OHS Management Systems Audit Report - uq.edu.au · PDF fileAudit Scope ... Occupational Health and Safety Division UQ Internal OHS Audit Program 3 April 2017, v1 Audit Week start:

Based on the National Self-Insurers OHS Audit Tool; Element 3

OHS Audit Program 2017 Page 1 of 37

Occupational Health and Safety Division UQ Internal OHS Audit Program 3 April 2017, v1

UQ Internal OHS Audit Program

OHS Management Systems Audit Report

Contents 1. Introduction ........................................................................................................................................................................ 1

2. Audit Scope ......................................................................................................................................................................... 1

3. Audit Criteria ....................................................................................................................................................................... 2

4. Audit Evaluation Statement ................................................................................................................................................ 3

5 Positive Findings, Opportunities for Improvement ............................................................................................................. 3

6. Audit Outcomes .................................................................................................................................................................. 5

Attachment 1 .......................................................................................................................................................................... 7

Detailed Audit Findings & Recommendations .................................................................................................................... 7

Attachment 2 ........................................................................................................................................................................ 28

Walk-through Inspection (1) ............................................................................................................................................. 28



Attachment 3 ........................................................................................................................................................................ 37

Audit Conformance Rating Definitions ............................................................................................................................. 37

Corrective Actions Priority Definitions ................................................................................................................................. 37

1. Introduction

An internal OHS audit of <organisationalunit> was undertaken as part of the University’s internal audit program. This report presents the findings of the site visit and audit, and provides recommended corrective actions to the audited area.

The University has a comprehensive set of OHS Policies, Procedures and Guidelines that form the OHS Management System (refer http://www.uq.edu.au/ohs/). The audit program is designed to assist local areas to evaluate the implementation and effectiveness of the UQ OHS Management System in their area, and to identify system deficiencies and opportunities for improvement. A primary objective of OHS auditing is continuous improvement of OHS systems to ensure the University continues to provide a safe and healthy environment for staff, students, volunteers, contractors and visitors.

The auditors would like to acknowledge and thank the staff of the <organisationalunit> for their full cooperation and positive involvement in the internal OHS Audit. We would also like to thank <WHSC/SafetyContact> for assisting with arranging the audit schedule and facilitating the interviews and inspections.

2. Audit Scope

Audit Location:

http://www.uq.edu.au/ohs/




Audit Week start: 1st

February 2017 Report Date:

Head of Section: Email:

Local WHSC: Email:

Local Contact: Email:

Audit Team: Email:

3. Audit Criteria

The internal OHS audit tool is an adaptation of the National Self-Insurer OHS Audit Tool (NAT). The tool criteria are adapted from Element 3 (Implementation) criteria of the National Self-Insurer OHS Audit Tool (NAT). The intent of the adapted tool is to reflect the NAT criteria as they directly relate to the UQ context and corporate systems. The following documents, databases and reporting software were referred to during the audit:

UQ internal OHS Audit tool

(adaptation of the National Self-Insurer OHS Audit Tool)

UQ OHS Goals for the University http://www.uq.edu.au/ohs/index.html?page=133948

UQ Occupational Health and Safety Policy http://www.uq.edu.au/ohs/PPL/2-10-03/OHS-Policy-Statement.pdf UQ Risk Management Database http://www.uq.edu.au/ohs/index.html?page=29960

UQ Incident Reporting Database http://www.uq.edu.au/ohs/index.html?page=141331

UQ Reportal https://mis-xi4-web.mis.admin.uq.edu.au/BOE/BI

http://www.uq.edu.au/ohs/index.html?page=133948

http://www.uq.edu.au/ohs/PPL/2-10-03/OHS-Policy-Statement.pdf



https://mis-xi4-web.mis.admin.uq.edu.au/BOE/BI




4. Audit Evaluation Statement

Sample paragraphs:

1. The audit scope consisted of a diversity of work environments and the auditors found a marked variation in OHS management system compliance across the work groups. This is clearly reflected in Audit Report’s corrective actions, detailed findings and facility inspections. Commendably, the <organisationalunit> demonstrated a local OHS management system that was highly compliant, risk-proportionate, consistent and effective. Other work groups with less potentially hazardous environments demonstrated moderately compliant OHS management systems as is proportionate to their risk profile.

The auditors have concluded that the health and safety system of <organisationalunit> has a compliance level within the moderate to high range depending upon the work group. The work groups must give priority to implementing relevant corrective actions in order to sufficiently develop, monitor and periodically review their compliance with OHS management system requirements as specified in the report.

2. ”The auditors have concluded that the health and safety system of the <auditedlocation> has a high level of compliance and that continuous improvement should occur by implementing, monitoring and periodically reviewing corrective actions to ensure system effectiveness”.

