Risk Assessment Form
HSD045M
RISK ASSESSMENT NO 69
Access into IMS-MRL by visiting guests.
Brief outline of
work/activity:
Location:
Significant
hazards:
IMS-MRL, levels 4 & 5 of the ATC
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Who might be
exposed to the
hazards:
Existing control
measures:
In all Laboratory based areas chemicals maybe used; some
toxic, corrosive and / or flammable.
In all four tissue culture rooms on level 5 they will be the
hazard of infection, especially relevant with Tissue Culture 3.
There is frequent use of radioisotopes in the Radioactive Suite
on level 5. No lone working is permitted.
Possible chance of Frostbite when in direct contact with
Liquid Nitrogen which is found in Equipment Bays 1 & 2 on
level 5.
Throughout IMS-MRL (all floors) there are heavy duty
freezers (-20 & -80’s). Frostbite upon contact without PPE is
a hazard.
Trip hazards throughout IMS-MRL: cables, chairs and
matting e.g. the matting protecting the floor where liquid
nitrogen is used.
Slip hazards in most areas e.g. water in the Social room,
Chemical spillage in labs or paper on the carpet of offices and
open areas.
Suffocation hazard / poisoning in the event of a gas leak. Both
Carbon Dioxide and Nitrogen gas is used in the MRL.
Security hazards to areas which are not applicable to trained
or unauthorised staff.
Any visiting guests or engineers.
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All flammable materials when not in use are stored away in
flammable cupboards.
All Corrosive Chemicals are also stored in cabinets when not
in use.
Please refrain from touching workbenches; unless otherwise
advised that it is clean to do so.
No unauthorised access is permitted in either Radioisotope
Suite or Tissue Culture 3 if the room is in use. Should access
be permitted, the guest must be accompanied by member of
staff and that PPE is worn.
PPE is to be worn at all times when accessing minus 20 units
or -80’s. Non authorised access to these units is strictly not
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permitted (see appendix for emergencies).
Only trained personnel may use the Liquid Nitrogen vessels.
In event of spillage, contact member of IMS-MRL staff and
do not attempt to proceed through or clean the spill up.
Chemical spillage kits are available to IMS-MRL trained staff
NOT visitors.
Those who have invited their guests must inspect the
walkways. Make sure that all walkways are clear, unblocked
and that there are no slip and trip hazards.
Please refrain from using routes in the IMS-MRL with trip
hazards such as equipment bay 1 where the matting is for the
liquid nitrogen area.
Areas which Nitrogen gas operates in has low oxygen sensors
(please see in-depth document in the appendix).
The Carbon Dioxide store cupboard comes complete with gas
leak detection. In the event of gas leak, contact a member of
staff.
Due to the sensitive nature of work (Confidential patients’
notes) majority of areas are restricted access. Permission is
required to visit any of these areas.
At all times, visitors must be vigilant for any hazards and be
accompanied at all times by a member of IMS-MRL staff.
Are risks adequately controlled? YES & NO
Additional controls:
If NO, list
Any visitors attending the IMS-MRL must be
additional
accompanied by those they are visiting at all times in the
controls
Laboratory, unless permission has been granted and all
and actions appropriate paperwork completed i.e. additional risk
required:
assessments and lone working.
Action by:
Before any work is to be conducted by any engineer in the
IMS-MRL, they must discuss access with the person
requesting and / or Jonathan Fort (36424) or Robert
Heavens (69048). Additional information maybe required.
For further information please see supporting document
attached in the appendix
Completed by:
Jonathan Fort
Name
……………….
Signature
…18/09/2010
Date
Supervisor:
……………………..
Name
Dates of
review:
06th Oct 2011
……………………….
Signature
………………
Date
Additional information and guidance to the Facilities in IMS-MRL
The following text is a fairly in depth account of what facilities are in place within the IMS-MRL on floors
1, 4 and 5 of the IMS / ATC. Each facility discussed will include the significant H&S risks that may be
experienced by those who use them as well as those who may attend emergencies e.g. contractors.
