WHS-PRO-029 Workplace Audit and Inspection Procedure

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:

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

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

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

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:

1. the results of previous audits;
2. accident and incident statistics;
3. the significance of problems encountered in the areas to be audited;
4. 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 Records Management Policy

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

Revision History