Module 2

Elements of Safety and Health Management SystemManagement System

PDCA Model

Continual improvement

PDCA Model

OH&S Policy

Management ReviewPlanning

Management Review

• Hazard identification, risk assessment and determining controls

Implementation & OperatioChecking

• Legal Requirements

• Objectives & Programme(s)

Reso rces roles responsibilitg • Resources, roles, responsibility,accountability and authority

• Competence, training and awareness• Communication, participation and Consultation

D t ti & C t l f D t

• Performance measurement and monitoring

• Evaluation of compliance• Incident investigation

N f it CA & PA • Documentation & Control of Documents• Operational control & Emergency Preparedness & response

• Nonconformity, CA & PA

• Internal audit

S S f & l h

NUS Occupational Health and Safety Management System

NUS Safety & Health Management Framework

– SMS@NUS

Faculty / Research Institute / Centre SMS

Departmental SMS

Laboratory SMS NUS Occupational Health and Safety (OH&S)NUS Occupational Health and Safety (OH&S)

Management System Standard for Laboratories

NUS Occupational Health & Safety NUS Occupational Health & Safety Management System Standard for

Laboratories

• NUS Occupational health and safety (OH&S) management system standard for laboratories - Part A: Requirements

• NUS Occupational health and f (O &S)safety (OH&S) management

system standard for laboratories - Part B: Guidance Notes

http://www.nus.edu.sg/osh/programmes/ohscert.htm

3.1 OH&S Management System

• Principal Investigator (PI) shall implement, maintain and continually improve his or her lab-based OH&S management System in a based OH&S management System in a documented manner

• PI shall manage the occupational safety and health risks associated with his or her laboratory

3 2 C it t t OH&S 3.2 Commitment to OH&S Management System

a) Implementing the University policies

b) Defining roles and responsibilities

c) Ensure availability of resources

d) Establish a lab based OH&S management systemd) Establish a lab based OH&S management system

e) Continually improving the OH&S management and performance

f) Compliance to regulatory and university requirements

g) Set and review OH&S objectives

NUS Safety & Health PoliciesNUS Safety & Health Policies

Policies– Overall OSH policy– Fire Safety Policy– Chemical Safety Policy– Radiation Safety Policy

Website screen shot

y y– Biological Safety Policy– Tenant Policy on Safety &

Health

http://www.nus.edu.sg/osh/policies/htm

University Directives A T & S i i f UG i L b f • Access To & Supervision of UG in Lab for project & research work (Dir 0701)

• Authorized Access to Laboratories (Dir 0702)

• Staff & Student working in BSL3 Facility (Dir 0703)

• NUS Students Working In Non NUS Organizations (Dir 0704) g ( )

3.3 Planning

3.3.1 Hazard identification, risk assessment & determining

t l (HIRADC)control (HIRADC)

3.3.2 Legal & other requirements

3.3.3 Objectives and programme(s)

3.3.1H d Id tifi ti Ri k Hazard Identification, Risk

Assessment And Determining C l ( C)Controls (HIRADC)

3.3.1 HIRADC• Identifying potential hazards during routine or Identifying potential hazards during routine or

non-routine lab activities , evaluating their risks and determining risk controls to eliminate or minimize the potential for harmp

• Considering hierarchy of controls

• Complying to legal requirements

– Documented and endorsed by PI

– Reviewed regularly (at least once every 3 year) and as and when there are major changes that and as and when there are major changes that may affect safety or any occurrence of incident/accident

– Record to be kept at least 3 years

Risk Assessment FormExperiment-Based Risk Assessment Form

Name of Department Location of Lab

Name of Laboratory Name of PI

Name of Name of Researcher/LO Activity/Experiment

1. Hazard Identification 3. Risk Control

No Description/Details of Steps in Activity

Hazards Possible Accident / Ill Health & Persons-at-Risk

Existing Risk Control (Mitigation) Severity Likelihood (Probability)

Risk Level Additional Risk Control Person Responsible By (Date)

1 0

2 0

3 03 0

4 0

5 0

6 0

7 0

8 0

9 0

10 0

Conducted By Approved By

Name

Signature

Approval date Next Revision date

(Maximum 3 years)

Risk Assessment MethodologyLikelihood Risk = Likelihood x SeverityLikelihood Risk = Likelihood x Severity

