Health & Safety Management Compliance Audit

Transcription

1 Health & Safety Management Compliance Audit The University of Edinburgh February 2010 Prepared by: Richard Sewell ACII, CMIOSH, AIEMA Senior Consultant Aon Limited Aon Global Risk Consulting OCCUPATIONAL HEALTH & SAFETY

2 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, Feb 10.doc (V1 0/110)

3 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, ehaustive 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 All rights reserved. Univ Edinburgh, Feb 10.doc (V1 0/110)

4 Site Visit Details Client Name: School Name Site Address: Occupancy: Conferred with: The University of Edinburgh Grant Institute The King's Buildings West Mains Road Edinburgh EH9 3JW Site Contact Details: Prepared By: Consultant s Contact Details: University Professor Martin Siegert, Head of School Gordon Waugh, Scientific & Technical Services Manager Helen Pearson, Health & Safety Manager Richard Sewell ACII, CMIOSH, AIEMA Aon Limited Aon Global Risk Consulting Arkwright House Parsonage Gardens Manchester M3 2LF Date of Visit: 28th January 2010 Document Ref: Document History Rev No: 0 Office: Mobile: richard.sewell@ars.aon.co.uk Univ Edinburgh, Feb 10.doc Univ Edinburgh, Feb 10.doc (V1 0/110)

5 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 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 eerted. 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. Page 1 of 17

6 2. SCORE SHEET SCORE SHEET Report Ref Subject Ma Score Marked Score % 1 Health and Safety Management 1.1. Organisation % 1.2 Policy % 1.3 Training % 1.4 Planning % 1.5 Audit and Review % Sub Total % 2 Health and Safety Controls 2.1. Risk Assessments % 2.2. Work Equipment % 2.3. Safe Working Procedures % 2.4. Occupational Health % 2.5. Visitors and Contractors % 2.6. Fire Safety % Sub Total % 3 Workplace Conditions/Activities 3.1 Housekeeping % 3.2 Machinery/Plant % 3.3 Vehicles % 3.4 Prevention of Falls % 3.5 Service Installations % 3.6 Storage Facilities % 3.7 Unsafe Acts % Sub Total % OVERALL TOTAL % Page 2 of 17

7 3. GRAPHICAL REPRESENTATION 1.1. Organisation 1.2. Po li cy 1.3. Tra ini ng 1.4. Planning 1.5. Audit and Review 2.1. Risk Assessments 2.2. Work Equipment 2.3. Safe Work Procedures 2.4. Occupational Health 2.5. Visitors, Contractors & Security 2.6. Fire S afety 3.1. H ou seke epi ng 3.2. Mach in ery/plan t 3.3. V ehicles 3.4. Prevention of Falls 3.5.Service Installations 3.6 Storage Facilities 3.7 Unsafe Acts OVE RALL SCORE 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% OVERALL AUDIT SCORE 81.5% 0-49% Poor 50-79% Fair % Good Page 3 of 17

8 4. EXECUTIVE SUMMARY Health & Safety Management Review In February 2006 the 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 eception 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 eception 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. Page 4 of 17

9 5. RECOMMENDATIONS All recommendations listed are prefied 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 net section. Classification of Recommendations A Requires immediate action to eliminate the imminent risk of accidents occurring. B Statutory duties and/or issues which require action with minimum delay to minimise accident and/or legal action being taken against the University. C Consistent with good risk control and if actioned should help improve standards of health and safety management. Rec No. Report Ref Classification Recommendation 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 B The school should adopt a systematic approach to the management and provision of health & safety training for all levels of staff. For eample 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 matri 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 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 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. Page 5 of 17

10 A Manual handling risk assessments should be completed to cover the handling and movement of heavy samples, and the handling of heavy field equipment. Eamples 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 A COSHH assessments should be completed to cover chemical use and storage in Labs 14, 20 and 23 in the Crew Lab block C DSE risk information should be displayed in student computer labs in order to demonstrate due care by the school on such matters 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 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 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 B All safe working procedures should be reviewed, as part of the risk assessment review process (ref recommendation above) 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 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 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. Page 6 of 17