3. “The auditors have concluded that the health and safety system of the <auditedlocation> has a moderate level of compliance. The <auditedlocation> must give priority to implementing corrective actions in order to sufficiently develop, monitor and periodically review the OHS management system to ensure its effectiveness”, or

4. “The auditors have concluded that the health and safety systems of the <auditedlocation> have an overall low level of compliance. The <auditedlocation> must give highest priority attention to implementation of corrective actions in order to ensure that sufficient OHS management system coverage is in place and the continuing development, monitoring and review of the system”.>

Completion of the recommended corrective actions is the final phase of the OHS audit cycle. The OHS Division routinely monitors the organizational areas’ progress in implementing corrective actions three months and six months after delivery of the audit report. The OHS Division Auditor may also provide guidance for implementing corrective actions as needed.

5 Positive Findings, Opportunities for Improvement

Positive Findings

The OHS management system in the <organisationalunit> has effective documentation, implementation, monitoring and review. Resources allocated to ensuring this occurs are optimal and the commitment from local management and staff is outstanding.

Strong OHS leadership amongst senior and middle managers and staff commitment to OHS was evident throughout the audit.

An innovative approach to improving OHS management for student placements as a way of enhancing the student experience was commendable as evidenced during an audit interview.

OHS consultative structures are well supported and accessible across the <organisationalunit>.

Opportunities for Improvement

The <organisationalunit> is currently reviewing the student placement program with a view to implementing a streamlined approach to induction; the corrective actions within this report can assist in development of the revised procedure. An industry placements register to identify student placement locations and dates is vital OHS management tool.




It is vital that managers and staff understand the requirement for UQ OHS Training Needs Analysis (or equivalent) at the time of induction and at annual R&D and about the need to consult with relevant direct report staff about the TNA.

Improving staff skill in OHS risk management methodology and ensuring that effective risk management controls are documented in <tasks> will improve the OHS management system performance.

Priority must be given to meeting the Work Health and Safety regulatory requirement for effective emergency communications for remote and isolated work for staff conducting international travel, students participating in placements and students/staff working after hours.

Legend

AFS Annual Fire Safety training

FLAG Faculty Leadership Adviser Group

FWG Faculty Workshop Group

FYSLC First Year Student Learning Centre

GWS General Workplace Safety training

HSR Health and Safety Representative

ITIG Information Technology Infrastructure Group

SOP Safe Operating Procedure

TNA Training Needs Analysis

WHSC Workplace Health and Safety Coordinator




6. Audit Outcomes

Recommended Corrective Actions1

Element Priority

Ranking Recommendation

3.1 Value Added

3.2

High

Value Added

3.3

High

Value Added

Suggest that WHSCs and HSRs consider refresher training in UQ OHS Functioning as a Work Health and Safety Adviser and OHS for Health and Safety Representatives training courses.

3.4 Value Added

Additional consideration:

Raise awareness of Faculty staff other than the FWG about HSR entitlements and their representation of designated work groups

3.5 Medium Display the UQ OHS policy on shared drives and communicate with all staff about this including a URL to the PPL 2.10.03 Occupational Health and Safety Policy Statement

Element Priority

Ranking Recommendation

3.6 Nil

1 Refer to Attachment 4 for corrective actions priority definitions



3.7, 3.8 Nil

3.9 High

3.10 High

Value Added

Improve awareness/training on use and selection of PPE especially correct installation of ear plugs where used.

Additional considerations:

3.11 High Confirm that there are sufficient emergency procedures for student placements

OHS Audit Program –Draft EAIT Report 2017 Page 7 of 37 Occupational Health and Safety Division UQ Internal OHS Audit Program 31 March, v1

Attachment 1

Detailed Audit Findings & Recommendations

3.1 Resources

Role Audit Criteria Findings/Comments Score C/PC/NC

a)

Senior/middle manager, finance,

WHSC

NAT 3.1.1

Are funds annually allocated for risk management controls (new equipment, hierarchy of risk controls applied, OHS Minor Works)

C

b)

Senior/middle Manager, human resources,

staff

NAT 3.1.2

Access to qualified and competent people eg staff qualifications, WHSC skills, central OHS Advisers, OHS Managers, external consultant/contractor

C

c)

Middle manager, supervisor, staff

NAT 3.1.1

Time allocated for staff, supervisors to do risk assessments, inspections, OHS training, OHS Committee Meetings, incident investigations etc.

C

3.1 Recommended Corrective Actions (Weighting: 3)

3.2 Responsibility and Accountability

Function Audit Criteria Findings/Comments Score


C/PC/NC

a) Senior executive, senior manager,

WHSC

NAT 3.2.2, 3.2.5

Is OHS included in board and management meetings, reporting, position descriptions, and performance appraisal for senior managers? (e.g. annual report, VCRCC, Faculty Executive or direct report meetings)

C

b) Senior executive, senior manager.

