Occupational Health and Safety Management System Audit Procedure by alendar

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									                                                Occupational Health and Safety Management
                                                         System Audit Procedure

UNSW Procedure

Control number                             OHS308
                                           This procedure details actions and processes pursuant to
Linked UNSW Policy                         The UNSW OHS Policy

Responsible Officer                        Director, Human Resources

Authorisation                              Director, Human Resources

Contact Officer                            Manager, OHS and Workers Compensation

Effective Date                             1 January 2007

Superseded Documents                       UNSW OHSMS Auditing Procedure v4, June 2006
                                           This procedure will be reviewed in accordance with the
Review                                     OHS Management System Review Procedure

File Number                                TRIM 2002/2778

1. Purpose/Objectives
       Provides direction for persons undertaking OHSMS Auditing at UNSW. In this
       procedure describes the methodology for ensuring consistency in the undertaking,
       recording and management of UNSW OHSMS Audits.

2. Scope
       This procedure applies to all persons who undertake OHSMS audits at UNSW as well
       as all activities and documents related to auditing the UNSW OHSMS.
                  Table 1 - Scope of UNSW Business Areas Requiring Auditing:

                                UNSW Auditable Business Areas
               Faculty of Arts and Social Sciences
               Faculty of Business
               Faculty of Built Environment
               Faculty of the College of Fine Arts
               Faculty of Engineering
               Faculty of Law
               Faculty of Medicine
               Faculty of Science
               Division of the Deputy Vice-Chancellor (Academic)
               Division of the Deputy Vice-Chancellor (Research)
               Division of the Chief Operating Officer
               Division of the Chief Financial Officer
               UNSW Foundation



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UNSW OHSMS Auditing Procedure                                                             Date Effective: 01/01/2007
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3. Definitions
    • Audit - systematic, independent and documented process for obtaining audit evidence
        and evaluating it objectively to determine the extent to which the audit criteria are
        fulfilled.
    • Audit evidence - records, statements of fact or other information, which are relevant to
        the audit criteria and verifiable.
        NOTE Audit evidence may be qualitative or quantitative.
    • Audit findings - results of the evaluation of the collected audit evidence against audit
        criteria.
        NOTE Audit findings can indicate either conformity or nonconformity with audit
        criteria.
    • Audit conclusion - outcome of an audit, provided by the audit team after consideration
        of the audit objectives and all audit findings.
    • Auditee – UNSW Faculty or Division being audited. All Auditee actions are the
        responsibility of the Dean or Divisional Manager.
    • Auditor(s) – person(s) with the competence to conduct an audit.
        Audit team - one or more auditors conducting an audit.
    • Audit plan - description of the activities and arrangements for an audit.
    • Audit scope - extent and boundaries of an audit.
    • Audit score – numerical value given to the audit findings.
    • Competence - demonstrated personal attributes and demonstrated ability to apply
        knowledge and skills.
    • The Procedure – refers to OHSMS Audit Procedure

4. Procedure

         4.1      Audit Frequency

         UNSW will conduct annual OHSMS Audits across all UNSW Business units (see
         Scope). The University will develop a 5 year Audit Schedule ensuring that all elements
         of the UNSW OHSMS are audited throughout UNSW business structure (UNSW
         OHSMS Audit Schedule 2008 – 2013).

         4.2      Authority

         The UNSW Manager OHS and Workers Compensation (Manager OHS&WC) is
         authorised by UNSW Senior Management to direct a broad, comprehensive program of
         OHSMS auditing across the University.

         The Manager OHS&WC and members of the audit team, including consultants
         engaged to undertake OHSMS audits, are authorised to have unrestricted access to all
         functions, property, personnel, records, accounts, files and other documentation of the
         University in relation to the audits. All information accessed is strictly used for audit
         purposes only.




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UNSW OHSMS Auditing Procedure                                                             Date Effective: 01/01/2007
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         4.3      Responsibilities

         OHSMS auditing does not relieve senior management from the responsibility of
         ensuring that adequate hazard controls are in place for all business activities for which
         they are accountable.

