collaborative laboratory safety inspections (clip) at the university of north carolina at chapel...
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Collaborative Laboratory Collaborative Laboratory Safety Inspections (CLIP)Safety Inspections (CLIP)
at the University of North Carolina at Chapel at the University of North Carolina at Chapel HillHill
Jonathan Moore, Associate Radiation Safety OfficerJonathan Moore, Associate Radiation Safety OfficerPeter A. Reinhardt, DirectorPeter A. Reinhardt, DirectorDepartment of Environment, Health and SafetyDepartment of Environment, Health and Safety
Scope of CLIP ProgramScope of CLIP Program
80-90 inspections per month80-90 inspections per month
Radiation laboratories (282 as of November Radiation laboratories (282 as of November 2003) quarterly or semiannually2003) quarterly or semiannually�� Focus on radiation safetyFocus on radiation safety�� GM and swipe surveys for removableGM and swipe surveys for removable
contaminationcontamination�� Annual physical inventory for radioactiveAnnual physical inventory for radioactive
materialmaterial
Comprehensive environment, health and Comprehensive environment, health and safety inspection done of all laboratories safety inspection done of all laboratories annually (406 total laboratories)annually (406 total laboratories)
Every principal investigator is considered to have Every principal investigator is considered to have one laboratory, which may consist of several one laboratory, which may consist of several rooms.rooms.
Inspection Breakdown by Type
0
10
20
30
40
50
60
70
80
90
Jan-03 Feb-03 Mar-03 Apr-03 May-03 Jun-03 Jul-03 Aug-03 Sep-03 Oct-03 Nov-03 Dec-03
Nu
mb
er o
f In
spec
tio
ns
per
Mo
nth
# RAD inspections
# Lab Inspections
Safety Officers Perform Safety Officers Perform InspectionsInspections
Four from radiation safety section, including Four from radiation safety section, including the survey technicianthe survey technician
Two from fire safety and emergency Two from fire safety and emergency response sectionresponse section
Two from the industrial hygiene and Two from the industrial hygiene and biological safety sectionbiological safety section
Assign fire safety officer to new buildings
Assign industrial hygiene and biological safety section to BSL2 laboratories
Pete ReinhardtDirector
Rich MillerEnvironmental
Affairs Manager
Billy MitchellCampus
Fire Marshal
Larry DawGeophysicist/
Licensed Geologist
Sharon MyersEnvironmental
Specialist/Geologist
Ray HackneyIndustrial
Hygiene Manager
Roger SitRadiation Safety
Officer
Mary CrabtreeWorkplace Safety
Manager
Kathy SchwabauerBusinessManager
Thursday, December 11, 2003UNC Environment, Health & Safety
Steve ParkerHazardous Materials
Manager
Daryle WhiteSenior RadioactiveWaste Specialist
Tommy HolmsFire Safety Officer
Fire Safety Officer
Neil MochelFire SafetyInspector
Nagui RizkallahIndustrial Hygienist
Gary ShaverEHS Construction
Specialist
Deborah HowardIndustrial Hygienist
Ron HowellIAQ Specialist
James GilbertSafety Officer
Brian EggertSafety Officer
Brad TaylorAssociate Radiation
Safety Officer
Riley SplittstoesserErgonomist
Lisa PerryInformation Assistant
Jonathan MooreAssociate Radiation
Safety Officer
Ken KawabataHealth Physicist
Mark BruecknerLaser Safety Officer
Keith BilgerSafety Officer
Mike SolesSafety Officer
Montego FearringtonRadiation Survey
Technician
Receptionist
Shelley KutiaReceptionist
Ray BondSenior HazardousMaterials Specialist
Shawn StaudtHazardous Materials
Specialist
Roger ConnerHazardous Materials
Technician
Industrial Hygiene &Biological Safety Section
Fire Safety & EmergencyResponse Section
EnvironmentalAffairs Section
Radiation SafetySection
Workplace SafetySection
Business &Support Section
University Employee Occupational Health Clinic
Brian Boehlecke, Medical DirectorLiska Lackey, Nurse PractitionerAnn Law, Registered NurseSherice Love, TranscriptionistTiffany Mitchell, Receptionist (EHS employee)
HASMIS/Network/IT Support
Stephanie LowtherWorkers' Comp/Clinical Hygienist
Safety Officer
John WorthingtonBiological Safety
Officer
Safety Officer
Emergency ResponseTeam Leader
EHS SurveyTeam Leader
Emergency ResponseTeam Member
EHS SurveyTeam Member
Craig Hyatt, IT/Network SupportJohn Rawlings, AIS Project ManagerDirk Kumashiro, AIS ProgrammerKelly Gallagher, AIS ProgrammerTinesh Tailor, AIS ProgrammerDavid McCormick, AIS Contact ProgrammerErik Talley, Web Design Consultant
ChemicalHygiene Officer
CLIP ASSIGNMENTS 2003
63%
23%
14%
RAD
FIRE
IH
Inspector Cross TrainingInspector Cross Training
All inspectors are required to learn all aspects of the comprehensive EHS inspection through:
Reading policies and proceduresReading policies and procedures
On-the-job training by participating in On-the-job training by participating in inspections with the CLIP Team Leader and inspections with the CLIP Team Leader and other inspectors who have experience in other inspectors who have experience in each EHS area.each EHS area.
