OHS308 Occupational Health and Safety Management System Audit Procedure

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This procedure details actions and processes pursuant to the UNSW OHS Policy Director, Human Resources OHS Manager, Adam Janssen x52214, email: a.janssen@unsw.edu.au OHS308 v5.2

TRIM 2002/2778 UNSW OHSMS Audit Schedule OHS631 OHSMS Audit Report Template
Self Audit Tool (SAT)
Approval Date Effective Date

6.1 1. 2. 3.

Director, Human Resources

09/06/2011

09/06/2011

4. 5.

Purpose and Scope ................................................................................................................... 1 Definitions .................................................................................................................................. 2 Procedure .................................................................................................................................. 3 3.1 Audit Scope ................................................................................................................... 3 3.2 Audit Frequency ............................................................................................................ 3 3.3 Audit Schedule .............................................................................................................. 3 3.4 Audit Methodology/Process ........................................................................................... 3 3.5 Audit Evidence ............................................................................................................... 4 3.6 Audit Opening Meeting .................................................................................................. 5 3.7 Audit Closing Meeting .................................................................................................... 5 3.8 Auditor selection, independence and competencies ..................................................... 5 3.9 OHSMS Audit Report and Distribution .......................................................................... 6 Review & History ....................................................................................................................... 6 Acknowledgements ................................................................................................................... 6

1. Purpose and Scope

Periodic audits of the OHS management system (OHSMS) are necessary to determine whether the OHSMS has been properly implemented and maintained. This procedure defines the OHSMS audit process for auditors and auditees to ensure consistency in selection, undertaking, recording and management of UNSW OHSMS Audits. This procedure applies to all UNSW Faculties and Divisions and all persons involved in the audit processes. This procedure outlines the: Audit scope; Audit frequency; Audit methodologies; Auditor selection, independence and competencies; Audit schedule; Audit process requirements and representative sample; Audit report and distribution requirements. UNSWs audit methodology is based on AS/NZS ISO 19011-2003 (Guidelines for quality and/or environment systems auditing).

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2. Definitions
Conformance (C): - The auditee has demonstrated: full implementation of University procedures, and compliance with legal requirements, and commitment to the principle of continual improvement. Based upon the evidence obtained during the audit it is evident that the auditee has conformed with University and legal requirements, and is active in implementing additional measures to achieve continual improvement. Minor Non Conformance: Based on the evidence obtained during the audit, it is evident that the auditee has not fully, effectively or consistently implemented University procedures, and/or there is evidence of isolated instances of legislative non-compliance. Preventive corrective action should be undertaken as a priority to avoid nonconformance in the future. The audit itself is a sampling exercise. If the sampling indicates isolated legislative non-compliance, it is likely that a regulator might reveal systematic non-compliance during more focused inspection or intervention. The criterion requiring correction may be linked to, or interdependent with, other parts of the OHSMS. A failure relating to this criterion may therefore lead to a significant reduction in total system effectiveness, or wider legal non-compliance. All nonconformances are documented in the audit report, and remedial action will be confirmed by subsequent verification. Major Non Conformance: The auditor finds evidence that there is an absence of system elements or a part of the system, and/or a failure to follow the documented systems or procedures, and/or a lapse in the system or procedure, and/or apparent systemic legislative non-compliance. Corrective action must be undertaken to prevent injury, ensure continued certification and ensure legislative compliance. The OHSMS auditor is required to report serious hazards or potentially dangerous occurrences to the Faculty or Divisions senior management, the Head of School or Department and the OHS Manager. All major non-conformances are documented on Corrective Action Reports, and remedial action will be confirmed by subsequent verification. Not Verified: The auditor cannot confirm implementation of elements of the OHSMS because: the related activity has not yet occurred, so objective evidence is not available; or the criterion, whilst included in the audit scope, was not examined during the audit; or evidence could not be provided due to an unforeseen circumstance. The auditor may not have reviewed key documents, interviewed staff or visited key areas owing to issues such as staff absence or time constraints. The criterion remains untested and should be considered for inclusion within the scope of subsequent audits. Not Applicable (NA): There is no indication of a particular activity having occurred, and therefore the auditee is not required to implement this part of the OHSMS to satisfy the specified criterion. Audit Guide: a member of staff from the area being audited who can escort the auditor to interview appointments and/or locations to be inspected as part of the audit. Audit Report: A report provided by the auditor to the auditee, detailing the results of the audit and any non-conformances.

