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”