Learn to use HASMIS and how to enter data Learn to use HASMIS and how to enter data from written proceduresfrom written procedures
Attend quarterly CLIP meetingsAttend quarterly CLIP meetings
Preparing for the Lab Preparing for the Lab InspectionInspection
The inspector reviews prior inspections, The inspector reviews prior inspections, which are included on the pre-inspection which are included on the pre-inspection checklistchecklist
Performing the Lab Performing the Lab InspectionInspection
Complete inspection formComplete inspection form
Review records (e.g., accessible safety Review records (e.g., accessible safety manual and MSDSs)manual and MSDSs)
Once a year, review the Semiannual Once a year, review the Semiannual Update* for room numbers, personnel, Update* for room numbers, personnel, exposure, training and in-house training.exposure, training and in-house training.
Visual inspectionVisual inspection
Annually evaluate lab hood flow rateAnnually evaluate lab hood flow rate
*The Semiannually update is also emailed to labs *The Semiannually update is also emailed to labs semiannually. The inspector verifies this data.semiannually. The inspector verifies this data.
Lab Inspection ProceduresLab Inspection Procedures
Unannounced.Unannounced.
Only occupied labs are inspected.Only occupied labs are inspected.
If a radiation lab is open and unoccupied, If a radiation lab is open and unoccupied, the lab receives a violation for unsecured the lab receives a violation for unsecured radioactive material and the inspector waits radioactive material and the inspector waits for the occupant to return or secures the for the occupant to return or secures the lab.lab.
Inspectors have a backup inspection ready Inspectors have a backup inspection ready in case a lab is vacant.in case a lab is vacant.
After the InspectionAfter the Inspection
For laboratories using radioactive material, For laboratories using radioactive material, the inspector counts swipe tests and the inspector counts swipe tests and complete contamination survey mapcomplete contamination survey map
Enter inspection results into HASMISEnter inspection results into HASMIS
Print inspection report letter to principal Print inspection report letter to principal investigator, which includes overall investigator, which includes overall assessmentsassessments
CLIP Team Leader DutiesCLIP Team Leader Duties
Conduct quarterly CLIP meetingsConduct quarterly CLIP meetings
Assign inspectors by rotation. Each lab is Assign inspectors by rotation. Each lab is inspected by different inspectors.inspected by different inspectors.
Prior to inspection, print map and Prior to inspection, print map and pre-inspection checklistpre-inspection checklist
After inspection, review checklist and After inspection, review checklist and principal investigator letter for accuracy, principal investigator letter for accuracy, then forward to front officethen forward to front office
Front office prepares summary of physical inventory, mails the PI letter, and files copies.
