Getting it right Why read this? The University is committed to compliance with all health and safety related legislation. This guide provides a brief overview of the University s systems and processes, applicable legislation and where you can find further information. Overview Health and Safety at the University The University has a dedicated and comprehensive health and safety function led by Andrea McMillan, Head of Health and Safety Compliance. See here for more information. The University s systems, policies and processes address compliance with a range of legislation and associated regulations and codes of practice including: Health and Safety in Employment Act 1992 (HSE Act) Accident Compensation Act 2001 (Accident Compensation Act) Hazardous Substances and New Organisms Act 1996 (HSNO) The Biosecurity Act 1993 (Biosecurity Act) The Radiation Protection Act 1965 (Radiation Protection Act) The Maritime Transport Act 1994 (Maritime Act). The University is a member of the ACC Partnership Programme. This allows the University, as an accredited employer, to act as an agent of ACC. Entitlements are provided under the Accident Compensation Act in relation to work-related personal injuries and illnesses caused by an accident (as defined by the Accident Compensation Act). See here for more information. November 12 1
All employees have health and safety responsibilities; however there is a hierarchy of responsibilities, as set out in the HSE Act. The following make up the University s health and safety management structure: Vice Chancellor DVC s/avc s/directors of Services Heads of Department/Managers of Services Supervisors Departmental Health and Safety Officers (DHSO) Health and Safety Representatives University Employees The flow of information of health and safety accountabilities and support at the University is represented as follows: Vice Chancellor University H & S Committee AVC/DVC Directors University H & S Team HOD Managers Supervisors Specialist Advice (IBSC/HSAG) Staff Departmental H & S Officers Further information on the responsibilities of each person shown in the diagram can be found here. 2 Getting it right
University Committees There is a range of health and safety related committees at the University. Risk Management, Ethics and Statutory Compliance Committee Its role is: to review and recommend to Council through the Vice-Chancellor on all matters relating to risk management, statutory compliance, health and safety and ethical approvals; to monitor risk policies, principles and practices throughout the University; and to monitor university policies and systems for ensuring compliance with statutory requirements with respect to ethical approvals, biological safety, hazards, and general health and safety. Hazardous Substances and Radiation Committee Its role is: to advise the University on all matters relating to hazardous substances and radiation safety in the Institution, including the development of policies and procedures relating to hazardous substances purchase, hazardous substance safety in laboratories, transportation of hazardous substance and radioactive substances on and off site, storage and disposal of hazardous waste; to facilitate and manage the development of emergency plans in relation to hazardous substances for compliance with HSNO; to develop policy to ensure the University and licensees comply with NRL policies and guidelines for the use of radioactive substances and radiation sources; to develop policy to ensure the University complies with HSNO regulations and guidelines in relation to the handling, use, transportation and disposal of hazardous substances, including the Code of Practice (Exempt Laboratories); and to report to the Risk Management, Ethics and Statutory Compliance Committee. 3
Institutional Biological Safety Committee (IBSC) This is a committee that has been have been formally delegated by the Environmental Protection Agency (EPA) the ability to make decisions on applications for low risk genetically modified organisms (GMOs) that will take place on all campuses within approved containment facilities (indoor only). Its other roles are: to advise the University and its staff on all matters relating to biological safety in the institution; to act as the channel for all communications between the University and EPA; to ensure that the University complies with the HSNO Act and Biosecurity Act with respect to its handling of GMOs and uncleared biological products; and to report to the University Council through the Risk Management, Ethics & Statutory Compliance Committee. Health and Safety Committee Its role is to: identify and facilitate the development of University policies in relation to health and safety matters, for approval by the Vice-Chancellor; provide a forum for discussion of occupational health and safety matters leading to policy development and advice, including employee and union representation; receive quarterly reports from the University Health and Safety Manager on accidents/ incidents and health and safety issues; perform the ACC Partnership Programme self-assessment requirement in preparation for the external ACC audit; receive reports from employee representatives on safety issues and health and safety compliance within Divisions; liaise with the Hazardous Substances and Radiation Committee, the IBSC, the Animal Ethics Committee and the Human Ethics Committee as appropriate; and report to the Risk Management, Ethics and Statutory Compliance Committee biannually. 4 Getting it right