WHSC

NAT 3.2.1, 3.2.2

Does senior manager describe OHS legal obligation, UQ OHS risk management system, operational OHS risks, incident response and correction, UQ OHS responsibilities ? How does management stay informed and communicate to managers and staff about management of OHS risks? e.g. reviews incident trends, progress of work are in meeting OHS goals including high risk tasks.

C

c) Middle manager, human resources, staff, HR.

NAT 3.2.3

Is there evidence of communication and documentation about UQ OHS responsibilities Does the local organizational chart show reporting relationships. Is there evidence of communication to staff about responsibilities to comply with SOP/risk assessments, completion of OHS training, walk through inspections?

PC

d) Senior manager, middle

NAT 3.2.5

Are workers held accountable for OHS

PC






manager, staff. responsibilities? eg discussion during R&D, incident corrective actions verified by manager, workers modify risk assessments when work changes or following an incident.

3.2 Recommended Corrective Actions (Weighting 8)

* See 3.10 (d) for NAT 3.2.4 “Where contractors are utilized in the organization, OHS responsibility and accountabilities of the organization and contractors have been clearly defined, allocated and communicated within the organization and to the contractors and their workers

3.3 Training and Competency

Function Audit Criteria Findings/Comments Score C/PC/NC

a) Senior Manager, Middle manager, HR, staff.

NAT 3.3.1

Do recruitment process and PDs identify specific OHS training needs and competency requirements? eg plant operator’s certificate of competency to operate (CTO), laboratory OHS knowledge, communications to emergency responders.

C

b) Middle manager, WHSC, staff.

NAT 3.3.1, 3.3.3, 3.3.10, 3.3.11

Is UQ OHS Training Needs Analysis (TNA) or equivalent completed for all staff, contractors, labor hire employees or visitors? eg induction training, mandatory General Workplace Safety and Annual Fire safety online training and refresher completion rates.

Is TNA review scheduled or conducted when work environment, process, plant/competency/staff

PC



changes arise?

Are all TNA requirements for staff, including refresher training, confirmed as completed? eg Annual Fire Safety training

c) Middle manager, building/facility manager, staff, WHSC.

NAT 3.3.5, 3.3.2 Is UQ OHS Induction for all staff, managers, contractors, RHD students and volunteers implemented?

Are both central and local OHS inductions used?

Are staff consulted about training needs at OHS committee meetings or in other communications?

C

d) WHSC, building/facility manager, staff

NAT 3.3.4, 3.3.6, 3.10.22 Do qualified, skilled staff or contractors deliver OHS training? eg OHS trainers from UQ Staff Development, equipment manufacturers/suppliers.

Is supervision provided when competency is verified? eg local competency to operate (CTO) procedures in place; supervision needs included in risk assessment/SOP, staff and students read risk assessment or risk management information and SOPs and have been observiced performing tasks safely before full supervision is withdrawn; focus upon medium to high risk tasks.

PC

e) Middle manager, staff, HR

NAT 3.3.7

Are tasks adjusted to suit individual competencies affected by medical conditions? Eg workers compensation return to work/rehabilitation program

C

f) Management, WHSC

Have managers completed the OHS for Senior Managers or OHS for Supervisors

C

http://www.uq.edu.au/ohs/?page=168925

https://staffdevelopment.hr.uq.edu.au/course/OWTOHR

https://staffdevelopment.hr.uq.edu.au/course/OWTOHR

https://staffdevelopment.hr.uq.edu.au/course/OM0008


and Managers training (or equivalent)

as reflected in UQ Reportal data ?

g) WHSC, WHSR Have the Work Health and Safety Coordinator /Safety Contact and Work Health and Safety Representative participated in relevant OHS training. (There may not always be a WHSR in place for the area.) Confirm in UQ Reportal data

C

3.3 Recommended Corrective Actions

https://staffdevelopment.hr.uq.edu.au/course/OM0008

https://mis-xi4-web.mis.admin.uq.edu.au/BOE/BI/

https://ppl.app.uq.edu.au/content/2.10.06-work-health-and-safety-co-ordinator-role-and-function

https://ppl.app.uq.edu.au/content/2.10.06-work-health-and-safety-co-ordinator-role-and-function

https://ppl.app.uq.edu.au/content/2.10.05-work-health-and-safety-representative-role-and-function

https://ppl.app.uq.edu.au/content/2.10.05-work-health-and-safety-representative-role-and-function




3.4 Consultation


a)

WHSC, HSR, senior executive, senior/middle manager, group leader, finance, staff

NAT 3.4.1

Are work areas’ OHS interests represented on Faculty /Institute/Divisional OHS Committee, and do workers know about the Committee process for communicating about OHS issues?

