicals like Potassium Permanganate, Acetic Anhydride, Acetone and Diethyl Ether under the Third Schedule

Must be locked and logged

Controlled Drugs Permit held by SoM Safety Office.

Regulates Explosive Precursors: Hydrogen peroxide, sodium nitrate, sodium nitrite, perchloric acid◦ Stock bottles stored under lock and key or in the spark-free

fridge? ◦ Are usage logs kept and updated?

Ensure that any EP that has expired and that is unsafe for storage is immediately removed from the licensed premises and disposed to the licensed toxic contractor.

Licence is held by SoM Safety Office.

Legislation Licence held by:

Petroleum And Flammable Materials (PFM) OSHE

Chemical Weapons Convention (NACWC) OSHE

Poisons Act SoM Safety Office

Environmental Protection & Management Act SoM Safety Office

Environmental Public Health Act None (NEA licence held by TIW contractors)

Sewerage and Drainage Act None

Misuse of Drug Act SoM Safety Office

Arms and Explosives (Amendment) Act SoM Safety Office

Fire Emergency Preparedness◦ What to do in case of fire?◦ Where is emergency assembly point?

Fire PreventionAre extinguishers and fire alarm points unobstructed? Are passageways at least 1.0 m wide? Are easily combustible materials placed on top of the

flammables cabinet? Are combustible materials kept to a minimum? Is there ≥ 50 cm clearance from the ceiling?Are all exit lights functioning?

Emergency Assembly Point – across the road from

MD11

Correct Biosafety Levels posted on BSCs?

Doors posted with appropriate hazard signs?

Biohazard wastes stored in covered bins and marked with biohazard symbol?

Are those using human-derived cell lines inoculated against HBV and/or HCV?

Liquid biological wastes properly decontaminated before disposing down the drain?

Not applicable to department

Does lab implement safety objectives and programmes in line with Departmental OSH Policy?

Must update every year following an audit/inspection or to improve safety practices

Fill up your lab’s form and file it in the SMS

folder. Edit if necessary.

Roles and responsibilities should be defined for the essential audit elements

Those named in the register should be prepared to describe how they carry out their duties

All lab members to have received the appropriate structured training (OSHE, SoM, Departmental)

In addition, should also have lab-specific training

All records must be present

How does PI assess competency of lab user after training?

How are safety matters communicated within the lab and from department?

Are there records of such communication?

Who is responsible for updating the lab on safety matters?

Any safety issues in the agenda of lab meetings?

Who is responsible for maintaining the SMS documents/records?

Who ensures that all documents are up-to-date and how are obsolete copies removed from circulation?

Basically what they want to see implemented in the lab. Includes:

Are lab SOPs adhered to? Applicable licences in place? Inventory / storage control with logs Security /administrative control (e.g. keys to controlled chemicals) Labelling (especially of hazard categories) Maintenance programme (Cold room, BSCs and fume hoods by dept) Occupational health programme (vaccinations, health surveillance) Personal protective equipment (long-sleeved lab coats, pants, covered

shoes, face shields/goggles) Waste disposal Decontamination / neutralization

All lab members aware of actions to take in the event of fire/fire drill?

Do you know who your first aiders are and how to get hold of them?

Do you know who is in charge of maintaining the first aid boxes?

Actions in the event of chemical/biological spill?

Who maintains spill kits?

Includes:Equipment maintenance reportsLab inspection checklistsMedical surveillance records (Booster shots, specific pathogen monitoring, etc.)Calibration scheme and calibration recordsAccident/Incident reports Internal audit and corrective action reports

Are all lab members aware of:Reportable Incidents:• Minor cuts and bruises • Slips, trips and falls • Animal bites, needle stick injuries • Chemical, biological spills • Glassware related incidents • Near misses

Reporting Procedure• PI/Safety Lead → Safety Committee → OSHE (via AIRS within 24 hrs – WHO

REPORTS?)