Summaries of key legislation Health and Safety in Employment Act 1992 Purpose To prevent harm to persons at places of work. Generally the HSE Act imposes duties on employers and other persons in control of work places to identify, then eliminate, isolate or minimise hazards. Employers, unions and employees must work together in good faith to maintain safe and healthy workplaces under the HSE Act. Activities likely to be illegal failure to provide and maintain health and safety facilities in the workplace; failure to isolate hazards in the workplace and to take all practicable steps to eliminate, isolate or minimise the risk of harm from hazards; failure to consult with employees (and unions) on health and safety issues; failure to develop procedures to deal with emergencies that may arise in the workplace; and failure to comply with the HSE Act s reporting provisions. Who is covered? Employees - persons employed to perform work for gain or reward under a contract of service are covered while at work. For mobile employees, this includes travelling to and from the workplace. Contractors - persons engaged to perform work at the workplace are treated as employees under the HSE Act. The Act also covers subcontractors, and employees of contractors and subcontractors. See the University s Compliant Contractors Policy. Volunteers - persons engaged in on-going, regular volunteer work which is an integral part of a business are treated as employees for certain parts of the HSE Act. Other volunteers are covered to a lesser extent. Loaned employees - where there is no loaning contract, loaned employees are treated as the borrowing employer s employees, with the exception of Part 2A, which does not apply. The lending employee retains some responsibility under the HSE Act. Persons on work experience programmes - they are treated as employees under the HSE Act, with the exception of Part 2A, which does not apply. Visitors - visitors who are in the workplace with the employer s knowledge or consent are protected under the HSE Act. Persons in the vicinity of the workplace - they are covered for the purpose of hazards under the control of the employer/person controlling the workplace. 5
Key concepts A hazard is an activity, arrangement, circumstance, event, occurrence or phenomenon, process, situation, or substance (whether arising or caused within or outside a place of work) that is an actual or potential cause or source of harm. Hazards can be divided up into those likely to cause serious harm, and other hazards. Harm includes injury, illness or death caused by work-related stress and fatigue. Serious harm includes death, severe or permanent loss of bodily function, respiratory disease, vision impairment, loss of consciousness by lack of oxygen, amputation of any body part, burns requiring specialist attention, and any harm that causes the person to be hospitalised for a period of 48 hours or more than 7 days of the harm s occurrence. Key duties Employers have a general duty to maintain a safe and healthy workplace, and to provide health and safety facilities, such as first aid. Employers must ensure that employees are properly trained in equipment and safety procedures. Employers must ensure that plant and equipment is safe for employees to use. Employers must develop procedures to cover emergency situations such as fire or accident. Employers must identify hazards in the workplace. Hazards must then be eliminated. Where elimination is not reasonably practicable, hazards must be isolated or minimised and employees protected. This applies to all hazards which are within the employer s control, both in and near the workplace. For more information about hazards at the University see here. Employers must provide employees with the results of health and safety monitoring in the workplace. Persons in control of workplaces must take all practicable steps to ensure that no hazard in the workplace harms any person entitled to be there, including visitors. Principals have a duty to ensure that no contractors, subcontractors and/or their employees are harmed while engaged in work at a workplace. Employees have a duty to ensure their own safety in the workplace, and to ensure that their actions do not harm other employees or persons in the workplace. 6 Getting it right
Employee participation Employers have a general duty to involve employees in the development of health and safety systems. As an employer with more than 30 employees, the University has established, in consultation with Unions, employees and the employer, an employee participation system. For information about employee participation at the University see here. Other provisions Employers must maintain a register recording every accident that harmed or might have harmed an employee or other person covered by the Act. Every incident of serious harm must be reported to an inspector. It is an offence to interfere with an accident site before an inspector has investigated the accident unless interference is necessary to save lives, prevent harm, relieve suffering, maintain public access to an essential service or prevent serious loss or damage to property. Application to maritime activities The use of small boats i.e. those under six metres in length, is recognised as a potentially high-risk area. The University has obligations under the HSE Act and the Maritime Act and its associated regulations and rules. Maritime New Zealand administers the Maritime Act and associated secondary legislation and the HSE Act as it is relevant to ships. Further information can be found here. The University has a Boat Safety Policy, which sets out how the University ensures that its Code of Practice for the Safe Use of Small Boats is met and how it meets its obligations under the Maritime Act, regulations and rules and the HSE Act with regard to boats. Hazardous Substances and New Organisms Act 1996 Purpose HSNO provides for the management, of hazardous substances and new organisms. It controls the import, manufacture, development, field testing and release of hazardous substances and new organisms. Its purpose is to provide for the protection of the environment, and the health and safety of people and communities, by preventing or managing the adverse effects of hazardous substances and new organisms. HSNO is administered by the EPA. A range of regulations provide the detail of how HSNO is to be implemented. 7
