Collaborative Laboratory Safety Inspections (CLIP) at the University of North Carolina at Chapel Hill

1. Collaborative Laboratory Safety Inspections (CLIP)at the University of North Carolina at Chapel Hill Jonathan Moore, Associate Radiation Safety Officer Peter A. Reinhardt, Director Department of Environment, Health and Safety

2. Scope of CLIP Program 80-90 inspections per month Radiation laboratories (282 as of November 2003) quarterly or semiannually Focus on radiation safety GM and swipe surveys for removable contamination Annual physical inventory for radioactive material Comprehensive environment, health and safety inspection done of all laboratories annually (406 total laboratories) Every principal investigator is considered to have one laboratory, which may consist of several rooms.

4. Safety Officers Perform Inspections Four from radiation safety section, including the survey technician Two from fire safety and emergency response section Two from the industrial hygiene and biological safety section Assign fire safety officer to new buildings Assign industrial hygiene and biological safety section to BSL2 laboratories

7. Inspector Cross Training All inspectors are required to learn all aspects of the comprehensive EHS inspection through: Reading policies and procedures On-the-job training by participating in inspections with the CLIP Team Leader and other inspectors who have experience in each EHS area. Learn to use HASMIS and how to enter data from written procedures Attend quarterly CLIP meetings

8. Preparing for the Lab Inspection The inspector reviews prior inspections, which are included on the pre-inspection checklist

9. Performing the Lab Inspection Complete inspection form Review records (e.g., accessible safety manual and MSDSs) Once a year, review the Semiannual Update* for room numbers, personnel, exposure, training and in-house training. Visual inspection Annually evaluate lab hood flow rate *The Semiannually update is also emailed to labs semiannually. The inspector verifies this data.

10. Lab Inspection Procedures Unannounced. Only occupied labs are inspected. If a radiation lab is open and unoccupied, the lab receives a violation for unsecured radioactive material and the inspector waits for the occupant to return or secures the lab. Inspectors have a backup inspection ready in case a lab is vacant.

11. After the Inspection For laboratories using radioactive material, the inspector counts swipe tests and complete contamination survey map Enter inspection results into HASMIS Print inspection report letter to principal investigator, which includes overall assessments

15. CLIP Team Leader Duties Conduct quarterly CLIP meetings Assign inspectors by rotation. Each lab is inspected by different inspectors. Prior to inspection, print map and pre-inspection checklist After inspection, review checklist and principal investigator letter for accuracy, then forward to front office Front office prepares summary of physical inventory, mails the PI letter, and files copies.

18. CLIP Team Leader Duties Handle comments and questions Track responses, if required If a required response is not received, suspend privileges for ordering radioactive materials Review written responses for adequacy Update maps Close inspection in HASMIS when responses are adequate

19. Laboratory Safety Violations De minimisExample: observe lack of personal protective equipment when it is appropriate Non-seriousExample: Omitted monthly self-survey for removable contamination SeriousExample: No lid or label on a hazardous waste container Inspectors have discretion to judge any violation as serious due to special circumstances.

22. Lab Inspection Result Variables Performance of laboratory personnel Inspector training, emphasis and experience (increase observation) Inspector thoroughness and inspection quality Turnover of laboratory and inspector personnel Changed policy to report items corrected at the time of the inspection (November 2001)

23. Overall CLIP Assessment Criteriafor laboratories using radioactive material OutstandingNo violations for two inspections in a row ExcellentNo violations or less than five de minimis violations GoodLess than five non-serious and/or five or more de minimis violations PoorOne repeat violation and/or five or more non-serious violations UnacceptableLoss of radioactive material

24. Enforcement Policyfor laboratories using radioactive material No violations for two inspections in a row No violations or less than five de minimis violations

25. Overall CLIP Assessment Criteriafor laboratories not using radioactive material OutstandingNo violations for two inspections in a row ExcellentNo violations or only one de minimis violation GoodOne non-serious and/or five or less de minimis violations PoorAny repeat violation, or two or morenon-serious and/or five or more de minimis violations UnacceptableAny serious violation

26. Enforcement Policyfor laboratories using not radioactive material No violations for two inspections in a row No violations or less than five de minimis violations

27. Future EHS Inspection Issues Enforcement of EHS rules in laboratories not using radioactive material that do not correct serious violations or do not respond when required. Implement a procedure to annually report departmental summary to Deans, Directors and Department Heads Use of tablet PC to improve efficiency Additional resources to assist EHS inspection program for non-laboratories (Hazards Management Program)

28. Other Possible CLIP Changes Better terminology? • Change “excellent” to “very good” • Change “non-serious” to “minor”