LONDON’S GLOBAL UNIVERSITY
UNIVERSITY COLLEGE LONDON
WORKING WITH SUBSTANCES
APPROVED CODE of PRACTICE
Introduction
This document, a UCL-approved Code of Practice (UCL-ACOP), provides a mechanism by which
departments can fulfil their duty to assess and manage the risk to health and safety of their work with
substances.
This Code of Practice forms part of UCL’s general arrangements for health and safety and is also part
of a department’s own arrangements for health and safety under its Statement of Safety Policy (SSP).
It will assist the department to comply with the requirements of UCL in accordance with the Control of
Substances Hazardous to Health (COSHH) regulations and the Dangerous Substances and
Explosives Atmospheres Regulations (DSEAR). If departments follow this advice, they will normally be
doing enough to comply with the UCL-ACOP. Departments may use alternative methods to those set
out in this Code but if so will have to show that they complied with the UCL-ACOP in some other way.
This ACOP and Appendices have been drawn up by Safety Services making use of guidance issued
by the Health and Safety Executive and other “best practice” where appropriate. They are approved
for use in UCL and its constituent Institutes and Departments by the Health and Safety Management
Team (HSMT) and are published after consultation with all concerned. The ACOP applies to all
workers (including students) involved in work with substances as well as to maintenance staff, service
engineers, visitors, cleaners etc. who may, from time to time, have to enter areas where work is
carried out.
Aim of this document
The aim of UCL's safety policy is to encourage and promote the safe management of departmental
work activities by its constituent departments whose staff have the expertise and experience to
understand and control those risks. The extent and variety of work with substances at UCL is
enormous. The setting of performance standards for safe working is complicated by these factors:
•
UCL has over 100 separate departments, Institutes, etc, all of which handle materials which
potentially fall within the category of "substances hazardous to health" or “dangerous substance”.
•
"substances" range in degree of hazard from the relatively trivial to fatal.
•
•
the circumstances and procedures in which substances are used varies widely from department
to department and within departments.
not all hazards affect health since the properties of some substances give rise to other risks principally those of fire and explosion.
Accordingly, this document sets out a strategy to guide the people responsible for supervising work
with substances, in the identification and control of risk. It aims to provide guidance in procedures to
assist departments to put suitable control measures in place while avoiding the imposition of
unnecessarily burdensome procedures for the control of risk which is clearly trivial.
The strategy set out below is to guide departments to prioritise their risk control measures in scale with
the risk. It takes managers through a process for classification of hazard in proportion to severity and
guides them through the "hierarchy of risk control” in accordance with the legislative requirement set
out in HSE guidance to the COSHH regulations 2002.
UCL Safety Service
UCL ACOP: Working with Substances
Legislation addressed by this UCL-ACOP
The Control of Substances Hazardous to Health Regulations 2002 (COSHH).
Although animal allergens are substances hazardous to health UCL has a specific ACOP in place to
manage the risks associated with them. All other respiratory sensitisers must be addressed as part of
this UCL-ACOP Working with Substances.
The Dangerous Substances and Explosives Atmospheres Regulations 2002 (DSEAR).
DSEAR covers safety aspects such as fires and explosions arising from “dangerous substances”.
NB. The DSEAR removes the need for licensing the storage of petrol and other petroleum spirits in
the workplace. Legislation mainly concerned with petroleum spirit has been amended, revoked or
repealed.
Legislation not addressed by this UCL-ACOP
The Control of Lead at Work Regulations 2002.
The Control of Asbestos at Work Regulations 2002.
The identification and removal (where appropriate) of asbestos on UCL premises is managed by the
Construction and Fire Safety Manager, Estates and Facilities.
The Ionising Radiation Regulations 1999.
UCL has an ACOP in the form of Local Rules for the use of ionising radiation. Contact your
Departmental Radiation Protection Supervisor (DRPS) if you intend working with radiation.
The Genetically Modified Organisms (Contained Use) Regulations 2000.
UCL has an ACOP for working with genetically modified organisms. Contact your Genetic Modification
Safety Officer (GMSO) if you intend working with genetically modified organisms.
Abbreviations
ACDP
Advisory Committee on Dangerous Pathogens
COSHH
control of substances hazardous to health
DSEAR
dangerous substances and explosive atmospheres regulations
EH40
guidance published by the HSE giving workplace exposure limits for substances
HSE
Health and Safety Executive
PPE
personal protective equipment
SSP
statement of safety policy
WEL
workplace exposure limit
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UCL ACOP: Working with Substances
1 Definitions applicable to this UCL-ACOP
UCL – ACOP
Substance
1.1
Any natural or artificial substance whether in solid or liquid form or in the
form of a gas or vapour (including micro-organisms). This includes
substances which have been supplied or which have been produced by a
work activity e.g. fumes, vapour, aerosols, products and waste materials.
Guidance
1.1
This definition includes “dangerous substances”, “substances hazardous to
health”, “biological agents” (except genetically modified organisms which have a
separate UCL-ACOP), “carcinogens”, “respiratory sensitisers” (except animal
allergens which have a separate UCL-ACOP) and “dust”.
UCL – ACOP
Dangerous Substance
1.2
Substances (including preparations) which are classified explosive,
oxidising, extremely flammable, highly flammable, and flammable. Dusts
formed from solid particles or fibrous materials which when mixed with air
can form and explosive atmosphere.
Guidance
1.2
A substance which because of its properties could cause harm to people from fire
or explosion. Dangerous substances include petrol, LPG, paints, varnishes,
solvents and dusts e.g. from milling or sanding operations.
UCL – ACOP
Explosive Atmosphere
1.3
Guidance
1.3
UCL – ACOP
1.4
A mixture, under atmospheric conditions, of air and one or more
“dangerous substances” in the form of gases, vapours, mists or dusts in
which after ignition has occurred, combustion spreads to the entire
unburned mixture.
