new health & safety management compliance audit · 2015. 11. 19. · health & safety...

Health & Safety Management Compliance Audit

The University of Edinburgh

School of GeoSciences

February 2010 Prepared by:

Richard Sewell ACII, CMIOSH, AIEMA Senior Consultant Aon Limited Aon Global Risk Consulting

OCCUPATIONAL HEALTH & SAFETY

Aon Limited is authorised and regulated by the Financial Services Authority in respect of insurance mediation activities only.

The University of Edinburgh School of GeoSciences

Contents 1. INTRODUCTION 1 2. SCORE SHEET 2 3. GRAPHICAL REPRESENTATION 3 4. EXECUTIVE SUMMARY 4 5. RECOMMENDATIONS 5 6. DETAILED SCORES 8


Univ Edinburgh School of GeoSciences, Feb 10.doc (V1 – 0/110)


DISCLAIMER "This report and any recommendations in it are based on certain observations made by us and/or from information supplied to us from sources which Aon believes it is entitled to assume are reliable. Conditions may have changed since our survey and/or the preparation of this report, and the reader must take this into account when acting in reliance on it. It is not, and is not intended to be, exhaustive or conclusive, covering every hazard or risk potential, nor to guarantee compliance with any statute or regulation, nor does its preparation and submission to insurers relieve you of your obligation to make full disclosure of all material facts to your insurers. It is offered to assist you in your assessment and/or management of risk. If you are in any doubt as to whether a fact is material and should be disclosed to your insurers, you should promptly discuss this with your insurance broker, if at all possible prior to the binding of the insurance contract. "

Senior Consultant …………………………………………….. Richard Sewell ACII, CMIOSH, AIEMA For and on behalf of Aon Limited Aon Global Risk Consulting 11 February 2010

CONFIDENTIALITY CLAUSE

“The information contained within this document is confidential to both Aon Limited and The University of Edinburgh and has been produced solely for the purpose of our discussions regarding the latter's health and safety risks. The contents may not be reproduced or disclosed to any third party without the prior written approval of Aon Limited and Aon Limited disclaims any liability whatsoever to any such third party. Please also read the important notes above". ©Copyright Aon Limited 2010. All rights reserved.






Site Visit Details

Client Name: The University of Edinburgh

School Name School of GeoSciences

Site Address: Grant Institute The King's Buildings West Mains Road Edinburgh EH9 3JW

Occupancy: University School of GeoSciences

Conferred with: Professor Martin Siegert, Head of School Gordon Waugh, Scientific & Technical Services Manager Helen Pearson, Health & Safety Manager

Site Contact Details: 0131 6513400

Prepared By: Richard Sewell ACII, CMIOSH, AIEMA

Consultant’s Contact Details: Aon Limited Aon Global Risk Consulting Arkwright House Parsonage Gardens Manchester M3 2LF

Office: 0161 9105265 Mobile: 07703316817 E-mail: [email protected]

Date of Visit: 28th January 2010

Document Ref: Univ Edinburgh School of GeoSciences, Feb 10.doc

Document History Rev No: 0


1. INTRODUCTION

1. This health & safety management compliance audit programme is designed to review the practical implementation of health and safety arrangements in Schools and Corporate Services.

This follows on from and forms phase 2 of the health and safety management system audit programme conducted by Aon between January 2006 and March 2008.

In addition, specific additional topics (Multi occupancy building user groups, Liquid nitrogen management and Use of the SciQuest “Chemical Manager” component) have been included in this audit for procedural compliance verification at the specific request of the University.

2. Good, fair or poor ratings have been determined by the auditor and the appropriate points awarded.

3. The following issues were considered when determining ratings:

Good: High degree of management control. Good and verifiable conformance with regulations. Good and verifiable conformance with documented health and safety management procedures.

Fair: Reasonable degree of management control. Reasonable conformance and verification of compliance with regulations. Reasonable conformance and verification of compliance with documented health and safety management procedures.

Poor: Little management control. Poor conformance and verification of compliance with regulations. Poor conformance and verification of compliance with documented health and safety management procedures.

No Score: No effective management control currently being exerted.

4. Where ratings of fair, poor, or no score have been awarded corresponding recommendations for corrective actions have been listed in the Summary of Recommendations section.