11 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 eperienced 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 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 B The gas supply isolation tap on the mechanical workshop brazing hearth should be clearly identified by signage A Old filing cabinets in the mechanical workshop that allow multiple drawer opening should be clearly labelled and plans made for their replacement A Hydraulic oil found stored in the high pressure control room 126, should be removed to safe storage A Boes 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 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. Page 7 of 17

12 6. DETAILED SCORES SECTION 1 - HEALTH AND SAFETY MANAGEMENT Good = 20, Fair = 10, Poor = 3, No Score = 0, N/A Report Ref Subject Good Fair Po or No Score N/A 1.1. Organisation What role do Heads of School/division play in promoting 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 in promoting and maintaining high standards of health and safety? (Sit on safety committee, demonstrate active role in health and safety management). What role do Employees play in promoting and maintaining high standards of health and safety? (Compliance with health and safety procedures, use of PPE, housekeeping etc). If the School occupies a multi-occupancy building has a MoBUG been put in place to consider the issues of communal interest and is the MoBUG effective in its operation? What standard of competent advice on health and safety is available to the School or Business Unit? Page 8 of 17

13 1.2 Policy What standard of Divisional Health & Safety Policy Policy has been prepared for the Division? (Recently reviewed, introduction by Head of Division, section on risk assessment etc.) What arrangements are employed for communicating and eplaining the purpose and content of the policy to Employees? (Vertification through signed records of receipt from emploeyes) What arrangements are employed for monitoring the effective implementation and achievement of the policy objectives? (Work area inspections, procedural compliance audits, active safety committee). What arrangements are employed for review and revision of the policy? (Safety management planning and organisation) 1.3 Training 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 staff and long termm visitors? (Verifiable induction training procedures) What arrangements are employed for the provision of general safety training? (Staff training plans). What arrangements are employed for identifying training needs and ensuring that appropriate training provisions are made? (Annual safety training needs review, training plan etc) Page 9 of 17

14 1.4. Planning What planning has been given to identifying objectives and targets for maintaining/improving performance? (Safety improvement plan) What arrangements are employed for communicating the 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? (Monitored by safety committee) What arrangements are employed for review and revision 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 all accidents and incidents are reported and investigated? (Report and discussion by safety committee) What arrangements are employed to ensure the results of the safety inspections and audit reports are analysed and effectively utilised. (Report and discussion by safety committee) What arrangements are employed to ensure the corrective actions identified from the inspections, etc., are effectively actioned? (Improvement action plans, summary status reports discussed by safety committee) Page 10 of 17

15 SECTION 2 - HEALTH AND SAFETY CONTROLS Good = 20, Fair = 10, Poor = 3, No Score = 0 Report Ref Subject Good Fair Po or No Score N/A 2.1 Risk Assessment To what standard have assessments been carried out for the following subjects: General work activities Manual handling operations The use of hazardous substances Eposure to noise The use of display screen equipment Field work activities Eposure to serious and imminent danger situations To what etent have employees / students been consulted in the Assessment process? What arrangements are employed for communicating the findings of the assessments to employees / students at risk? (Verification of procedure, signed records etc). What arrangements are employed for ensuring corrective actions identified by the assessments are effectively actioned? (Improvement action plan, dsicussion by safety committee) What plans have been made to review and revise the assessments? 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 PAT Testing procedures? What systems are employed for routine inspections of plant, machinery, access equipment and vehicles? What standard of training is provided for users of work equipment? What systems are employed to ensure the purchase, installation and use of safe work equipment? (Documented procedures requiring risk assessment prior to use) Page 11 of 17

16 2.3. Safe Working Procedures What systems are employed for minimising risks from high risk work activities? (Permits to work and/or written safe working procedures) Has use of the Chemical Manager component of the SciQuest system been considered or implemented? (Chemisty can provide guidance and training. Where no chemicals score n/a). 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 risks associated with the use of liquid nitrogen and are these arrangements regularly reviewed? What arrangements are employed for informing and instructing 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. Occupational 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. 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/supervision, permits to work) What consideration has been given to identifying the Security risk at the premises? (Unauthorised access, security of "hazardous" materials and biological agents). Page 12 of 17