An accumulation of gas, mist, dust or vapour which could catch fire or explode
when mixed with air. Explosive atmospheres do not always explode but if they
catch fire the flames can rapidly travel through them. If this happens in a confined
space (e.g. in plant, equipment or laboratory scale reaction vessels) the rise in
pressure and rapid spread of flames could cause an explosion.
Substances Hazardous to Health
Substances (including preparations) which are classified as very toxic,
toxic, harmful, corrosive, irritant, carcinogenic, dust, biological agent, any
substance assigned a WEL (see 1.10) and any substance that is used or
present in the workplace that creates a risk to health.
Guidance
1.4
This definition includes gases and vapours that at high concentrations in air can
reduce the oxygen content and therefore be a threat to life.
UCL – ACOP
R-phrases
1.5
Standard risk phrases which give advice on the risks associated with
particular substances. R-phrases are specified by the Chemicals (Hazard
Information and Packaging for Supply) Regulations 2002.
Guidance
1.5
R-Phrases can be found on labels and safety data sheets which are provided by
suppliers for each substance.
A key to the phrases can be found in Appendix 2, “Sources of Information”
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UCL – ACOP
S-phrases
1.6
Standard safety phrases which give advice on the precautions necessary
when working with particular substances. S-phrases are specified by the
Chemicals (Hazard Information and Packaging for Supply) Regulations
2002.
Guidance
1.6
S-Phrases can be found on labels and safety data sheets which are provided by
suppliers for each substance.
A key to the phrases can be found in Appendix 2, “Sources of Information”.
UCL – ACOP
Biological Agent
1.7
Guidance
1.7
Any micro-organism, cell culture or human endoparasite, including any
that have been genetically modified, which may cause any infection,
allergy, toxicity or otherwise create a hazard to human health. The
definition of a micro-organism includes non-cellular microbiological entities
(such as viruses).
There are two possible ways by which people could be exposed to biological
agents at the workplace;
a) a deliberate intention to work with them i.e. for research, teaching or
diagnostic purposes;
b) as a result of a work activity i.e. working on or near potentially
contaminated water or handling waste;
UCL – ACOP
Carcinogen
1.8
Any substance or preparation which is known to be or regarded as
carcinogenic to humans or listed in or arising from a process specified in
Schedule 1 (COSHH Regulations 2002)
Guidance
1.8
Substances labelled with the risk phrase R45 (may cause cancer) or R49 (may
cause cancer by inhalation) or arising from a process specified by Schedule 1 of
the COSHH Regulations 2002. See Appendix 1. See also “Sources of
Information” Appendix 2.
UCL – ACOP
Dust
1.9
Dust of any kind when present at a concentration in air equal to or greater
than:
• 10mg/m3 inhalable dust;
• 4mg/m3 respirable dust;
as a time-weighted average over an 8-hour period.
Guidance
1.9
In practical terms if dust is detectable i.e. it can be seen in the air or lies on
surfaces in the vicinity of the dust producing activity then measures must be taken
to control exposure. If the activity is carried out routinely e.g. cutting wood with a
circular saw then local exhaust ventilation should be considered. If the activity is
non-routine or non mechanical then it may be sufficient to provide good general
ventilation and personal protective equipment (PPE).
UCL – ACOP
Workplace Exposure Limit (WEL)
1.10
A number of substances hazardous to health have been given a
workplace exposure limit (WEL). A WEL is the maximum concentration of
an airborne substance, averaged over eight-hour and/or 15-minute
reference periods, to which employees may be exposed by inhalation.
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UCL ACOP: Working with Substances
Guidance
1.10
WELs are published by the HSE in their guidance document EH40 and by
suppliers in the safety data sheets that are prepared and supplied for each
substance. A substance that has not been assigned a WEL is not necessarily
harmless. Seek advice from the supplier about suitable exposure levels i.e. a level
that will allow exposure day after day without any harmful health effects.
UCL – ACOP
Control Measures
1.11
A measure taken to reduce exposure to a substance
• engineered controls (e.g. safety cabinets, fume cupboards)
• management controls (e.g. supervision & safe operating
procedures)
• personal protective equipment
UCL – ACOP
Hierarchy of risk control
1.12
A sequence of control measures starting with the most stringent which
must be applied where the risk to health is greatest.
Guidance
Control measures should be applied in the following order of priority according to
the magnitude of risk as identified by the risk assessment:
•
•
1.12
•
•
•
changing the process or activity so that the substance is not needed or
generated;
replace the substance with one that is less harmful or use in a different
form;
engineered controls;
management controls;
personal protective equipment.
UCL – ACOP
Competence
1.13
People who have the skills, knowledge and experience required to
discharge safely a particular duty and who know the limits of their
competence and seek advice when reaching those limits.
UCL – ACOP
Reasonably practicable
1.14
If a precaution is practicable it must be taken, unless the cost in achieving
a gain in safety is grossly disproportionate to the benefit.
Guidance
1.14
The term “so far as is reasonably practicable” is interpreted by the courts as
allowing economic considerations to be taken into account as one factor with time
or trouble to be set against the risk.
UCL – ACOP
Respiratory sensitisers
1.17
A substance which when breathed in can trigger an irreversible allergic
reaction in the respiratory system. When the sensitisers are work-related
the resultant condition is occupational asthma.
Guidance
1.17
Sensitisation does not usually take place right away. It can happen after several
months or years of being exposed to a substance. Look for substances labelled
R42 “May cause sensitisation by inhalation”. See also Appendix 2, “Sources of
Information” for a link to the HSE site on asthma which lists the commonest
workplace sensitisers.
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UCL – ACOP
Manager
1.18
An individual responsible to the Head of Department for the management
and/or supervision of work activities, work areas, staff and students.