Aon Limited is authorised and regulated by the Financial Services Authority in respect of insurance mediation activities only. Page 1 of 17


2. SCORE SHEET

SCORE SHEET

Report Ref Subject Max Score Marked Score %

1 Health and Safety Management1.1. Organisation 100 100 100%1.2 Policy 80 70 88%1.3 Training 80 60 75%1.4 Planning 80 80 100%1.5 Audit and Review 80 70 88%

Sub Total 420 380 90%2 Health and Safety Controls2.1. Risk Assessments 220 163 74%2.2. Work Equipment 100 100 100%2.3. Safe Working Procedures 100 70 70%2.4. Occupational Health 40 40 100%2.5. Visitors and Contractors 60 50 83%2.6. Fire Safety 40 30 75%

Sub Total 560 453 81%3 Workplace Conditions/Activities3.1 Housekeeping 20 10 50%3.2 Machinery/Plant 20 10 50%3.3 Vehicles 20 20 100%3.4 Prevention of Falls 20 10 50%3.5 Service Installations 20 10 50%3.6 Storage Facilities 20 10 50%3.7 Unsafe Acts 20 10 50%

Sub Total 140 80 57%

OVERALL TOTAL 1120 913 81.5%



3. GRAPHICAL REPRESENTATION

OVERALL AUDIT SCORE 81.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

OVE RALL SCORE

3.7 Unsafe Acts

3.6 Storage Facil ities

3.5.Service Insta lla tions

3.4. Prevention of Falls

3.3. V ehicles

3.2. Machinery/Plant

3.1. Housekeeping

2.6. Fire S afety

2.5. Visitors, Contractors & Security

2.4. Occupationa l Health

2.3. Safe Work Procedures

2.2. Work Equipment

2.1. R isk Assessments

1.5. Audit and Review

1.4. Planning

1.3. Tra ining

1.2. Po licy

1.1. Organisation

0-49%Poor

50-79%Fair

80-100%Good



4. EXECUTIVE SUMMARY

Health & Safety Management Review In February 2006 the School of GeoSciences achieved an audit score of 89.6%.

From our brief review of the recommendations made as a result of this audit we are pleased to report that, with the exception of a review of training management and the adoption of a systematic approach to heath & safety training and the setting of competency standards (1.3B); our recommendations have largely been adopted. Helen Pearson has only recently been appointed as the school health & safety manager and is conducting a review of health & safety training, as well as conducting an area by area audit of the school, in order to develop a programme of improvement.

Compliance Audit Results The main issues identified from the review are summarised below.

The total audit score of 81.5% is rated “good” by the criteria used as a benchmark in this audit.

All sections are rated good with the exception of:

1.3 Training, rated “fair”.

2.1 Risk Assessments, rated “fair”.

2.3 Safe Working Procedures, rated “fair”

2.6 Fire Safety, rated “fair”.

3.1 Housekeeping, rated “fair”.

3.2 Machinery/Plant, rated “fair”.

3.4 Prevention of Falls, rated “fair”.

3.5 Service Installations, rated “fair”.

3.6 Storage Facilities, rated “fair”.

3.7 Unsafe Acts, rated “fair”.

Whilst we make a number of improvement recommendations relating to workplace conditions/activities observed during our audit tour, our main concern is the fact that some operational high risk areas such as the Crew Laboratories were found to have no risk assessment, and other areas of the school were found to have risk assessments that have passed their review dates. As risk assessment is now widely regarded as the basis upon which you should identify and manage safety hazards, this must be regarded as a significant issue requiring urgent attention.

We recognise that Helen Pearson has only recently taken up the position of school health and safety manager and we are confident that she will be able to use the findings of this compliance audit as the basis for a systematic and sustainable safety improvement programme.



5. RECOMMENDATIONS All recommendations listed are prefixed with the section of the questionnaire to which they relate and a classification for completion. They should be read in conjunction with the scores allotted in the next section.

Classification of Recommendations

A Requires immediate action to eliminate the imminent risk of accidents occurring.

Statutory duties and/or issues which require action with minimum delay to minimise accident and/or legal action being taken against the University. B

Consistent with good risk control and if actioned should help improve standards of health and safety management. C

Rep

ort R

ef

Cla

ssifi

catio

n

Recommendation

Rec

No.

2010.1 1.2 B The school should consider ways of refreshing staff awareness of the school’s health & safety policy on a regular basis by holding an annual “safety day”, or by holding regular safety awareness training sessions for staff as part of an ongoing programme.

