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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 deficiency.

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.

Compliance is the specified requirements have been fulfilled.

Local areas mean Research Schools, Colleges and Divisions of ANU.

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.

The Work Health and Safety Management System (WHSMS) Handbook provides practical guidance for University and its local areas on how to implement the University WHS Management System and defines the responsibilities and actions required by management and workers within the management system.

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. Unscheduled WHS audits are 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

  1. The WHS audit structure at the University consists of the following types of WHS audits:
  • Tier 1 WHS audits of the corporate WHS management systems by external auditors;
  • Tier 2 Internal WHS audits of the WHS management system implementation using WHS Management System Handbook as guidance or specific compliance and hazard based audits.

Tier 1 WHS audits

  1. The purpose of the Tier 1 audit is to ensure that the University’s WHS management systems comply with the NAT Self Insurer WHS audit tool requirements and legislative requirements.

Tier 2 WHS audits

  1. 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 and its Handbook as well as WHS legal and other requirements.

Designing a WHS audit program

  1. The Associate Director Work Environment Group (WEG) designs and implements a WHS audit program for a three year period that includes Tier 1 and Tier 2 scheduled audits.
  2. The Tier 1 audits are scheduled for the WHS, Claims and Rehabilitation management systems in accordance with the Self-insurance licence conditions and licensee requirements.
  3. The Tier 2 audit inputs are scheduled over the three year period based on the inherent risk of the local area and that high risk local areas will be audited annually and low risk local areas will be audited once per three years.
  4. The Associate Director WEG nominates auditors (either internal or external), to areas to conduct the audits for the planned audit quarter in the schedule. The auditors are independent of the area to be audited.
  5. The Director Human Resources (HR) endorses the program and the selection of auditors prior to consultation on the program as described further below.

WHS auditor selection and competency

  1. The Associate Director WEG keeps a register of qualified internal auditors as well as their qualifications.
  2. The Associate Director WEG engages qualified third party (e.g. SAI Global or Comcare engaged) auditors to conduct external audits.

Consulting, approval and communication of the WHS audit program

  1. The Associate Director WEG ensures the proposed WHS audit program is presented to the University WHS Committees for consultation and approval as per the WHS communication and consultation procedure.
  2. Following approval, the audit program is provided as an appendix in the WHS Performance Report to University Council for information.
  3. Once the WHS audit program is approved, the Associate Director WEG or delegate provides communication to the auditors and areas to be audited of the final planned audits. A copy of the WHS audit program is accessed from the WEG website.

WHS audit methodology

Planning for a WHS audit

  1. The nominated auditor plans for and prepares the areas to be audited in accordance with WHSMS Handbook Chapter 4.5 guidance.

Conducting WHS audits

  1. In conducting the audit, the auditor observes and seeks evidence from a representative sample of workers that the WHSMS procedure and its corresponding Handbook Chapters are understood and properly implemented. The audit must test the performance of the system, not the individuals. The auditor may involve the Health Safety Representatives (HSRs) in the interviews.
  2. The representative sample for a Tier 2 audit consists of at least one local area.

Reporting of findings from a WHS audit

  1. For a Tier 1 WHS audit, the auditor records all findings into an approved WHS Audit Report template from the third party the University engages.
  2. The Tier 1 external auditor provides the WHS audit report to the University for review and to verify the findings. The University then prepares corrective actions plan in Figtree for any deficiencies found.
  3. For a Tier 2 WHS audit, the auditor records all findings in Figtree.
  4. The findings from a WHS audit are classified as below:
  • Compliance (i.e. 95%-100% question answers and/or documents meet WHSMS Handbook requirements, whichever is lower);
  • Opportunity for improvement (i.e. 80%-95% of question answers and/or documents meet WHSMS Handbook requirements, whichever is lower);
  • Observation (i.e. 65%-80% of question answers and/or documents meet WHSMS Handbook requirements, whichever is lower)
  • Non-conformance (i.e. Below 65% of question answers and/or documents meet WHSMS Handbook requirements, whichever is lower);
  1. The Tier 2 internal auditor provides the WHS audit report to the local area where the audit was conducted for review and to verify the findings. The internal auditor also assigns corrective actions for any deficiencies (i.e. where a No is selected in audit questions or documents).
  2. School/Division Directors, College Deans, General Managers are responsible to ensure sufficient resources are in place and ensure that corrective actions arising from audits are treated as priority.
  3. School/Division Directors, College Deans, General Managers monitor quarterly the completion of all corrective actions in areas under their control, including ones arising from audits, to ensure they are completed and not overdue in accordance with WHSMS Handbook Chapter 4.5 requirements.

Reporting WHS audit results

  1. The Associate Director WEG reports the progress of the WHS audit program and the results of audits in accordance with WHSMS Handbook Chapter 4.5 Section 4.5.2.3 guidance and as per the WHS reporting, WHS communication and consultation and WHS management review procedures.

Reviewing the effectiveness of the WHS audit program

  1. The Associate Director WEG reviews 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

Refer to ANU WHS Legal and Other Requirements Matrix.

Information

Printable version (PDF)
Title Work health and safety audit
Document Type Procedure
Document Number ANUP_015807
Version 5
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 Workplace Health and Safety Policy and is one of the WHS Management System Procedures.
Audience Staff
Category Administrative
Topic/ SubTopic Health, Safety & Environment - Occupational Health & Safety
 
Effective Date 20 Jul 2020
Review Date 19 Jul 2023
 
Responsible Officer: Director, Human Resources
Approved By: Chief Operating Officer
Contact Area Human Resources Division
Authority: Work Health & Safety Act 2011
Work Health and Safety Regulations 2011
Delegations 0