Guidance
1.18
The term manager is used throughout this document and applies to principal
investigators, laboratory superintendents, office managers and the equivalent.
UCL – ACOP
Monitoring
1.19
Monitoring is a systematic process carried out to compare what is
observed or measured with a pre-agreed procedure or standard.
Guidance
In terms of this document monitoring has two meanings:
1.
2.
1.19
Checking the correct operation of risk control systems e.g. codes of
practice, instruction sheets etc;
Measuring the amount of a substance in the air when process controls
cannot completely prevent exposure.
2 Management responsibility, supervision and other duties
UCL – ACOP
2.1
Guidance
2.1
Head of Department (HOD)
The Head of Department is responsible to Provost and Council for the safe
management of work with substances in accordance with the UCL
Statement of Safety Policy (SSP) and the Departmental Statement of Safety
Policy (DSSP).
The duties of the HOD for ensuring the safe management of work with substances
are the same as those for all other aspects of safety management as described in
the UCL SSP. The HOD authorises specific staff to work with, or supervise work
with, certain categories of substances based on that individual’s competence.
UCL – ACOP
Managers
2.2
The Head of Department delegates the duty to ensure safe working with
substances to senior departmental staff appropriate to the local
departmental arrangements.
Guidance
This delegated duty is the normal pattern for the supervision of work. If the
manager is absent from the department they should delegate the day-to-day
management of the work to a named member of the team who is suitably skilled
and experienced to carry out the necessary management duties. These
2.2
management duties include assessment of risk and ensuring the
implementation of the risk control measures required by their assessments.
It is the duty of the person supervising the work to ensure that all staff
students and visitors are informed of any precautionary measures they must
observe.
UCL – ACOP
Staff and Students
2.3
Staff and students working with substances must observe the control
measures required as a result of the risk assessment of their work and any
other measures as directed by UCL or the Department that are designed to
protect their health and safety. In taking due care for their own safety they
shall have regard for the safety of others. This duty applies also to visitors
to the Department.
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Guidance
These duties are in accordance with and do not exceed the duties imposed on
employees under s. 7 of the health and Safety at Work Act 1974. Graduate
students are treated for the purposes of this ACOP as if they were employees.
Visitors to the Department who are undertaking work may be treated as if they were
employees but care should be taken to supervise their work. Despite the fact that
they may be experienced, they are not likely to be knowledgeable about UCL and
its systems and procedures.
2.3
UCL – ACOP
2.4
Guidance
2.4
Departmental Safety Officer (DSO)
The DSO is appointed by the Head of Department to monitor the day-to-day
standard of safety management in the department. Where appropriate i.e.
the department exists on more than one site, it may be necessary to appoint
one or more deputies.
The Departmental Safety Officer (DSO) role is to assist in monitoring the
department’s compliance with this ACOP.
It is not the duty of the DSO to carry out risk assessments but to ensure that they
have been carried out and to bring to the attention of the Head or departmental
management any non-compliance with departmental arrangements for safe
working with substances.
UCL – ACOP
Visitors
2.5
Visitors engaged on work involving substances must observe the risk
control measures required as a result of the risk assessment, and take due
care for their own safety and that of others.
Guidance
2.5
Visitors are non-departmental employees including contractors, maintenance
workers, cleaners, etc. (though they might be UCL employees) who may be
permitted to enter areas where work with substances is conducted.
Visitors (including observers, contractors, etc.) should be provided with relevant
safety information including the precautions necessary to ensure their safety while
on site.
3 Controlling Access to Substances
UCL – ACOP
3.1
The HOD must ensure that those who have access to substances have the
competence to use them or supervise their use.
Guidance
Access
•
•
•
means the;
authority to purchase or receive substances;
ability to retrieve them from storage i.e. have physical access to them;
authorisation to use them in work processes.
It is the Head of Department’s duty to authorise senior managers to have access to
substances based on that person’s competence. These managers will in turn be
responsible for assessing the competence of the individuals whom they supervise
and ensuring an appropriate level of access to substances according to the
competence of that individual.
UCL has developed a system of categorising substances that ensures an
appropriate level of control can be exercised. In this context control relates to
restricting access to substances in such a way that the most hazardous are only
available to a minority of competent people.
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These categories are not listed purely according to hazard; they take into account
the circumstances in which a substance is used and the likely knowledge of the
people who are using it.
The categories are defined as follows:
Category 1
This category applies to all Departments
Substances in category 1 may be accessed by the majority of staff groups e.g.
cleaning products, photocopier toner etc.
Category 2
This category applies mainly to workshops and studios
Substances used in processes of a routine kind which are used in accordance with
standard procedures i.e. manufacturer's instructions or best practice e.g. impact
adhesives, degreasing agents, white spirit, cutting oil, etching reagents, flux-cored
solder, varnish spray, welding gases, lithium sulphide grease.
Category 3
This category applies to laboratory work
Substances used in laboratory processes where the hazardous properties of the
substance are unchanged e.g. substances used in tissue section preparation,
HPLC, optical rotation measurements and many other routine laboratory activities.
Category 4
This category applies to laboratory work
Substances used in laboratory processes which:
a. change the nature of the hazard by chemical reaction;
b. are of a larger scale than routine bench work;
c. involve continuous flow processes;
d. involve biological agents which are classified by the ACDP as belonging to
hazard group 2, (see appendix 4 for Hazard Group Definitions), or for which a
DEFRA licence is required;
e. when mixed with air can form an explosive atmosphere.
Category 5
This category applies to laboratory work
Substances which are exceptionally hazardous e.g. carcinogens, neurotoxins or
other highly toxic or hazardous materials and biological agents classified as
belonging to ACDP hazard group 3 (see Appendix 4 for Hazard Group Definitions).