Likely Possibly Unlikely RISK DECISION PROCESS

ever

ity

Low 3 2 1< 3 RISK ACCEPTABLE

Med 6 4 23 4 CONSIDER ADDITIONAL RISK CONTROL

Se

3, 4 CONSIDER ADDITIONAL RISK CONTROL

High 9 6 3> 4 ADDITIONAL RISK CONTROL REQUIRED

Likelihood

1UnlikelyNot likely to occur

2Possible Possible or known to occur

3Very LikelyCommon or repeating occurrence

Severity1Low (e.g. No injury, injury or ill-health requiring first aid treatment only - includes minor cuts and bruises, irritation, ill-health with temporary discomfort)

2Medium (e.g. Injury requiring medical treatment or ill-health leading to disability – includes lacerations, burns, sprains, minor fractures, dermatitis, deafness, work-related upper limb disorders)

3High (e.g. Fatal, serious injury or life-treatening, occupational disease – includes amputations, major fractures, multiple injuries, occupational cancer, acute poisoning and fatal diseases)

Severity - Consider the magnitude/severity of the consequences of the Risk Factor occurring and then list this as 3 (High), 2 (Moderate) or 1 (Low). Severity normally will not change unless there is a physical change to the equipment or process.

Likelihood - Team should rely upon their experience and consider realistic scenarios. Listed below are examples of factors that may be considered in determining the likelihood.- Past experience / incidents- Complexity of the activity- Number of personnel involved in the activity (e.g. all personnel, a limited number of trained personnel, etc)- Frequency of use or execution

Degree of control (involvement of contractors)- Degree of control (involvement of contractors)- Strength/completeness of administrative controls- Sufficiency/formality of training- Other....

Risk Assessment RegisterNo Name of Experiment Conducted

byDate Approval

DateNext

Revision D t

Remarks

Date123456789101112131415N t Pl tt h ll i k t i th t l t i th t k h tNote: Please attach all risk assessments using the template in the next worksheet

3.3.23.3.2

Legal And Other RequirementsLegal And Other Requirements

3.3.2 Legal and Other Requirements

• Take into account applicable legal and NUS requirements when establishing OH&S Management Systemg y

• Information to be communicated to all lab personnel

OSH Legal Register OSH Legal Register

http://www.nus.edu.sg/osh/legalreg.htm

Applicable Legal RegisterLegislations applicable to the labLegislations applicable to the lab

No Legislations/ guidelines Applicable to lab

1 Workplace Safety and Health Act

2 Petroleum And Flammable Materials (PFM) Regulations

3 Chemical Weapons Convention (NACWC)3 Chemical Weapons Convention (NACWC)

4 Poisons Act

5 Environmental Protection & Management Act

6 Environmental Public Health Act

7 Sewerage and Drainage Act

8 Misuse of Drug Act

9 Arms and Explosives (Amendment) Act

10 Radiation Protection Act

11 Fire Safety Act

12 Biological Agents and Toxin Act

13 WHO guidelines for biosafety

14Singapore Biosafety Guidelines for Research on Genetically Modified Organisms (GMOs)14 Organisms (GMOs)

15Singapore Guidelines on the Release of Agriculture-Related Genetically Modified Organisms (GMOs)

16 Any other Acts or Guidelines (if yes, please provide details)

3 3 33.3.3Objectives and Programmes

3.3.3 Objectives and Programmes

• Participation in university, faculty or department-level programmes

d l ddi i l bj i h• To develop additional objectives where applicable

Objectives and Programmes

E t bli h d i t i t hi OH&SEstablish and maintain programmes to achieve OH&S

OObjectives and programmes include :– Responsibility and authority for

– Achievement at relevant

– functions and levels;

– Means; and

– Time scale

Objectives and ProgrammesObj i d i i l fi h • Objectives expressed in numerical figure where possible

• Objectives should be:S – SpecificpM – MeasurableA – AchievableR – Realistic/RelevantT – Timeliness

Examples of Objectives & Targets

PolicyReduce injuries

ObjectiveTo reduce the number of chemical related incidents by50% by Sep 0850% by Sep 08

Programmes– Proper storage of chemicals by June 2008– Implement 5 S good housekeeping programme by Dec

