AS/NZS 4801
OHSAS 18001
OHS20309
SAI Global
OHS AUDIT PROCEDURE
September 2014
TABLE OF CONTENTS
1.
PURPOSE ............................................................................................................................. 2
2.
SCOPE .................................................................................................................................. 2
3.
ABBREVIATIONS ................................................................................................................... 2
4.
DEFINITIONS .......................................................................................................................... 2
4.1
4.2
4.3
4.4
4.5
5.
SPECIFIC RESPONSIBILITIES ............................................................................................. 3
5.1
5.2
5.3
5.4
6.
.............................................................................................................................................. 2
.............................................................................................................................................. 2
OHS AUDIT ............................................................................................................................................................. 2
OHS AUDIT REPORT .................................................................................................................................................... 2
TYPES OF OHS AUDIT .............................................................................................................................................. 3
CORRECTIVE ACTION
NON-CONFORMANCE
OCCUPATIONAL HEALTH & SAFETY (OH&S) ............................................................................................................... 3
OHS AUDITOR ......................................................................................................................................................... 3
LEAD AUDITOR........................................................................................................................................................ 3
HEADS OF ACADEMIC/ADMINISTRATIVE UNITS ............................................................................................................ 4
AUDIT.................................................................................................................................... 4
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
AUDITS WILL BE CONDUCTED TO ........................................................................................................................... 4
OHS AUDIT PROGRAM.............................................................................................................................................. 4
AUDITOR COMPETENCY ........................................................................................................................................... 4
PRE-AUDIT ACTIVITIES ............................................................................................................................................. 5
OPENING MEETING .................................................................................................................................................. 5
CONDUCTING THE AUDIT.......................................................................................................................................... 5
AUDIT REPORT ....................................................................................................................................................... 6
CORRECTIVE ACTIONS............................................................................................................................................. 6
CLOSING MEETING .................................................................................................................................................. 6
AGREED ACTION IMPLEMENTATION ........................................................................................................................... 7
MANAGEMENT REPORTING....................................................................................................................................... 7
7.
RECORDS............................................................................................................................. 7
8.
TOOLS .................................................................................................................................... 7
9.
COMPLIANCE ........................................................................................................................ 7
10.
REFERENCES ...................................................................................................................... 8
10.1
11.
MONASH UNIVERSITY OHS DOCUMENTS .................................................................................................................... 8
DOCUMENT HISTORY ......................................................................................................... 8
OHS audits at Monash University, v5
Date of first issue: June 2006
Responsible Officer: Manager, OH&S
Date of last review: September 2014
For the latest version of this document please go to: http://www.monash.edu.au/ohs/
Page 1 of 8
Date of next review: 2017
18/08/14
1.
PURPOSE
This document sets out the processes for developing and conducting the OHS audit
programs at Monash University.
2.
SCOPE
The processes described apply to all OHS management system audits conducted at Monash
University.
3.
ABBREVIATIONS
Monash Occupational Health & Safety
Occupational Health & Safety Management System
Occupational health and safety
Staff Development Unit
OH&S
OHSMS
OHS
SDU
4.
DEFINITIONS
A comprehensive list of definitions is provided in the Definitions tool. Definitions specific to
this procedure are provided below.
4.1
CORRECTIVE ACTION
Corrective action is action taken to eliminate the cause of a detected nonconformance or other undesirable situation.
4.2
NON-CONFORMANCE
A non-conformance is an activity or item that does not conform to the OHS policy,
relevant work standards, practices, procedures or legal requirements or any other
requirements of the Monash University OHS management system.
4.3
OHS AUDIT
An OHS audit is a systematic, independent and documented process for obtaining
evidence of the implementation of an OHS management system.
OHS Audits are risk-based, designed to manage high risk areas/processes. Higher
risk areas/processes are audited more frequently than lower risk areas/processes.