Level 1 IMS-MRL
The rooms in which we occupy in the basement are:
- Freezer Room 1 (HR-36-01-73)
- Freezer Room 2 (HR-36-01-104)
- Cardboard Storage (HR-36-01-69)
- CIDEM IT (HR-36-01-72)
- Chute Room 2 (HR-36-01-70)
- Gas cage on the loading bay
Both the freezer rooms contain mostly minus 80 freezers and a small number of minus 20 freezers. All
but a couple of these minus 80 units are wired into the BMS system which is an alarm system that is
activated primarily when the temperature of these units rises to approximately -60oC. The minus 20’s
situated downstairs are not wired into the BMS system nor do they have any other alarm systems.
If an alarm whether freezer or BMS is activated then the next step is to contact either Svitlana
Korolchuk or I during the working hours or alternatively the key contact individual out of hours (please
see appendix 1). Under NO circumstances should any contractor tempt to neither open these units nor
remove any of their content. Attached in the appendices are a number of in-house Risk Assessments of
which Access of a minus 80 is included.
From a Security aspect, only those who have samples stored in these units have access to these
rooms and these include the MRC and the University of Cambridge Pediatrics Department. A list of ‘oncall’ personnel is attached to the notice boards in the freezer rooms and there is a telephone installed in
the first room.
The Cardboard storage room contains a mobile skip which the Trust’s waste collection team collects
daily. This skip is where we dispose of our cardboard waste. We aim to collapse all the boxes within as
the Trusts then recycle them. Also in this room are white polystyrene freezer boxes. These are stored
for long term in this facility as there are no sources of ignition in the vicinity. It was highlighted during
the Fire Risk Assessment that Carillion investigated that we had far too many stored on level 5 near
sources of ignition.
In a similar way, we use the Chute room 2 in the basement to dispose of our clinical waste. Again the
disposal team from the NHS collects from this room on a daily basis. All the items in the yellow bags etc
in this room go and gets incinerated. Any chemicals or a material that are produced in IMS-MRL that
cannot be disposed of in this way gets done internally.
The CIDEM IT Room carries a H&S risk to which Carillion and the University authorized personnel are
aware of. Permission to access into this room must be given beforehand and that there is no
unauthorized access.
Finally on the basement area of the ATC we have sole use of the gas cage which is visible on the
loading bay. We use this facility to store back up gas cylinders (Carbon Dioxide and Nitrogen), dry ice
(minus 80oC) and Liquid Nitrogen cylinders.
The access code for your information is 7532 in case of emergencies. The cage tends to be used
heavily each Tuesday and Thursday evening as there is a fresh delivery of liquid nitrogen the following
day.
Level 4 IMS-MRL
The majority of space on level 4 of the IMS-MRL is primarily used for dry working e.g. office space. The
only risks with regards these areas are security risks as some occupants do have patient confidential
information. Therefore access into these rooms must be coordinated with either me or Robert Heavens
prior.
There are a few facilities on the fourth floor which are also heavily used such as the Meeting Rooms 1,
2 and 3 (HR-36-04-136). These are used during the week from 8am until 6pm and any modification
works in these rooms must be booked in using the diary – please see either Robert or I. The only other
dry area with high dependency is the Nick Hales Social Room (HR-36-04-133). This is a staff canteen
area which the MRC staff use with the IMS-MRL staff. All the equipment within this facility is serviced by
University Parties. The only exception to these is the hot water supply above the sink.
As far as significant H&S risks go on level 4 it’s just the wet laboratories that need consideration for
visitors, engineers and sub contractors.
Lab 1 (HR-36-04-116) consists of a large amount of technical equipment used in Molecular Biology
research Chemical hazards in this room tend to be stored in a flammables cupboard. If during the ‘out
of hours’ period an alarm is sounding, then attached on Health 7 Safety boards is a list of key contacts
including the chief responsibility person(s) for the equipment.