17 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) Page 13 of 17

18 SECTION 3 - WORKPLACE CONDITIONS/ACTIVITIES Good = 20, Fair = 10, Poor = 3, No Score = 0 Report Ref Subject Good Fair Po or No Score 3.1. Housekeeping What standard of housekeeping was observed? Consideration will be given to: Access to, from and around workstations. Housekeeping standards both internally and eternally. Access to fire safety provisions and emergency first aid stations. Layout of work areas. Maintenance of buildings, fitures and fittings. Spillage procedures and waste disposal facilities. 3.2 Machinery/Plant/Equipment What level of safety was observed on plant and machinery? Consideration will be given here to: Guarding of dangerous parts of machinery and plant. Safety distances and heights for fencing and mesh guarding. The use of interlocks and other safety devices for preventing 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 Vehicles What provisions have been made to ensure the safety of pedestrians from moving vehicles? Consideration will be given here to: Provision of separate pedestrian routes and access points Marking of restricted pedestrian access to vehicle manoeuvring points. Observed activities of drivers. Appointment of vehicle controller Page 14 of 17

19 3.4 Prevention of Falls What provisions are made eto minimise the risk of persons falling from heights? Consideration will be given here to: Provision of barriers/hand rails on high level platforms amd stairs Provision of fencing around pits etc., Safe erection of scaffolding and ladders. Provision of hoop protection on vertical access ladders. 3.6 Service Installations What are the standards of safety regarding service installations? Consideration will be given here to: Condition and testing of electrical systems both fied and portable. Security of access to electrical equipment. Suitable provisions for the safe storage of gas cylinders, flammable liquids and dangerous Visual integrity of pressure systems. Dosing and cleansing of water systems. 3.7 Storage Facilities What 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 containers Marking of pipework Provision of suitable racking. Restricted access to storage areas. Storage of "high" hazard materials 3.8 Unsafe Acts To what level of safety were employees/students seen to 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. Page 15 of 17

20 Aon Global Risk Consulting Effective management of the risks facing business today is essential to protect market share and shareholder confidence. The objective of Aon Global s Risk Consulting Practice is to provide a consultancy service that generates costeffective solutions to address and minimise risks. Our consultancy services cover every aspect of risk, identifying and quantifying it, giving advice on how it should be managed and providing focused risk related consultancy services. Our Consultants will work in partnership with you to: minimise the risks which threaten your business develop and support your risk control programmes reduce your risk financing costs Our capabilities include: Health and Safety: management system audits; general and specific risk assessments; policy development; design and implementation of appropriate safety standards and procedures. Specialist advice on legal requirements and compliance. Security: general and specific reviews on security eposures, advice on the implementation of standards and procedures for protecting people, property and information. Business Continuity Management: project initiation; risk and business impact analysis; strategy development; liaison with other parties; detailed planning; advice on plan preparation and contents. Staff training, plan testing and maintenance. Fied Asset Protection: evaluation and assessment of material damage risks and loss potentials for both general and highly protected risks, advice on protective/preventive measures and damage limitation controls. Motor Fleet: management system audits; general risk assessments; policy development; design and implementation of appropriate operating standards and procedures. Information Technology: assessments of hardware and software protection standards, data and access control standards and disaster recovery planning. Training: accredited suppliers of IOSH safety training, providers of general and specific training on all aspects of risk control for Shop Floor to Boardroom audiences. Aon Global s Risk Consulting Practice seeks to work alongside and in close co-operation with our clients. Our mission is to help and support eisting in-house resources to meet agreed aims, targets and business objectives. Our team of Consultants have considerable epertise and eperience of the risk control issues affecting your business, be they strategic, operational or technical. We have both multi-skilled Consultants and qualified topic specialists whose practical eperience and knowledge can provide you with cost effective solutions to minimise risks that could adversely affect your business. Working in partnership with Aon Global Risk Consulting will: secure advice which is independent and unbiased enable risks to be identified and controlled increase the certainty of business continuity may reduce the total cost of risk Working alongside and in close co-operation with our clients helps Aon Global Risk Consulting to understand your business and provide you with practicable and cost effective solutions to help you reduce risks and meet agreed aims, targets and business objectives. Page 16 of 17

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