4.4
OHS AUDIT REPORT
An OHS audit report is a documented report of audit findings.
OHS audits at Monash University, v5
Date of first issue: June 2006
Responsible Officer: Manager, OH&S
Date of last review: September 2014
For the latest version of this document please go to: http://www.monash.edu.au/ohs/
Page 2 of 8
Date of next review: 2017
18/08/14
4.5
5.
TYPES OF OHS AUDIT
4.5.1
Self-audit
A self-audit is an OHS audit conducted by an academic/administrative unit
of their own OHS systems. A Monash University self-audit questionnaire
is available at the OH&S web site.
4.5.2
Internal OHS audit
An internal OHS audit is an OHS audit conducted by a Monash University
internal auditor (s) independent of the area under audit. Internal audits
may be based on the broad requirements of University’s OHS
Management System or in applicable areas, on university chemical
management requirements.
4.5.3
External OHS audit
An external OHS audit is an OHS audit conducted by an external
consulting subject matter expert and assesses the implementation of the
requirements of the University’s OHS Management System for a particular
hazard, activity or procedure.
4.5.4
Certification and surveillance audits
Certification and surveillance OHS audits are audits conducted by a
certification body to assess whether the Monash University’s OHS
management system meets the requirements of AS/NZS 4801:2001
Occupational Health & Safety Management Systems – specifications with
guidance for use and OHSAS 18001:2007 Occupational Health and
Safety Systems – Requirements.
SPECIFIC RESPONSIBILITIES
A comprehensive list of OHS responsibilities is provided in the OHS roles, committees and
responsibilities procedure. The responsibilities of OHS audit participants are detailed within.
5.1
OCCUPATIONAL HEALTH & SAFETY (OH&S)
It is the responsibility of OH&S to:
•
coordinate the university’s OHS audit program;
•
distribute audit results;
•
maintain records of audit programs; and
•
assist academic/administrative units to develop and apply corrective actions
and controls to system or procedural deficiencies and non-conformances.
•
verify that agreed corrective actions adequately address detected system or
procedural deficiencies and non-conformances; and
•
assist academic/administrative units to address system or procedural
deficiencies and non-conformances.
5.2
OHS AUDITOR
It is the responsibility of OHS auditors to:
•
conduct audits;
•
report on audit findings and non-conformances.
5.3
LEAD AUDITOR
Lead auditors are responsible for:
OHS audits at Monash University, v5
Date of first issue: June 2006
Responsible Officer: Manager, OH&S
Date of last review: September 2014
For the latest version of this document please go to: http://www.monash.edu.au/ohs/
Page 3 of 8
Date of next review: 2017
18/08/14
•
•
5.4
ensuring the report is delivered to the area within the agreed timeframes
ensure the audit meets the agreed scope and provide briefing to the audit
team.
HEADS OF ACADEMIC/ADMINISTRATIVE UNITS
It is the responsibility of the heads of academic/administrative units to:
•
ensure self-audits are conducted annually and that preventative and corrective
actions are implemented;
•
provide the lead auditor with evidence of current system and procedural
practices in response to audit questions;
•
communicate audit results to the local OHS committee/s;
•
Follow up on the implementation of corrective and preventative actions, and
•
Review the efficacy of preventive and corrective actions implemented.
6.
AUDIT
6.1
6.2
AUDITS WILL BE CONDUCTED TO:
6.1.1
assess compliance of the Monash University OHS management system
with the requirements of AS/NZS 4801:2001 Occupational Health &
Safety Management Systems – specifications with guidance for use and
OHSAS 18001:2007 Occupational Health and Safety Management
Systems- Requirements;
6.1.2
assess the extent of implementation of the Monash University OHS
management system in the university's operations and activities; and
6.1.3
verify the implementation and effectiveness of the university’s OHS policy
and procedures.
OHS AUDIT PROGRAM
6.2.1
An audit program will be prepared and maintained by OH&S. The audit
schedule will be available at the OH&S web site.
