Health, Safety, and
Environmental
Audits
Michael C. Quinlan, CIH
Associate VP for Business Services
Rutgers,
The State University of New Jersey
WELCOME



“If you have a job without aggravations, you don’t have
a job.” (Malcom Forbes)
“We are not put in this world to sit still and know, we
are put in it to act.”
(Woodrow Wilson)
“We always admire the other fellow more after we have
tried his job.”(William Feather)
OVERVIEW
 Why
do audits? Nature/types of audits.
 Specific
 EPA
examples of EHS audits.
Self Audit Policy
Rutgers,
The State University of New Jersey
50,000 students
 10,000 faculty and staff
 29 degree granting colleges/schools
 $1.2 billion budget / $166 million (research)
 871 buildings / 6407 acres
 16 million gross sq. ft. space
 15,011 beds / 4.4 million meals annually
 Five major campuses
 Land grant college, Ag. Experiment Station
 Member, Association of American Universities

National Safety Council Facts
 20
million Americans suffer disabling injuries
each year
 100,000
die from these injuries
 Unintentional
death
injuries are the 5th leading cause of
Unintentional Injuries
Leading Causes
Motor Vehicle Deaths - 2003
On the job injuries - 2003
 138,988,000
 3,400,000
 4,500
 3.2
workers in the US
disabling injuries
on the job fatalities
deaths / 100,000 workers
 $156.2
billion
Work Related Deaths
Air Pollution – NY, NJ Region
Rutgers Annual Air Emissions
New Brunswick Campus Emissions
350
300
NOx
CO
SO2
VOC
CO2
TSP
250
200
150
100
50
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
93
0
19
Tons / Year (CO2 x 1,000)
400
“This planet is our home. Taking care
of our world and of our planet is like
looking after our own home. In a way,
one can say that the Earth is our
mother.”
Tenzin Gyatso,
The 14th Dalai Lama
“When health is absent, wisdom cannot reveal itself,
art cannot become manifest, strength cannot
fight,
wealth becomes useless, and
intelligence cannot be applied.”
~Herophilus of Chalcedon, 335-280 BC,
Physician to Alexander the Great~
TYPES OF EHS AUDITS
 Compliance
/ regulatory
 Management
 Quality
oversight
I. COMPLIANCE / REGULATORY
 Health
and Safety (OSHA, State OSHA programs)
 Biosafety (NIH, Select agent program)
 Radiation Safety (NRC, Agreement state rules)
 Animal Care (AALAC)
 Hospitals (JCAH)
 Environmental (EPA, State – NJDEP)
OSHA 29 CFR 1910.47

Lockout / Tagout of Hazardous Energy Sources
– (c) (6) (i) Employer shall conduct a periodic inspection at least
annually to ensure the procedures and the requirements of this
standard are being followed.
OSHA 29 CFR 1910.146

Confined Space Entry
– (d) (13):
Review entry operations when the employer has
reasons to believe that … the program may not protect
employees and revise the program to correct deficiencies.
OSHA 29 CFR 1910.120

Hazardous Waste Operations & Emergency Response
(HAZWOPER)
– (b) (4) (iv): Inspections shall be conducted … to determine the
effectiveness of the site safety and health plan…
OSHA 29 CFR 1910.1450

Lab Standard (“Chemical Hygiene”)
– (e) (4):
The employer shall evaluate the effectiveness of
the Chemical Hygiene Plan at least annually and update it as
necessary.
SELECT AGENTS RULE


Regulates the possession, use, and transfer of select
biohazardous agents (bacteria, viruses, fungi, toxins,
plant pathogens)
(42 CFR Parts 72 and 73)
– CDC / NIH
– USDA
– Overlap agents

Requires detailed plans for:
– Security (73.11)
– Biosafety (73.12)
– Incident Response (73.14)
SELECT AGENTS RULE
 Required
audits
– Laboratory inspections
– Plans must be reviewed annually and revised as
necessary:
 Security
73.11(f)
 Biosafety 73.12(d)
 Incident Response
73.14(d)
Nuclear Regulatory Commission

