n.pdf
OHS CORRECTIVE ACTION PROCEDURE
AS/NZS 4801
OHSAS 18001
OHS20309
SAI Global
November 2013
TABLE OF CONTENTS
1.
PURPOSE .................................................................................................................................. 2
2.
SCOPE ....................................................................................................................................... 2
3.
ABBREVIATIONS ...................................................................................................................... 2
4.
DEFINITIONS ............................................................................................................................. 2
4.1
4.2
4.3
4.4
5.
STAKEHOLDERS ...................................................................................................................................................
2
SPECIFIC RESPONSIBILITIES ................................................................................................. 2
5.1
5.2
5.3
6.
ACTION SEQUENCE .............................................................................................................................................. 2
CORRECTIVE ACTION............................................................................................................................................ 2
CORRECTIVE ACTION REGISTER ......................................................................................................................... 2
HEAD OF ACADEMIC/ADMINISTRATIVE UNITS (PERSON IN CONTROL OF A WORKPLACE) .............................................. 2
SAFETY OFFICERS AND SPECIALITY OFFICERS ...................................................................................................... 3
STAKEHOLDERS ................................................................................................................................................... 3
CORRECTIVE ACTION PROCEDURE .......................................................................................3
6.1
6.2
6.3
6.4
6.5
6.6
NEW ACTION IDENTIFIED ....................................................................................................................................... 3
CONSULTATION PROCESS .................................................................................................................................. 3
CORRECTIVE ACTION MANAGEMENT .................................................................................................................... 4
ACTION SEQUENCE CLOSE-OUT .......................................................................................................................... 4
REPORTING ......................................................................................................................................................... 4
CORRECTIVE ACTION REVIEW ................................................................................................................................ 4
7.
RECORDS .....................................................................................................................................6
8.
TOOLS ........................................................................................................................................ 6
8.1
9.
REFERENCES ..............................................................................................................................6
9.1
9.2
9.3
9.4
10.
CORRECTIVE ACTION REGISTER TEMPLATE .......................................................................................................... 6
LEGISLATION ....................................................................................................................................................... 6
AUSTRALIAN STANDARDS .................................................................................................................................. 6
MONASH UNIVERSITY PROCEDURES THAT CREATE CORRECTIVE ACTIONS ................................................................ 6
MONASH UNIVERSITY OHS DOCUMENTS ............................................................................................................... 6
DOCUMENT HISTORY .................................................................................................................7
Corrective Action Procedure, v3
Date of first issue: August 2007
Responsible Officer: Manager, OH&S
Date of last review: November 2013
Page 1 of 7
Date of next review: 2016
31/10/2013
1.
PURPOSE
This document sets out the processes to be used for corrective action at Monash University
in accordance with the Occupational Health and Safety Act (2004) and associated
regulations and with Standards AS/NZS 4801:2001 Occupational Health & Safety
Management Systems – specifications with guidance for use and OHSAS 18001:2007
Occupational Health & Safety Management Systems – requirements. Corrective action must
be undertaken to meet the objective of the Occupational Health and Safety Act (2004) to
eliminate, at the source, risks to the health, safety or welfare of employees and other person
at work.
2.
SCOPE
The processes described apply to all activities conducted on Australian campuses of Monash
University.
3.
ABBREVIATIONS
CAR
HSR
OHS
OH&S
4.
Corrective Actions Register
Health and Safety Representative
Occupational health and safety
Monash Occupational Health & Safety
DEFINITIONS
A comprehensive list of definitions is provided in the Definitions Tool. Definitions specific to
this procedure are as follows.
4.1
ACTION SEQUENCE
A designated set of steps designed to implement a solution identified as part of a
corrective action.
4.2
CORRECTIVE ACTION
Corrective action (inclusive of preventive action) is an action taken to correct a
health and safety related problem or potential problem, and to prevent, so far as is
practicable, a recurrence. A corrective action must have an assigned responsible
party, have been consulted upon with key stakeholders, have a specific solution
identified and have an agreed timeframe for implementation.