6.2.2
The audit schedule will reflect:
•
•
•
•
6.2.3
Unscheduled audits may be conducted at any time based upon:
•
•
•
•
•
•
6.3
the level of risk associated with the activity, policy or procedure;
the OHS importance of the specific element of the Monash University
OHS management system;
the results of previous audits; and
the significance of problems encountered in the areas to be audited.
external audit results;
regulatory inspections/entry reports;
operational changes;
management reviews;
incidents; or
identified n o n -conformances.
AUDITOR COMPETENCY
Audit programs and processes are developed by staff, who have undertaken Lead
Auditor OHS training.
6.3.1
OHS audits at Monash University, v5
Date of first issue: June 2006
All auditors must be appropriately trained and experienced. Minimum
competency requirements have been set as:
Responsible Officer: Manager, OH&S
Date of last review: September 2014
For the latest version of this document please go to: http://www.monash.edu.au/ohs/
Page 4 of 8
Date of next review: 2017
18/08/14
•
•
6.3.2
6.4
Auditors must be approved by OH&S.
PRE-AUDIT ACTIVITIES
6.4.1
Prior to the audit, the OHS Systems and Audit Coordinator is responsible
for:
•
•
•
•
6.5
management system lead auditor training
technical understanding of the OHS control requirements for the area
or subject being audited.
preparing an audit timetable;
preparing audit checklists as required;
collating relevant information for review by the audit team which may
include operating procedures, previous audit findings, standards,
legal requirements, internal procedures;
contacting the academic/administrative unit to agree on and confirm
the above information.
OPENING MEETING
The OHS Consultant/Advisor for the academic/administrative unit audited arranges
opening meeting with:
•
Head of academic/administrative unit;
•
Safety officer;
•
Health & Safety representative;
•
Resources manager;
•
other appropriate area personnel; and
•
OHS Systems and Audit Coordinator.
OHS Systems and Audit Coordinator, OHS Consultant/Advisor and area personnel
must meet to discuss the following topics:
•
scope of audit;
•
how the audit will be conducted;
•
success arrangements to laboratories;
•
resources required (keys, PPE);
•
what the team will do if they find an unsafe situation; and
•
reporting process.
6.6
CONDUCTING THE AUDIT
Audits should be conducted by the audit team as follows using the following steps
as a guideline:
6.6.1
The auditor will conduct audit, which will involve the following steps:
•
•
•
6.6.2
On completion of the audit, the OHS Lead Auditor, OHS Systems and
Audit Coordinator will conduct a post audit debrief, which will include the
following:
•
•
•
•
6.6.3
OHS audits at Monash University, v5
Date of first issue: June 2006
conduct interview/discussion with area staff;
obtain objective evidence for examination to assess conformance;
follow audit trails to confirm evidence.
confirm completion of audit;
return keys, PPE, etc.;
provide a general statement regarding findings; and
confirm reporting process.
Within 2 working days the audit team will discuss and complete audit
questions.
Responsible Officer: Manager, OH&S
Date of last review: September 2014
For the latest version of this document please go to: http://www.monash.edu.au/ohs/
Page 5 of 8
Date of next review: 2017
18/08/14
6.6.4
6.7
OHS Lead auditor and OHS Systems and Audit Coordinator to follow-up
any outstanding items with the participating area.
AUDIT REPORT
The OHS Lead auditor is responsible for finalising the audit report which may
include:
•
•
•
•
•
•
area and element/procedure/process audited;
audit team, audit scope, persons interviewed;
executive summary;
summary of key findings (identified non-conformances);
recommendations:
 non-conformances
 opportunities for improvement, which are areas that may become nonconformances in the future; and
graphical representation of findings.
The completed draft report is reviewed by OHS Systems and Audit Coordinator and
is distributed to Head of academic/administrative unit and others as appropriate for
comment. One to two weeks are allowed for comment and discussion of any
requested changes.
