28 July 2011
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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
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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.
Occupational Health and Safety Policy
2. Risk Assessment
3. Legal and Other Requirements
4. Objectives and Programmes
5. Roles and Responsibilities
6. Training
7. Communication
8. Documentation and Document Control
9. Operational Control
10.Emergency Preparedness and Response
11.Performance Measurement and Monitoring/Internal Audit
12.Incident Reporting
1.
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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
Compliance
Prevention of
Ill-Health
and Injury
Continual
Improvement
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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:
Severity
Probability
• 1: Low- minor injuries
• Unlikely - 1
• 2: Medium – medical treatment
required
• Possible - 2
• 3: High - Serious injuries with
possible fatality
• Very likely - 3
Why is severity 2 and not 3? Must
be able to explain to auditors
Why do you implement
additional risk controls?
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).
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Why a legislation does or does not apply to your lab
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What your lab does to comply with it
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What the licence requirements are
 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 nonroutine activity
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Petroleum And Flammable Materials (PFM) Regulations
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Chemical Weapons Convention (NACWC)
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Poisons Act
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Environmental Protection & Management Act
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Environmental Public Health Act
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Sewerage and Drainage Act
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Misuse of Drug Act
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Arms and Explosives (Amendment) Act
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General Requirements:
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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.
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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, 5
400 litres for MD4A Level 2 and MD7 Level 2
200 litres for MD4A Level 1
including amount in flammables cabinets (170 litres) and
solvent wastes
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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
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The only chemical that falls under this act in the
department is Triethanolamine
◦ Must be locked and logged. Disposal must be declared to OSHE.
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Annual declaration to OSHE
Licence to store CWC chemicals held at the University level and
administered by OSHE
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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 betamercaptoethanol, 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’)
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Applies to:
◦ Hazardous Substances - Includes concentrated acids and bases, phenols,
formaldehyde
◦ Ozone Depleting Substances – department does not use these substances
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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
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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.
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Annual declaration to OSHE
Licence is held by SoM Safety Office. Local vendors will require a
copy of the licence.
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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)
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No licence requirement
Good practice: Waste bottle affixed with both departmental waste
disposal and hazard warning labels.
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Regulates the discharge of effluent into public sewer.
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Only buffers of pH 6 – 9 and10% bleach.
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All solvents or buffers containing solvents must be
collected and disposed by TIW contractors.
No licence requirement
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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
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Must be locked and logged
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Controlled Drugs Permit held by SoM Safety Office.
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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?
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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
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Fire Emergency Preparedness
◦ What to do in case of fire?
◦ Where is emergency assembly point?
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Fire Prevention
 Are 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
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Correct Biosafety Levels posted on BSCs?
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Doors posted with appropriate hazard signs?
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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?
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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.
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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
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All lab members to have received the appropriate structured
training (OSHE, SoM, Departmental)
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In addition, should also have lab-specific training
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All records must be present
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How does PI assess competency of lab user after training?
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How are safety matters communicated within the lab and from
department?
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Are there records of such communication?
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Who is responsible for updating the lab on safety matters?
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Any safety issues in the agenda of lab meetings?
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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?
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Basically what they want to see implemented in the lab.
Includes:
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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
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All lab members aware of actions to take in the event of fire/fire drill?
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Do you know who your first aiders are and how to get hold of them?
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Do you know who is in charge of maintaining the first aid boxes?
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Actions in the event of chemical/biological spill?
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Who maintains spill kits?
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Includes:
 Equipment maintenance reports
 Lab inspection checklists
 Medical surveillance records (Booster shots, specific pathogen monitoring, etc.)
 Calibration scheme and calibration records
 Accident/Incident reports
 Internal audit and corrective action reports
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Are all lab members aware of:
 Reportable Incidents:
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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?)