2008

Establishing Management ProgrammeEstablishing Management Programme

S ACTIVITIES J F M A M J J A S O N D WHO

1 Id if l i f h i l d L b T h

To eliminate chemical hazards from chemical storage and handling by end 2008

1 Identify locations of chemical storage and usage within lab

Lab Tech

2 Identify potential chemical hazards arising Lab Tech

3 Identify suitable material handling equipment Lab Tech

4 P h d k il bl i t PPE L b4 Purchase and make available appropriate PPE at areas of chemical use and storage

Lab Manager

5 Establish safe work procedures on chemical handling

Lab Manager

6 Conduct safety inspections Lab Manager

7 Identify deviations and implement corrective actions

Lab Manager

B f Ch i l t d iBefore: Chemicals stored in a haphazard manner

After : Proper segregation ofAfter : Proper segregation of chemicals

Aft P l b lliAfter : Proper labelling

3.4 Implementation & Operation

3.4.1 Resources, roles, responsibility, accountability

and authority

3 4 2 Competence training and awareness3.4.2 Competence, training and awareness

3.4.3 Communication, participation and consultation

3.4.4 Documentation & document control

3.4.5 Operational control

3.4.6 Emergency preparedness & response

3.4.1R l ibilit Resources, roles, responsibility,

accountability and authority

Resources

• PI to ensure availability of resources to establish, implement, maintain and improve OH&S Management SystemOH&S Management System

Roles, Responsibility, Accountability and Authority (R2A2)

• Define roles

• Allocate responsibilities and accountabilities

• Delegate authorities

• Facilitate effective OH&S management

R2A2 to be defined, documented & communicated

E l 1 Th ibilit d th it t d f l b b

Area of Principal Research Lab Student OSO/

Example 1: The responsibility and authority expected of lab members should be defined, documented and communicated. Eg. via a matrix system

Area of Responsibility

Principal Investigator

Research Fellow

Lab. Officer

Student OSO/ Contractors/

Visitors

Conduct Risk A t

Assessment

Approve Risk Assessment

Coordinate on Coordinate on waste disposal

Coordinate maintenance of equipment

equipment

Developing lab. Specific protocols

Report any p yaccidents/incidents

Example 2Example 2

Example (cont’d)Example (cont d)

Roles & Responsibility RegisterNo Description of Duties Frequency Responsible Person Remarks

Primary Secondary1239

101112131415161718192021222324

3.4.23.4.2Competence, Training and

AwarenessAwareness

Ref: Pg 23

Training, Awareness & Competence

• PI to ensure person(s) performing tasks are competence

– Education

– Training

– Experience

• Records to be kept

• Identify training needs

OSHE’s mandatory training courses– OSHE s mandatory training courses

– Induction training by faculty, Department

– Lab-specific needsp

Example 1: Training Needs AnalysisType of training

Research Fellow

Lab. Officer Student OSO /Contractorstraining Fellow /Contractors/Visitors

Risk Assessment

Agent Specific training - SSTS

Lab. Specific equipment

Lab Specific Lab. Specific protocols

General lab. S f t

Safety orientation

Training Needs Analysis (TNA) Training MatrixMinimum Training Requirements

Role in the Lab Faculty Safety

Orientation

Department Safety

Orientation

Lab Specific Training

Biosafety Training (OSHE)

Chemical safety

Training (OSHE)

Radiation safety

Training (OSHE)

Non-ionizing radiation

f

Fire safety

Training (OSHE)

First Aid

Training

Others-pls specify

(OSHE) (OSHE) safety Training(OSHE)

(OSHE)

1 Research Fellow

2 Research Assistant2 Research Assistant

3 Post Graduate Students

4 Honors Students

5 Urops Students5 Urops Students

6Short Term attachment Students

7 Visitors

8 Others8 Others

Example 2 - Training

ExampleExample

Example 3 – New Staff Orientation

Example 3 – New Staff Orientation (cont’d)

Training recordsb i i h kliLaboratory Training Checklist 

Name of lab member Designation Faculty Safety

Orientation

Department Safety

Orientation

Lab Specific Training

Biosafety Training (OSHE)

Chemical safety

Training (OSHE)

Radiation safety

Training (OSHE)

Fire safety

Training (OSHE)

First Aid Training

External Training

Others-pls

specify

1

2

3

4

5

6

7

8

9

(indicate training completed and date of completion of the respective training courses by each lab member)

3.4.33.4.3Communication, participation

and consultation and consultation

3.4.3. Communication, participationand consultationand consultation

PI shall establish, implement and maintain procedures for:

• External communications with external parties (communication with regulators via OSHE)

• Internal communications

– within lab (hazards, risks, controls & OS&H management system)g y )

– with department & safety committee and safety officer and OSHE.

