Research Safety Laboratory Inspections
The EH&S Office of Research Safety generally conducts all lab inspections in a designated building during the same month. Your lab will be contacted to schedule a time that we can meet with the Principal Investigator (PI) or a safety representative from the lab (i.e. “Lab Safety Contact”) to participate in the inspection process. It is essential that we have a member of your lab present during the inspection to:
- explain your research
- verify your lab’s hazards
- show us around the lab
- provide you the opportunity to ask any research safety questions
Preparing for an Inspection
Each laboratory inspection is an integrated evaluation of biosafety, chemical safety, and general lab safety and compliance requirements based on the type of hazards used and experiments conducted in the laboratory. Laboratories can prepare for safety inspections by reviewing the self-inspection checklists below, reviewing protocols, verifying chemical inventories, checking training records and reviewing deficiencies identified during the previous lab safety inspection.
Refer to Radiation Safety for inspection schedules if your laboratory is restricted for radioactive material
use (posted “Caution – Radioactive Material” sign), contains X-ray machines, or contains
equipment that generates non-ionizing radiation hazards such as lasers, radio-frequency,
unenclosed ultraviolet/infrared light, or magnets that may generate a hazardous magnetic
Additional Lab Safety Visits
Additional lab safety visits, walk-throughs or unannounced inspections are conducted by the EH&S Office of Research Safety staff under the following circumstances:
- To evaluate specific lab safety issues in a specific department or set of labs that share common safety deficiencies.
- To evaluate how effectively lab personnel adhere to safety procedures when they are not anticipating a scheduled inspection.
- If laboratory personnel request a follow-up lab safety inspection (e.g. following a new lab start-up visit).
- If safety deficiencies were identified during a previous inspection that pose a high risk but remain unresolved.
- If a lab accident or incident has occurred or other circumstances when a lab safety visit is deemed necessary.
When EH&S conducts unannounced inspections, the auditor will be focused primarily on the specific lab safety issue(s) that initiated the unannounced inspection. A lab safety representative may or may not be expected to participate in the unannounced inspection process. Auditors will be respectful of the researcher’s time when conducting inspections that were not scheduled.
Inspection Report and Corrective Actions
Within a few days after the completion of your annual (announced) lab safety inspection, the PI and/or Lab Safety Contact will receive an email notification that includes a link to access your lab inspection report. This report will include any deficiencies identified, a description of compliance requirements pertaining to each deficiency, and a compliance reference. Your lab will be responsible for documenting an appropriate corrective action plan for each deficiency within two weeks of receiving the report. Most deficiencies should be resolved within two weeks; however, an anticipated completion date will be required when deficiencies take longer than two weeks to correct. If a facility-related deficiency is identified, the submission of a work order request will qualify as an attempt to correct the deficiency. Your lab will also receive a final email notification after your corrective action plan has been submitted and the report has been reviewed by EH&S research safety staff and closed out. Some research proposals may require a successfully closed out lab safety inspection as a prerequisite for approval.
There are a few labs that consistently maintain a high level of safety and compliance. Department Chairs and Deans are encouraged to recognize Principal Investigators who maintain a high compliance score without unresolved or serious safety issues from their annual laboratory safety inspections for multiple consecutive years. EH&S may be consulted for nominations of labs that achieve high safety standards.
EH&S research safety staff are available for consultations (upon request) to assist lab personnel to define and implement appropriate corrective actions for the safety issues identified during the inspection. The EH&S staff may conduct a follow-up inspection to confirm the status of overdue corrective actions or perform additional inspections. Department Chairs and Deans are encouraged to appoint a Laboratory Safety Coordinator to assist labs in their Department/College with resolving overdue corrective action plans, leading safety initiatives within their Department or College, and consulting with EH&S staff for guidance. The cost of correcting most safety and compliance deficiencies is the responsibility of the PI, Department and/or College.
USC Area Campuses
The designated safety representative at each area campus is responsible for assisting their laboratories with the implementation of corrective actions for identified deficiencies. If lab safety deficiencies are not resolved in a timely manner, it is the responsibility of the area campus safety representative to escalate overdue corrective actions for resolution.
Overdue Inspection Report Corrective Actions
The correction of safety or compliance deficiencies identified during lab inspections is essential to promoting a safe laboratory environment. Deficiencies that do not have a documented corrective action plan entered in the inspection report by the specified date will be subject to a formal process to escalate overdue corrective actions for resolution. The following actions will be conducted when a laboratory has not submitted their corrective action plan by the designated due date:
- Situation 1: A safety deficiency is identified that creates an imminent risk of serious injury, property damage or other adverse consequences. Actions: EH&S will define an appropriate corrective action plan and the situation will be immediately reported to the PI. This type of deficiency must be resolved within 24–48 hours depending on the severity/nature of the incident. If possible, the issue should be resolved at the time of the inspection and the PI or Lab Safety Contact must notify Facilities immediately if the corrective action requires their involvement. If the deficiency is not resolved at the time of the inspection, the auditor will also notify the Department Chair, EH&S Director and Research Safety Manager. In these special circumstances, the Biological Safety Officer, Chemical Hygiene Officer and Radiation Safety Officer (depending on the hazardous situation identified) in consultation with the Director of EH&S and the Research Safety Manager has the authority to shut down laboratory operations or evacuate the lab until the serious safety concern has been addressed. If a serious deficiency is not resolved within 24–48 hours, the Department Chair must notify the Dean.