Type A Broad Scope Program
– Laboratory inspections by the Radiation Safety Office
 Required by license conditions
 Quarterly for all labs
 Annual wipe tests
– 10 CFR 20.1101 ( c ): requires the licensee to review the
radiation safety program content and implementation
periodically (at least annually)
NRC Annual Audits

Radiation Safety Committee

External auditors

Report to executive management

Reports reviewed by NRC during inspections
EPA TITLE V PROGRAM
 Based
on a facility “Potential to emit”
 Regulates
 Detailed
all emission sources
permitting and reporting requirements
 Aggregates
all Federal and State requirements
into one enforcement and compliance tool
 Annual
emission inventory
EPA TITLE V PROGRAM

6 Month Deviation report
– Submitted to NJDEP
– Identify any deviations in continuous or periodic monitoring
 Opacity
monitoring
 Fuel monitoring
 Emissions inventory averaging
 Run times on emergency generators
– Must be certified by a “responsible official”

Annual Compliance Certification
– Identify any non-compliance conditions
– Must be certified by a “responsible official”
Spill Prevention, Countermeasure, and
Control Plans
 List
all sources of oil
– Above ground tanks
– Underground storage tanks
– Drum storage
 Detailed
plan to address loading, unloading, and
potential spills or releases
 Plans
years
must be reviewed and updated every three
II. MANAGEMENT OVERSIGHT

Employee Performance
– Radiation Safety Officer
– Responsible Official for Select Agents
– EHS Staff

Adequacy of resources

Risk Management
– Insurance coverage
III. QUALITY

“Beyond compliance” (J&J Philosophy)

OSHA Voluntary Protection Program

EPA Performance Track



Health and Safety Management Systems
– ANSI Standard (ANSI/AIHA Z-10 2005)
Environmental Management Systems
– ISO 14000
Sustainability programs
EPA
SELF AUDIT
SELF DISCLOSURE
POLICY
OVERVIEW
 SELF
AUDIT POLICY
 WHY
AN AUDIT AGREEMENT?
 NEGOTIATION
PROCESS
 EXPERIENCE
TO DATE
 CHALLENGES
AHEAD
EPA Quotes
“. . . It has come to our attention that some
colleges and universities do not fully comply with
environmental regulations. If inspections
determine non-compliance, formal enforcement
action with monetary penalties against
significant violators is possible.”
Letter From: George Pavlou, Director Division of Enforcement and Compliance
Assistance To: Dr. Francis Lawrence, President Rutgers, The State University
of New Jersey
SHOCK AND AWE!!!
EPA
(philosophy for higher education)
 Commitment
of resources to comply
 High expectations
 Obligation to train future citizens
 Senior management support - “must be more
than good intentions”
 Environmental Management Systems
“Incentives for Self Policing:
Discovery, Correction, and Prevention
of Violations”
65 Federal Register 19618
April 11, 2000
AUDIT POLICY

