Lab Inspection SOP

1. PURPOSE
The purpose of this procedure is to outline the process used for conducting laboratory inspections at
Arkansas State University.
2. SCOPE
This procedure applies to all laboratories of Arkansas State University.

3. DEFINITIONS
3.1 Deficiency: A problem found during an inspection that must be corrected.

3.2 PI: Principal Investigator
3.3 Laboratories: All labs belonging to Arkansas State University campus including those off
campus that contain biological, chemical, physical, or radiological hazards.
3.4 PPE: Personal Protective Equipment
3.5 DSL: Department Safety Liaison
3.6 Inspection team: The person or persons inspecting a lab
3.7 IDLH: Immediately Dangerous to Life or Health

4. RESPONSIBILITIES
4.1 Arkansas State University Department Heads
4.1.1 Communicate the importance of following safety policies and procedures identified in the
Arkansas State University Laboratory Safety Manual, Biological Safety Manual, Radiation
Safety Manual and Hazardous Waste Management Plan.
4.1.2 Encourage and support laboratories to conduct self-inspections using the self-inspection
checklist and explanation key.
4.1.3 Encourage Principal Investigators to correct deficiencies noted by the inspection team.
4.2 Arkansas State University Principal Investigators and Lab Managers
4.2.1 Understand and follow safety policies and procedures identified in Arkansas State
University Laboratory Safety Manual, Biological Safety Manual, Radiation Safety Manual and
Hazardous Waste Management Plan.
4.2.2 Be aware of the self-inspection checklist and explanation key and use them to prepare for
lab inspections.
4.2.3 Ensure all deficiencies found during lab inspections are corrected by the appropriate
deadline.
4.3 Arkansas State University EHS

4.3.1 Maintain and update the inspections webpage, self-inspection checklist and
explanation key and other resources to assist researchers meet their safety and
compliance responsibilities.
4.3.2 Schedule and perform laboratory inspections according to the goals and objectives
and this SOP.
4.3.3 Follow-up on noted deficiencies according to this SOP.

5. LABORATORY INSPECTION SCHEDULING
5.1 The following steps are involved for scheduling laboratory inspections.
1) Send out email memo to PIs two weeks prior to the planned start date for inspections.
Included in the email memo should be a link to the inspection template and a lab
characterization sheet. The PI or lab representative may have to fill out and return the lab
characterization sheet which includes a lab roster.
2) Send out a subsequent email memo one week prior to the initiation of inspections. This
memo should include a list of the labs in a facility with the name of the person responsible for
the lab attached. Request the PI or lab representative to ensure the information in the list is
still correct.
3) Set schedule based on time requests by Principal Investigators or other lab representative.
4) Add inspection time to calendar with an invite for the appropriate DSL.

5) Complete the inspections per the schedule.
6) Notify PI or lab representative if critical deficiencies are found that will result in imminent
closure of the lab (see DEFICIENCIES section below).
7) Give inspection results to the lab representative at the end of the inspection. A more detailed
report may follow at a later time if further information is needed or is requested.
5.2 While the scheduling period for a facility should be over the course of 4-6 weeks, exceptions
should be made for labs whose PI wishes to present for inspections but whose schedule does
not allow it during the given time period.
6. LABORATORY REPRESENTATION DURING INSPECTION
6.1 The PI or his/her designee should be present during the lab inspection. The lab representative
should be knowledgeable of the daily operations of the lab and must be employed by
Arkansas State University.
6.2 If the PI refuses to have lab representation for the inspection, carry out the inspection with
the appropriate DSL present.
6.3 If the PI refuses to have lab representation for the inspection and the appropriate DSL is not
available, the case shall be referred to the Director of EHS.

6.4 If possible, the appropriate DSL should be present during some of the inspections.
7. INSPECTION
7.1 Before the lab visit, a roster of the lab workers should be provided by the PI or other lab
representative. Based on the lab characterization, the inspection team should check to be
sure that all lab workers have completed all appropriate training.
7.2 Prior to the inspection, the Principal Investigator in charge of the lab should have the lab
users examine the inspection template to see items that will be checked. Correcting
deficiencies prior to the inspection is allowed and encouraged.
7.3 A representative of the lab should meet the inspection team outside of the lab to ensure that
the inspection team is apprised of the hazards of the lab and have the appropriate PPE.
7.4 During the inspection, the lab representative should stay with the inspection team to answer
any question the team may have.
7.5 The inspection should take anywhere from 20 minutes to an hour. Large labs may take longer
than an hour. (Note: On the first round of inspections, the process may take longer due to the
new procedure and the length of time since previous inspections).
7.6 Only items addressed on the inspection form may be counted as deficiencies. If a critical item
is found that is not on the checklist, it may be counted as a deficiency at the discretion of the
Director of EHS.
7.7 At the end of the inspection or by the end of the inspection day a copy of the inspection
results are given to the lab representative. A more detailed report may be provided at a later
time if necessary.
7.8 It is the goal of EHS to visit each lab once per year. After going through the first round it may
be determined that higher risk labs need more frequent visits while lower risk labs may only
require biannual (every other year) inspections.
8. DEFICIENCIES
8.1 Deficiencies are classified as non-compliant and critical
8.2 Critical Deficiencies
8.2.1 Deficiencies found that are IDLH can result in immediate closure of the lab. If such a
deficiency is found:

8.2.1.1 Contact the PI responsible for the lab for immediate resolution.
8.2.1.2 If the deficiency cannot be corrected immediately, the PI refuses to correct this
deficiency or the PI or another lab representative cannot be reached:
8.2.1.2.1 Contact the Director of EHS
8.2.1.2.2 Once the director gives approval for closure of the lab, post signage stating
that the lab is unsafe for entry and contact information.
8.2.1.2.3 Contact the appropriate DSL to lock the lab
8.2.2 If a deficiency is critical but is not IDLH, a time frame must be established for correction of
the deficiency.
8.3 Re-inspection on the basis of deficiencies
8.3.1 A lab will be re-inspected if:
8.3.1.1 A critical deficiency is found
8.3.1.2 The number of other deficiencies is high enough to cause the total inspection
percentage to be below 80%
8.3.2 Re-inspection of labs will not be announced, but at least one week will be given to correct
non IDLH deficiencies
8.4 Correction of Deficiencies
8.4.1 Whether or not re-inspection occurs, it is the responsibility of the PI to ensure that ALL
deficiencies are corrected.
8.4.2 Correction of deficiencies, can, in some cases, be evidenced to the inspection team by
photograph.
8.4.3 Continued failure to correct deficiencies to an acceptable level will result in an escalation
process described in the next section
9. ESCALATION PROCESS

9.1 Unless the deficiencies found are sufficiently critical to the life and health of the lab workers
or the regulatory status of the laboratory, laboratories will be given a minimum of two weeks
to correct deficiencies.
9.2 If upon follow-up inspection critical deficiencies remain unresolved or the laboratory
inspection correct percentage remains below 80% an email message will be sent reminding
the PI in charge of the lab and the appropriate DSL as to the status of the lab. An additional
seven days will be given to bring the lab into compliance.
9.3 If after these seven days the lab is still non-compliant (does not meet the criteria of 9.2),
another email communication will be sent to the PI, the appropriate DSL and the Chair of the
appropriate department. An additional seven days will be given to bring the laboratory into
compliance.
9.4 At this point the PI has had a minimum of 28 days to bring the lab into compliance. If the lab
is still not in compliance, then a third email communication will be sent to the PI, the
appropriate DSL, the Chair or the appropriate department and the Dean for the appropriate
college.
9.5 If the lab still fails to comply after two weeks of the dean being contacted, the Associate Vice
Chancellor of Research or the Vice Chancellor for Academic Affairs (depending on whether
the lab is a research lab or a teaching lab) will be contacted to inform them of the imminent
closure of the lab due to non-compliance. Human Resources may also be contacted.
9.6 Failure to bring a lab into compliance after the 28 days will also result in the refusal of the EHS
to sign any safety documentation regarding grants or permits until such time as the lab is in
compliance.
9.7 Extensions to any of these periods may be granted at the discretion of EHS. A request for an
extension should be requested by an email to the inspection team.
9.8 The escalation process will NOT be used for lab inspection findings that are out of the control
of the PI. For items outside the control of the PI a separate escalation process will be used.
10. REFERENCE DOCUMENTS FOR SELF-INSPECTION
10.1 Included in the email to the PI regarding the scheduling of the inspection will be links to the
following documents:
10.1.1 A blank copy of the inspection form

10.1.2 An explanation of the criteria for each inspection item to achieve the highest level of
compliance
10.1.3 The Laboratory Safety Manual
10.1.4 The Chemical Hygiene Plan
10.1.5 The Biological Safety Manual
10.1.6 The Hazardous Waste Management Plan
10.2 Requirements to meet the minimum compliance level will be linked to the appropriate
regulation or standard as a demonstration of why the item is being checked in the inspection.
11. BENEFITS FOR HIGH COMPLIANCE RATINGS
11.1 Laboratories that have no critical deficiencies, score higher than 95% minimum compliance
and meet the highest compliance level (currently called excellent) on 50% or more of the
inspection items will have the advantage of the following benefits:
11.1.1 A streamlined process for signing off on safety documentation for permits or grants
wherever EHS has that responsibility
11.1.2 Priority on inspection scheduling
11.1.3 The opportunity to self-inspect in lieu of EHS inspections (high risk labs do not qualify)
11.1.4 Other benefits TBD