- Situation 2: The corrective action plan for all identified deficiencies has not been submitted within the required two-week timeframe. Actions: The EH&S auditor will send a reminder notice shortly after the corrective action due date to notify the lab that they have overdue corrective actions and to request that the lab submit their corrective action plan. Most lab inspections for a specific building are conducted within a specific month, and most departments have labs primarily in one building. Approximately two weeks after the last PI’s lab inspection is completed in the main departmental building, EH&S will send an email notification to the Department Chair that includes a web-based lab safety inspection summary report. This report will include a table with the name of each PI in their department, lab inspection date, a link to the inspection report, inspection status, and compliance score. Any lab with an overdue corrective action plan will be highlighted for the Chair. The Chair will be responsible for ensuring all PIs in their department submit their corrective action plan or the Chair can take actions deemed appropriate to address the issue (e.g. notify the Dean). The Chair will continue to have access to this summary report that is automatically updated as the status changes, so the Chair can monitor the compliance status of each investigator and easily identify any PI that still has not submitted their corrective action plan.
Roles and Responsibilities
The APLU recently published a guide to implementing a safety culture in universities [pdf]. This report lists 5 core institutional values to promote a culture of laboratory safety. One of these values is that “safety is everyone’s responsibility”. The report encourages institutions to commit to providing a campus environment that supports the health and safety practices of its community and empowers the community to be responsible for the safety of others. A safe campus learning environment is a right of all involved in education and research. Another core value is that “good science is safe science.” Safety is a critical component of scholarly excellence and responsible conduct of research. A successful laboratory safety inspection program also requires an oversight partnership with active support and involvement of all stakeholders to create a safe research and lab environment for all the University’s faculty, staff, students and visitors. The following roles and responsibilities apply to the University’s laboratory safety inspection program:
Deans and Department Chairs
- Work collaboratively with researchers toward the common goal of supporting a culture of safety in their departmental laboratories.
- Work collaboratively with EH&S personnel. Consult with EH&S when laboratory safety or compliance questions or concerns arise.
- Ensure all PIs in their department submit a corrective action plan for all deficiencies identified during annual lab safety inspections.
- Ensure PIs report all safety incidents in a timely manner to the department Chair, Dean and EH&S.
Principal Investigators / Laboratory Supervisors
- Facilitate an open dialogue about laboratory safety. Lead by example, modeling good safety behavior. Supervise the safety performance of lab staff.
- Verify laboratory personnel complete all required EH&S research or laboratory safety training courses. Provide lab-specific training to instruct and train staff.
- Identify hazardous materials or operations in the lab, implement safe work procedures and controls and communicate this information to lab personnel.
- Participate in EH&S lab safety inspections. Correct all reported safety or compliance deficiencies and submit a corrective action plan by the requested due date.
- Consult with EH&S on the use of high-risk materials or experimental procedures. Obtain required committee approvals for experiments (e.g. IBC, RSC, IACUC).
- Report lab accidents, injuries and near misses to EH&S and comply with incident reporting procedures. Discuss lessons learned from lab accidents or near-misses.
- Review and follow applicable guidance in laboratory safety manuals (e.g. Chemical Hygiene Plan, Biosafety Manual, Radiation Safety Manual, SDSs, SOPs).
- Follow verbal and written safety rules, regulations, policies and SOPs required for the tasks assigned or hazardous materials involved in experiments.
- Complete all required laboratory safety training. Consult with the PI/Supervisor before using highly hazardous materials and demonstrate proficiency.
- Immediately report all accidents and unsafe conditions to the PI/Supervisor and EH&S. Discuss lessons learned from incidents and near-misses.
Environmental Health & Safety
- Assist the university community in the evaluation of hazards and the development of guidance resources to mitigate the risk of laboratory incidents.
- Conduct annual laboratory safety inspections to evaluate compliance with lab standards, identify deficiencies, and recommend corrective action plans.
- Provide consultations, hazard assessments or advice on the safe use of hazardous materials, and compliance with research safety regulations and guidelines.
- Review protocols (in collaboration with safety committees) for experiments involving highly hazardous chemicals, biological hazards, ionizing or non-ionizing radiation, and other high-hazard research.
- Provide general laboratory safety training programs (e.g. Laboratory Safety, Biosafety, Hazardous Waste). Provide guidance on the shipment of dangerous goods.
- Coordinate the annual certification of biological safety cabinets and chemical fume hoods. Review laboratory facility design plans for safety and compliance when requested.
It is recommended that each laboratory periodically conduct self-inspections (i.e. internal audits). The self-inspection process is intended to supplement inspections conducted by EH&S and to facilitate a shared responsibility for laboratory safety and compliance. Principal Investigators are responsible for initiating corrective actions for potential hazards or safety deficiencies identified during both self-inspections and EH&S lab inspections. The following self-inspection checklists can be used by Principal Investigators or their designee as a guide for evaluating specific safety or compliance requirements. This list does not include every possible safety issue that may need to be evaluated. Labs can consult with EH&S for guidance on appropriate corrective actions when necessary.
Annual Laboratory Safety Verification
The PI will receive an annual email notification to review and update their laboratory information. This email will include a link to the Research Safety Management System (RSMS). Research laboratories must update the following information on an annual basis to ensure EH&S records remain accurate:
- Inventory of Lab Hazards
- Laboratory Locations
- Laboratory Personnel
- Emergency Contacts