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Work Health and Safety Audit Procedure

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Section 1 - Purpose

(1) This Procedure describes the auditing processes used to verify the implementation of and evaluate the effectiveness of the Work Health and Safety (WHS) Management System at Charles Sturt University (the University).

(2) WHS audits include evaluating:

  1. the level of compliance with University WHS policy and procedures; and WHS legislation;
  2. whether the WHS Management System has been properly implemented and maintained; and
  3. the effectiveness of the WHS Management System.

Scope

(3) This Procedure outlines the requirements for auditing the implementation of the University’s WHS Management System throughout the organisation.

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Section 2 - Glossary

(4) For the purpose of this Procedure:

  1. Audit – means a systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which the audit criteria are fulfilled;
  2. Audit criteria – means the requirements which the audit will be assessing as taken from legislation, standards, codes of practice, policies and procedures;
  3. Auditee – means the person or area being audited;
  4. Audit evidence – means records, statements of fact or other verifiable information, which are relevant to the audit criteria;
  5. Audit findings – means the results of the evaluation of the audit evidence against audit criteria;
  6. Audit scope – means the extent and boundaries of the audit;
  7. Audit objectives – means the intended purposes of the audit;
  8. Auditor – means a person with the competence to conduct an audit; and
  9. Audit plan – means a description of the activities and arrangements for an audit.
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Section 3 - Policy

(5) Refer to the Work Health and Safety Policy.

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Section 4 - Procedures

Part A - Responsibilities

Work Health and Safety Systems and Compliance Officer

(6) The Work Health and Safety Systems and Compliance Officer will:

  1. prepare a WHS audit plan and schedule, as detailed in Part B;
  2. prepare the audit scope, objectives and criteria;
  3. ensure audits are conducted in accordance with this procedure;
  4. manage and conduct the University’s WHS audit program including:
    1. establishing the objectives and extent of the audit program;
    2. defining the responsibilities and procedures in accordance with regulatory and University requirements;
    3. ensuring resources are provided to complete the audit program;
    4. implementing the audit program;
    5. ensuring that appropriate audit records are maintained; and
    6. review and continuous improvement of the audit program.
  5. prepare a quarterly University-wide audit report, as detailed in Part B; and
  6. conduct an annual review of audit non-conformances, as detailed in Part B.

Auditor(s)

(7) Auditors will adhere to the following principles of auditing derived from the ISO 19011 while conducting the audit:

  1. ethical conduct – trust, integrity, confidentiality and discretion;
  2. fair presentation – audit findings, audit conclusions and audit reports reflect truthfully and accurately the audit activities.  Significant obstacles encountered during the audit and unresolved diverging opinions between the audit team and the audit area are reported; and
  3. due professional care – auditors exercise care in accordance with the importance of the task they perform and the confidence placed in them by audit clients and other interested parties. Having the necessary competence is an important factor.

(8) Auditors will also:

  1. complete WHS management system auditor training;
  2. hold WHS qualifications and/or relevant WHS work experience;
  3. maintain a level of independence from the area being audited, where possible;
  4. carry out the audit methodology, as detailed in Part B;
  5. hold an initial meeting/opening meeting, as detailed in Part B;
  6. collect audit evidence, as detailed in Part B;
  7. report Audit Results, as detailed in Part B; and
  8. conduct corrective action progress reviews, where required, as detailed in Part B.

Managers of Faculties/Divisions/Offices

(9) Managers will:

  1. develop an audit corrective action plan in consultation with the auditor, as detailed in Part B; and
  2. ensure that any remedial actions required as an outcome of a WHS audit are implemented within their area of control.

Part B - WHS Audit

General Audit Arrangements

(10) Work Health and Safety (WHS) audits sit in two distinct parts:

  1. Within the University there are three levels of WHS audit:
    1. WHS Inspections: these inspections should be performed at regular intervals of at least six monthly, depending on the risks of the work and the workplace. Refer Workplace Inspections and Reports Procedure for more information. These inspections provide an opportunity to regularly review compliance with local safety procedures;
    2. WHS Systems Audits: these audits are conducted by the WHS Unit according to a plan and schedule. These audits are an objective assessment of the extent to which the University’s WHS Framework, Policy and Procedures have been implemented and compliance with statutory requirements. Faculties/Divisions/Offices are the auditee during WHS systems audits; and
    3. Internal Audits: these audits are conducted by the University’s Internal Audit and Risk Management Team. Internal audits assess the University’s compliance with WHS legislation, Codes of Practice and applicable standards. The WHS Unit is the auditee during internal audits.
  2. External Audits: periodically the University may be audited by an external auditor or assessor who is totally independent of the business. This is to verify that the internal audits are a valid assessment of the current status of WHS implementation.

