6.1.1 Local Periodic Inspections
The first tier (Level I) is a self-inspection program consisting of required weekly and periodic monthly inspections conducted by DLC EHS Representatives or their designees. Weekly Level I Inspections must be conducted in those areas which contain Satellite Accumulation Areas (SAA) while inspections of other labs or facilities will occur on a schedule determined by the EHS Office and DLC. A Level I Inspection Checklist has been developed for laboratories that include sections on environmental management, including satellite accumulation areas; health; safety; and emergency response. The EHS Office manages the Institute's "less than 90 day" hazardous waste storage areas that are also inspected on a weekly basis. If a problem is identified in this level of inspection action can be taken to correct the problem at the time of the inspection. For those findings not readily correctable, the PI or Supervisor must develop and initiate an action plan to correct the problem. The inspection process is designed to ensure that DLCs make consistent checks of key components in their work areas essential for maintenance of the EHS program, and foster good working habits with respect to the environment, health and safety. A review of the self-inspection system is performed when the more comprehensive Level II inspections are carried out. Records of these Level I inspections are not required to be kept, although some DLCs may elect to do so.
6.1.2 DLC-wide Inspections
The second tier is a DLC-wide inspection, called Level II Inspections, performed twice a year by a team consisting of the DLC EHS Coordinator and other parties selected by the EHS Coordinator. For some operational areas within the Division of Comparative Medicine, Division of Student Life and Department of Facilities inspections are done on an appropriate periodic basis as determined by the DLC and the EHS Office. At least once a year, one member of the team will be the EHS Lead Contact or other EHS office representative. A Level II Inspection SOP has been developed and must be followed when conducting this inspection. The DLC EHS Coordinator will provide a comprehensive report on findings and recommendations to the appropriate parties for action. In addition, as part of Level II Inspections, EHS Office staff may review some specific supplemental topics. These supplemental review components will be developed to assess different local program effectiveness. This may be done at the time of joint Level II Inspections with the EHS Coordinator, or independently. EHS Office staff will be responsible for compiling a report on these supplemental inspection topics. (See Inspections: Level I - Level II for inspections tools and guidance.)
6.1.3 Institutional Audits
The third tier is an Institute-wide or targeted systems or compliance audit examining the overall implementation and effectiveness of the EHS Management System. The MIT Audit Division and/or an outside consultant will audit MIT's EHS-MS at least biennially. A Level III SOP has been developed and is followed when conducting these audits. A summary of the audit results will be included in the annual EHS Programs Office and EHS Office report to the President and will be distributed to the Institute Council on EHS. The EHS Office oversees implementation of the recommendations emanating from the systems audit. In addition, as part of the process for evaluating the EHS Management System, there will be an internal management review conducted by members of the EHS Programs Office and EHS Office at least annually. At the time of the management review, the review team will:
- Discuss the results of the most recent internal and external audits,
- Incorporate the necessary changes resulting from the most recent audits into the EHS-MS,
- Determine whether revisions to the EHS-MS Manual are needed, and
- Coordinate the distribution of meeting minutes and action items of the annual review to appropriate members of the MIT community.