CLIP Team Leader DutiesCLIP Team Leader Duties
Handle comments and questionsHandle comments and questions
Track responses, if requiredTrack responses, if required
If a required response is not received, If a required response is not received, suspend privileges for ordering radioactive suspend privileges for ordering radioactive materialsmaterials
Review written responses for adequacyReview written responses for adequacy
Update mapsUpdate maps
Close inspection in HASMIS when responses Close inspection in HASMIS when responses are adequateare adequate
Laboratory Safety ViolationsLaboratory Safety Violations
De minimisExample: observe lack of personal Example: observe lack of personal protective equipment when it is appropriateprotective equipment when it is appropriate
Non-seriousExample: Omitted monthly self-survey for Example: Omitted monthly self-survey for removable contaminationremovable contamination
SeriousExample: No lid or label on a hazardous Example: No lid or label on a hazardous waste containerwaste container
Inspectors have discretion to judge any violation as serious due to special circumstances.
Monthly Variation in Violations per Principal Investigator
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
Aug-99 Mar-00 Oct-00 Apr-01 Nov-01 May-02 Dec-02 Jun-03 Jan-04
# Serious Variances/PI
# Variances/PI
Six Month Trailing Violations per Principal Investigator
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Mar-00 Oct-00 Apr-01 Nov-01 May-02 Dec-02 Jun-03 Jan-04
# Serious Violations/PI(six month period)
# Violations/PI(six month period)
Lab Inspection Result Lab Inspection Result VariablesVariables
Performance of laboratory personnelPerformance of laboratory personnel
Inspector training, emphasis and experience Inspector training, emphasis and experience (increase observation)(increase observation)
Inspector thoroughness and inspection Inspector thoroughness and inspection qualityquality
Turnover of laboratory and inspector Turnover of laboratory and inspector personnelpersonnel
Changed policy to report items corrected at Changed policy to report items corrected at the time of the inspection (November 2001)the time of the inspection (November 2001)
Overall CLIP Assessment Overall CLIP Assessment CriteriaCriteria
for laboratories using radioactive materialOutstandingNo violations for two inspections in a rowNo violations for two inspections in a row
ExcellentNo violations or less than five de minimis No violations or less than five de minimis violationsviolations
GoodLess than five non-serious and/or five or more Less than five non-serious and/or five or more de minimis violationsde minimis violations
PoorOne repeat violation and/or five or more non-One repeat violation and/or five or more non-serious violationsserious violations
UnacceptableLoss of radioactive materialLoss of radioactive material
Enforcement PolicyEnforcement Policyfor laboratories using radioactive material
No violations for two inspections in a No violations for two inspections in a rowrow
No violations or less than five de No violations or less than five de minimis violationsminimis violations
Overall CLIP Assessment Overall CLIP Assessment CriteriaCriteria
for laboratories not using radioactive materialOutstandingNo violations for two inspections in a rowNo violations for two inspections in a row
ExcellentNo violations or only one de minimis violationNo violations or only one de minimis violation
GoodOne non-serious and/or five or less de minimis One non-serious and/or five or less de minimis violationsviolations
PoorAny repeat violation, or two or moreAny repeat violation, or two or more non-serious and/or five or more de minimis non-serious and/or five or more de minimis violationsviolations
UnacceptableAny serious violationAny serious violation
Enforcement PolicyEnforcement Policyfor laboratories using not radioactive material
No violations for two inspections in a No violations for two inspections in a rowrow
No violations or less than five de No violations or less than five de minimis violationsminimis violations
Future EHS Inspection Future EHS Inspection IssuesIssues
Enforcement of EHS rules in laboratories not Enforcement of EHS rules in laboratories not using radioactive material that do not using radioactive material that do not correct serious violations or do not respond correct serious violations or do not respond when required.when required.
Implement a procedure to annually report Implement a procedure to annually report departmental summary to Deans, Directors departmental summary to Deans, Directors and Department Headsand Department Heads
Use of tablet PC to improve efficiencyUse of tablet PC to improve efficiency
Additional resources to assist EHS inspection Additional resources to assist EHS inspection program for non-laboratories (Hazards program for non-laboratories (Hazards Management Program)Management Program)
Other Possible CLIP ChangesOther Possible CLIP Changes
Better terminology?Better terminology?
Change “excellent” to “very good”Change “excellent” to “very good”
Change “non-serious” to “minor”Change “non-serious” to “minor”