In order to assist Departments to produce arrangements to achieve control of
access to substances a guidance document and notification form can be found at
appendix 3.
3.1
4 Assessment of the risks of working with substances
UCL – ACOP
4.1
Managers must ensure that before work begins the hazardous properties of
any substance(s) to be used is (are) identified.
Guidance
There are many sources of information which will assist you to identify the
hazardous properties of substances. These include;
• labels on substances give information on hazards and precautions;
•
safety data sheets, provided by the supplier, which list information under
several headings including hazards, precautions handling, storage,
disposal and fire fighting measures.
•
Approved list of Biological Agents. See Appendix 2, “Sources of
Information”;
Guidance published by the HSE. See Appendix 2, “Sources of Information”
The Internet. See Appendix 2, “Sources of Information”
•
•
The information gathered is not in itself an assessment of risk as the risks will vary
according to the way in which the substance is used, the quantity and the people
involved, but provides the basis for carrying out the assessment.
4.1
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UCL – ACOP
4.2
Guidance
Managers must ensure that when the hazardous properties of substances
have been identified a suitable and sufficient assessment of the risks to
health and safety created by the work must be made.
In the majority of routine processes and procedures a generic risk assessment will
already have been carried out. This will mean that the control measures for
substances in UCL categories 1 and 2 may already be detailed in the
manufacturers’ instructions for use. For category 3 substances a laboratory code of
practice (COP) or standard operating procedure (SOP) will have been developed
and form part of the department’s arrangements for managing safety. It is important
to note that although in these cases the process or procedure will remain the same,
the location and/or people involved may vary and it is for the manager to ensure
that the precautions that are in place are still adequate under all circumstances.
A generic risk assessment may not be appropriate for category 4 and 5 substances
which are not used routinely and where the risks are high.
A suitable and sufficient assessment must include:
• an assessment of the risks to health and safety arising from substances
used in or created by workplace activities by any route: i.e. inhalation;
absorption through the skin or mucous membranes; contact with the skin
or mucous membranes; ingestion; injection; or as a result of fire or
explosion;
• identification of people who could be exposed; including visitors, cleaners,
maintenance staff and vulnerable individuals e.g. those with a known
•
•
•
•
•
•
•
4.2
allergy to a substance or who are pregnant;
the practicality of preventing exposure or where this is not possible the
steps necessary to control exposure to the risks, see 5.2 & 5.3 “Measures
to Prevent or Control the Risk of Exposure”;
storage arrangements for substances; segregating non-compatible
substances; suitable containers, cabinets and storage areas;
measures to prevent access to substances by non-departmental personnel;
unauthorised departmental staff, see 3.1 “Controlling Access to
Substances”;
arrangements for transporting substances within the building, between
buildings or institutions. See Appendix 2, “Sources of Information”;
hazard warning signs and labelling for storage areas, containers for
transportation or for decanted or waste substances; areas where the risk
assessment identifies the likelihood of an explosive atmosphere being
present;
emergency procedures should be prepared to deal with: first aid, the first
aiders for your area must be made aware of substances that have specific
first aid treatment e.g. hydrofluoric acid; spill procedures, you should have
enough suitable absorbent material to deal with the largest spill that could
occur; fire fighting measures, some substances require specialist fire
extinguishers;
disposal of waste substances which includes the packaging and the
containers i.e. bottles and jars. See Appendix 2, “Sources of Information”
for waste disposal arrangements.
Increasingly, UCL Cleaning and Waste Services are being asked to
dispose of substances which are unopened or almost unused. It is often
more expensive to dispose of a substance than to purchase it. This is not
only wasteful in terms of resources (cost, time and space) but from an
environmental viewpoint it is unacceptable. As part of the assessment of
risk you should only order the amount of a substance that you expect to
use in a given period. Although it may be cheaper to buy larger quantities
many substances have short shelf lives. Storing limited quantities of a
substance reduces the risk from spillage, requires less storage space,
keeps disposal costs to a minimum and reduces the contribution a
substance may make to the spread and intensity of fire.
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5 Measures to prevent or control the risk of exposure
UCL – ACOP
5.1
Guidance
Managers must ensure that exposure to substances is prevented or
adequately controlled by measures other than personal protective
equipment.
5.1
The purpose of the risk assessment process described in section 4 is to enable
managers to select the most suitable controls or combination of controls that are
proportionate to the risk.
UCL – ACOP
5.2
Managers must ensure that exposure to substances is prevented if it is
reasonably practicable to do so.
Guidance
Preventing exposure can be achieved by:
• changing the process or activity so that the substance is not needed or
generated i.e. dusts or aerosols;
•
5.2
•
replace the substance with one that is less harmful; substances which are
carcinogenic should only be used if carcinogenicity is the property being
investigated or there is no other suitable alternative;
use the substance in a different form e.g. pellets instead of powder.
UCL – ACOP
5.3
Where it is not reasonably practical to prevent exposure to substances
Managers must ensure that exposure is adequately controlled.
Guidance
If preventing exposure is not possible then exposure must be controlled in such a
way that the health of staff and students is not affected by the substances in use.
Methods of control are:
• engineered controls e.g. general ventilation, local exhaust ventilation;
• management controls e.g. supervision and safe operating procedures.
5.3
UCL – ACOP
5.4
Guidance
5.4
Where measures to control exposure are not in themselves adequate to
achieve control then Managers must ensure that appropriate personal
protective equipment is also provided.
PPE may be used as additional protection in combination with other control
measures such as local exhaust ventilation. Seek the advice of the supplier to
ensure that the PPE selected is appropriate protection for the substance in use.
Respiratory protective equipment (RPE) should not be used for routine tasks. It
may be used as an interim measure while engineered controls are installed or
when dealing with emergency situations or one-off situations or periodic
maintenance.