Audit and disclose violations

Certify all violations are corrected

Commit to mechanisms to prevent recurrence

EPA may waive some/all gravity based penalties
EPA VIOLATIONS
 GRAVITY
BASED PENALTIES
 ECONOMIC
BENEFIT PENALTIES
– Serve to “level the playing field”
EPA SELF AUDIT POLICY
(Conditions)
 Systematic
 Voluntary
 Prompt
Discovery
Discovery
Disclosure
 Independent
 Correction
of Government/Third Party
and Remediation
EPA SELF AUDIT POLICY
(Conditions)
 Prevent
 No
Recurrence
Repeat Violations
 Other
Violations Excluded (serious harm to
“human health or the environment”)
 Cooperation
I.
Why an audit agreement?
 Experiences
of other institutions
 Consequences
 Potential
 Time
of an inspection
for inspection at RU
frame to achieve compliance
 Protection
from inspection
SELF DISCLOSURE
issues / concerns
 Expectations
 Complexity
 Size,
of the EPA
of the regulatory requirements
scope of Rutgers
SELF DISCLOSURE
issues / concerns
 Need
to ensure comprehensive corrective actions
 Cooperation
 Economic
of the University community
benefit penalties
SELF DISCLOSURE
(issues / concerns)
 Time,
effort, expense to do the audits
 Cost of corrective actions
 Resources to maintain compliance
 Potential for adverse publicity
 Ability to negotiate agreement with EPA
 Unknown course of action (no precedent with
academic institutions)
What do we expect?
“Prediction is very difficult, especially
about the future.”
Niels Bohr
“Fail while daring greatly…”
 “Far
better to dare mighty things, to win glorious
triumphs, even though checkered by failure, than
to take rank with those cold and timid souls that
know neither victory, nor defeat.” Theodore
Roosevelt (1899)
II. Negotiating an agreement
 EPA
competing philosophies
 No waiver of penalties
 Adequate time to complete audits
 Protection from enforcement during audits
 “Leap of faith”
 Better understanding of expectations
 Lack of state (NJ DEP) audit policy
EPA
REGULATORY PROGRAMS
 RCRA
- Hazardous waste/universal waste
 Underground
Storage Tanks
 SPCC
Plans (Oil spills)
 Clean
Air Act - NSPS (Boilers)
 Clean
Air Act - Ozone depleting substances
 Underground
Injection Control (UIC)
EPA
REGULATORY PROGRAMS
 TSCA
(PCB’s)
 NESHAPS
 Risk
Management Plans
 FIFRA
 Lead
(Asbestos)
(Pesticides)
Based Paint Disclosure Rule
EPA Disclosure Schedule
November 30, 2001
Sign Audit agreement
March 1, 2002
Disclosure reports for
UST, NESHAPS,
NSPS, PCB, LBP
June 30, 2002
Disclosure reports for
RCRA, SPCC, CFC,
FIFRA, RMP
EPA Disclosure Schedule
October 31, 2002
Disclosure reports for
SPCC, FIFRA, Lead
Paint
March 31, 2003
Disclosure reports for
RCRA, UIC
(Final submittal)
January 1, 2003 - ?
Implement EMS
EPA Web Page Notice
III. Experience to date
Self Audit - Goals
 Environmental
 Regulatory
 Avoid
protection
compliance
monetary penalties
 Minimize
 Control
adverse publicity
of the process??? - implement
compliance programs without an ACO
Clean Air Act
New Source Performance Std..
 Requirements:
Boilers/turbines >10
mmBtu, notifications to EPA, daily fuel
monitoring, Sulfur analysis
