HSE Compliance Sub Committee

Transcription

1 HSE Compliance Sub Committee Subject: Origin: EMS Compliance Update, Nik Hunt Purpose of the report: To provide an update on compliance across the Environmental Management System (EMS) Introduction: The EMS requires the University to undertake internal compliance audits to assess compliance with both legislation and the procedures of the system. This report summarises the outcome of these audits, the assessment of compliance undertaken as a result of these and the Non-conformances occurring within the EMS. Executive Summary: The Compliance Audits and Legislative Compliance assessment were undertaken. 25 actions have been identified as a result of the compliance audits including 15 OFI s, 5 Minor and 1 Major Non Conformance. The Minor NC s relate to Chemicals and COSHH records and the Major F-Gas (which is addressed in Paper 14). Only one other item has been logged in the Corrective Action Log, a Major Non Conformance around protecting campus biodiversity and this has been closed out. The assessment of legislative compliance also highlights the F-Gas compliance concern. Compliance Audits: The compliance audits each year consist of areas which must be audited and then a selection of areas based on a rolling program based on risk. The areas undertaken each year are those overseen by the, and along with F- Gas. All other areas are done every 2-3 years. This year the additional areas audited were: School of Science School of Business and Economics School of Mechanical, Electrical and Mechanical Engineering School of Aeronautical, Automotive, Chemical and Materials Engineering Procurement Domestic Services, Fitters, FM Development and Gardens all as part of the Construction and Maintenance of the Estate. The audits this year highlighted some very good practice across all areas and continued improvements in the awareness, and requirements of, the EMS. There were as ever areas of opportunity for improvement with a total of 25 Actions made up of: 4 clarification actions 15 Opportunities For Improvement 5 Minor Non Conformance 1 Major Non Conformance The OFI s are nothing to be concerned about, the Minor Non Conformances are failings to evidence compliance with procedures and the Major is a failure to evidence compliance with legislation. The Minor Non Conformances are associated with two key areas; 1. COSHH records for, and storage of, Chemicals 2. Availability of HSE Tour Reports Page 1 of 6

2 The Major Non Conformance related to F-Gas and is covered by the accompanying report (Paper 14) Other corrective actions logged in the EMS: All of the above will be logged in the Corrective Action Log of the EMS, the only other item logged in this since the last report is the major non-conformance which was raised around the protection of Campus Biodiversity which was closed out in October. There is also currently an investigation underway as to whether there has been a breach of procedure (Minor NC) in respect of the LUSEP development. Assessment of Legislative Compliance The full assessment of legislative compliance can be seen in Appendix 1. This considers the requirement to verify compliance with legislation and splits this into verifications required: Annually After an incident On review of Strategy On Contract renewal / project commencement On an adhoc basis as indicated Check TBC No check required All necessary areas were reviewed and compliance was reassured across all these areas with the exception of F-Gas which is covered by the accompanying report (Paper 14). Page 2 of 6