See Appendix 2, “Sources of Information” for advice and guidance on PPE.
UCL – ACOP
5.5
Adequate control will have been achieved when exposure to a substance
has been reduced to a level unlikely to cause harm.
Guidance
For inhalable substances control will have been achieved if:
• pre-agreed standard has not been breached;
• exposure is well bellow the WEL.
5.5
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6 Use of control measures
UCL – ACOP
6.1
Managers must ensure that the control measures, which are provided to
reduce the risk of exposure to substances, are used correctly.
Guidance
Managers and supervisors must ensure that staff and students are given sufficient
instruction and information to enable them to use control measures correctly. This
will involve varying degrees of supervision according to the competence of the
individual, periodic inspection while work is underway and ensuring a system for
fault reporting is in place. A system for the repair or replacement of faulty items
should also be developed.
6.1
UCL – ACOP
6.2
Guidance
6.2
Staff and students must use the control measures, which are provided to
reduce the risk of exposure to substances, as instructed. They must report
any faults or deficiencies in the control measures to their manager.
Staff and students must use the control measures that have been provided in the
way they have been instructed and according to the information which they have
been given. They must also report any faults or deficiencies in accordance with the
system that is in place.
7 Maintenance, examination and test of control measures
UCL – ACOP
7.1
Guidance
Managers must ensure that the measures which are employed to prevent or
control exposure to substances are maintained in efficient working order, in
good repair and in a clean state. Managers must ensure that a system for
fault reporting is established.
In order to ensure that control measures perform as they were originally intended
i.e. continue to prevent or adequately control exposure to substances they should
be maintained as follows:
• Engineered controls e.g. fume cupboards,
• visually inspected at least once a week;
• maintained according to the manufacturers instructions;
•
examined and tested against its performance standard by a competent
person every 12-14 months. Keep records of this for at least 5 years;
• cleaned regularly;
• decontaminated when contamination occurs or is suspected.
Personal Protective Equipment
• cleaned and maintained according to manufacturers instructions;
• visually inspected for damage or contamination each time it is worn;
•
decontaminate or dispose of when contamination occurs or is suspected or
as recommended by manufacturer, (PPE may be single use);
• dispose of in accordance with UCL waste procedures;
• stored in a well defined place separate from outdoor clothing and
belongings
Fault reporting
In all cases a system must be in place to enable faults or problems to be reported
by individuals and procedures established for removal from use, repair and/or
replacement of faulty equipment. The system must include a named individual who
is responsible for ensuring this is carried out.
Record Keeping
7.1
Records of maintenance and inspection of PPE and engineered controls must be
kept. Records of annual testing and examination of engineered controls must be
kept for 5 years.
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8 Information, Instruction and Training
UCL – ACOP
8.1
Managers must ensure that all those who work with or who may be affected
by substances that are in use are provided with information.
Guidance
The findings documented in the risk assessment should be communicated to all
who will be affected by the work including visitors and others, where necessary,
who may not be directly participating in the work.
8.1
In addition to the findings of the risk assessment staff and students must be
provided with information about the substances they are working with.
This will include:
• the name of the substances and the hazards;
• the risks which they present to health and safety;
• symptoms of associated health problems and procedures for reporting;
• WEL, access to the safety data sheet;
• the precautions they must take to prevent or control exposure;
• how to use control measures, including PPE;
• emergency procedures;
• the system in place for reporting faults.
UCL – ACOP
8.2
Managers must provide suitable instruction and training to staff and
students working with substances.
Guidance
The purpose of instruction and training is to ensure that staff and students working
with substances do not put themselves or others at risk.
Instruction and training should include;
• how and when to use control measures;
• the method of work; i.e. standard operating procedure;
• how to use, clean and store PPE;
• what to do in an emergency.
• Training should include elements of theory and practice.
Record Keeping
8.2
A record of the information, instruction and training that is provided should be kept.
This should be in the form of a standard checklist.
9 Monitoring
UCL – ACOP
9.1
Managers must monitor the implementation of the measures which have
been identified to control risk where exposure cannot be prevented.
Guidance
Inspections of working practices and procedures as described in codes of practice,
standard operating procedures or instruction sheets should be carried out
periodically. This can be achieved by observing staff and students carrying out
normal work routines to ensure that procedures are followed. In addition managers
should ensure that access to substances is restricted to the staff and students
whom they have authorised to use them.
Record Keeping
9.1
UCL – ACOP
9.2
Results of inspections may be recorded in the form of a checklist which provides a
record and ensures a consistent approach.
Managers must ensure that exposure to substances in the general
workplace is monitored under circumstances where prevention of exposure
cannot be prevented by engineering controls.
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Guidance
Most engineered controls do not provide 100% protection e.g. ventilated benches
and fume cupboards therefore where routine procedures are carried out it is not
unreasonable to periodically monitor exposure. Air monitoring can confirm that the
control measures in place are working as intended with the current reading being
compared with the previous. This is important where a substance has been
assigned a WEL because these substances have the most serious health effects
and therefore exposure must be adequately controlled i.e. exposure must be well
below this level. Where these substances are used routinely i.e. in processes
carried out daily then periodic monitoring of exposure would be appropriate.
Detection tubes
The simplest method of air monitoring is with diffusion tubes which although
designed as a personal monitor can be used to monitor areas e.g. laboratories.
They are however only available for a limited number of gases and vapours. They
must never be used to replace suitable control measures but to confirm that control
measures are working.
