Procedure: Work health and safety audit

Transcription

1 Procedure: Work health and safety audit Purpose This procedure describes how the University establishes, implements and maintains audits for the work health and safety, rehabilitation and claims (WHS) management systems. This procedure meets compliance requirements of the Work Health and Safety Act 2011 (Cth) (WHS Act), the Work Health and Safety Regulations 2011 (Cth) (WHS Regulations) and the Safety, Rehabilitation and Compensation Act 1988 (SRC Act). This WHS audit procedure is based on the requirements in Australian Standards New Zealand (AS/NZ) 4801:2001, ISO19011:2002 and the National Audit Tool (NAT) for work health and safety. This procedure is linked to the University s Work Health and Safety Policy and is one of the WHS Management System Procedures. Definitions Action is an action raised in response to an identified non-conformance. Audit is a systematic and independent process for obtaining evidence and evaluating it objectively to determine the extent to which the audit criteria are fulfilled. Conformance is the fulfilment of specified requirements. Local area is the college, research school or service division. Non-conformance is the non-fulfilment of specified requirements. Observation is a deviation from the written instructions or information that will not compromise the WHS management system. Opportunity for improvement is an idea to improve the efficiency or effectiveness of the activity. Procedure Scope 1. This procedure applies to all activities which are subject to scheduled and unscheduled work health and safety (WHS) audits. Scheduled WHS audits are required to meet compliance with the NAT requirements for Self-Insurers. Procedure: Work health and safety audit Page 1

2 Unscheduled WHS audits may be conducted on an as needs basis as a result of an incident or non-conformance from an external audit. 2. The WHS audits are exclusive of, and in addition to, the audits undertaken in accordance with the University s Internal Audit Charter. 3. The key activities in this procedure for complying with WHS audits are: Types of WHS audits; Designing a WHS audit program for the University; WHS auditor selection and competency; Consulting, approval and communicating the WHS audit program; WHS audit methodology; Reporting audits results; and Reviewing the effectiveness of the WHS audit process. Types of WHS audits 4. The WHS audit structure at the University will consist of the following types of WHS audits: Tier 1 WHS audits of the corporate WHS management systems; Tier 2 WHS audits of the WHS management system procedures and safety procedures; and Tier 3 compliance or hazard based audits. Tier 1 WHS audits 5. The purpose of the Tier 1 audit is to ensure that the University s WHS management systems comply with the NAT Self Insurer WHS and Rehabilitation audit tool requirements. Tier 2 WHS audits 6. The purpose of the Tier 2 audit is to ensure that the activities of the University comply with the requirements stated in the University s WHS management system procedures and WHS safety procedures. Tier 3 audits 7. The purpose of the Tier 3 audit is to ensure that the control activities for specific hazards (such as working with radiation or working on cooling towers) within local areas are effective. Ideally these audits should be performed by members from the local WHS Committees or Health and Safety Representatives Procedure: Work health and safety audit Page 2

3 (HSRs). Designing a WHS audit program 8. The Associate Director Work Environment Group (WEG) will design and implement a WHS audit program for a three year period that will include Tier 1 and Tier 2 scheduled audits. The local areas will be responsible for designing their own annual Tier 3 audit program for the hazards with unacceptable levels of risks (i.e. residual hazard scores of greater than 14 as per the WHS hazard management procedure. 9. The Tier 1 audits will be scheduled annually for the rehabilitation management system and every two years for the WHS management system. 10. The Tier 2 audit inputs will be scheduled over the three year period based on the hazard score of the document or the rating criteria as per table 1 below. The inputs for the Tier 2 audits will include: the key WHS policies as defined in the Safety Management System Manual; the WHS management system procedures; the WHS safety procedures; and the Rehabilitation Manual. Table 1 Priority rating for Tier 2 WHS audit inputs. Priority Rating criteria Priority 1 Hazard score >=20 and/or activities associated with this procedure resulted in an external audit result of nonconformance or a notifiable incident. Priority 1 items are recommended to be audited every 18 months. Priority 2 Hazard score >12 and/or activities associated with this procedure resulted in an LTI incident, internal audit result of nonconformance. Priority 2 items are recommended to be audited every 24 months. Priority 3 Hazard score <=12 and/or activities associated with this procedure resulted in an external audit result of not verified or observation. Priority 3 items are recommended to be audited every 36 months. Procedure: Work health and safety audit Page 3