Activities likely to be illegal importing, manufacturing or releasing a hazardous substance without approval under HSNO; developing, field testing, importing or releasing a new organism without approval under HSNO; failure to comply with any controls imposed as part of an approval under HSNO; failure to comply with a compliance order served by an enforcement officer; and committing an infringement offence as may be provided for by HSNO regulations. Key concepts In summary a hazardous substance is any substance (including manufactured articles) which has one or more of the following intrinsic properties: explosiveness; flammability; a capacity to oxidise; corrosiveness; toxicity; ecotoxicity; or any substance (including manufactured articles) which on contact with air or water generates a substance with any one or more of the properties listed above. The definition excludes any substance which regulations prescribe as not being hazardous for the purposes of HSNO. In summary a new organism is: an organism that arrived in New Zealand after 29 July 1998; an organism that became extinct before July 29 1998; an organism with approval to be in containment; an organism with approval to be released with controls; a genetically modified organism; an organism that was deliberately eradicated from New Zealand (as the result a specified eradication programme with a stated goal or purpose of eliminating the organism from New Zealand); 8 Getting it right
an organism that was present in New Zealand before 29 July 1998 in contravention of the Animals Act 1967 or the Plants Act 1970 (except for the rabbit haemorrhagic disease virus (rabbit calicivirus)); or a risk species as defined by regulation. It does not include an organism for which approval to release has been granted under HSNO. Key duties relating to hazardous substances In general terms under HSNO all businesses are required to: identify a person in charge to manage the hazardous substances that are stored and used at the place; prepare a hazardous substances inventory that lists the substances at the site and their hazardous properties; ensure staff are appropriately trained to handle the substances safely and use the required personal protective equipment; ensure that there is adequate information available for staff and visitors, such as product labels, safety data sheets and signs; have emergency management procedures and equipment in place to deal with any potential emergency, e.g. fire extinguishers and an emergency response plan; and have current test certificates to confirm that these key controls are being properly addressed. There is an exemption under section 33 of HSNO for small-scale use of hazardous substances in research and development or teaching. This exemption is subject to a range of conditions including that the University complies with the approved Code of Practice for CRI and University Exempt Laboratories. The advantages of the University opting to comply with the Code of Practice are: use of unapproved substances in laboratories without application to the EPA; and approved handler training is not required for all staff and students working in laboratories with hazardous substances. 1 1 HSNO Exempt Laboratory Compliance Manual - Version 2 June 2006 9
However to operate as a HSNO exempt laboratory, the University must: have an approved laboratory and hazardous substances management structure in place; have laboratories designed and operating to the standards in the code; have substances labelled and identified, and stored appropriately; and have process for safe methods of use of hazardous substances. Details of how the University meets its HSNO requirements can be found here and in the University s HSNO Exempt Laboratory Compliance Manual. Key duties relating to new organisms In summary 2 : Development or importation of a new organism requires approval from the EPA or from the IBSC acting under delegated authority from the EPA (in summary, as noted, applications for low-risk genetically modified organisms in the laboratory). The organism must be held under the containment controls imposed by the EPA or the IBSC (if applicable). Release requires a separate approval from the EPA. Also, under the Biosecurity Act 1993, importation of a new microorganism also requires a permit to import from the Ministry of Primary Industries (Biosecurity New Zealand) and the imported organism must be held in a containment facility as specified by the import health standard issued with the permit. Certain uncleared restricted biological products that are imported subject to a Biosecurity New Zealand permit must also be held at a transitional facility. Applicable laboratories at the Dunedin Campus are an approved Containment and Transitional Facility. Similarly laboratories within the UOW School of Medicine and Health Sciences that are involved in work with imported restricted biological products, genetically modified organisms and/or genetically modified animals are also a Containment and Transitional Facility. Key references documents include: The University of Otago Containment and Transitional Facility for Microorganisms and Uncleared Biological Products - Dunedin Campus - Containment and Quarantine Manual; and The University of Otago Wellington - Containment and Transitional Manual. For more information see the Biological Compliance web page. 2 Material sourced from University of Otago - Containment and Transitional Manual 10 Getting it right
