Operational Responsibility:
Related Policy/Procedure:
Related Policy/Procedure
Section:
This instruction is designed to assist a School / Department develop their Corrective Actions Trackers in order to ensure that all health and safety risks are identified for University or off-campus University-related operations and controlled.
INSTRUCTION STEPS AND ACTIONS:
Instruction (including key points) Responsibility Timeline
1. Responsibility
Head of School/Department
Ensure compliance with the Corrective Actions Instruction within their area of authority
Ensure every corrective action is fully implemented by an action sequence within an agreed timeframe
Stakeholders
Participate in the consultation process for all relevant self- assessments being conducted. Stakeholders are not responsible for ensuring that an action is undertaken.
2. New action identified
The list below may be utilised to identify health and safety hazards that will require corrective action:
Hazard and incident reporting
Incident investigations or Hazard Assessments
OHS Audits
Emergency Preparedness
Risk Assessments
OHS committees
OHS management system implementation
Workplace Inspections
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3. Consultation of Corrective Actions
When an issue has been identified that requires action, the consultation process must be initiated.
The resolution of an issue must be assigned to a responsible party who has management authority. In a situation where multiple responsible parties are identified (e.g. multiple organisational units involved), agreement must be reached on whom the most appropriate party is.
Consultation with key stakeholders must occur for all corrective actions. Stakeholders must include, where applicable; Head of School or Department or approved delegate, 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, Health Safety and Wellbeing
Team 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
If agreement on any of these elements cannot be reached, escalation of the responsible party must follow the RMIT University Health and Safety Issue Resolution process.
Once agreement has been reached, the Corrective Actions Tracker must be completed which contains information including:
Source of issue
Date issue identified
Title of issue
Portfolio/College
School/Department
Description of issue
Risk Ranking
Corrective Action
Due Date
Responsible person
Status (open/closed)
4. Implementation of Corrective Actions
By using the Hierarchy of Controls Instruction, it will help to identify the most appropriate action to be taken consistent with the level of risk. Corrective actions must be discussed with people affected prior to implementation.
In situations where many corrective actions are identified at once (e.g. following a health and safety workplace inspection), the corrective actions should be assigned a priority rating according to identified risk so that those posing the highest risk are addressed first.
There should be a record of corrective actions implemented using the Correctives Actions Register
Template.
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5. Assigning Responsibility
Responsibility, authority and accountability for corrective actions are designated as follows:
When assigning corrective actions, the competency of the person to whom the action is assigned must be taken into account. Advice should be sought from personnel with specific expertise as appropriate
Property Services is responsible for corrective action relating to building and grounds infrastructure
Property Services is responsible for corrective action relating to plant and equipment associated with building infrastructure and grounds.
The Managers of Schools and Departments are responsible for corrective action relating to plant, equipment, hazardous substances, dangerous goods, work procedures (including training), in their day-to-day operations
Supervisors or nominated responsible persons are responsible for ensuring corrective actions from hazard and incident reports are completed.
Nominated responsible persons for corrective actions from workplace inspections are responsible for ensuring the corrective actions assigned to them are completed by the date recommended.
Corrective actions not completed in a timely manner shall be reported to the Head of School or
Department. The Head of School or Department will then contact the person(s) responsible for the corrective action to ensure completion.
Any corrective action that cannot be fixed by the local area needs to be escalated to the
College/Portfolio office or the Health Safety and Wellbeing Team.
6. Monitoring of Corrective Actions
Corrective actions are reviewed and monitored by school or work area unit by monitoring the corrective action status report.
All new hazards should be documented in the school or work area unit risk register.
Colleges and Portfolios review and monitor corrective actions beyond the scope of schools/ work areas.
The Health Safety and Wellbeing Team reviews and monitors corrective actions beyond the scope of
Colleges/Portfolios, schools, and work areas.
Effectiveness of implemented corrective actions are assessed as being appropriate by re-inspections, audit follow-up, re-testing of plant and equipment, consulting with workers and reviewing hazard, incident and workers compensation statistics.
Supporting
Documents
Related Documents
Risk Assessment Instruction
Hierarchy of Control Instruction
Corrective Actions Register Template
Commencement date Review date
Secretariat
Posting
Approval
REVISION HISTORY – section maintained by the University Policy Officer
Revision Ref. No. Status / Type
Amendment
Date
Approved
Approval
Authority
Resolution
Number
TRIM Reference
Approval/Other
V1.0
ACCOUNTABILITIES
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Policy Sponsor:
Implementation:
Compliance:
Monitoring and Evaluation:
Development/Review:
Approval Authority:
Interpretation and Advice:
Data Collection and Analysis:
Chief Operating Officer
Chief Operating Officer
Executive Director, Human Resources
Health, Safety and Wellbeing Team – Human Resources
Health, Safety and Wellbeing Team – Human Resources
Vice-Chancellor and President
Health, Safety and Wellbeing Team – Human Resources
Health, Safety and Wellbeing Team – Human Resources
Definitions and acronyms
Key words for search engine
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.
Stakeholder: Stakeholders include any individual (staff, student, contractor or visitor) who is affected by a hazard which requires controlling.
Corrective Action Register (CAR): A record of all corrective actions that have been agreed upon and/or undertaken within a designated area. A template is available from the RMIT University health, Safety and Wellbeing website.
Control Measure
Eliminate
Hazard
Hazard Management
Hierarchy of Controls
Likelihood
Risk
Risk Assessment
Safety
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