4 11. The Associate Director WEG will nominate auditors (either internal or external), areas to conduct the audits across (such as the Research School of Biology), and planned audit dates in the schedule. The auditors will be independent of the area to be audited. 12. The Director Human Resources will endorse the program and the selection of auditors prior to consultation on the program as described further below. WHS auditor selection and competency 13. The Associate Director WEG will keep a register of qualified auditors. 14. The internal auditors will be qualified in internal auditing to AS/NZ 4801:2001 by a third party that is recognised as a Nationally Recognised Training provider with experience in auditing AS/NZ 4801: The external auditors will have qualifications for safety auditing to RABQSA International requirements for AS/NZ 4801:2001 or be an approved Comcare auditor. The external auditor qualifications will be verified by the Associate Director WEG prior to engaging them and will be stored in the Electronic Record Management System (ERMS). Consulting, approval and communication of the WHS audit program 16. The Associate Director WEG will ensure the proposed WHS audit program is presented to the WHS Committees and relevant stakeholders (such as the auditors), for consultation as per the WHS communication and consultation procedure. All feedback from the consultation process will be recorded on a consultation log sheet. 17. Following consultation, the Associate Director WEG will present the WHS audit program to the University WHS Committee to recommend the WHS audit program for approval by the University Council. 18. Once the WHS audit program is approved, the Associate Director WEG will provide communication to the auditors and areas to be audited of the final planned audits. This can be done via the WHS Committees and direct s. A copy of the WHS audit program can also be accessed from the WEG website. WHS audit methodology Planning for a WHS audit 19. The nominated auditor should plan for and prepare the areas to be audited. It is recommended the nominated auditor prepares in the following ways (for Tier 1 and 2 audits): Procedure: Work health and safety audit Page 4

5 Request the results from previous audits on the topic/scope of audit from WEG. It is important to understand the areas of deficiencies and to test if they have been addressed effectively; Review the procedure/documentation as required for the scope of the audit; Prepare a checklist of questions and criteria (if they do not exist). The questions should test the requirements stated in procedures (hint: these as typically stated as shall or will in the documentation); and Ring key stakeholders that they wish to audit and send an agenda. It is recommended that the auditor has a conversation if possible to explain what they will be doing, understand any access issues and to make sure that the local area is comfortable with the audit process. 20. The auditor for a Tier 3 audit should prepare by: referring to the local area hazard register for the listed controls; and reviewing any documentation on the controls. Conducting WHS audits 21. In conducting the audit, the auditor should observe and seek evidence from a representative sample of workers that the procedure is understood and properly implemented. The audit must test the performance of the system, not the individuals. The auditor where possible may involve the HSRs. 22. The representative sample for a Tier 1 audit should consist of at least three local areas or examples from the University. The representative sample for a Tier 2 audit should consists of at least one local area. The representative sample for a Tier 3 audit should consist of the activity that the hazard is associated with. Reporting of findings from a WHS audit 23. For a Tier 1 WHS audit, the auditor will record all findings into an approved Comcare WHS Audit Report template available from the Comcare website. 24. For a Tier 2 and 3 WHS audit, the auditor will record all findings in a WHS audit report template available from the WEG website. 25. The findings from a WHS audit can be classified as below: conformance is the specified requirements have been fulfilled; non-conformance is the non-fulfilment of specified requirements; observation is a deviation from the written instructions or information that will not compromise the WHS management system. Procedure: Work health and safety audit Page 5

6 opportunity for improvement is an idea to improve the efficiency or effectiveness of the activity. 26. The auditor will provide the WHS audit report to the local area where the audit was conducted for review and to verify the findings. The area will then define the necessary corrective actions for any non-conformances as a minimum. The area is not obliged to commit to actions for observations and opportunities for improvements. 27. The auditor will forward the completed report and details of any actions to the Associate Director WEG for reporting purposes as per the WHS management review procedure. Reporting WHS audit results 28. The Associate Director WEG will report the progress of the WHS audit program and the results of audits as per the WHS reporting, WHS communication and consultation and WHS management review procedures. 29. All audit reports will be stored in the ERMS. Reviewing the effectiveness of the WHS audit program 30. The Associate Director WEG will review the effectiveness of the WHS audit program during and after the completion of each audit program cycle. The key measures of effectiveness are: completed audits vs planned audits; number of non-conformances; and auditor competency (such as the number of internal auditors). Sources Legal and other requirements Work Health and Safety Act 2011 (Cth) Work Health and Safety Regulations 2011 (Cth) Safety, Rehabilitation and Compensation Act 1988 (Cth) AS/NZ 4801:2001 Occupational health and safety management systems Procedure: Work health and safety audit Page 6

7 ISO 19011:2002 Guidelines for auditing management systems Procedure: Work health and safety audit Page 7

8 Document information Title Document Type Document Number Work health and safety audit Procedure ANUP_ Version 3 Purpose Audience Category Topic Subtopic This procedure describes how the University establishes, implements and maintains audits for the work health and safety, rehabilitation and claims (WHS) management systems. This procedure meets compliance requirements of the Work Health and Safety Act 2011 (Cth) (WHS Act), the Work Health and Safety Regulations 2011 (Cth) (WHS Regulations) and the Safety, Rehabilitation and Compensation Act 1988 (SRC Act). This WHS audit procedure is based on the requirements in Australian Standards New Zealand (AS/NZ) 4801:2001, ISO19011:2002 and the National Audit Tool (NAT) for work health and safety. This procedure is linked to the University s Workplace Health and Safety Policy and is one of the WHS Management System Procedures. Staff Administrative Health, Safety & Environment Occupational Health & Safety Effective Date 1 Jul 2017 Review Date 1 Jul 2020 Responsible Officer Director, Human Resources (director.hr@anu.edu.au) Approved By Contact Area Chief Operating Officer (chris.grange@anu.edu.au) Human Resources Division (director.hr@anu.edu.au) Authority Work Health & Safety Act 2011 Printed On 15 Jul 2018 Work Health and Safety Regulations 2011 Please ensure you have the latest version of this document from the Policy Library website before referencing this.