Lab 2 (HR-36-04-149) is very similar to Lab 1 in that it is heavily used for molecular Biology research.
Those who work in this lab are actually supported by the Trust.
As with any Laboratory environment unless the engineer or visitor has been alerted to a
significant problem within those atmospheres then they should not be touching or picking up chemicals.
If there is a leak spotted, then either Robert or I should be immediately called.
Lab 3 (HR-36-04-115) is the IMS-MRL Histology Facility. This is where microscope slides are
assembled for researchers use. The lady in charge of this area during working hours is Keli Philips and
then out of hours any problems e.g. alarms should be reported to the on call rota. This room can often
contain a large quantity of ethanol, but this is strictly stored in a flammables cupboard.
Warning – Suitable footwear must be worn in this room due to the possibility of wax being on the floor.
Autoclave Room (HR-36-04-114) houses the Getinge Autoclave, two lancer dishwashers and a drying
oven. Gary Webb is the core user of this facility for during hours and again for out of hours please
refers to the on call Rota.
Hazards in this room include hot surfaces and chemical spillages from the detergent used for the
dishwashers. There are safety signs up.
The Confocal Microscope Room (HR-36-04-150) houses a very expensive microscope and any work
scheduled in this facility has to be discussed with either me or the key user; Greg Strachan. Please
could you warn all of your engineers and contractors that they MUST knock before entering due to a
Class 3B Laser been housed within the microscope. A Risk Assessment for Laser Safety must be
completed before anyone unauthorized works in this room.
The Microscopy Room (HR-36-04-151) again as per above houses a critical item of equipment and
contains lasers. Therefore knocking before entering would be the best practice.
Level 5 IMS-MRL
Due to level 5’s complex nature of Health and Safety hazards, each hazardous room is individually
discussed.
1. Tissue Culture Rooms
2. Radioisotope Suite
3. Dark Rooms
4. Cold Rooms
5. Equipment Bays inc Refrigeration
6. Laboratories / bays
7. Gas Cupboard
8. Offices
1. Tissue Culture
Within IMS-MRL we have 4 tissue culture rooms on level 5:
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Tissue Culture 1 (HR-36-05-140) Cateorgory I
Tissue Culture 2 (HR-36-05-139) Cateorgory I
Tissue Culture 3 (HR-36-05-125) Cateorgory II
Tissue Culture 4 (HR-36-05-128) Cateorgory I
Within these rooms is where the IMS-MRL researchers conduct tissue culture work which involves
biological agents. A biological agent is best defined as:
‘A micro-organism, cell culture, or human endo parasite, whether or not genetically
Modified, which may cause infection, allergy, and toxicity or otherwise create a hazard? To
human health.’
The table below illustrates precisely what each of the Cateorgory above represent from a hazard
prospective:
Hazard
Low
Cell type Baseline
Well characterized or authenticated finite or continuous cell lines
of human origin with a low risk of endogenous infection
with a biological agent presenting no apparent harm to laboratory
workers and which have been tested for the most serious
Pathogens
Medium Finite or continuous cell lines/strains of human origin not
fully characterized or authenticated, except where there is a high
risk of endogenous biological agents, e.g. blood borne viruses.
Containment
Level
I
II
With the above information any work conducted by Carillion in these rooms MUST BE Coordinated via
either Robert or Jonathan. Also whilst Tissue Culture 3 is in use, no unauthorized access is permitted
One additional H&S hazard which concerns tissue culture 3 is the installation of a gas alarm. These
alarms are annually serviced by IMS-MRL and are designed to alarm when there is a shortage of
oxygen within the room. A shortage of oxygen would result if the cylinder of Nitrogen gas ever leaked.
Because of the severity of this hazard, when the item of equipment is not used, the cylinder is either
removed or closed off.