2010.2 1.3 B The school should adopt a systematic approach to the management and provision of health & safety training for all levels of staff. For example all staff with responsibility for the management of work areas or for the supervision of staff and students should receive basic health and safety training (IOSH Managing Safely, or something similar). All staff should receive basic health and safety awareness training over and above that given at induction.

Training should be regularly reviewed and tracked using training matrix.

2010.3 1.5 B Local area walk trough safety inspections should be formalised as part of a planned and managed programme. Inspections should be recorded and lodged in local area safety files. The programme should be monitored for compliance and audited for quality.

2010.4 2.1 A General RA1 risk assessments should be completed for all work areas and for all work activities of the school involving “significant hazard”. During this audit a number of laboratories were found to have no risk assessment completed. These included labs 12, 14, 15 and 20 in the Crew Labs block.

2010.5 2.1 B General risk assessments should also be produced for low risk areas such as offices and seminar rooms, and be posted in the areas concerned.



2010.6 2.1 A Manual handling risk assessments should be completed to cover the handling and movement of heavy samples, and the handling of heavy field equipment. Examples of areas requiring manual handling risk assessments include Micrometeorological Lab 14 in the Crew Lab block, and rock/soil sample storage in the Geography building.

2010.7 2.1 A COSHH assessments should be completed to cover chemical use and storage in Labs 14, 20 and 23 in the Crew Lab block.

2010.8 2.1 C DSE risk information should be displayed in student computer labs in order to demonstrate due care by the school on such matters.

2010.9 2.1 B All risk assessments should be reviewed and if necessary updated, as part of an annual programme. During this audit we identified a number of work areas with risk assessments that had past their designated review dates. The areas concerned included Grant Institute mechanical workshop, lab 23 of the Crew Labs block and 1.02 in the Geography building.

2010.10 2.3 B Safety procedures covering the use and storage of liquid nitrogen within the school should be reviewed to ensure they are compliant with the university’s latest standards.

2010.11 2.3 A Laboratory safety files should be properly maintained in all areas. During this audit lab 136 in the Grant Institute was found to have no safety file, and files in the Crew Labs building were found to be incomplete.

2010.12 2.3 B All safe working procedures should be reviewed, as part of the risk assessment review process (ref recommendation 2010.9 above).

2010.13 2.5 B The school has a duty to provide information to visitors and to ensure their safety whilst on the premises. We recommend an information board similar to that in the main entrance way to the geography building be located in the entrance way of the Grant Institute, alternatively video screen displays could be used.

2010.14 2.6 A Recently installed self closing fire doors in the Grant Institute are causing a hazard to people carrying materials through the areas concerned. The university Fire Officer and Estates building manager should be consulted on this matter to see if such doors can be held open by magnetic catches during normal working hours.

2010.15 3.1 A The standard of housekeeping in the Thin Sections lab 10 was considered poor and this area should be tidied up and redundant equipment removed.

Rock crushing and grinding rooms should be cleared of rubbish and debris after their seasonal use.

Bench top housekeeping and storage on top of wall cabinets in the Mechanical Workshop should be improved.

Redundant machinery in Geography building corridor near 1.03 should be removed.



2010.16 3.2 B The safety standards on older workshop machinery and equipment in the Mechanical Workshop are not strictly compliant with the HSE guidance on the Provision and Use of Work Equipment Regulations, particularly in relation to marking of controls and the provision of emergency stops. Whilst we recognise that an independent machinery safety study has been completed and that the risk is much reduced due to use by only experienced technical staff, a further review should have been conducted when the apprentice was employed due to the greater duty of care owed to such persons. We recommend the standards in this workshop be kept under review and that a programme of improvement be implemented.

2010.17 3.4 A Storage of goods and materials at height in various areas of the school introduces a risk of fall from height when people try to retrieve such items for use or disposal. During the audit storage at height was observed in John Murray Labs office 27, Grant Institute lab 136, Crew Labs 12 & 14. Such situations should be identified by routine safety inspections and action taken to eliminate the risk or provide a safe means of access.

2010.18 3.6 B The gas supply isolation tap on the mechanical workshop brazing hearth should be clearly identified by signage.

2010.19 3.7 A Old filing cabinets in the mechanical workshop that allow multiple drawer opening should be clearly labelled and plans made for their replacement.

2010.20 3.7 A Hydraulic oil found stored in the high pressure control room 126, should be removed to safe storage.

2010.21 3.7 A Boxes of rocks stored on a damaged pallet in a corridor close to room 1.03 in the geography building represent a significant hazard. This storage should be reorganised in a safe manner.