4.3
CORRECTIVE ACTION REGISTER
Corrective Action Register (CAR) is a record of all corrective actions that have been
agreed upon and/or undertaken within a designated area. A template is available
Monash
University
OHS
website:
from
the
Corrective-actions-register
4.4
STAKEHOLDERS
Stakeholders include any individual (staff, student, contractor or visitor) who is
affected by a hazard which requires controlling.
5.
SPECIFIC RESPONSIBILITIES
A comprehensive list of OHS responsibilities is provided in the document OHS Roles,
Committees and Responsibilities Procedure. A summary of the specific responsibilities
relevant to this procedure is provided below.
5.1
HEAD OF ACADEMIC/ADMINISTRATIVE UNITS (PERSON IN CONTROL OF A WORKPLACE)
A head of academic/administrative unit has the overall responsibility for ensuring
that every corrective action is fully implemented by an action sequence within an
agreed time frame. They may delegate this responsibility to a management
representative who is authorised to approve changes to a workplace. This is
Corrective Action Procedure, v3
Date of first issue: August 2007
Responsible Officer: Manager, OH&S
Date of last review: November 2013
Page 2 of 7
Date of next review: 2016
31/10/2013
commonly a manager or deputy head.
5.2
SAFETY OFFICERS AND SPECIALITY OFFICERS
Safety officers may only act on corrective actions when instructed by a head of
academic/administrative unit (or delegate) or if they have been authorized as
delegate to approve changes to a workplace. They must be included in the
consultation process.
5.3
STAKEHOLDERS
Stakeholders are responsible for participating in the consultation process for all
relevant actions being considered. Stakeholders are not responsible for ensuring
that an action is undertaken.
6.
CORRECTIVE ACTION PROCEDURE
6.1
NEW ACTION IDENTIFIED
Process associated with the following procedures may identify occupational health
and safety issues that will require corrective action:
• Hazard and incident reporting, investigation and recording (pdf 147kb)
• OHS Audit Procedure (pdf 124kb)
• Emergency Preparedness
• Risk management program (pdf 385kb)
• OHS roles, committees and responsibilities procedure (pdf 153kb) – Specifically
committees
• OHS management system implementation procedure – Specifically OHS plans
6.2
CONSULTATION PROCESS
When an issue has been identified that requires action, the consultation process
must initiated.
6.2.1
The resolution of an issue must be assigned to a responsible party who is
either the head of academic/administrative unit or their delegate. In a
situation where multiple responsible parties are identified (e.g. multiple
organizational units involved), agreement must be reached on whom the
most appropriate party is. A head of academic/administrative unit may
assign a delegate.
6.2.2
Consultation with key stakeholders must occur for all corrective actions.
Stakeholders
must
include,
where
applicable;
a
head
of
academic/administrative unit or approved delegate, area or activity head,
relevant supervisors, the designated work group’s HSR and/or any staff,
students, contractors or visitors undertaking work or located near work
area. OHS chairpersons, safety officers and any other specialty safety
roles, Monash University OH&S and/or external consultants may be
included in consultation if requested or required.
Stakeholders must agree upon:
• what is the problem
• what potential solutions are available and which of these is the
preferred option
• what time frame for this action is reasonable
• who is responsible for resolving the matter
6.2.3
If agreement on any of these elements cannot be reached, escalation of the
responsible party must follow the Health and Safety Issue Resolution
Procedure.
Corrective Action Procedure, v3
Date of first issue: August 2007
Responsible Officer: Manager, OH&S
Date of last review: November 2013
Page 3 of 7
Date of next review: 2016
31/10/2013
6.2.4
6.3
6.4
6.5
Once agreement has been reached; the problem, the preferred option, the
agreed timeframe and the responsible party, must be recorded in a
Corrective Actions Register (CAR) and the status recorded as “Open”.
CORRECTIVE ACTION MANAGEMENT
6.3.1
A responsible party must create an action sequence to complete all aspects
of an “Open” corrective action. Guidance on creating and implementing
action sequences can be found in the Guideline for implementing corrective
actions (to be implemented).