Radiation Protection Act 1965 Purpose The Radiation Protection Act and the Radiation Protection Regulations 1982 (Regulations) control the use of ionising radiation by requiring: users of radioactive materials or irradiating apparatus to hold a licence (users will also normally be required to comply with a Code of Safe Practice); importers, exporters and dealers of radioactive material to obtain a consent; vendors and purchasers of irradiating apparatus to notify all transactions; and transporters of radioactive material to comply with transport regulations. 3 Activities likely to be illegal Failing to comply without lawful excuse with any provision of the Radiation Protection Act or Regulations, including; transporting radioactive material into New Zealand or through New Zealand unless packaged, labelled and transported in accordance with the IAEA Transport Regulations; or purchasing or using radioactive material or irradiating apparatus without a licence, or in contravention of any terms of a licence. wilfully obstructing an authorised inspection officer for inspecting any radioactive material or irradiating apparatus; and making a false declaration or statement for the purposes of obtaining a licence or any other purpose in relation to the Radiation Protection Act. Key concepts Radioactive material is any article containing a radioactive substance giving it a specific radioactivity exceeding 100 kilobecquerels per kilogram and a total radioactivity exceeding 3 kilobecquerels. Radioactive substance means a radionuclide or mixture of radionuclides, either alone or in chemical combination with other elements. Radionuclide means an isotope of any element which spontaneously emits ionising radiation. Irradiating apparatus means any apparatus that can be used for the production of X-rays or gamma rays or for the acceleration of atomic particles in such a way that it produces a dose equivalent rate of or exceeding 2.5 microsieverts per hour at a point which could be reached by a living human being. 3 www.nrl.moh.govt.nz/regulatory/default.asp 11
The Radiation Protection Act and the Regulations are administered by the National Radiation Laboratory (part of the Institute for Environmental Research and Health Ltd (ESR) from 1 December 2011, previously part of the Ministry of Health). See here for further information. Key duties The key requirement is that no radioactive materials or irradiating apparatus may be used for any purpose unless the user holds a licence under the Radiation Protection Act for that purpose, or is acting under the supervision or instructions of a person holding such a licence. There are a range of categories of licence depending on the particular use involved (see section 18 of the Radiation Protection Act). A person who is licensed to use radioactive material or an apparatus for one purpose, may not use that material or apparatus for another purpose. Licensees must comply with the applicable codes of safe practice relating to the specific classification of licence they hold. Licence classifications are as follows: for diagnostic purposes; for therapeutic purposes; for dental purposes; for chiropractic diagnostic purposes; or for industrial, experimental, testing, demonstration, veterinary, research, or other specified purposes. Specific conditions may be imposed on any licence granted (see section 17 of the Radiation Protection Act), e.g. restricting the licensee to the use of certain kinds of radioactive material or irradiating apparatus, specified uses of those or limitations on their type and nature, or restricting any use at a specified place. Part 3 of the Regulations contains a range of specific requirements relating to: storage, labelling, safe care, and disposal of radioactive material and irradiating apparatus; appointment of Radiation Safety Officers; general precautions to be taken when working with radioactive material and irradiating equipment; disposal of waste products and containers; and provision of information. 12 Getting it right
Part 4 of the Regulations contains requirements relating to exposure to radiation, including measurement of doses, actions to be taken in event of overexposure, and designation of controlled areas. Part 5 of the Regulations deals with the use of irradiating apparatus for radiotherapy and diagnosis, record keeping and special precautions that must be taken. University requirements These requirements are reflected in the University s Radiation Safety Plan. In summary (among other things), under the Plan (which is reviewed annually): Local Radiation Safety Plans must be prepared at Department/Unit/Laboratory Level wherever ionising radiation is used within the University. A template manual for Departments using radiation can be found here. The University is required to appoint a medical or health physics expert with appropriate expertise in managing radiation hazards to provide professional oversight of the University Radiation Plan and Local Radiation Safety Plans. The University s Health and Safety Office is required to keep copies of Local Radiation Safety Plans which are to be approved by the Radiation Safety Adviser and reviewed annually. Each Local Radiation Safety Plan should contemplate appointment of a Radiation Safety Officer. Radiation doses to workers and members of the public are limited to those specified by the National Radiation at any time. The University and the licensee has a range of responsibilities as per the Radiation Protection Act and Regulations. In the event of the loss, or release beyond control of the licensee, of any radioactive material (other than proper disposal), steps to minimise the consequent hazard. The licensee should seek advice and assistance from the University Radiation Safety Adviser, the Health & Safety Office and if, judged appropriate, the National Radiation Laboratory. If the possibility exists of anyone receiving a dose approaching the Member of the Public Limit then the NRL must be notified. 13
Other useful sources of information Department of Labour Environmental Protection Agency The National Radiation Laboratory This guide is intended solely for use by the University of Otago and its related entities. The guide is general in nature and, if you have a particular query or problem, specific legal advice may be required. Please contact the University s risk manager, Alex Sweetman at Alexandra.Sweetman@otago.ac.nz or (03) 479 5005 if you have any feedback on the guide or any general compliance or risk related queries. 14 Getting it right