Depletion Monitors
Many asphyxiate gases are colourless and odourless and cannot be detected
easily. In certain locations there is potential for large quantities of these inert or low
toxicity gases (e.g. nitrogen) to be released. This can be as a result of a failure in
pressurised equipment or a slow build up in badly ventilated areas. This can result
in the displacement of oxygen in the immediate environment and lead to the risk of
asphyxiation. Under these circumstances it is appropriate to monitor the oxygen
content of the air to give an early warning that a problem exists. Warning monitors
must not be installed as a substitute for equipment maintenance and good working
procedures. Depletion monitors must be maintained and serviced in accordance
with the manufacturer’s instructions and emergency procedures must be produced
to ensure that everyone who may be involved knows what to do should it be
activated. N.B. O2 depletion monitors are not suitable for areas where the risk is
from CO2 build up. In these situations a CO2 monitor is appropriate.
Record Keeping
9.2
Records of the results of monitoring must be kept. Where depletion monitors are
installed a record of activation should be kept and the result of any investigation
and the actions taken.
10 Health surveillance
UCL – ACOP
10.1
Employers must provide suitable health surveillance if employees are
exposed to certain substances.
Guidance
If health surveillance is required it will be conducted by UCL Occupational Health
Service. It is the responsibility of the supervisor of work involving substances which
require health surveillance to inform UCL Occupational Health Service.
Health surveillance is only required:
•
when an employer is working in a process listed in schedule 6 of the
COSHH Regulations (see Appendix 1) and is likely to receive significant
exposure to the substances listed;
•
where employees are exposed to a substance linked to a particular disease
or adverse health effect and there is both:
•
a reasonable likelihood under the conditions of that work of that disease or
health effect occurring
and it is possible to detect that disease or health effect.
•
Some of the conditions and the risk factors are as follows:
•
Dermatitis R43 (May cause sensitisation by skin contact). The correct
choice of control measures will ensure that most cases of dermatitis are
prevented.
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•
•
•
Cancer R45 (May cause cancer), R49 (May cause cancer by inhalation).
Strict control of substances or work processes which may cause cancer is
essential.
Asthma R42 (May cause sensitisation by inhalation).
Diseases caused by micro-organisms in Hazard Groups 2, 3 & 4.
Record Keeping
10.1
Records of the outcome of health surveillance must be kept by the employer for 40
years. The full health surveillance record will be kept by UCL Occupational
Health Service for 40 years;
11 Consultation
UCL – ACOP
11.1
When introducing new substances and techniques anyone who may be
affected must be consulted and informed of any possible health effects.
Guidance
The aim of consultation is to provide information to others who, while they may not
be directly involved in the work, might nevertheless be adversely affected by the
work. Matters for consideration include not only health issues but also the
possibility of conflicting or hazardous interactions between work activities. This may
occur between groups sharing the same work space or departments sharing the
same building.
Consultation does not imply veto. However, it is necessary to ensure that all
relevant information is gathered for risk assessment purposes. Consultation may
involve, for example, the Departmental Safety Committee or other formal
staff/student consultative process or staff safety representatives.
11.1
12 Record keeping
UCL – ACOP
12.1
Departments must ensure that records, relating to the work activities that
are conducted on its behalf, are kept.
Guidance
Managers are responsible for maintaining records relating to the staff, equipment
and work activities within their areas of responsibility.
Records of:
• significant findings of the risk assessment;
• the results of annual testing and examination of engineered controls;
records must be kept for 5 years;
• maintenance of equipment LEV, PPE etc.; routine and as a result of faults;
• the results of monitoring or inspections that have been carried out;
•
12.1
the outcome of health surveillance must be kept by the employer for 40
years; the full health surveillance record will be kept by UCL Occupational
Health Service for 40 years;
• the information, instruction and training that has been given to individuals.
Copies of these records may be passed to the Departmental Safety Officer for
Departmental Records. The DSO is not responsible for maintaining the records
which form part of the supervisor’s management of the work.
UCL – ACOP
12.2
Records may be kept in any format but must be comprehensible and readily
retrievable for inspection.
Guidance
Records may be kept in writing or recorded electronically or any other easily
retrievable format. They must, however be available for examination at any
reasonable time by the Head of Department, Safety Representatives, HSE
inspectors, Safety Services etc. Records must be presented in such a way that they
are understood by those who inspect them.
12.2
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13 Review of risk assessments
UCL – ACOP
13.1
Guidance
The assessment of risk must be reviewed at 12 monthly intervals or sooner
if there is any reason to suspect the assessment is no longer valid or if
there has been a significant change to the work.
The assessment may no longer be valid because:
new information on the substance, being used, has come to light;
• the results of periodic tests and examinations of engineering controls
indicates a problem; e.g. reduced effectiveness
• there is a confirmed case of occupationally-induced disease;
•
the results from monitoring activities indicate that controls are not working
or not being used properly;
• an accident or incident indicates a failure in the system of control.
A significant change in the work would be if:
• the substance which was originally assessed is changed for another;
• the quantity or form e.g. pellet, powder, of the substance used is changed;
•
•
there is a change in the process used, the people involved or the way in
which the work is carried out;
there is a change/modification in the plant or the engineered controls.
13.1
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Appendix 1
Schedule 1 (COSHH Regulations 2002)
Other substances and processes to which the definition of
‘carcinogen’ relates
Aflatoxins.
Arsenic.
Auramine manufacture.
Calcining, sintering or smelting of nickel copper matte or acid leaching or electrorefining of roasted
matte.
Coal soots, coal tar, pitch and coal tar fumes.
Hardwood dusts.
Isopropyl alcohol manufacture (strong acid process).
Leather dust in boot and shoe manufacture, arising during preparation and finishing.
Magenta manufacture.
Mustard gas (ß, ß’ -dichlorodiethyl sulphide).
Rubber manufacturing and processing giving rise to rubber process dust and rubber fume.
Used engine oil.
Schedule 6 (COSHH Regulations 2002)
Medical Surveillance
Substances for which medical
surveillance is appropriate
Vinyl chloride monomer (VCM).