                  4.3.1 Manager OHS and WC
                  Is responsible for:
                  • establishing and maintaining the UNSW OHSMS Audit Schedules
                  • ensuring OHSMS audits are conducted according to the OHSMS Audit
                      Procedure.
                  • reporting OHSMS audit results to the Level 1 OHS Strategic Planning
                      Committee and the Vice Chancellor.
                  • establishing, maintaining and coordinating UNSW’s OHSMS Audit
                      Procedure and audit processes.

                  4.3.2 Lead Auditor and Auditor (engaged to conduct OHSMS Audits)
                  Is responsible for:
                  • conducting OHSMS audits according to this procedure.
                  • following any audit procedures established by the OHS and WC Unit.

                  4.3.3 Auditee
                  Is required to:
                  • complete UNSW Self Audit Tool upon request by the Manager OHS & WC
                      or the lead auditor,
                  • cooperate with the requests of the lead auditor and provide unfettered
                      access to staff, documents and records relevant to the audit.
                  • assign a guide to accompany the auditor during the audit.

                  4.3.4 Audit Guides
                  Are responsible for:
                      • accompanying and guiding the auditor(s) during the audit process;
                      • establishing contacts and timing for interviews;
                      • arranging visits to specific parts of the audit site;
                      • ensuring that rules concerning the safety and security precautions are
                         known and respected by the audit team members;
                      • witness the audit on behalf of the auditee;
                      • provide clarification or assisting in collecting information.

         4.4      Internal Audit Standards and Auditor Competence

               OHSMS audits shall comply with the UNSW OHSMS Audit procedure.

               All auditors shall be appropriately qualified and/or part of an experienced audit
               team in accordance with AS/NZS ISO 19011-2003.

         4.5      OHSMS Audit Process

         1) The Manager OHS & WC will annually review the UNSW OHSMS Audit Schedule
         2008 -2013 (OHS 067) to identify when and what area will be audited. Each area

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         being audited will be contacted by the Manager OHS & WC or the lead auditor to
         initiate the audit process.

         2) The OHSMS Audit Process (OHS 068) document will be used to establish the flow of
         work activities, timeframes and associated deadlines that must be used for all OHSMS
         audits.
         The auditee will complete the online Self Audit Tool (SAT):
                 • SAT score of less than 70% = Audit failed (audit failure reported, audit
                  corrective actions to be addressed).
                 • SAT score of 70% or higher = Onsite audit will proceed.

         3) Audit findings and any corrective actions will be communicated to the
         Faculty/Division. Audit non-conformances must be placed on the all School/Unit
         corrective action registers.

         4) The Manager OHS & WC will communicate the results of OHSMS audits to UNSW
         Senior Management via the Level 1 OHS Committee

5. Legal & Policy Framework
    • UNSW OHS Policy.
    • Australian Standard AS/NZS ISO 19011:2003 Auditing Quality and Environmental
        Management Systems.
    • Occupational Health and Safety Model for Self Insurers, July 2005.

         5.1   Associated Documents
         • UNSW OHSMS Audit Schedule 2008 -2013
         • OHSMS Audit Process v 2.1
         • Self Audit Tool (SAT) www.technet.unsw.edu.au/audit

6. Evaluation & 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.

         6.1    Modifications
          Version   Date                  Author          Approval           Sections        Details of
                                                                             modified        amendments
          1.0            24/05/2002       Kathy           Director, Risk     N/A             New document
                                          Richardson      Management
                                                          Unit
          2.0            19/05/2003       Kathy           Director, Risk                     Not recorded
                                          Richardson      Management
                                                          Unit
          3.0            28/05/2003       Kathy           Director, Risk                     Not recorded
                                          Richardson      Management
                                                          Unit
          4.0            1/06/2004        Kathy           Director, Risk                      Not recorded
                                          Richardson      Management
                                                          Unit
          5.0            1/01/2007        Adam            Director,          Entire           Reformatted document
                                          Janssen         Human              Document         and revised all sections
                                                          Resources
          5.1            26/09/2008       Adam            Manager OHS        Entire           Reformatted document
                                          Janssen         & WC               Document         and revised all sections



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UNSW OHSMS Auditing Procedure                                                             Date Effective: 01/01/2007
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