The completed report distributed includes:
•
covering email to auditee area participants; and
•
responses recorded against each applicable audit question.
Copies of the report are distributed to:
•
Head of academic/administrative unit
•
Safety officer(s);
•
Health & Safety representative;
•
Resources manager;
•
Dean of faculty/Head of division;
•
faculty manager;
•
OHS Consultant/Advisor for area;
•
Manager, OH&S; and
•
others as appropriate.
Copies of the report are filed in the:
•
agenda of the next Monash University Occupational Health and Safety
meeting.
6.8
CORRECTIVE ACTIONS
For information on corrective actions produced by an audit please see the OHS
Corrective Actions Procedure.
6.9
CLOSING MEETING
The Lead Auditor, OHS Systems and Audit Coordinator and OHS
Consultant/Advisor of the area meet with representatives from the
academic/administrative unit to discuss the audit findings and to jointly develop a set
of agreed actions. The agreed actions will be recorded in a corrective action report
and provided to the area within 2 weeks of the closing meeting.
OHS audits at Monash University, v5
Date of first issue: June 2006
Responsible Officer: Manager, OH&S
Date of last review: September 2014
For the latest version of this document please go to: http://www.monash.edu.au/ohs/
Page 6 of 8
Date of next review: 2017
18/08/14
6.10
AGREED ACTION IMPLEMENTATION
The academic/administrative unit in consultation with the OHS Consultant/Advisor is
responsible for:
•
closing out all agreed actions within the nominated timeframe; and
•
reporting status of corrective actions to management & to the local
OHS committee; and
•
tracking the progress and effectiveness of the corrective actions;
6.11
MANAGEMENT REPORTING
The Manager, OH&S is responsible for reporting results of audits to university
management at each quarterly Monash University Occupational Health and Safety
committee meeting and to the Audit & Risk Committee of Council.
7.
RECORDS
Records to be kept by
Records
To be kept for
Academic/Administrative u n i t
Records of audits including:
- self-audits
- internal OHS audits
- external OHS audits
- certification and surveillance
audits
7 years
OH&S
Records of audits including:
10 years
-
8.
self-audits
workplace inspections
internal OHS audits
external OHS audits
certification and surveillance
audits
TOOLS
Monash University OHS self-audit questionnaire
9.
COMPLIANCE
This procedure is written to meet the requirements of:
Occupational Health and Safety Act 2004 (Vic)
Occupational Health and Safety Regulations 2007 (Vic)
AS/NZS 4801:2001 Occupational Health & Safety Management Systems –
specifications with guidance for use.
OHSAS 18001:2007 Occupational Health & Safety Management Systems –
requirements
OHSAS 19011:2002 Guidelines for quality and/or environmental management
systems auditing
OHS audits at Monash University, v5
Date of first issue: June 2006
Responsible Officer: Manager, OH&S
Date of last review: September 2014
For the latest version of this document please go to: http://www.monash.edu.au/ohs/
Page 7 of 8
Date of next review: 2017
18/08/14
10.
REFERENCES
10.1
MONASH UNIVERSITY OHS DOCUMENTS
Monash University OHS Self audit questionnaires
OHS management system implementation procedure
OHS roles, committees and responsibilities procedure
OHS Records management
11.
DOCUMENT HISTORY
Version
number
3
4
5
Date of Issue
Changes made to document
February 2011
February 2013
August 2014
OHS Audits at Monash
OHS Audit Procedure
Removed workplace safety inspections
Updated Definitions
Added Compliance section and removed this information from
the scope.
Included step by step audit process with responsibilities.
OHS audits at Monash University, v5
Date of first issue: June 2006
Responsible Officer: Manager, OH&S
Date of last review: September 2014
For the latest version of this document please go to: http://www.monash.edu.au/ohs/
Page 8 of 8
Date of next review: 2017
18/08/14