If any Carillion engineer or visitor ever observes the alarm in this facility (yellow box near entrance to
facility) THEY MUST NOT ENTER! Please report to member of staff immediately
2. RADIOISOTOPE SUITE (HR-36-05-134)
This room has been designated as a Supervised Area. It contains a designated sink for radioactive
waste disposal. The Radio-isotope Room also contains a fridge/freezer (-20oC) for storage of
radioactive materials, a multi gas incubator and a flow cabinet.
The accumulated level of radioactivity stored in this suite does not exceed that permitted in a
Supervised Area, or the locally imposed limits displayed on the door panels and listed below:
32P 150MBq
125I 20MBq
35S 250MBq
14C 100MBQ
3H 150MBq
75Se 50MBq
Any problems with this facility during working hours must be reported to a Radiation Protection
Supervisors (RPS) Individual (s) and these are:
Mr. Robert Heavens
Dr J. Sethi
Mr. C. Ford
As discussed above, the room contains a multi gas incubator and therefore this suite has a low oxygen
detector. This alarm is annually serviced by IMS-MRL and is designed to alarm when there is a
shortage of oxygen within the room. A shortage of oxygen would result if the cylinder of Nitrogen gas
ever leaked. Because of the severity of this hazard, when the item of equipment is not used, the
cylinder is either removed or closed off.
This room is strictly controlled regarding access and only those users who have received the training
may enter the room. Therefore any Carillion representative or sub contractors MUST gain permission
from an RPS for entry and MUST NOT ENTER UNDER ANY CIRCUMSTANCES IF THE ROOM IS IN
USE.
3. DARK ROOMS
There are two rooms designed for researchers to work under dark conditions; Dark Room 1 (HR-36-05135) and Dark Room 2 (HR-36-05-123).
Dark Room 1 is used specifically for hybridization research work and has restricted entry – a key must
be signed out (See Svitlana). Hybridization is the process of establishing sequence-specific interaction
between two or more complementary strands of nucleic acids into a single hybrid (combination of two or
more different things, aimed at achieving a particular objective or goal).
Dark Room 2 (Revolving door) is specifically what it says. Researchers use this facility to process their
films using a Xograph machine. Other equipment based in this room includes shaking incubator (used
for experiments that require minimum sunlight), gamma counter (machine to measure gamma radiation
emitted by a radionuclide and a scintillation counter (measures ionizing radiation).
Please be aware of the ramp before the door as it could be potentially a tripping hazard. Please also be
vigilant in the Dark Room 2 for leaks, as the room maybe in the dark.
The hazards associated with this room are minimal. The two machines connected with radioactivity are
clean and are often tested. With the shaking incubator, spills are likely of bacterial media. The Xograph
uses fixer and developer and these are hazardous upon contact / ingestion.
With these specific hazards its advisable that authorization be granted by Robert or Jonathan for any
work to be conducted in this facility. The engineers that may work in this room should not touch the
experiment as its all University of Cambridge service contracted. If an area near a unit is to be worked
on, then basic PPE should be worn e.g. Nitrile gloves.
Finally due to the specific environment of this room – dark, researchers must have right of use
to this facility at all times.
4. COLD ROOMS
These rooms are used primarily as cold storage with the odd frequency used as a research station.
Unlike other rooms there is no particular hazard for working in these rooms as the chemicals stored
within are non hazardous and are sealed.
The only danger we allow for is that any lone working the door must be kept ajar. Please be conscious
of wet floors in these rooms.
5. EQUIPMENT BAYS
There are three equipment bays in IMS-MRL on the 5th floor:
- Equipment bay 1 (HR-36-05-167)
- Equipment bay 2 (HR-36-05-127)
- Equipment bay 3 (HR-36-05-121)
All three are used to locate core items of equipment that are available to use by all researchers in the
MRL.
