Policy WHS-PRO-029 Workplace Audit and Inspection Procedure
WHS-PRO-029 Workplace Audit and Inspection Procedure
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Intent
James Cook University (JCU) is committed to monitoring the University’s Work Health and Safety Management System (WHSMS) to evaluate its implementation and effectiveness. This procedure describes the monitoring process for conducting organisational and local level Workplace Health and Safety (WHS) audits/inspections.
WHS audits and inspections evaluate:
- the level of compliance with University WHS policy and procedures; and WHS legislation;
- whether the WHS Management System has been properly implemented and maintained; and
- the effectiveness of the WHS Management System
Scope
This Work Health and Safety Workplace Audit and Inspection Procedure applies to all staff, students, JCU affiliates and contractors involved in JCU business operations and activities.
This Procedure does not apply to the JCU Controlled Entities.
Definitions
Term | Definition |
Action Plan | An action plan lists what steps must be taken to achieve compliance. |
Auditee | The person or business unit being audited. |
Auditor | The person who conducts audits. |
Audit Criteria | Set of requirements used as a reference against which objective evidence is compared (requirements may include legal, policies, procedures, work instructions, contractual obligations, etc.). |
Audit Evidence | Records, statements of fact or other information, which are relevant to the audit criteria and verifiable. |
External Entities | In the context of this procedure examples of external entities are:
|
Officer | A person who makes decisions, or participates in making decisions that affect the whole or a substantial part of JCU or has the capacity to significantly affect the financial standing of JCU. |
RiskWare | RiskWare is JCU’s cloud based online safety management system. The audit module in RiskWare is used to design audits, checklists and inspections, schedule them to be conducted, and create corrective actions for non-conformances. |
Work Health and Safety Advisory Committee (WHSAC) | A Committee that makes recommendations to the Vice Chancellor on all matters relating to work, health and safety issues. |
Workplace Safety Audit | A workplace safety audit is 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. |
Workplace Safety Inspection | A workplace safety inspection is a formal process of observing and documenting safety hazards and unsafe practices in the workplace using a checklist to assist with the identification and monitoring of hazards and risks. |
Table of Contents
1 Duties, Obligations and Responsibilities
1.1 WHS Unit
The WHS Unit is responsible for ensuring that WHS audits and inspections are completed in accordance with this procedure.
- Developing an annual audit and inspection program;
- Reviewing audit and inspections criteria annually;
- Planning and scheduling of audits and inspections;
- Managing the audit and inspection tools and registering on RiskWare;
- Providing awareness to staff regarding their obligations and duties for compliance;
- Monitoring, and where necessary, assisting with closing of corrective actions;
- Reporting statistics relating to WHS audits to WHS Committees.
1.2 Auditor
The Auditor engaged by the WHS Unit will be responsible for the following activities, in line with the overall coordination remit of the WHS Unit:
- Communicating objectives and outcomes;
- Planning and scheduling audits and inspections;
- Conducting the audit in line with the principles outlined in this procedure;
- Consultation on compliance and improvements;
- Monitoring action completion.
1.3 Auditee
The Auditee is the person/s representing the business unit or workplace being audited or inspected. The Auditee will be responsible for the following activities:
- Attending the WHS audit or inspection;
- Understanding the activities being conducted and access to resources to confirm and or verify components of an audit or inspection;
- Appointing person/s responsible for completing actions from the audit or inspection;
- Communicating the audit or inspection outcomes back to their area of the business;
- Closing assigned actions within the allotted time.
1.4 Officers
Officers as defined under WHS-PRO-001 WHS Responsibilities Procedure for each Directorate or College are responsible for;
- Allocating time for staff to attend audits and inspections;
- Allocating time and resources to ensure compliance as per the audit or inspection criteria.
2 Workplace Safety Audits & Inspections
2.1 Principles
The purpose of auditing and conducting inspections is to provide accurate information on the performance of nominated areas of the Work Health and Safety Management System. To ensure the audits and inspections are effective, the WHS Unit will apply the following principles when undertaking audits and inspections:
- Integrity (Auditors perform their work ethically, with honesty and responsibility; only undertake audit if competent to do so; perform their work in an impartial manner; be objective and sensitive to any influences that may be exerted on their judgement);
- Report truthfully and accurately (this includes acknowledging any obstacles in the audit process);
- Diligence and judgement – reasoned judgements in all audit situations;
- Maintain confidentiality of information;
- Independent – Auditors should be independent of the activity being audited where practicable;
- Evidence-based approach (verifiable evidence);
- Risk-based approach – matters should be significant for the safety of the JCU community.
2.2 Audit and inspection program
At the end of each calendar year, the WHS Unit will review the audit and inspection program for the following year. The program will be determined after considering:
- The reported hazards and risks, assurance needs and expectations of the University;
- WHS management system requirements;
- Incident trends and results from investigations (including industry trends);
- Changes to legislation / Australian Standards / industry standards;
- Resourcing;
- Results of previous audits.
2.3 Types of WHS management audits and inspections
JCU WHS management audits and inspections are conducted to verify that key aspects of the Work Health and Safety management system are effectively implemented and operate as desired. The audits / inspections focus on the areas that have the greatest WHS risk exposure.
