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Chapter 7 - Operational safety

This page forms part of UCL’s Safety Management System. This is Chapter 7 - Operational safety.

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Management of fire safety


The foundation of fire safety management at UCL is a risk-based approach.

An annual review of the UCL estate is carried out by the fire safety team, during which risks are considered on a building-by-building basis.

Each building is given a ‘Category’, between 1 and 3, which reflects the experience of the Fire Safety Team in terms of assessment of the local fire management standards, process or storage hazards and the general standard of the building and the fire precautions therein. The review is qualitative as opposed to quantitative.

Fire safety signage and extinguishers are managed by the Fire Safety Team. This includes the locations for signage and other equipment, organising placement of equipment and maintenance of condition and location of equipment, including reactive maintenance. The team also provides specialist input into active fire equipment contract management, where those contracts are managed by others, within UCL Estates.

Heads of Department have a duty to ensure that relevant persons that may be affected by their acts or omissions are mitigated from exposure to fire risks and explosions, as far as reasonably practicable, within their department’s occupied and teaching space.

> Fire Safety website

Management of biosafety


Genetic modification

The Genetic Modification Safety Committee provides advice on risk assessment of GM activities as required under the Genetic Modification (Contained Use) Regulations. Because of the scale of the work carried out at UCL, only a proportion of assessments are formally reviewed by the committee when it meets.

The University Biological Safety Adviser (UBSA), on behalf of the GMSC, reviews and advises on all assessments as they are submitted to Safety Services. Assessments of higher risk activities (Class 2 and 3 along with hazard group 3 work) are also peer-reviewed by at least 2 members of the UCL GM advisory pool. The GMSC formally ratifies all assessments when it meets. This ensures that GM work is not delayed but allows both the UBSA and GMSC to maintain oversight of the activities across UCL.

Containment Level 3 activities

Containment Level 3 (CL3) laboratories are deemed by the Health and Safety Executive Microbiology and Biotechnology Unit to be high hazard facilities and as such need to be subject to high standards of management; both in terms of the facility and the staff who work in them.

Safety Services carries out a regular programme of inspection and audit of UCL’s CL3 laboratories and also facilitates a UCL CL3 user group to promote consistency of approach and sharing of good practice.

Management of ionising radiations


Radiation protection at UCL is coordinated by the Radiation Protection Team (RPT) in Safety Services. The RPT is responsible for the production, implementation, maintenance and monitoring of the organisation and arrangements for work with ionising radiations, to ensure compliance with relevant statutory requirements.

UCL’s Operator’s Procedures for Radiation Safety (OPs) outline the organisational framework and processes in place for working with ionising radiations and managing radioactive material and waste. This enables a consistent approach to the management of radiation safety.

The OPs also include written roles and responsibilities pertaining to the procedures, to identify the framework of duty holders and practical means by which duties can be delivered in relation to work with ionising radiation at UCL.

This also covers work undertaken in accordance with the conditions and limitations of permits issued under Environmental Permitting Regulations 2016 (as amended 2018).

All UCL departments that work with ionising radiations must meet the requirements of the OPs, as well as appoint, in writing, a suitable Radiation Protection Supervisor (RPS). The RPS will oversee and supervise work with ionising radiation at a departmental level and monitor compliance with UCL’s OPs.

The full responsibilities of the RPS are described in Roles and Responsibilities: Radiation Protection Supervisors.

The organisational and reporting structures for UCL management of ionising radiations are found in Chapter 3.4 - Health and safety committees.

Management of chemical safety


Chemical safety is managed by Departments in co-ordination with Safety Services. A designated Safety Advisor in Safety Services works with the departments to ensure compliance on managing regulated chemicals, especially those under the Chemical Weapons Convention, the Illicit Drug Precursor Control Regulations and the Poisons Act.

