By
Stefan Sanchez & Eryl Marsh
October 2003
Hazardous Installations Directorate
Chemical Industries Division 2
Project Aims:
It was felt that considering the majority of major hazard sites were classed as such due to their inventories of hazardous chemicals (used in processes and handled on site), the exposure of workers to chemicals was a priority topic, as it is in a wide range of industries. This also coincided well with the European Health and Safety week initiative, which this year was on the topic of substances hazardous to health.
We therefore undertook a project across a number of major hazard sites to examine the standards of control. Feedback has indicated that simply by proposing project inspection work on site, significant focus has been put onto the subject and most sites have reviewed their arrangements, clearly having a positive effect.
This has served to raise the profile of COSHH, and has been followed up with a detailed inspection at each site. A standard letter was used to inform companies of our intention to visit and inspect their COSHH controls. Enforcement, although not the only way to raise standards, is a very useful tool to achieve improvements, and with major hazard sites, a very meaningful tool.
Objective 4 of this project was to improve COSHH compliance across all sites inspected in the Hazardous Installations Directorate (HID), including the smaller chemical sites.
To reinforce the work carried out in the inspection phase of the project, a feedback event was organised to include all participating companies, and others. This was attended by representatives from the major hazard sites visited under the project as well as smaller local companies (SME's) where HID inspectors had identified COSHH as a priority topic on site.
The project was piloted on 2 major hazard sites before being rolled out to other companies. Minor modifications were made to the administration of the project at this stage to improve the quality of information gathered.
Assessing compliance with COSHH was carried out in stages:
These are described in more detail below:
It was felt that the best value would be obtained by inspecting a sample of assessments selected as higher priority. This was done in two stages:
each company was asked to select their top ten priority COSHH substances based upon three key factors - the hazard posed by exposure to the dangerous substance; the duration of exposure to the dangerous substance and the potential for multiple exposure (more than one person).
Detailed inspection of 5 specific COSHH hazardous substance assessments was an appropriate number to carry out on each site. The inspector selected 5 assessments from the 10 supplied by each company for detailed inspection, looking to identify a variety of examples and unusual work procedures.
To ensure that results and information gathered could be standardised, the inspection proforma was designed to assess exposure to one specific chemical/substance involved in a work procedure. A copy of the proforma can be found in the inspection tool . It is designed to specifically identify areas of non-compliance.
The COSHH project profoma was designed to obtain an assessment of the standards being reached, and is split up into sections that correspond with the numbered regulations.
Inspection was carried out for each of the substances associated with a discrete work activity and the proforma completed - usually 5 per site.
Each inspection consisted of a detailed discussion of each of the 5 processes, followed by physical inspection of the work on site, where possible. Further discussion then followed, and completion of the proformas for each activity. A 'wash up' session was provided to the company at the end of each inspection, summarising the findings of the process.
Use of a standardised and systematic proforma allowed us to assess the difference between the standard of COSHH management achieved and the benchmark standard. Where standards were found which did not meet the 'benchmark' the difference was termed 'the risk gap'.
5 categories of risk gaps were used depending on the extent of the failings found. These were: no risk gap; nominal risk gap; moderate risk gap; substantial risk gap; and extreme risk gap. Inspectors used their judgment and HSE guidance to ensure a transparent and proportionate approach to this categorisation.
Most sites were required to provide a response to the communication and a detailed action plan of how they intended to address the main issues raised in the visit report. This was followed up in the same manner as any other inspection visit, and forms part of the ongoing work on these sites. In some examples, the findings of the COSHH project work may contribute towards the decision to audit, or closely inspect other aspects of the safety management system on site.
The results of the inspection phase are shown in Figure 1 below. 59 assessments of each proforma were completed. Figure 1 shows the breakdown of the 'risk gaps' found:
No risk gap
'No risk gaps' were recorded for 3 out of the 59 completed proformas (5.1%). This represents full compliance with COSHH and the minimum legal benchmark standard.
Nominal risk gaps
Nominal risk gaps were recorded in 2 out of 59 proformas (3.4%). In these cases the legal benchmark was not quite being met.
Moderate risk gaps
Moderate risk gaps were recorded in 36 out of 59 proformas (61%). This is where moderate deviations from the benchmark standards have been found from the actual standard achieved. Positive and corrective action is often required by the company to address this shortfall, usually in the form of a written plan of action. A moderate risk gap usually leads to either an improvement notice or written advice in a letter and associated follow up work. This was the approach taken in the majority of cases in this project.
Substantial risk gaps
Substantial risk gaps were recorded for 14 out of 59 proformas (23.7%). Again, these represented significant deviation from the benchmark standard and positive and corrective action was required by the company.
Extreme risk gaps
The 2 cases of extreme risk gaps out of 59 proformas (3.4%) resulted in an improvement notice and strong advice. The reason that only advice was given in the second case was because the proforma inspection related to a process that was not taking place, but one that could take place. Stronger enforcement action was therefore not appropriate.