2.3.1 Difference between audits and inspections
Inspections | Audits |
Identify unsafe acts & unsafe conditions (prevent immediate causes of incidents) | Identify unsafe processes (prevent root causes of incidents) |
Focus on an action (what) | Focus on a process (why) |
Quantitative (visual / observational) | Quantitative and Qualitative (visual / observational and interviews) |
Compliant / not compliant | Involves making judgement |
Simple | Complex |
2.3.2 Types of audits
- Desktop audits (review of existing documentation);
- Gap analysis against standards;
- Compliance audit testing (auditing system elements, policies, procedures, processes, premises, plant & equipment against legislative requirements, codes and standards);
- Systems audit;
- Process audit;
- WHS Management Plan Audit.
(Some audits may be a combination of the above).
2.3.3 Examples of WHS inspections
- Regulatory inspection:
- Electrical test and tag & residual current device;
- Fire safety installations;
- Registrable plant;
- Emergency - first aid kits, automated external defibrillator, eyewash and safety showers;
- Vehicle.
- Equipment inspections;
- Scheduled inspection of locations:
- Plant room;
- Workshops;
- Accommodation;
- Emergency preparedness;
- Off-campus sites;
- Grounds;
- Laboratories.
2.4 Frequency
The frequency of WHS audits is determined on the level of risk associated with the activity, area or a procedure and the WHS Unit will determine audit frequency as part of development of the annual audit and inspection program. It considers:
- the results of previous audits;
- accident and incident statistics;
- the significance of problems encountered in the areas to be audited;
- emerging hazards or issues.
2.5 Criteria
Audit and inspection criteria are used to determine conformity. Criteria may be taken from applicable policies, processes, procedures, regulatory requirements, management system requirements or information regarding the risk, codes of practice and industry standards.
Audit criteria is created and reviewed each year once the audit and inspection program has been determined by the WHS Unit. Audit criteria will remain in place for the entire annual program to ensure consistency for each Auditee.
2.6 Verifying information
During the audit / inspection, information relevant to the audit / inspection criteria should be verified with evidence where possible. Methods of collecting information includes interviews, observations, review of documentation and analytical procedures.
The workplace safety audits require information verification to obtain compliance against criteria of the audit.
Workplace safety inspections will only require confirmation that compliance is demonstrated or sighted.
Verifying information means the information is:
- Complete (all expected content is contained in the documented information);
- Correct (the content conforms to other reliable sources such as standards and regulations);
- Consistent (the documented information is consistent in itself and with related documents);
- Current (the content is up to date).
2.7 Compliance
To meet compliance the Auditee must demonstrate and provide evidence that:
- University procedures have been implemented / met; and
- All pertinent WHS legislative requirements are met.
2.8 Non-compliance
To draw conclusion of non-compliance, the Auditor must find evidence that there was:
- an absence of evidence towards compliance;
- an absence or failure of system elements or a part of the system;
- an absence in documented systems or procedures;
- a failure to follow the documented systems or procedures;
- apparent legislative non-compliance; or
- little or no evidence towards continued improvement.
If a non-compliance has been identified, the non-compliance must be discussed with the Auditee to determine if a follow up workplace safety audit or inspection is required outside of the normal frequency. Where appropriate a Compliance Action Plan is to be completed.
2.9 Action Plan
If a non-compliance is identified because of a WHS Audit, the Auditor will enter an action plan into RiskWare in consultation with the Auditee. Where required, any resulting corrective actions will be assigned to responsible person(s) for implementation and agreed timeframes.
The purpose of an action plan is to clarify what resources are required to reach the compliance and formulate a timeline for when specific tasks need to be completed.
Action plans developed by external Auditors will be placed into RiskWare by the WHS Unit.
2.10 Overdue Actions
Action items that are not completed within the agreed timeframes may be included in quarterly reports to WHSAC and Division Heads.
Related Policy Instruments
JCU Work Health and Safety Policy
WHS-PRO-001 WHS Responsibilities Procedure
WHS-PRO-003 WHS Consultation and Participation Procedure
WHS-PRO-004 WHS Training and Competency Procedure
WHS-PRO-005 WHS Incident and Hazard Management Procedure
WHS-PRO-007 Health Engagement Procedure
WHS-PRO-008 Asbestos Management Procedure
WHS-PRO-009 Biosafety Procedure
WHS-PRO-011 Drugs and Poisons Procedure
WHS-PRO-014 Ionising Radiation Procedure
WHS-PRO-015 Field Trip Procedure
WHS-PRO-018 Remotely Piloted Aircraft Procedure
WHS-PRO-025 Contractor Safety Management Procedure
WHS-PRO-028 Student Placement Procedure
Administration
NOTE: Printed copies of this procedure are uncontrolled, and currency can only be assured at the time of printing.
Approval Details
Policy Domain | Work Health and Safety |
Policy Sponsor | Deputy Vice Chancellor, Services and Resources |
Approval Authority | Deputy Vice Chancellor, Services and Resources |
Date for next Major Review | 30/06/2027 |
Revision History
Version | Approval date | Implementation date | Details | Author |
22-1 | 29/06/2022 | 30/06/2022 | Procedure established | Principal Technical Officer, WHS |
Keywords | Audit, Inspection, compliance |
Contact person | Manager, Work Health and Safety |