OHS 308 OHSMS Auditing Procedure Current Version: 6.1, 09/06/2011

3. Procedure
3.1 Audit Scope
To establish that relevant OHSMS procedures, guidelines, forms and checklists are sufficiently implemented across Faculties and Divisions to meet the NATNSW criteria and a minimum OHSMS implementation audit score of 75%. Internal OHSMS audits shall be undertaken against the requirements of the National Self-Insurers OHS Audit Tool WorkCover NSW User Guide and Work Book (NATNSW), and the University of New South Wales (UNSW) OHSMS procedures, guidelines, forms and checklists.

3.2

Audit Frequency
UNSW will conduct annual OHSMS Audits across selected Faculties and Divisions based on their OHS risk profile. The OHS Manager of the OHS Unit, in consultation with Faculty/Division OHS Coordinators shall assess each Division and Faculty, to determine an OHS risk classification, based on the known operational risks of each area. The OHS risk profile includes the following measures: Number of regulated hazards that are present in a significant proportion of the workplace Lost time injury frequency rate (LTIFR) of the Faculty or Division The Risk Classifications include: No. of Score Audits per Year Faculties/Divisions Audit Cycle Low 1-5 1 5 5 years Med 6-9 2 5 2 years High 10+ 4* 3 1 years * Two high-risk faculties will be audited twice every year. The OHS Manager may increase internal audit frequency for any Faculty or Division for one or more of the following reasons: significant adverse findings resulting from an internal audit; significant adverse findings resulting from an external audit; significant escalation in workers compensation claims or incident frequency rate; significant escalation in regulatory activity; or other information that may indicate the OHS Management System is not performing optimally.

3.3

Audit Schedule
The OHS Manager, in consultation with Faculty and Divisional OHS Coordinators, shall develop the OHSMS Audit Schedule. The schedule shall be reviewed annually and based on: previous audit results; the risk profile of the Faculty or Division; and where applicable, any of the reasons for varying audit frequency that are listed in Section 4.2.

3.4

Audit Methodology/Process
The auditee will be contacted by the auditor with adequate notice to arrange a suitable date, time, and place for the OHSMS audit and pre-audit meeting, and to appoint an audit guide to develop an audit schedule, and to liaise about details

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of the audit. The auditee must complete the Self Audit Tool (SAT) and return it to the Auditor at least two weeks prior to the commencement of the OHSMS audit. The OHSMS auditor should then follow the audit process as follows: 1. Conduct a pre-audit meeting with the auditee prior to the audit to explain the audit process, finalise the audit schedule, and provide an opportunity for the auditee to ask any questions about the audit. It is recommended the following representatives of the area being audited be present: The head of school or senior manager The audit guide The chair of the OHS committee The person responsible for OHS document control The senior administrator. 2. On the day of the audit, conduct an opening and closing meeting with the relevant auditee representatives. If possible, all persons who will be interviewed during the audit should attend. 3. Interview a representative sample of stakeholders to review effective implementation of the OHSMS and consultative arrangements. Interviews should include: Management representative(s) OHS Committee member or OHS representative Other personnel representing a cross-section of the activities of the area being audited. 4. Review and assess relevant local workplace documentation, including: Operational/Management Plans, Key Performance Targets (KPTs), Objectives and Targets OHS Risk Register(s), Risk Assessments and Safe Work Procedures (SWPs) OHS Training Needs Analysis, Training Plan and Training Records OHS Inspection Testing and Monitoring register, and Workplace Inspections Pre-purchase checklist/risk assessments and purchasing documentation Permits, licences, approvals Emergency and First Aid systems Chemical inventories, risk assessments, and Material Safety Data Sheets (MSDS) Plant Register, risk assessments, maintenance and inspection records OHS Committee meeting minutes. 5. Review and assess the implementation of local workplace risk controls, including: Plant Electrical Chemical storage and handling Manual Handling Housekeeping Emergency and First Aid equipment and facilities Other relevant risks. 6. Conduct any other relevant information gathering required to complete the audit. 7. Auditor to prepare the audit report and provide it to relevant management and OHS Committee representatives for distribution. The auditor will also provide a copy to the manager of the OHS Unit, and to the relevant Faculty/Divisional OHS Coordinator.

3.5

Audit Evidence
During the OHSMS audit, information relevant to the audit criteria and OHSMS implementation will be collected by appropriate sampling, observation and

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discussion with people who work within the audit area. Only information that is verifiable may be audit evidence.

3.6

Audit Opening Meeting

The OHSMS auditor should, where reasonably practicable, commence the audit with an opening meeting with the relevant auditee representatives, addressing the following agenda items: 1. Introduction 2. Confirmation of the audit scope 3. Explanation of the audit process 4. Confirmation of the audit schedule, expected closing meeting time, and location 5. Confirmation of audit details with the audit guide(s) 6. Other business, including questions.