Process
Nitro or amino derivatives of phenol and of
benzene or its homologues.
In manufacture of nitro or amino
derivatives of phenol and of benzene or its
homologues and the making of explosive with
the use of any of these substances.
Potassium or sodium chromate or dichromate.
In manufacture.
Ortho-tolidine and its salts.
Dianisidine and its salts.
Dichlorobenzene and its salts.
In manufacture, formation or use of these
substances.
Auramine. Magenta.
In manufacture.
Carbon disulphide.
Disulphur dichloride.
Benzene, including benzol.
Carbon tetrachloride.
Processes in which these substances are used,
or given of as vapour, in manufacture of
indiarubber or of articles or goods made
wholly or partially of indiarubber.
Pitch.
In manufacture of blocks of fuel consisting of
coal, coal dust, coke or slurry with pitch as a
binding substance.
In manufacture, production, reclamation,
storage, discharge, transport, use or polymerisation.
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Appendix 2
Sources of Information
Topic
Biological agents
Source
See: http://www.hse.gov.uk/pubns/misc208.pdf
Contact: Safety Services ext. 28854 for advice
Carcinogens
IARC Classification of carcinogens list see: http://www.iarc.fr/
Chemicals
See: http://www.hse.gov.uk/pubns/chindex.htm
Dangerous
pathogens
See: http://www.hse.gov.uk/pubns/danpath.htm
Electrical/electronics
See: http://www.hse.gov.uk/pubns/elecindx.htm
Engineering
See: http://www.hse.gov.uk/pubns/engindex.htm
Gases
See: http://www1.boc.com/uk/sds/
Flammable
Substances
See: http://www.hse.gov.uk/pubns/flamindx.htm
Fire and Explosion
See: http://www.hse.gov.uk/pubns/flamindx.htm
Contact: Safety Services ext. 28854 for advice
contact: College Fire Officer ext. 41240 for advice
contact: College Fire Officer ext. 41240 for advice
Occupational
Asthma
See: http://www.hse.gov.uk/asthma/index.htm
OR http://www.hse.gov.uk/pubns/indg95.pdf
Contact: Occupational Health Service ext. 32802 for advice
Personal Protective
Equipment
See: http://www.hse.gov.uk/pubns/ppeindex.htm
Printing
See: http://www.hse.gov.uk/pubns/printidx.htm
Risk assessment
See:
http://www.ucl.ac.uk/efd/safety_services_www/guidance/risk_assessment/index.htm
Safety Data Sheet
Why do you need one? See:http://www.hse.gov.uk/pubns/indg353.pdf
Safety & Risk
Phrases
See: http://www.hse.gov.uk/chip/phrases.htm
Waste Disposal
See: http://www.ucl.ac.uk/efd/efm_www/cleaningandwaste/waste/waste.shtml
OR http://www.ucl.ac.uk/efd/safety_services_www/guidance/ppe/index.htm
Contact: Cleaning and Waste Services ext. 37001
Woodworking
See: http://www.hse.gov.uk/pubns/woodindx.htm
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Appendix 3
Guidance for Creating Arrangements for Controlling
Access to Substances
Defining the scope of your arrangements
The first step for a department in creating these arrangements will be to define their scope in
order to limit the arrangements to an appropriate scale. The scale is determined by the
nature and variety of work with substances at UCL which has been defined as falling into the
following 5 categories. Departments should define the level of control they are exercising by
adopting one or more of the following statements, as appropriate.
Category 1 Statement
This category applies to all departments, since they all carry out office-based work, whether
administrative and/or academic. This statement needs to be completed and brought to the
attention of all staff.
The Department uses substances of a domestic or office nature for which
all staff are required to observe any precautionary advice given by the
supplier. All purchases of this kind are made by <name or staff group >
who is/are aware of these arrangements and the control which they must
exercise.
For this category no particularly elaborate system of purchasing control is necessary or
appropriate, other than those required by Financial Regulations. Authorised purchasers must
ensure that any proposed purchase satisfies the declaration made in the first sentence and
does not fall into category 2.
Departments should then select the categories, from those remaining, which apply to their
work and disregard those which do not. The definition of scope should take the following
forms:-
Category 2 Statement
This category applies to departments with workshops (e.g. engineering, electronic) and
photographic studios etc.
Substances are used in our <engineering / workshop / photographic
processes>; these are processes of a routine kind and the substances
involved are always used in accordance with standard procedures i.e.
manufacturer's instructions. It is Departmental policy that all users are
made familiar with those procedures by their managers. The following
people are authorised to use or supervise the use of the substances
listed;
Manager
J Smith
Substance(s) or class of substances
impact adhesives, degreasing agents, "super
glue", white spirit, cutting oil
A Robinson
etching reagents, flux-cored solder, varnish
spray, welding gases, lithium sulphide grease
The named manager will ensure that these materials are used only by
competent staff who can be relied upon to use them in accordance with
manufacturer's instructions or by less experienced staff under the
supervision of experienced staff.
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Authorised managers must ensure that any proposed purchase satisfies this declaration.
The remaining three categories apply to laboratory work.
Category 3 Statement
The Department uses substances in laboratory processes which do not
involve any change to the nature of the material.
The following people are authorised to use or supervise the use of the
substances listed;
Manager
Substance or Class
Process
J Pilkington
various organic solvents tissue section
e.g. toluene, ethanol
preparation
I Kharasch
various naturally
optical rotation
occurring compounds
measurements
e.g. lactic acid, etc
M Thompson
acetonitrile, methanol
HPLC
etc
These managers are responsible for the assessment of the risks involved
in the handling and disposal of these substances and for ensuring that all
workers authorised by them to work with these substances, understand
the precautions they are required to take. Only those named managers
are authorised to bring the substances attributed to them into the
Department.