RI/RC Safety WikiRI/RC – Safety Wiki

3.4.43.4.4Documentation & Document ControlDocument Control

Documentation & Document Control

• NOT A PAPER CHASE!

• DOCUMENT AS MUCH AS IS NECESSARY FOR EFFECTIVE MANAGEMENT OF OH&S RISKS AND LEGAL COMPLIANCE!

P d f t lli d t d d t • Procedures for controlling documents and data • Ensure that :

– They can be located– They be periodically reviewed revised & approved– They be periodically reviewed, revised & approved– Only current versions available– Obsoletes promptly removed & identified

Some examplesRoles & responsibilities • Roles & responsibilities

• Legal register • Licences from authorities

Ri k t• Risk assessment• SOPs• Training Needs Analysis and training records

f h ( )• Safety Data Sheets (SDS)• Chemical and Agent Inventory List • Maintenance records (BSC, Fume Hood)• Notes of safety meeting• PPE maintenance (respirator)

Documentation and Document Control

NUS standard format for procedure writing:• Objective• Scope• Responsibilities• Definition

Procedure• Procedure• Records• Appendixes

Include: Author, Reviewer, Approving Officer, Page number, Date, Reference Number, Revision Number

ExampleExample

Standard Operating Procedure RegisterNo Name of Procedure Prepared

byDate Approval

DateNext

Revision Date

Remarks

1123456789

10111213141415

Note: Please attache all approved Procedures

3 4 53.4.5Operational Control

Operational Control

• To implement controls identified in risk assessment

• Stipulate operating criteria and conditions

• To consider :

– purchasing of equipment, materials and services

– risk associated with contractors and visitors

• Operation controls to be communicated to all relevant partiesparties

U i it L l M l University Level Manuals, Procedures and Programmes

SMS@NUS documentation structure

• Laboratory Biorisk Management Manual

• Chemical Safety Manual

• Radiation Safety Manual

• General Lab Safety Manual

University-Level SOPs

L b i ti d l b lli• Lab sign posting and labelling

• Project / task risk assessment

• Accident/Incident reporting

• Control of Contractors Working in Laboratories and H ll f R id Halls of Residences

• Laboratory Decommissioning Procedures

• Etc.

Hazards in the Lab Personal Protection Required

Special Procedures or Precautions for Entry:

9694176068745961Peck TGIn Emergency

9694176068745961Peck TGFor Entry or Advice

Contact after Office HourOffice TelCall or SeeNotice

67795555NUHx2880Unversity Health

995Ambulance / Fire999Police

Mr/Ms Jesslyn Soh - 68745966

Faculty Safety Officerx1616Campus

Security

67795555NUHx2880and Wellness Centre

Date Posted: 1/31/2005 Department: OSHE

Room No: 68745961 Name of Lab: OSHE

Compulsory Occupational Health screening required prior to commencement of work

Health hazard Condition/s Mandatory Occupational HealthHealth hazard Condition/s Mandatory Occupational Health Controls

Animal (vertebrate)work

If staff or students are working with animals (vertebrate)

• Staff and students - tetanusvaccine prior to working with these animals(vertebrate) animals

• Booster shot every 3 years.

Human Material If staff or student will be in • Staff and students to be tested if contact with human blood, tissues, etc (non commercial sources)

Hepatitis antibodies are present. If negative, staff and student to be administered with a Hepatitis B vaccine. After six months screening of antibody levelsscreening of antibody levels should be done. Re-screening should be done 10 years later.

Compulsory OH screening required prior to commencement of work

Health hazard Condition/s Mandatory Occupational Health Controls

Any materialcontaining

If staff or student is conducting deliberate

• To determine appropriate medical surveillance,containing

infectious agents of risk group 2.

conducting deliberate research on materials containing risk group 2 and above agents

medical surveillance, immunization needed by referring to the MSDS of the infectious agent.

Compulsory OH screening required prior to commencement of work

Health hazard Condition/s Relevant Legislation To Comply With

Noise If staff or student is exposed to noise sources

• WSHA and its subsidiary legislation

resulting in noise exposure levels of 85 dBA over a period of 8 hours.

• WSHA (Noise) Regulations• WSHA (Medical Examinations)

Regulations

Chemical If staff or student is • Workplace Safety and Health expected or suspected to be exposed to permissible exposure limits (PELs) of scheduled chemicals

Act (General Provisions) Regulations

Radiation If staff or student is towork with ionizing or non ionizing radiation sources or equipment.

