Monitoring - Health and Safety

Safety monitoring is an important element of safety management and is carried out to assist with the improvement of safety performance.

Departments are required to carry out safety monitoring as part of UCL's governance and legal compliance arrangements.

> UCL's Organisation & Arrangements for Safety - Section 5.11 'Monitoring Performance'

Types of safety monitoring

Active monitoring

Active monitoring is a planned process which allows departments to identify potential issues before they result in incidents/accidents or ill-health and involves:

• visits, checks and inspections of the workplace, equipment and plant
• health surveillance of staff involved in certain work activities

An active monitoring programme provides information on:

• the effectiveness of risk control measures implemented as a result of the risk assessment
• work conditions or practices which introduce new hazards
• risks due to non-compliance with previously agreed risk control measures

Reactive monitoring

Reactive monitoring is carried out when an incident has occurred. It involves:

• investigating accidents and incidents, including near misses
• monitoring cases of ill-health and sickness absence records

Incidents do not always result in injury and ill-health - they can cause damage to property, equipment or the environment.

An investigation will help to:

• identify why existing control measures may have failed or not been used and improve future risk management
• provide a snapshot of what really happens and how work is done (workers may find shortcuts to make work quicker or easier)
• identify lessons learnt that can be communicated to other parts of UCL
• demonstrate a commitment to improving health and safety

> Report an incident 

Who should monitor?

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Active monitoring

All monitoring in the department should be actively promoted and supported by the Head of Department and senior management. To ensure appropriate levels of monitoring, departments should develop monitoring programmes for all areas and activities. The programmes should specify the scope of the monitoring activities i.e. location, topic, timeframe and recording method, the people responsible and the frequency.

Developing programmes of active monitoring (visits, checks and inspections) can be the function of Departmental Safety Committees which are constituted in larger departments.

In departments that do not have a safety committee, the Departmental Safety Officer can draft a programme of active monitoring to be discussed and agreed with the Head of Department and senior managers.

Although it is most effective when carried out by senior members of the department, less senior members of staff may be as effective provided their reports are acted upon.
The manager of the activity or work area must ensure that the person(s) delegated to carry out monitoring on their behalf:

• is familiar with the activities, locations and hazards being monitored
• is authorised to take remedial action

Health surveillance is carried out by UCL Workplace Health.

> UCL Workplace Health

Reactive monitoring

The manager of the individual or work activity involved in the incident is responsible for investigating the causes of the incident. Incident Co-ordinators and Departmental Safety Officers may assist with the investigation but it is not their primary responsibility. See UCL Roles & Responsibilities for more information.

> UCL Roles and Responsibilities

Work-related ill-health and sickness absence are investigated by UCL Workplace Health.

> UCL Workplace Health

How to monitor

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Active monitoring

Active monitoring must be a thorough process which examines compliance with agreed control measures and identifies weaknesses or omissions in the departmental safety arrangements, especially for those conditions or practices which are hazardous.

There are a number of different approaches to active monitoring. 

Types of monitoring

Type of monitoring	Description	Good Practice Guidance
Safety tour	Ad hoc visits to selected parts or the entire department. Especially effective if carried out by senior departmental managers as this demonstrates their commitment to safety.	The visit can provide staff and students with the opportunity to raise safety issues with senior staff. It's vital that concerns are documented and the actions taken are communicated to the individuals or groups who raised the issue(s).
Workplace hazard spotting	An informal method of identifying potential problems. The results however will just be a 'snapshot' of current practices.	This method can be used to identify hazards not previously considered or recently introduced. It can also be used to identify trends if records are kept. For example, observing the same hazard at different locations in the department or in the same location at different times.
Inspection checklist	Used to examine specific work areas or activities.	The checklist questions should be based on agreed departmental or UCL standards. This is a consistent means of gathering information which can be used to review compliance across the department.
Reviewing documents	Examination of risk assessments or codes of practice and comparing the requirements set with observed practices.	This is a method of identifying whether risk control measures are being used in accordance with approved documentation.
Interviewing staff and students	Ask staff and/or students to explain the controls in place for their work and how they have been trained to implement these controls.	This method can be used in conjunction with other methods as the responses can be used to verify a number of aspects of the safety management system e.g. training records, risk assessments etc.
Topic-based review	Examination of the overall management of risk associated with a specific hazard e.g. liquid nitrogen, display screen equipment or lasers.	Using a checklist based on statutory, UCL or good practice requirements for a specific hazard.