2010.22 3.8 A A damaged lead acid battery, with a broken top left in the corridor of the Crew Labs outside lab 14 represents an unsafe act. Proper arrangements should be made for the storage and disposal of hazardous goods and materials.



6. DETAILED SCORES

Report Ref Subject

Goo

d

Fair

Poor

No

Sco

re

N/A

1.1. OrganisationWhat role do Heads of School/division play in xpromoting and encouraging high standards of health and safety? (Sits on safety committee, demonstrates active interest and involvement in health and safety management)

What role do senior members of staff play inpromoting and maintaining high standards of healthand safety? (Sit on safety committee, demonstrate active role in health and safety management).

What role do Employees play in promoting and maintaininghigh standards of health and safety? (Compliance with health and safety procedures, use of PPE, housekeeping etc).

If the School occupies a multi-occupancy building hasa MoBUG been put in place to consider the issuesof communal interest and is the MoBUG effective in itsoperation?

What standard of competent advice on health and safety isavailable to the School or Business Unit?

Good = 20, Fair = 10, Poor = 3, No Score = 0, N/A

SECTION 1 - HEALTH AND SAFETY MANAGEMENT

x

x

x

x



1.2 PolicyWhat standard of Divisional Health & Safety PolicyPolicy has been prepared for the Division? (Recently reviewed, introduction by Head of Division, section on risk assessment etc.)

What arrangements are employed for communicatingand explaining the purpose and content of the policy to Employees? (Vertification through signed records of receipt from emploeyes)

What arrangements are employed for monitoring the effectiveimplementation and achievement of the policy objectives? (Work area inspections, procedural compliance audits, active safet

x

x

x

y committee).

What arrangements are employed for review and revision

of the policy? (Safety management planning and organisation)

1.3 Trainin

x

g What standard of safety training is provided for Divisional

Managers and Safety Advisors. (HOD received formal induction to safety management role, DSA & safety awareness training for Managers and Safety Advisor).

What arrangements are employed for training new staffand long termm visitors? (Verifiable induction training procedures)

What arrangements are employed for the provision ofgeneral safety training? (Staff training plans).

What arrangements are employed for identifyingtraining needs and ensuring that appropriate trainingprovisions are made? (Annual safety training needs review, training plan etc)

x

x

x

x



1.4. PlanningWhat planning has been given to identifying objectivesand targets for maintaining/improving performance? (Safety im

x

provement plan)

What arrangements are employed for communicatingthe safety plans to employees? (Publish safety plan or summary on notice boards)

What procedures are employed to monitor implementation and achievement of the safety plan?

x

x

(Monitored by safety committee)

What arrangements are employed for review andrevision of the safety plan? (Planned review by HOD, DSA and safety committee)

1.5. Audit and Review What inspection arrangements are employed for

monitoring safety performance and standards? (Planned and checklist based work area inspection programme).

What arrangements are employed to ensure allaccidents and incidents are reported and investigated? (Report and discussion by safety committee)

What arrangements are employed to ensure the resultsof the safety inspections and audit reports are analysedand effectively utilised. (Report and discussion by safety committee

x

x

x

x

)

What arrangements are employed to ensure the correctiveactions identified from the inspections, etc., areeffectively actioned? (Improvement action plans, summary status reports discussed by safety committee)

x



Report Ref Subject

Goo

d

Fair

Poor

No S

core

N/A

2.1 Risk AssessmentTo what standard have assessments been carried outfor the following subjects:

General work activitiesManual handling operationsThe use of hazardous substancesExposure to noiseThe use of display screen equipmentField work activitiesExposure to serious and imminent danger situations To what extent have employees / students been consultedin the Assessment process?

What arrangements are employed for communicatingthe findings of the assessments to employees / students at risk?

xxx

xx

xx

x

x

(Verification of procedure, signed records etc).

What arrangements are employed for ensuringcorrective actions identified by the assessments areeffectively actioned? (Improvement action plan, dsicussion by safety committee)

What plans have been made to review and revise theassessments?

2.2. Work Equipment What systems are employed for ensuring statutory

inspections are carried out? (Arrangements for testing and maintenance of LEV systems and equipment)

What systems are employed for compliance with PATTesting procedures?

What systems are employed for routine inspections ofplant, machinery, access equipment and vehicles?

What standard of training is provided for users of workequipment?

