CSHEMA 2007, BOSTON, MA CLIP AT UNC CHAPEL HILL-TEN YEARS LATER Collaborative Laboratory Inspection Program at UNC Chapel Hill-Ten Years Later Jonathan Moore, MS, CHP, Associate RSO Dept. of Environment, Health & Safety

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Presentation Outline Brief Description of CLIP Brief Description of CLIP Key Indicators Key Indicators Standards / Regulations Standards / Regulations Violations / Severity Violations / Severity Assessment of Inspection Results Assessment of Inspection Results Future EHS Inspection Issues Future EHS Inspection Issues

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA What is CLIP? Collaborative Laboratory Inspection Program

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Strategic Planning Process-1997  Internal/External Customer Survey  EHS Retreats  Quality Teams  Organizational Changes/Programs

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Scope of CLIP Program inspections per month Comprehensive environment, health and safety inspection done on all laboratories annually (462 total laboratories) Every principal investigator is considered to have one laboratory, which may consist of several rooms.

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Scope of CLIP Program Radiation laboratories (249 as of June 2007) quarterly or semiannually  Focus on radiation safety  GM and swipe surveys for removable contamination  Annual physical inventory for radioactive material

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA UNC BENCHMARKS  EHS Staff 38  Radioactive Materials Users 278  Biological Safety Cabinets 391  Research Income $290M  Michael Jordan $100M

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA What is a CLIPper?

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA EHS Safety Officers (CLIPpers)  Four from radiation safety section  Two from fire safety and emergency response section  Two from the industrial hygiene and biological safety section

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA CLIP Team Leader Duties Assign inspectors by rotation. Each lab is inspected by different inspectors. Prior to inspection, print contamination survey map and pre-inspection checklist After inspection, review checklist and principal investigator letter for accuracy, then forward to front office After inspection, review checklist and principal investigator letter for accuracy, then forward to front office.

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA CLIP Team Leader Duties  Conduct quarterly CLIP meetings  Handle comments and questions  Track inspection report responses, if required  Review written responses for adequacy  If a required response is not received, suspend privileges for ordering radioactive materials  Update survey contamination maps  Close inspection in HASMIS when responses are adequate

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Inspector Cross Training All inspectors are required to learn all aspects of the comprehensive EHS inspection through:  Reading policies and procedures  On-the-job training by shadowing inspections with the CLIP Team Leader and at least one safety officer from each EHS discipline  Learn to use HASMIS database and how to enter data from written procedures  Attend quarterly CLIP meetings

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Strategic Planning Process After 1997  Utilization of the HASMIS database  Continuing Quarterly CLIP meetings  Performance evaluation of Safety Officer –”Tag-a- Longs”  Expansion of Biological Safety Lab inspections

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA UNC BENCHMARKS  EHS Staff3842  Radioactive Materials Users  Biological Safety Cabinets  Research Income $290M $593M  Michael Jordan $100M $32M

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Standards / Regulations 2007 Increased focused on the following since 1998  OSHA Bloodborne Standard  CDC/NIH’s Biosafety in Microbiological and Biomedical Laboratories (4 th Edition) New since 1998  Export Controls  Enhanced Security Measures for Certain Radioactive Materials

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA UNC LAB ENVIRONMENT  Radioactive Materials Users  Biological Safety Level  Biological Safety Level  Biological Safety Level  Total # Principal Investigators  Total # Laboratory Workers2, 0773,486

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Key Indicators  Records  Personal Protective Equipment  Chemical Storage  Hazardous Waste  Laboratory Facilities  Life / Fire Safety  General Lab Safety  Biological safety

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Laboratory Facilities Chemical Hoods Pertinent Information included on pre-inspection info sheet

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Fire/Life Safety Fire Prevention and Detection Equipment CLIPpers trained on annual checks of fire extinguishers

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Biological Safety  Infectious Waste handling/processing  Bloodborne Pathogens standard enforcement (training, Hep B vaccination, etc)  Recombinant DNA protocol verification  Sharps precautions/minimization  Biosafety Level 2 containment

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Laboratory Safety Violations Example: observe lack of personal protective equipment when it is appropriate De minimis Example: observe lack of personal protective equipment when it is appropriate Example: Omitted monthly self- survey for removable contamination Non-serious Example: Omitted monthly self- survey for removable contamination

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Laboratory Safety Violations Example: No lid or label on a hazardous waste container Serious Example: No lid or label on a hazardous waste container Safety Officers have discretion to judge any violation as serious due to special circumstances.

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Overall CLIP Assessment Criteria Lab (Non-Radiation) Lab With Radiation OutstandingNo violations for two inspections in a row Excellent No violations or 1 de minimis violation No violations or < 5 de minimis violation Good 1 non serious and/or 5 or < de minimis < 5 non serious and/or 5 or > de minimis Poor Any repeat violation and/or 5 or > de minimis Any repeat violation and/or 5 or > Non Serious UnacceptableAny serious violationLoss of radioactive material

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA What has not worked  Use of tablet PC for data collection during lab inspections  Single Assessment of Laboratory Safety

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MA Future EHS Inspection Issues  Better enforcement of EHS rules in non- radioactive laboratories who do not correct serious violations or do not respond when required.  CLIPper’s participating in the UNC planned EPA Self-Audit.

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MASummary  “Front line” of EHS  Less distraction in labs by EHS  Increase Safety Awareness  All laboratories Inspected at least annually  Optimum Utilization of staff

CLIP AT UNC CHAPEL HILL-TEN YEARS LATER CSHEMA 2007, BOSTON, MAQuestions? Jonathan Moore Department of Environment, Health & Safety University of North Carolina 1120 Estes Drive Extension CB# 1650 Chapel Hill, NC