• Radiation Protection Act • Radiation Protection Act

(Ionizing Radiation)• Radiation Protection Act

(Non-ionizing Radiation)(Non-ionizing Radiation)

NUS Occupational Health ProgrammeProgramme

htt // d / h/ /http://www.nus.edu.sg/osh/programmes/occup_health/programme.htm

NUS R i t P t ti NUS Respirator Protection Programme

http://www.nus.edu.sg/osh/programmes/ 30040 h/rpp300407.htm

3.4.63.4.6Emergency Preparedness &

ResponseResponse

Emergency Preparedness & Responsep

• PI to identify possible emergency situations in the lab.

• Develops lab-specific emergency procedures (to be consistent with CEM Framework)

f f l• Ensure proper maintenance of emergency facilities (Fire extinguisher, Emergency shower , Eye wash) and consumables (first aid boxes)

• PI to ensure staff and students participate in NUS emergency response training (eg. fire safety, first aider) and drills

3.5 Checking

Checking

3 5 1 Performance measurement and monitoring3.5.1 Performance measurement and monitoring

3.5.2 Incident investigation, corrective action and preventive action

3.5.3 Internal audit

3.5.13.5.1Performance Measurement and

MonitoringMonitoring

3.5.1 Performance Measurement & Monitoringg

• Monitor extent to which OH&S objectives are met

• Monitor effectiveness of controls (thru’ regular • Monitor effectiveness of controls (thru regular inspections)

• Evaluate compliance with legal and other regulations

• Maintain and calibrate measuring equipment (e.g. GM counter, noise meter)

• Maintain records • Maintain records

Measurement & Monitoring Medical Surveillanc and Hygiene Requirements

No Activity Medical Checkup/Vaccination Required

Hep A Hep B

Annual Medical Checkup

EYE Checkup Others

Hygiene Monitoring

1

2

3

4

5

6

7

8

9

10

11

3.5.2I id t I ti ti Incident Investigation,

Corrective and Preventive iAction

3.5.2 Incident investigation, corrective & preventive action

All shall

• Report to OSHE via On-line Online Accident and Incident Reporting (AIRS) within 24 hrsIncident Reporting (AIRS) within 24 hrs

PI shall investigate the incident

• Analyse and determine root cause(s)• Analyse and determine root cause(s)

• Propose corrective and preventive actions

• Implement and evaluate its effectiveness p

Accident reporting and investigation is for purpose of l i it i t it h h t!learning; it is not a witch hunt!

Accident & Incident ReportingI id t R i tIncident Register

No Name of Incident Breif Description of IncidentReport Date Reported by

Incident Reprot Filed Remarks

Note: Please attach all past incidents reports

3 5 33.5.3Internal Audit

Department

3.5.3 Internal Audit (IA)

• Internal auditors are appointed by HOD

• Internal auditors are adequately te a aud to s a e adequate ytrained

• Internal audits are to be conductedte a aud ts a e to be co ducted

• PIs are to participate and support IAs.

IA is not a witch hunt! Auditors help auditees to identify areas for improvement.

Management Review

Management Review

• PI to review OHSMS

– at pre-determined interval; and p

– ensure it is suitable, adequate & effective

• Necessary information to be collected

PI Licensing/Certification

Issued to PIs who have Issued to PIs who have demonstrated an effective SMS

being implemented in their l b t ilaboratories

S

Certified Labs Are S.A.V.E.D.Self – regulating : ownership of laboratory safety by the PI

All encompassing : covers all lab activities, and looks at the holistic interaction of 4M - Man, Materials, Machines and Methods

V l Addi PValue Adding Process : Sharing of Best Practices by PeersNot fault finding but stress on continual improvement

Educating : Lab group is educated on risk assessments, safety management systems

D hb d f fDashboard : Provides a gauge on safety compliance status of labs

Benefits from the scheme Waiver of submission of PRA No delay in activation of new grants Approval is immediate

Sharing of best practices among peers (including common SOPs)

Enhanced safety awareness among l b tlaboratory group

Improved safety performance

Certification Maintenance Certification is valid for 3 years Surveillance audit on annual basis Review and revise Risk Assessment

whenever Any changes in materials, protocols,

equipment etc. or A f i id t id t Any occurrence of incident or accident or

Once every 3 years

Lab OHS Certification Scheme Lab OHS Certification Scheme

http://www.nus.edu.sg/osh/programmes/ohscert.htm

Th k Y !Thank You!