3 Appendix 1 Check Annually After incident On Review of Strategy On Contract renewal / Project Kick Off on an Adhoc Basis Requirements TBC Not required Evaluation of Compliance Description these pieces of legislation involves submissions, the production of documentation or a clear compliance requirement these are only applicable in the event of an incident and therefore compliance can only be checked if such an incident occurs. There may be processes which can be checked to ensure we are ready to comply but these will be checked as part of the evaluation of Operational Control effectiveness. these pieces of legislation do not pose a direct requirement on the University but may reflect a strategic requirement to be included. a routine action on many new contractors is a compliance / due diligence audit and the legislation in this section will be linked to the checks required of new contractors these are different pieces of legislation which require some form of compliance check but not on a basis which fits in any of the other categories we are uncertain at this point as to the frequency of checks required, further assessment is to be undertaken these pieces of legislation have an impact on the University in some way but either do not require a specific action or the action required is covered by a different piece of legislation. Ch Legislation Reasoning and Method of Evaluation Audit & Date Summary Outcome of Audits Check Annually 2 The Carbon Reduction Commitment Energy Efficiency Scheme (CRC) Verified CRC emission report and sign off by the Chief Operating Officer. Verified by screen shot in s audit 2 Energy Performance of Buildings (England & Wales) Regulations The Greenhouse Gas Emissions Trading Scheme Regs 2012 (EUETS) 3 The Hazardous Waste (England and Wales) Regulations The Hazardous Waste (Miscellaneous Amendments) Regulations The Waste (England and Wales) Regulations The Control of Substances Hazardous to Health Regulations 2002 (COSHH Regulations) 3 Control of Pollution (Oil Storage) Regulations The Countryside and Rights of Way Act Natural Environment and Rural Communities Act Town and Country Planning Act Wildlife and Countryside Act 1981 & Wild Mammals Protection Act 1996 DEC s random selection of buildings to be checked as part of annual compliance audit. Verified EU ETS emission report submitted to EA The University must comply with these and compliance can be assessed during compliance audits each year by reviewing the registration and the Consignment Notes Compliance can be checked by auditing a selection of Waste Transfer Notes for the correct EWC Code and viewing waste stored. This Regulations place a direct responsibility on the University and as such the University must demonstrate it is complying with the Waste Hierarchy, the required paperwork and the requirement to segregate key waste streams. These Regs are mainly about H&S but the COSHH Assessment should include an environmental risk assessment. A sample of COSHH assessments should be audited during routine School/Departmental Audits These regulations require fuels and oils to be correctly stored and need to form part of the annual checks through the inspection of the facilities and/or review of the records. The University is required to manage access to the Burleigh Wood as permissive and should annually close the wood for 28 days or less to ensure it remains permissive. Closure excludes Christmas Day, Good Friday and Bank Holidays as per Chapter 2, Section 22 of the Act. The University has an obligation under this act to ensure ongoing protection, conservation and enhancement of biodiversity on campus. Compliance should be assessed during compliance audits each year based on the areas inspected. The University must comply with this Act and compliance should be monitored through the Facilities Management Development and Projects Team. Aspects of it will be overseen by the Sustainability Team and Woodland Management Plan / Group. The University has an obligation under this act to ensure the protection of wildlife including wild animals, birds and plants on campus. Compliance should be assessed during compliance audits each year based on the areas inspected. Page 3 of 6 Schools and C & M of Estate (21/03/18-19/04/18) Schools and C & M of Estate (21/03/18-19/04/18) and C & M of and C & M of Visually inspection found one out of date which was quickly corrected as the DEC was on site but had been missed. Verified by screen shot in s audit Four School s & Maintenance of the Estate audited, a few OFI s and one minor on storage. EM audit confirms overall compliance. Verified through specific documents audited as part of EM audit as evidenced in audit report. Ten School s / Departments audited demonstrating application of waste hierarchy. EM audit included review of paperwork A few OFI s raised as a result of the audit of C & M of the estate but school s / Departments were demonstrating complaint practice. All areas discussed / viewed were demonstrating compliance Verbally verified in audit of through acces to woodland policy Verbally verified in audit of covered by BAP, ecological management plan for science park and woodland management plan Biodiversity and planning conditions relating travel highways and parking picked up through the sustainability team verified by Verbally verified in audit of