What systems are employed to ensure the purchase,installation and use of safe work equipment? (Documented procedures requiring risk assessment prior to use)

Good = 20, Fair = 10, Poor = 3, No Score = 0

SECTION 2 - HEALTH AND SAFETY CONTROLS

x

x

x

x

x

x

x



2.3. Safe Working ProceduresWhat systems are employed for minimising risks fromhigh risk work activities? (Permits to work and/or written safe working procedures)

Has use of the Chemical Manager component of theSciQuest system been considered or implemented?(Chemisty can provide guidance and training. Whereno chemicals score n/a).

What arrangements are employed for ensuring the effective use of safe working procedures? (Compliance audit procedures)

What arrangements are in place for the control of risksassociated with the use of liquid nitrogen and arethese arrangements regularly reviewed?

What arrangements are employed for informing andinstructing employees / students on the use of safe working procedures? (Availability / display of written safe working procedures in work areas and verification through signed training records)

What arrangements are employed for reviewing and revising the procedures?

2.4. Occu

x

n/a

x

x

x

x

pational Health What standard of First Aid facilities are available? (Adequate trained staff available)

What arrangements are employed for dealing with serious accident occurrences? (Documented procedure)

2.5.

x

x

Visitors, Contractors and Security What arrangements are employed for ensuring the

health and safety of visitors including long term visiting students, researchers, lecturers etc? (Recording of Visitors, provision of information to visitors, Identification of visitors, induction training of long term visitors, minimum language requirements)

What arrangements are employed for the selection,control and management of contractors? (Logging-in, Induction/su

x

x

pervision, permits to work)

What consideration has been given to identifying theSecurity risk at the premises? (Unauthorised access, security of "hazardous" materials and biological agents).

x



2.6. Fire Safety What consideration has been given to identifying fire

safety risks? (Housekeeping inspections, control of flammable materials, PAT testing etc).

What systems are employed for fire safety training?(Recorded induction training on fire procedures and fire safety training courses)

x

x



Report Ref Subject

Goo

d

Fair

Poor

No

Sco

re

3.1. Housekeeping xWhat standard of housekeeping was observed?

Consideration will be given to:Access to, from and around workstations.Housekeeping standards both internally and externally.

Layout of work areas.Maintenance of buildings, fixtures and fittings.Spillage procedures and waste disposal facilities.

3.2 Machinery/Plant/EquipmentWhat level of safety was observed on plant andmachinery?

Consideration will be given here to:Guarding of dangerous parts of machinery and plant.Safety distances and heights for fencing and mesh guarding.

access to dangerous parts of machinery.Protection against hot surfaces.Provision of suitable and sufficient emergency stop facilities.Provision of suitably marked controls.

3.3 VehiclesWhat provisions have been made to ensure the safety ofpedestrians from moving vehicles?

Consideration will be given here to:Provision of separate pedestrian routes and access pointsMarking of restricted pedestrian access to vehicle

Observed activities of drivers.Appointment of vehicle controller

Good = 20, Fair = 10, Poor = 3, No Score = 0

SECTION 3 - WORKPLACE CONDITIONS/ACTIVITIES

Access to fire safety provisions and emergency first aid stations.

The use of interlocks and other safety devices for preventing

manoeuvring points.

x

x



3.4 Prevention of Falls

What provisions are made eto minimise the risk ofpersons falling from heights?

Consideration will be given here to:

Provision of fencing around pits etc.,

Provision of hoop protection on vertical access ladders.

3.6 Service Installation

x

sWhat are the standards of safety regarding serviceinstallations?

Consideration will be given here to:

Security of access to electrical equipment.

Visual integrity of pressure systems.Dosing and cleansing of water systems.

3.7 Stora

x

ge FacilitiesWhat standards of storage facilities are provided for the safe storage of articles and substances?

Consideration will be given here to:Marking and bunding of storage vessels and containersMarking of pipework

Restricted access to storage areas.Storage of "high" hazard materials

3.8 Unsafe ActsTo what level of safety were employees/students seento be carrying out their work activities?

Consideration will be given here to:The safe and proper use of plant and equipment.The proper use of personal protective equipment.Adherence to safe working procedures.

Safe erection of scaffolding and ladders.

Provision of suitable racking.

Provision of barriers/hand rails on high level platforms amd stairs

Condition and testing of electrical systems both fixed and portable.

Suitable provisions for the safe storage of gas cylinders, flammable liquids and dangerous

x

x



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