Reactive monitoring

The reason for investigating accidents and incidents is not to find someone to blame, but to identify the immediate and underlying causes in order to prevent it from happening again.
The purpose of the investigation is to gather and record the facts by:

• observation at the scene and taking photographs if necessary
• interviewing those involved
• examining documentation e.g. risk assessments, codes of practice or training records

The results of the investigation should be used to determine the immediate and underlying causes of the accident/incident and to make recommendations for improvement to departmental management.

> Report an accident or incident
> Investigate an accident or incident

When to monitor

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Active monitoring

The amount of monitoring that needs to be done, i.e. the frequency and depth of measurement, will depend on several different factors including:

• mandatory monitoring requirements with defined maximum intervals i.e. statutory testing
• the degree of risk associated with the particular location/activity
• individual UCL requirements e.g. monthly fire extinguisher checks
• historical evidence of poor standards of workplace safety i.e. accident/incident data, results from previous inspections

Heads of Department must ensure that the monitoring programme is based on the risk profile of the Department with higher risk activities and areas being monitored more frequently than low risk activities and areas. Departments that have a health and safety risk register can use this to determine frequencies for monitoring programmes.

Where an improvement or change to a control measure has been made as a result of an incident, the manager responsible for implementing the change must monitor its effectiveness.

Example of a monitoring programme

Type of monitoring	Example	Frequency	Carried out by	Responsible for ensuring it is carried out
Safety tour	Visit to all areas of the department.	Arranged to ensure all areas are visited annually	Senior Managers	Head of Department
Workplace hazard spotting	Informal method of identifying potential problems.	6 months	Delegated person	Manager of the work area
Checklist of risk control measures	Chemical waste management, housekeeping standards, first aid provision.	*Monthly	Delegated person	Principle investigator/Manager of the activity or work area
Examination of documents	Risk assessments, codes of practice.	Annually	Delegated person	Principle investigator/Manager of the activity or work area
Risk survey	Examination of the overall management of a specific risk e.g. flammable gases.	1 risk category per month	Delegated person	Head of Department
Statutory testing**	Lifting Equipment	Every 6-12 months	Competent third party	Manager of the equipment
Statutory testing**	Pressure Equipment	In accordance with the Written Scheme of Examination (WSE)	Competent third party	Manager of the equipment
Statutory testing**	Local Exhaust Ventilation	Every 12-14 months	Competent third party	Manager of the equipment

*Frequencies can be increased or decreased according to results i.e. if the results of an inspection/check are consistently positive then the frequency can be reduced and vice versa. This will ensure that resources needed to carry out monitoring activities can be utilised more effectively.

**Statutory testing and examination must only be carried out by a competent person on certain types of equipment where safe operation is critically dependant on its condition and where deterioration could result in significant risk to individuals. This type of inspection is independent of routine maintenance programmes (although they may be combined if contracted out).

Reactive monitoring

An investigation must be always be carried out following an incident (as defined on the incident reporting webpage), such as:

• work related injury or ill-health
• near miss
• failure of equipment etc

The level of investigation necessary will depend on the severity of the incident.

Results

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Active monitoring

The remedial action needed and the date by which it should be carried out must be documented and communicated to the person responsible for implementation. The results of monitoring and the actions taken should be reported to the relevant managers and/or Departmental Safety Committee, who can determine if any changes are required e.g. new control measures to be introduced, refresher training for staff or review of departmental arrangements for managing safety.

It is recommended that the riskNET system is used to record inspections as it will facilitate implementation of the monitoring programme and enable trends to be analysed.

Reactive monitoring

The result of accident/incident investigations must be recorded and include:

• the remedial action taken
• the immediate and underlying causes
• recommendations for improvement
• timescale for completion

The results of accident and incident investigations must be entered on riskNET.

Departmental arrangements should ensure that a procedure is established to track the progress of actions arising out of both active and reactive monitoring activities.