4 5 The Control of Pesticides Regulations 1986 (As Amended) 7 The Fluorinated Greenhouse Gases Regulations 2015 Ozone-Depleting Substances Regulations SI 2015/168 8 Water Act 2003 & Water Resources Act Trade Effluent (Prescribed Processes and Substances) Regulations The Environmental Permitting (England and Wales) Regulations Environmental Protection Act Environmental Protection Act (EPA) 1990 Part II (Waste on Land) The University Grounds and Gardens Team will need to adhere to these regulations. Compliance should be assessed during compliance audits each year based on the areas inspected. The University has to comply by maintaining the appropriate register of gases and records of leak testing as well as ensuring that the contractors used are appropriately trained. Compliance can be assessed during audits by reviewing the records held. Check abstraction licences annually to see if any licences require renewal Check Trade Effluent consents are still valid and Red List (prescribed substances) is still relevant in the Operational Control Management of Laboratory Reagents Chemicals and Solvents The University has to comply by maintaining the appropriate permits and ensuring its contractors do likewise. These should be audited as part of the compliance audit. The main area for compliance here is the Duty of Care in respect of Waste. An overview of compliance can be assessed during compliance audits each year based on the areas inspected. Any nuisance issues arising under this act would be dealt with as they arise. All about Duty of Care, Licences and Permits. Need to check that the Universities permits are upto date, that it s contractors are appropriately licensed and that operational controls deliver compliance. Check after an incident 3 The Control of Asbestos These Regs are on the whole delivered as Health & Safety Regs and are Regulations 2012 strictly managed through the Duty Authorised Person. Compliance with legislation would only be investigated if there was a suspected incident of incorrect disposal. 5 Protection of Badgers Act 1992 The University has processes and procedures in place to meet the requirements of this legislation. No specific evaluation is required unless an incident or project has or is likely to impact the badger population on campus. 5 Environmental Protection Act (EPA) 1990 Part IIA (Contaminated Land) & The Contaminated Land (England) Regulations 2006 This Act would come into force if a pollution incident occurred. Currently the University has no known areas of contamination. The Emergency spill response procedure provides the necessary control to prevent and or mitigate pollution of controlled waters. 9 Noise Act 1996 This Act would only come into force if there was a noise incident at which point we would need to comply with the requirements of the Act 10 Environmental Damage These regulations only apply if the University causes environmental damage (Prevention and Remediation) and therefore no specific evaluation is required except after such an incident Regulations 2015 when compliance with the legislation would be evaluated Check on review of Strategy 2 The Climate Change Act 2008 This legislation is not directly applicable to the University but should be considered within our strategy reviews. 2 The Energy Act 2013 This legislation is not directly applicable to the University but should be considered within our strategy reviews. 3 Animal By-Products (Enforcement) (England) Regulations The Scrap Metal Dealers Act 2013 Check on contract renewal / Project Kick Off Food waste is segregated in catering outlets and as long as this continues we will be compliant. No specific evaluation This legislation does not require the University to do anything other than ensure its scrap metal is disposed of through a licenced contractor which it does with its main waste contractor and therefore no regular evaluation is required Page 4 of 6 C & M of the Estate (21/03/18) C & M of Estate (21/03/18) and Schools (21/03/18-19/04/18) and DAP Asbestos (DATE) Evidenced by screen shots of control records during audit Schools are much more aware and University approach to compliance through EM is correct but weaknesses in application of the procedures highlighted non-conformances which need correcting. Licence checked and correct Not covered in audit but subsequently checked Sample checked during audit Annual duty of care note checked for main waste contractor. School audits evidenced duty of care demonstrated in respect to waste. Some contractors records out of date raised as OFI There has been no review of the relevant strategy There has been no review of the relevant strategy Confirmed as compliant by EM in audit. Confirmed as compliant by EM in audit. 3 The Transfrontier Shipment of This legislation relates to the shipment of waste between countries. The Confirmed as compliant by EM in audit.