This category includes micro-organisms which can safely be handled in the laboratory using
good microbiological practice (GMP), i.e. biological agents classified as “hazard group 1”
according to the ACDP1 guidance “Categorisation of biological agents according to hazard
and categories of containment2 ”.
Category 4 Statement
Unlike the other categories, this category covers certain laboratory processes, which create
increased risk due to scale, etc.
The Department uses hazardous substances in laboratory processes
which
a. change the nature of the hazard by chemical reaction.
b. are of a larger scale than routine bench work.
c. involve continuous flow processes.
d. involve biological agents which are classified by the ACDP as
belonging to hazard group 2, or for which a DEFRA licence is required3 .
e. which when mixed with air can form an explosive atmosphere i.e.
‘dangerous substance’
The following people are authorised to use or supervise the use of the
substances listed;
1
Manager
R Woodward
Substance(s) or class Process
heterocyclic acids,
esterification
dimethyl sulphate
R Woodward
ether (10l), magnesium large scale Grignard
(100g), alkyl halides (2- reactions
300g)
Advisory Committee on Pathogens.
Categorisation of biological agents according to hazard and categories of containment. Fourth Edition 1995 ISBN 0-71761038-1. Approved list of biological agents revised 1998.
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2
UCL ACOP: Working with Substances
J Wilkinson
A Fleming
low boiling olefins,
continuous flow over
oxygen (large cylinder) heated catalysts
various mould species culturing and extraction of
metabolites
These managers are responsible for the assessment of the risks involved
in the handling and disposal of these substances and for ensuring that all
workers authorised by them to work with these substances, understand
and observe the precautions which they are required to take. Only those
named managers are authorised to bring the substances attributed to
them into the Department.
Category 5 Statement
Some work in the Department involves the use of exceptionally hazardous
substances (e g carcinogens, neurotoxins or other highly toxic or hazardous
materials and biological agents classified as belonging to ACDP hazard
group 3). The following people are authorised to use or supervise the use of
the substances listed;
Manager
Substances
Processes
S Winter
benzidine, aflatoxin,
benzpyrene
effects on specific cultured
cells
M Faraday
F Sanderson
osmium tetroxide
electron microscopy prepn
DFP, atropine, choline mechanism of neurotoxins
esterase
G Wilkinson
carbon monoxide,
salts of rhodium,
iridium, platinum
high pressure reactions
These managers are responsible for the assessment of the risks involved in
the handling and disposal of these substances and for ensuring that all
workers authorised by them to work with these substances, understand and
observe the precautions which they are required to take. Only those named
managers are authorised to bring the substances attributed to them into the
Department.
3
I.e. present significant environmental risk through pathogenicity to plants or animals.
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NOTIFICATION OF USE OF SUBSTANCES
This form should be completed by Managers and is the first step in the risk assessment process
MANAGER
UNIT
My current work involves the use of various substances according to the categories described in
the guidance document:-
CATEGORY 2
SUBSTANCES
Processes of a routine kind where the substances are used
according to standard procedures i.e. manufacturers instructions
Name the substances:-
Individuals/groups whom I authorise to access the above substances are:
CATEGORY 3
SUBSTANCES
Substances used in laboratory processes which do not involve
changes to the hazardous nature of the material and biological
agents classified as belonging to ACDP guidance hazard group 1.
Name the processes:-
As an indication of the level of hazard involved, I would regard the following materials to be
among the most hazardous:-
Individuals/groups whom I authorise to access the above substances are:
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Hazardous substances in laboratory processes which lie within the
following descriptions:a. Chemical reactions of the general type:-
CATEGORY 4
SUBSTANCES
As an indication of the level of hazard involved, I would regard the following substances or
products to be among the most hazardous:-
Individuals whom I authorise to access the substances involved in the above processes are:
b. The following processes carried out on a scale larger than 100g material, 1l of solution or larger
than that described in the standard literature:-
Individuals whom I authorise to access the substances involved in the above processes are:
c. The following continuous processes are carried out:-
Individuals whom I authorise to access the substances involved in the above processes are:
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d. The following biological agents, rated ACDP guidance hazard group 2, or require a DEFRA
licence are involved:-
Individuals whom I authorise to have access to the above substances are:
e. The following ‘dangerous substances’ which when mixed with air can form explosive
atmospheres:-
Individuals whom I authorise to have access to the above substances are:
CATEGORY 5
SUBSTANCES
Substances which are categorised as exceptionally hazardous
and biological agents classified as belonging to ACDP guidance
hazard group 3.
Substance and Use
Individuals whom I authorise to have access to the above substances are:
I will ensure that these materials are used only by experienced /competent staff who can be relied
upon to use them in accordance with the control measures identified by a risk assessment or by
less experienced staff under the supervision of experienced staff.
MANAGERS SIGNATURE
DATE
I authorise the above supervisor to access, use and supervise the use of the substances identified
in this form.
HEAD OF DEPARTMENTS
SIGNATURE
DATE
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Appendix 4
Definitions of Hazard Groups
From ACDP Guidance “Categories of biological agents according to hazard and categories
of containment”
Hazard Group 1:
A biological agent unlikely to cause human disease.
Hazard Group 2:
A biological agent that can cause human disease and may be a
hazard to employees; it is unlikely to spread to the community
and there is usually effective prophylaxis or effective treatment
available.
Hazard Group 3:
A biological agent that can cause severe human disease and
presents a serious hazard to employees; it may present a risk
of spreading to the community, but there is usually effective
prophylaxis treatment available.
Hazard Group 4:
A biological agent that causes severe human disease and is a
serious hazard to employees; it is likely to spread to the
community and there is usually no effective prophylaxis or
treatment available.
UCL-ACOP Working with Substances
First Published
Reviewed
May 2005
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