 Scope:
13 total sources (boilers,
turbine in Camden) Busch cogen excluded
 Violations:
Original notifications, fuel
records, quarterly reports, fuel meters
Clean Air Act - CFCs
 Requirements:
Log use of CFC, list of
equipment > 50 lbs., certify mechanics, register
recycle equipment
 Scope:
All campuses and off
 Violations:
Initial registration of eqpt,
campus facilities
records
TSCA - PCBs
 Requirements:
Annual log of activity,
Identify transformers, etc., disposal, storage
and labeling, specific research requirements
 Scope:
Annual log (1998-2000),
Storage at ESB, PCB research labs (5)
 Violations:
Recordkeeping - annual
log missing one manifest
Lead Based Paint
 Requirements:
Occupant Notification,
Licensed Contractors, Prevent LBP hazards
 Scope:
20% of target housing (800
total units, audited 171)
 Violations:
Recordkeeping
Underground Storage Tanks
 Requirements:
Upgrades, daily fuel
reconciliation, system testing, closures
 Scope:
All Fed regulated tanks (26)
(gasoline, emergency generators)
 Violations:
Recordkeeping, annual
certifications, closures > 12 months
NESHAPS - Asbestos
 Requirements:
Notifications to EPA, Wet
methods for removal, Disposal at licensed facility
 Scope:
EPA regulated
 Violations:
All projects for 2001 (>300), 16
None
Spill Prevention, Control, and
Countermeasure Plans
 Requirements:
Plan, identify
responsibilities, spill equipment, tank testing,
inspection, records, containment for deliveries
and above ground tanks
 Scope:
 Violations:
All major campuses, 5 farms
Plans due
1990/implemented 1999, tank testing,
inspections, records
Resource Conservation and Recovery Act
 Requirements:
Container management,
TSD facility, waste manifests, contingency plans,
training.
 Scope:
All labs (72 depts/90 bldgs),
TSD, generator status (16 I.D. numbers)
 Violations:
Container management,
failure to identify waste, drain disposal, manifest
problems (total violations:
603)
FIFRA - Pesticides
 Requirements:
Worker Protection std.,
training, emergency equipment, etc.
 Scope:
research farms
 Violations:
Major campuses and
Posting of applications, reentry times, decontamination eqpt.
Underground Injection Control
 Requirements:
Register septic systems,
prevent discharge of hazmats to UIC.
– Note: EPA / NJDEP philosophies
 Scope:
Major campuses, off campus
facilities and farms
 Violations:
Failure to register
Risk Management Plans
 Requirements:
Review use/storage of
hazmats, plan to prevent release
 Scope:
 Violations:
All major campuses
None, don’t exceed
threshold quantities of hazmats
EPA Penalty Assessments
 CAA-NSPS
 CAA-CFC
 RCRA
 SPCC
 UST
 Lead
Based Paint
$270,000
$195,000
$120,445
$71,120
$65,587
$15,070
($125,000)
EPA Penalty Assessments
 TSCA
– PCBs
 FIFRA
 NESHAPS
 RMP
 UIC
 TOTAL
$220
0
0
0
?
$740,000
($100,000)
($25,000)
($250,000)
EPA Region 2 Inspections
2001-2002
Pratt Institute $301,000
RCRA, SPCC
Manhattan
RCRA, UST
$111,119
NY Pres Hosp $324,000
LBP
NJ City Univ $88,344
RCRA, SPCC
LIU
$219,883
Multi-media
Columbia
$797,000
Multi-media
To audit or not to audit…