5 Waste Regulation 2007 University does not directly undertake this but must make sure its contractors comply with this. 3 The Waste Electrical and The University must make sure its WEEE is disposed of through appropriate Electronic Equipment channels and WEEE is not sold as this would place additional responsibilities Regulations 2013 on the University. 5 Hedgerow Regulations 1997 This will only apply for specific projects where hedgerows may be impacted. Appropriate processes and procedures are in place to manage this. 5 The Town and Country Planning (Environmental Impact Assessment) Regulations Climate Change and Sustainable Energy Act Waste Batteries and Accumulators Regulations The Environmental Protection (Disposal of Polychlorinated Biphenyls and other Dangerous Substances) (England and Wales) Regulations The Traffic Management Act The University must comply with these Regulations and compliance should be monitored through the Facilities Management Development and Projects Team. Aspects will be overseen by the Sustainability Team and external Planning Consultants. Check on an adhoc basis as indicated This legislation is not directly applicable to the University but would be if micro-generation developments are undertaken. Batteries are segregated and the Regs used to enable the collection of these through an approved contractor. Adhoc audits of our waste will identify whether any batteries are being disposed of as general waste. A test of PCB levels in transformers has been undertaken and there are no concerns with equipment on campus. This should be checked every 2-3 years but is unlikely to change. The University s activities are required to comply with this legislation and an 2004 assessment should be undertaken of this every other year. 7 Clean Air Act 1993 Checks for compliance in respect of this will be undertaken on an adhoc basis Chimneys will be monitored on an ongoing basis for black smoke and generators will be monitored when they are fired up for test purposes - evidence of this will be recorded. 8 Water Supply (Water Fittings) Regulations Climate Change Levy (General) Regulations The Controlled Waste (England and Wales) Regulations Pollution Prevention and Control Act The Conservation of Habitats and Species Regulations The Food and Environment Protection Act Plant Protection Products (Sustainable Use) Regulations 2012 Check - TBC Water fittings used are of a standard which ensures this legislation is met and standard building checks for both new and existing would identify anything which is not compliant. No formal environmental checks are therefore undertaken. No check required This is general UK legislation and applied as a tax on bills. No requirement to monitor as it is the responsibility of the utility provider to charge it. These regs allow for the classification of controlled wastes and for charging for collection by local authorities. It is legislation which the University is effected by but does not need to comply with and therefore no specific evaluation is This Act gives powers to the Secretary of state in respect of IPPC, it places no specific requirements on the University and therefore no specific evaluation is required The exception is that it also makes it an offence to deliberately capture, kill, disturb or trade in animals and plants listed. Compliance with other Acts ensures the University meets this part of the legislation, and C & M of and C & M of and C & M of Estate (21/03/18) and C & M of Estate (21/03/18) C & M of Estate (21/03/18) Confirmed as compliant by EM in audit. School audits evidenced awareness of the need for WEEE segregation and management Evidenced through SM that ecological surveys are undertaken and through C&M of the estate that the Sustainability team are consulted on any such projects. Confirmed in both audits that no requirement to undertake EIA in last 12 months Not currently applicable Not audited this year Submission to Information submitted to the EA and acknowledged as appropriate. Letter viewed. Need to monitor departmental machinery Verbal confirmation of audit A review of how this is monitored is Not covered this year in C & M of Estate Verbal confirmation in the audit Page 5 of 6

6 8 Water Industry Act 1991 The University has a TEC for the Swimming pool but there are no monitoring requirements on this. Our sewage undertaker has stipulated they do not require us to have a TEC for the rest of our activities. Compliance would only need to be checked if there was a change in activities, legislation or requirement from our sewage undertaker. 9 Anti-Social Behaviour Act 2003 There is no requirement to check compliance to this legislation as it would 9 Noise and Statutory Nuisance Act Statutory Nuisances (Artificial Lighting) (Designation of Relevant Sports) (England) Order Clean Neighbourhoods and Environment Act Control of Pollution Act 1974 Parts 1 and 3 only kick in if the University was deemed to be causing a nuisance. There is no requirement to check compliance to this legislation as it would only kick in if the University was deemed to be causing a nuisance. There is no requirement to check compliance to this legislation as it would only kick in if the University was deemed to be causing a nuisance. This is a historical Act much of which has been replaced. The two key areas remaining are waste and noise. Neither aspect require specific monitoring and therefore no specific evaluation is 10 Environment Act 1995 This Act established the Environment Agency, amended other legislation, makes requirements of government. It places no specific requirements on the University and therefore no specific evaluation is required 10 The Environmental Civil Sanctions (England) Order 2010 (As Amended) This order is about the sanctions regulators may impose, it is not legislation the university needs to comply with and therefore no specific evaluation is Compliance with Non Legislative factors: 11 ISO14001 Requirements Assessed through external audit EMS Manager 3 external audits undertaken in Data Reporting to HESA Evidenced through submission Sustainability Manager Report evidenced 11 The Requirement to have a Carbon Assessed through produced plan supported by relevant committee, plans to be Carbon Management plan exists but needs updating Management Plan published along with subsequent progress against it. 11 Notify NQA of any potential legislative breaches. Must notify NQA of any breach of legislation which may lead to a prosecution Environmental Manager No requirement to do so this year. Date of Completion: 24/04/18. Audited By: Print N.O.Hunt. Sign:. Page 6 of 6