An analysis was made of compliance with individual Regulations examined in the proforma. These analyses are limited as they do not directly relate to the 'risk gap' and simply provide a measure of the 'compliance gap' (this is the difference between the actual standard found and the legal benchmark standard). Risk gaps can only be determined by assessing the 'overall picture'. However, these analyses do highlight the Regulations that are more consistently complied with, and identify the Regulations that are not well complied with, which is useful information when gathering information about 'common failings'.
The results show that the Regulation (included in this project) most complied with was 12: Information and Training at 95.5%. The least complied with Regulation was 6: Assessment, at 66.8%.
The percentage of compliance with other Regulations were:
In all but one case (Regulation 6), more than half the companies scored 'above average' for each Regulation.
Only 5.1% of all proformas completed indicated full compliance with COSHH, which effectively means that 94.9% of COSHH assessments we inspected did not comply fully with the legislation.
Clearly the 'no risk gap' situation is the ideal, but it would be difficult to consistently achieve such a high level of control on busy industrial premises, however it is the legal standard, which should be aimed for.
The 'nominal risk gap' situation recorded in 3.4% of cases is surprisingly small. This is the category which one might expect a major hazard site to fall under when taking a close look at their COSHH performance, the rationale being that major hazard sites are highly regulated and required to control major hazards to a very high standard. One might therefore expect such standards to reflect upon more fundamental 'day to day' health and safety issues. This does not seem to be the case from the evidence of this project.
As the largest group, 'moderate risk gaps' were found in 62% of cases. Similarly, substantial risk gaps were recorded in 25% of cases. Together they form the bulk of the data (nearly 90%), meaning that for over 90% of the COSHH 'scenarios' we inspected on the major hazard sites we visited, the standards fell short of the mark, and enforcement was appropriate.
The response of all companies involved in this project was positive, so it was therefore possible to limit enforcement to provision of written advice and swift remedial action by the company.
Generally these results show that the control over exposure of employees to substances hazardous to health on COMAH sites is not what it should be.
Regulation 6 is arguably the most significant COSHH Regulation. In order to ensure that adequate control is being achieved, it is essential to ensure that an accurate assessment has been carried out. It is also the most difficult Regulation to comply with as it is 'goal setting', which is borne out by these results. Carrying out a suitable and sufficient assessment involves consideration of the hierarchy of control , where each level of the hierarchy should be implemented where reasonably practicable. Unfortunately, higher levels of the hierarchy are often dismissed prematurely.
There were a couple of examples where assessment in accordance with Regulation 6 had not been carried out fully, but it was clear that there was a high level of control in place. This is often the case where there is a historical health hazard that has routinely been controlled over the years (such as VCM* exposure). This explains why Regulation 7 'control' is better complied with than Regulation 6 'assessment'.
*VCM - Vinyl chloride monomer
Maintenance (Regulation 9) is essentially prescriptive, so easier to comply with, which is why the compliance rate was 90.5% (LEV systems to be thoroughly examined at least every 14 months etc.)
Monitoring (Regulation 10) was the second worst Regulation complied with at 75.9%. Monitoring is essential to be able to demonstrate ongoing control, but is resource intensive as well as costly to achieve satisfactorily. Often inadequate monitoring is carried out, but at the same time there appears to be adequate control measures in place (especially where the control measures fully comply with industry standards or are in excess of what might be expected). This explains why there is a higher level of compliance with 'control' than monitoring.
Health surveillance (Regulation 11) was generally well complied with. Inadequacies in the compliance here was due to health surveillance not being specific enough (for example, not looking specifically for skin sensitisation in people exposed to substances that can cause this complaint). Where particularly hazardous substances were involved (e.g. VCM), the requirements are better defined and there is a high standard of compliance with this Regulation.
Information and training (Regulation 12) was the most complied with Regulation looked at in this project (95.5%). It is difficult to fully assess compliance with this Regulation in a proactive inspection initiative such as this, as there are generally (on the face of it) good records in place to demonstrate that appropriate training has been given. We suspect that actual compliance with this Regulation is lower than indicated, but such information does not become evident until carrying out reactive investigation work.
It is obvious that this project has had a positive effect upon the standards of COSHH compliance on major hazard sites in South Wales. This has been demonstrated by responses from the companies involved, as well as the significant enforcement action (mainly in the form of written advice) that has resulted because of this. Although these results are useful in drawing conclusions regarding standards of control, they are only an indication, a 'sample', as on many sites in all industries there are hundreds of COSHH scenarios that have not been inspected.
The positive effect on raising standards from a generally poor baseline provides a clear case for extending the project to other regions. This will ensure consistency of approach across major hazard industries, as well as ensuring compliance with COSHH is up to scratch on major hazard sites that may have previously been considered to be 'performing well in general health and safety'.
This project has highlighted that it is appropriate to identify and focus upon companies with a wide range of diverse hazards and target these specifically.
By analysing compliance with each Regulation, this work suggests that inspection work and company efforts should be focused for maximum effect upon 'assessment' and 'monitoring' in particular, as these are the least complied with, and possibly the most complex and difficult to comply with.