Significant penalties

Waiver of penalties

Negative publicity

EPA Award

Consent order

Disclosure schedule

Disruption

Culture change
Audit Agreement - Benefits
 Environmental
 Avoid
protection -correct violations
penalties (conserve scarce resources)
 Experience
 Engage
for REHS staff
the EPA (audit checklists)
Audit Agreement - Benefits
 Relationship
 Recognition
with NJDEP (Greenstart)
amongst academic institutions
 Catalyst
for change within RU
 Win/Win
(EPA & Rutgers)
What now ?
“This is not the end,
it is not even the beginning of the
end,
it is perhaps,
the end of the beginning.”
Winston S. Churchill (November
1942)
IV. Challenges Ahead
 Preventing
recurrence
 Institutional
will
 Environmental
 Compliance
Management Systems
course
Root Causes of Noncompliance
 Lack
of culture to attain/maintain compliance
 Lack
of systems to achieve compliance
 Lack
of adequate audit / oversight functions
EPA
(philosophy for higher education)
 Commitment
of resources to comply
 High expectations
 Obligation to train future citizens
 Senior management support - “must be more
than good intentions”
 Environmental Management Systems
Rutgers University

Large, complex
organization


Highly decentralized


Limited resources

Significant compliance
obligations
Aggressive enforcement
climate
High visibility
Environmental Management System
 Provides
a framework to achieve:
– Compliance
– Environmental Protection
– Pollution Prevention
– Continuous improvement
– Stewardship of university resources
Environmental Management System
 I.
POLICY STATEMENT
 II.
PLANNING
 III.
IMPLEMENTATION/OPERATIONS
 IV.ASSESSMENT
 V.
AND CORRECTION
MANAGEMENT REVIEW
OSHA Safety and Health Program Rule
 Management
leadership and employee
participation
 Hazard identification and assessment
 Hazard prevention and control
 Information and training
 Evaluation of program effectiveness
Health, Safety, and Environmental
Management System

Why?
–
–
–
–

Protect people
Protect the environment
Comply with regulations
Stewardship of university resources
What?
– Policy Statement
– Committee structure
– System to optimize EHS performance
EHS MS BENEFITS
Improved employee
health status
 Lower workers comp.
costs
 Reduced LWDs
 Reduced turnover
 Increased productivity

Reduced impacts on the
environment
 Reduced business
interruption costs
 Reduced property
damage due to incidents
 Compliance
 Higher employee morale

A New Policy for Rutgers
I.

A statement about our culture
“Commitment to Health, Safety, and Environmental
Affairs”
– Commitment (definition)
 The
state of being bound emotionally or intellectually to an ideal or
course of action
A
pledge to do something
II. Sets a standard for performance
 “…Rutgers
shall be a leader amongst public
research universities for health, safety, and
environmental performance.”
III. Management is responsible
 “Faculty
and supervisory staff must assure that
their employees and students work in a safe,
healthful, and environmentally responsible
manner and comply…”
IV. Everyone must participate
 “All
members of the University community….must
be cognizant of, and conform with university
policies and procedures...”
V. Endorsed at the highest level
 “Commitment
to Health, Safety, and
Environmental Affairs”
– signed by Richard L. McCormick, President of Rutgers,
the State University of New Jersey
Rutgers, The State University of New Jersey
President’s Administrative Organizational Chart
2005
PRESIDENT
Richard L. McCormick
Executive Vice
President,
Academic
Affairs
Vice President
University
Relations
Senior
Vice President
& CFO
Executive Vice
President,
Administrative
Affairs
Philip Furmanski
Kim Manning-Lewis
Jeff Apfel
Provost,
Rutgers-Newark
And Dean,
Graduate
School-Newark
Karen Kavanagh
Steven J. Diner
Provost,
Rutgers-Camden
Roger J. Dennis
Rutgers, The State University of New Jersey
Environmental Health & Safety Management System
Committee Structure
2005
University President
President’s Advisory
Council on Health,
Safety, & Environmental
Affairs
BioSafety
Radiation
Safety
Laboratory
Safety & Design
Occupational
Health &
Safety
Environmental
Affairs
Sustainability
President’s Advisory Council



Advise the President and senior administration on the
state of the EHS program.
Promote and communicate health, safety, and
environmental stewardship throughout the university.
Assist in recommending EHS goals, including identifying
resources to achieve these goals.
University Technical Committees



Responsible for specific functional areas.
Broad representation that includes faculty, staff, and in
some instances, students.
Assist with developing policies and procedures, audits,
and ensuring the quality of university programs.
University Technical Committees
 Promote
greater involvement
 Reinforce
 Serve
the importance of EHS to the university
to assist management with review of the
EHS efforts
“Where there is no discipline, there is no
character. And without character there is no
progress…”
J. Williard Marriott, Sr
.
Keep things in perspective!
 Protect
People
 Protect
the Environment
 Comply
with Regulations
For more information:



http://rehs.rutgers.edu
(Rutgers EHS)
http://web.mit.edu/environment/ehs/ehs_management.
shtml (MIT)
www.c2e2.org
(Campus Consortium for
Environmental Excellence)

www.c2e2.org/evc
(Environmental virtual campus)

www.osha.gov
(Federal OSHA)

www.epa.gov
(Federal EPA)
– www.epa.gov/ne/assistance/univ/index.html
 (Region
1 web site for colleges & universities)