The Safety Advisor manages the compliance of the legislative requirements, specifically managing the permits of use or regulated chemicals including new applications, variations and revocations and provision to the regulating authorities (Home Office and UK CWC National Authority part of the Department for Energy and Climate Change) annual inventory returns.

The departments that use/store these regulated substances must appoint and include in the Responsible Person Register a Chemical Co-ordinator who will be responsible for helping the department achieve and maintain compliance. The management of waste is controlled by the department, with the collaboration of Safety Services and managed by Hazardous Waste Services Technician.

> Chemical Safety pages
> Hazardous waste removal

Management of asbestos safety


UCL recognises its responsibilities and duties under the Control of Asbestos Regulations 2012 (CAR) and will take appropriate action to ensure the health and safety of staff, students, contractors and others who may be affected by the risks associated with asbestos-containing materials present in buildings within the University estate.UCL has an active Asbestos Management Plan (AMP) which sets out the inspection and testing parameters for identifying ACM’s in its estate and how they are then dealt with. UCL Estates Facilities and Infrastructure Department has an asbestos ‘Appointed Person’ as the operational lead on asbestos management.

> Asbestos management at UCL

Management of construction safety


Construction activities are managed by UCL Estates Capital and Facilities & Infrastructure Project Officers. Procedures called Stage Gates, based on RIBA building lifecycle, are used to ensure a consistent approach to delivering construction projects. Projects Officers monitor contractors’ health and safety performance via frequent site inspections, progress meetings and unannounced site visits. To further ensure compliance and to promote positive health and safety culture within the organisation, senior managers conduct monthly site Safety Tours.

Safety Services' Construction and Maintenance Safety Advisor provides guidance and support to ensure that UCL Estates' construction and maintenance projects are being carried out in compliance with current legislation, relevant regulations and organisational requirements.

Higher risk activities such as working in confined spaces, hot works, work at height etc is controlled by UCL Estates' permitting system which currently is undergoing a full review. Deliveries for construction activities are controlled internally by UCL Estates Logistics Department.

UCL Estates has implemented systems and procedures to enable the management and control of the means of escape and the risk of fire during construction works. Where construction or refurbishment work is to be carried out in occupied premises, Project Officers must ensure that suitable arrangements and risk assessments are in place, to establish the extent of the building’s fire safety arrangements likely to be affected by the works. Further guidance is available from the fire safety website (see Mandatory Instruction MI02).

> UCL Estates Permit 

Safe place to work


The responsibility for providing UCL with buildings of sound construction with safe means of access and egress rests with the Director of UCL Estates. UCL Estates is responsible for the construction, maintenance, refurbishment and demolition of all UCL buildings. It is also responsible for the care and maintenance of the UCL estate (except for public roads and pathways). No staff other than those in the above services may engage in any of these activities. The Director of Safety Services has appointed a Construction Safety Advisor for specialist advice in this area.

Safety of plant and equipment


All plant and equipment which is an integral part of the UCL infrastructure is the responsibility of UCL Estates. This includes such items as large power generators, lifts, boilers, access barriers, fixed installation fume hoods, etc.

All other items are the responsibility of the owning Department and in some cases, these may be shared between more than one Department. Where this is the case, roles and responsibilities are set out in the following UCL Standards:

Permit to work and control of contractor arrangements


Responsibility for the permit to work system for activities on or in UCL premises rests with the Director of UCL Estates.

Arrangements for the Control of Contractors and permits to works are detailed in documents held with UCL Estates and local Permit to Work offices on UCL sites.

Local control for the administration of the Permit to Work arrangements is carried out by the UCL Estates managers.

> Estates Permits

Safe systems of work


Departments are responsible for ensuring that any work procedures which expose the individual to a significant hazard are assessed for risk and appropriate control measures are applied.

One of the control measures is to use a safe system of work which is a work procedure specifically designed to reduce exposure of the operator to health and safety risks. They may be verbal or, preferably, in the form of a written scheme.


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Chapter 8 - Document and record management

Last updated: Friday, January 21, 2022