3.7

Audit Closing Meeting

The OHSMS auditor should, where reasonably practicable, conclude the workplace verification component of the audit with a closing meeting with the relevant auditee representatives, addressing the following agenda items: 1. Appreciation of those involved in the audit 2. Brief outline the findings known to date, that is, areas of: Good performance Average performance Poor performance 3. Explanation of the next stages in the audit process, including expected completion date of the written report and its subsequent distribution 4. Other business, including questions.

3.8

Auditor selection, independence and competencies

The OHS Manager shall ensure that OHSMS auditors are independent of the area they are auditing (auditors must not have provided OHS services, advice or consultancy to the auditee area within the last 2 years); or put in place suitable arrangements to manage any potential conflicts of interest. The OHS Manager shall select OHSMS auditors that are sufficiently qualified, competent and experienced to perform OHSMS audits. Where the auditor(s) are not sufficiently qualified, competent and experienced, the internal auditor(s) may be supported by other experts to enable them to perform audits competently. When determining the suitability of OHSMS auditors the OHS Manager shall take into account the following criteria: Essential: relevant tertiary qualifications; knowledge of current NSW Occupational Health & Safety legislation (OHS, Dangerous Goods and other relevant Acts and regulations); successful completion of a recognised OHS auditor training course; one year of recent experience in an OHS role. Preferable five years of work experience with at least three years of experience in an OHS role; relevant tertiary qualifications; successful completion of a recognised OHS auditor training course;

OHS 308 OHSMS Auditing Procedure Current Version: 6.1, 09/06/2011

knowledge of current NSW Occupational Health & Safety legislation (OHS, Dangerous Goods and other relevant Acts and regulations); experience conducting at least four OHS Management Systems audits, totaling not less than 20 days on site, within the last three years, against the NATNSW, Australian Standard AS/NZS ISO 19011:2003 Auditing Quality and Environmental Management Systems or equivalent.

3.9

OHSMS Audit Report and Distribution

Internal OHS Audit Report Template: The OHS Manager, shall develop and maintain an OHSMS Audit Report template. The OHSMS auditor(s) shall use the template to report OHSMS audit findings to the auditee. Internal OHS Audit Report Distribution: The OHS Auditor, should provide an OHSMS Audit Report to the Head of School or Divisional Manager four weeks from the OHSMS Audit closing meeting. The OHSMS Audit report shall include: Criteria not assessed Minor non-conformances Major non-conformances The Head of School or Divisional Manager shall, within four weeks of receiving the OHSMS audit report, ensure that documented Corrective Action Plans, including prioritisation of planned corrective actions (Major non-conformances should be actioned as soon as possible or no later than 3 months, minor non-conformances should be corrected within 6 months), are developed and provided to the OHSMS auditor, for each Non Conformance identified. The Head of School or Divisional Manager shall ensure that the OHSMS audit reports are tabled at the Level 2 and Level 3 OHS Committee meetings, for monitoring the implementation of corrective actions. The OHS Manager shall report Internal OHS audit results to: Level 1 Occupational Health and Safety Committee Risk Management Committee of Council (UNSW Council) UNSW Senior Management

4. Review & History

The OHSMS Audit Procedure will be reviewed in November 2013 at the end of the 5 year audit cycle along with the UNSW OHSMS Audit Schedules 2008 - 20013.

5. Acknowledgements
UNSW OHS Policy. Australian Standard AS/NZS ISO 19011:2003 Auditing Quality and Environmental Management Systems. Occupational Health and Safety Model for Self Insurers.

OHS 308 OHSMS Auditing Procedure Current Version: 6.1, 09/06/2011

Appendix A: History The authorisation and amendment history for this document must be listed in the following table. Refer to information about Version Control on the Policy website.
Version 1.0 2.0 3.0 4.0 5.0 5.1 5.2 6.0 6.1 Authorised by Director, Risk Management Unit Director, Risk Management Unit Director, Risk Management Unit Director, Risk Management Unit Director, Human Resources Director Human Resources Director Human Resources Director Human Resources Manager, OHS Unit Approval Date 24/05/2002 19/05/2003 28/05/2003 1/06/2004 1/01/2007 26/09/2008 23/10/2009 10/12/2010 09/06/2011 Effective Date 24/05/2002 19/05/2003 28/05/2003 1/06/2004 1/01/2007 26/09/2008 23/10/2009 10/12/2011 09/06/2011 Sections modified New document Not recorded Not recorded Not recorded Reformatted document and revised all sections Reformatted document and revised all sections Section 4.4 Auditor competency clarification Complete review Updated definitions and process

OHS 308 OHSMS Auditing Procedure Current Version: 6.1, 09/06/2011