Audit Plan

(11) Prepare a WHS audit plan to cover a three year cycle.

(12) Prepare an annual WHS audit schedule in consultation with the University Safety and Health Management Committee (USHMC) and the areas which will be audited (auditees). It is important to ensure audits do not conflict with peak business periods such as exams or residential schools.

(13) Base the WHS audit schedule on risk (hazard profile, incidents, previous audit results and workplace inspection results).

Audit Methodology

(14) Conduct the audit using audit scope, objectives and criteria based on the WHS Policy and/or relevant WHS Procedures being audited.

(15) Observe the following audit protocols:

  1. the auditor will review any previous audit reports for the area which relate to the audit scope;
  2. the date and scope of the audit is to be notified in writing to the Manager of the area one month prior to the scheduled audit commencing;
  3. the auditor will request documents, which are within the audit scope, for review prior to the initial meeting;
  4. an initial meeting with the management and key personnel of the area to be conducted prior to the audit;
  5. the audit is conducted by the WHS Unit which may involve interviews, documentation review and/or physical inspection of areas as determined from the scope of the audit;
  6. an audit debrief meeting will be held which provides preliminary findings and the official closing of the audit;
  7. both positive observations and opportunities for improvement are to be identified;
  8. a draft audit report is prepared by the lead auditor utilising the audit report template which outlines non-conformances and recommendations for improvement;
  9. the draft audit report is sent to the Area Manager and WHS Unit for consultation;
  10. after the consultation period is closed, the final report is sent to the management of the area; and
  11. any area which fails an audit will be re-audited within 6 months of the initial audit. The purpose of a re-audit is to assist the area in implementing and assessing the effectiveness of improvements.

Initial Meeting/Opening Meeting

(16) Hold an initial meeting with the auditee’s management or, where appropriate, those responsible for the functions or processes to be audited. Where the auditee has a Health and Safety Representative, they must be invited to this meeting.

(17) The purpose of an initial meeting is to:

  1. provide a short summary of how the audit activities will be undertaken;
  2. confirm communication channels;
  3. confirm employees to be interviewed for the audit;
  4. provide an opportunity for the auditee to ask questions;
  5. provide auditees the opportunity to identify specific tasks or activities to focus on;
  6. clarify the process for the reporting of hazards identified throughout the audit; and
  7. outline the purpose, scope, methodology, scheduling of any interviews, required documents results, corrective action plan and any questions.

(18) Hold an opening meeting on the first day of the audit. The opening meeting should include:

  1. auditors;
  2. a management representative from the auditee;
  3. any other key personnel identified by the auditee; and
  4. Health and Safety Representatives for the area, if they have them.

(19) The purpose of the opening meeting is to officially commence the audit process and to provide the auditee the opportunity to communicate or clarify any changes or additions to the audit scope.

Audit Evidence

(20) Collect information relevant to the objectives and criteria from a representative sample of personnel through observation and discussion with people who implement the system. Only information (including verbal evidence) which is provided at the time of the audit can be included as sufficient evidence to determine conformance to the criteria.

(21) Classify findings as:

  1. Conformance: all elements of the audit criteria are in place and there are no significant open external audit findings;
  2. Partial Conformance: not all elements of the criteria are in place. Some non-critical weaknesses are evident which need to be rectified; or
  3. Non Conformance: major elements are not yet implemented. Significant corrective action is required.

Reporting of Audit Results

(22) Determine audit results by removing all non-applicable and non-verifiable criteria from the results. The remaining criteria are then assigned a ‘conformance’ ‘partial conformance’ or ‘non-conformance’ rating based on the compliance shown through the audit. The audit results are then based on the percentage of conforming criteria.

(23) Report audit results, including findings, to management and key personnel of the area through the final audit report.

(24) Prepare a quarterly University-wide audit report and present it to University Safety and Health Management Committee (USHMC), Finance, Audit and Risk Committee of the University Council, and WHS Committees.

Corrective Action Plan

(25) Where deficiencies are identified:

  1. develop an audit corrective action plan. Audit Corrective Action Plan Template (Appendix A) is provided in the associated information to this procedure and a copy will be included in the audit report; and
  2. conduct corrective action progress reviews within a six month period from the time of the audit.

Review and Improvement

(26) Conduct an annual review of audit non-conformances for each year to identify trends and system improvement initiatives.

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Section 5 - Guidelines

(27) Nil.