Equipment Bay 1 holds a significant hazard; Liquid Nitrogen. We have a number of small dwers here
which are topped up daily with liquid nitrogen from a main header vessel. The hazards associated
concern the researchers and unless there is a leak of the main tank, no hazard would be applicable to a
Carillion Engineer or sub contractor (be aware of the matting on the floor in this area; potential trip
hazard). Liquid Nitrogen is pure nitrogen in a liquid state at a very low temperature. Liquid
nitrogen is a colour less clear liquid. It’s a cryogenic fluid which can cause rapid freezing on
contact with living tissue, which may lead to frostbite.
Again there is a large Dewar of liquid nitrogen found in Equipment Bay 2. This is used for long term
storage and keeps refilled once a week. As per the instructions above; Carillion do not need to touch
this tank (again please be aware of the trip hazards)
Finally in Equipment bay 3 there is a number of floors standing centrifuges, which are used for
spinning large quantities of research material or samples at very high speeds. They are all locked into
position and if they are required to be moved; they must be decommissioned prior.
Refrigeration units
Throughout the entire space of IMS-MRL there are a number of
refrigeration units, ranging from underbench refrigerators to the
upright
minus 80 freezers.
If at any time a Carillion or contractor notices a problem with a minus
80 or other unit they are NOT PERMITTED to open the item.
The best practice followed would be to contact Svitlana or Jonathan
during the day or use the on call rota during out of hours.
Whether it’s a minus 20 freezer or a minus 80 freezer, both have the
capacity to cause frostbite to skin
6. OPEN LABORATORY / BAYS
The main laboratory areas (HR-36-05-120 & HR-36-05-126) contain the bays to which are often stated /
involved in the helpdesk calls. There are 12 bays (8 on one side and 4 on the other). Each Bay
accommodates specific research groups and the maximum occupancy per bay is 12.
There are significant hazards in the large laboratory areas, however there are Flammables, Corrosive
and Toxic cupboards scattered around which houses the relevant chemicals. Other chemicals which
carry a standard warning are stored on the shelves of each bay. They should be no reason for Carillion
engineers or contractors to come into contact with these, unless there is a serious problem e.g. water
pipe leak. In this case the engineer or visitor MUST AT ALL TIMES WEAR GLOVES AND LAB COAT
should there be laboratory work being conducted in the vicinity. In case of accidents or spillage, you
must seek First Aid Treatment immediately from a First Aider on site. A list is included in the appendix
at the back of this document. All IMS-MRL First Aiders have access to the chemicals MSDS sheet’s /
COSHH Forms.
7. GAS CUPBOARD
Located in Equipment Bay 3 opposite the back fire escape stairs, there is a cupboard which houses a
maximum 6 bottles / cylinders of Carbon Dioxide. They are arranged into two sets of three and are
hooked into a feeding box which regulates the intake of gas which feed the incubators. These
incubators are positioned in the Tissue Culture rooms.
The administrative team are responsible for exchanging any empty cylinders from the gas cage on the
loading bay. We have all received training and read all the information including risk assessment.
As per other areas, if there is a problem (either an alarm or gas leak) a member of MRL must be alerted
immediately during office hours. Out of these hours, plus return to the on call rota.
Please note
Prolonged exposure to moderate concentrations of Carbon Dioxide can cause acidosis and adverse
effects on calcium phosphorus metabolism resulting in increased calcium deposits in soft tissue.
Carbon dioxide is toxic to the heart and causes diminished contractile force.
8. OFFICES
Finally there are 4 offices located on the fifth floor and a meeting room:
Office 1 (HR-36-05-117)
Office 2 (HR-36-05-118)
Office 3 (HR-36-05-119)
Office 4 (HR-36-05-141)
Meeting Room 4 (HR-36-05-142)
As per the offices on level 4 described already, there are no particular hazards in these rooms to be
aware of.
Best practice for fellow colleagues and contractors e.g. Carillion would be to be aware trip hazards
when operating in these areas such as cables and paper on the carpeted floor (very slippery).