6.3.2
The head of academic/administrative unit or delegate must either complete
the action sequence or assign agreed actions to suitable staff, students,
contractors and/or visitors.
6.3.3
Responsibility for the completion of an action plan remains with the head of
academic/administrative
unit
or
delegate.
The
head
of
academic/administrative unit or delegate must review progress against
each action plan until the action sequence is completed or the agreed time
frame has lapsed.
ACTION SEQUENCE CLOSE-OUT
6.4.1
Head of academic/administrative unit or delegated must ensure that each
corrective action has been closed-out. Upon completion, stakeholders must
be notified of the completion (e.g. via email or phone message) and the
status of the action must be recorded in a CAR as “Closed: Completed”.
6.4.2
Where an action was not achievable due to a change of circumstances
(e.g. lack of resources), the status shall be recorded as “Closed:
Incomplete” in a CAR and consultation on a new action must be initiated.
When a new corrective action has been created, this action must be linked
with the previous incomplete action within a CAR.
REPORTING
All entries in the CAR that have recently changed status must be reported to
relevant the local OHS committee and/or suitable staff meeting.
6.6
CORRECTIVE ACTION REVIEW
All entries in the CAR shall be reviewed regularly by the head of
academic/administrative unit or delegate (at least quarterly) and the outcome of the
the
local
OHS
committee.
review
reported
to
Corrective Action Procedure, v3
Date of first issue: August 2007
Responsible Officer: Manager, OH&S
Date of last review: November 2013
Page 4 of 7
Date of next review: 2016
31/10/2013
Corrective Action Procedure, v3
Date of first issue: August 2007
Responsible Officer: Manager, OH&S
Date of last review: November 2013
Page 5 of 7
Date of next review: 2016
31/10/2013
7.
8.
RECORDS
Record to be kept by
Records
To be kept for:
Academic/administrative
unit
Records of corrective actions
including complete and/or
incomplete actions
5 years
TOOLS
8.1
CORRECTIVE ACTION REGISTER TEMPLATE
(http://www.monash.edu.au/ohs/forms/index)
9.
REFERENCES
9.1
LEGISLATION
Occupational Health and Safety Act 2004 (Vic)
Occupational Health and Safety Regulations 2007 (Vic)
9.2
AUSTRALIAN STANDARDS
AS/NZS 4801:2001 Occupational Health & Safety Management Systems –
specifications with guidance for use.
OHSAS 18001:2007 Occupational Health & Safety Management Systems –
requirements.
9.3
MONASH UNIVERSITY PROCEDURES THAT CREATE CORRECTIVE ACTIONS
(http://www.monash.edu.au/ohs/)
Hazard and incident reporting, investigation and recording (pdf 147kb)
OHS Audit Procedure (pdf 124kb)
Emergency Preparedness
Risk management program (pdf 385kb)
OHS roles, committees and responsibilities procedure (pdf 153kb) – Specifically
committees
OHS management system implementation procedure – Specifically OHS plans
9.4
MONASH UNIVERSITY OHS DOCUMENTS
(http://www.monash.edu.au/ohs/)
Guideline for implementing corrective actions (to be implemented)
Health and Safety Issue Resolution Procedure.
Corrective Action Procedure, v3
Date of first issue: August 2007
Responsible Officer: Manager, OH&S
Date of last review: November 2013
Page 6 of 7
Date of next review: 2016
31/10/2013
10. DOCUMENT HISTORY
Version
number
2
3
Date of Issue
Changes made to document
February 2011
February 2013
OHS Corrective Action Procedure, v2
1. Deleted old summary table;
2. Added responsibilities section;
3. Added procedural section in section 6;
4. Added flowchart as a visual representation of section 6;
5. Refined definitions section;
6. Added document history section; and
7. Added Tool section Corrective Action Register Template.
Corrective Action Procedure, v3
Date of first issue: August 2007
Responsible Officer: Manager, OH&S
Date of last review: November 2013
Page 7 of 7
Date of next review: 2016
31/10/2013