Is OHS considered routinely for purchasing, work planning, refurbishments, construction, and changes?

Are workers consulted about such OHS matters?

C

b)

Middle manager, HSR, WHSC, staff

NAT 3.4.2

Are managers, staff aware of: Regulatory WHSR entitlements and their representation of designated work groups ; any existing WHSR arrangements in place for their work group; and have those arrangements been communicated to workers.

Does the WHSR exercise their entitlements including representation of designated work area on the OHS Committee.

C

https://www.worksafe.qld.gov.au/injury-prevention-safety/managing-risks/health-and-safety-representatives-and-health-and-safety-committees




c)

HSR, WHSC, middle manager

NAT 3.4.3

Is WHSR provided with:

time to conduct role on OHS Committee and other duties;

opportunity to discuss issues with management at OHS Committee meeting;

resources for training/ equipment/information needs.

C

d)

Staff, HSR, WHSC

NAT 3.4.4

Are staff or the WHSR involved in the development, implementation and review of procedures for the identification of hazards and the assessment and control of risks?

C



3.5 Communication


a) Senior manager, middle manager, staff, RHD student

NAT 3.5.1

Where do managers, staff go to access UQ and local OHS information? eg UQ OHS Division website, local OHS webpage, local shared drive, UQ PPL. Are managers, staff aware of the UQ OHS Policy?

Is OHS communication adapted for language and literacy needs as needed? eg verbal, show/do, symbols, more than one language.

PC

b)

Middle manager, staff, RHD student, WHSC

NAT 3.5.2

Are communications about resolution of OHS issues sent to workers? eg OHS Committee minutes, emails

Is there awareness/ use of UQ PPL 2.10.12 Right of Entry for UQ Permit Holders as it relates to OHS disputes?

C

c)

Finance, HR, building/facility manager, staff

NAT 3.5.3

Is OHS information exchanged with visitors, contractors, regulatory authorities, suppliers? eg local induction, safe work plan, risk assessments, incident investigations.

C

d)

Manager, staff, facility manager, HR, WHSC

NAT 3.5.4

How do you respond to OHS complaints, issues raised by external parties such as contractors, students, visitors?

Awareness/use of the

UQ Complaints Management system

C



http://www.uq.edu.au/about/complaints-management



* NAT 3.6.4, 3.6.5 can be informed by any UQ-wide OHS Strategic and Operational Plan that may arise from OHS Review or HSW Strategy.

3.6 Reporting


a)

Senior executive, senior/middle manager, staff, RHD student, WHSC

NAT 3.6.1, 3.6.3, 3.6.4, 3.6.5, 3.6.6, 3.9.5.

Are managers, staff, students aware of requirement to report incidents on the UQ OHS Incident Reporting database?

Are corrective actions implemented, signed off by HOS within 12 weeks of incident?

Are hazards reported, rectified using UQ Hazard Reporting Procedures ?

Are 2015-2017 OHS Goals compliance report or other trend statistics used to monitor progress in achieving goals, and submitted to OHS Div?

Is OHS performance included in an annual report?

Is the implementation of corrective actions arising from annual OHS inspections and internal OHS audits communicated to workers or OHS Committee, and HSR; monitored by senior management or OHS Committee, until completed?

C

b) Senior executive, middle manager,

NAT 3.6.2

Is there demonstrated knowledge and/or practice of determining if

C


http://www.uq.edu.au/ohs/report-a-hazard

http://www.uq.edu.au/ohs/ohs-goals-of-the-university



staff, WHSC incidents, injuries, illnesses meet legislative criteria for regulatory notification within requisite time frame? ie WHSQ, OGTR, Biosecurity, Qld Radiation Health, Electrical Safety Office, Maritime and Marine Safety, Civil Aviation Authority, Qld Health.Is OHS performance included in an annual report?

Are managers, staff aware of legislative criteria for regulatory notification within requisite time frames? Ie WHSQ, OGTR, Biosecurity, Qld Radiation Health, Electrical Safety Office, Maritime and Marine Safety, Civil Aviation Authority, Qld Health.



3.7 Documentation and 3.8 Document and Data Control


a) Senior/middle manager, HR, staff, RHD student, WHSC, HSR.

NAT 3.7.1, 3.8.1, 3.8.2, 3.8.3, 3.8.4

Is there a local repository (eg shared drive, website, lab. folders) where OHS information is organized?

Does the OHS information refer to the UQ OHS Policy and procedures, online training modules, local risk assessments, SOPs, competency to operate, training registers?

Do workers access current OHS communications and information ?

Are OHS documents version controlled, current and reviewed by competent workers as scheduled?

Are obsolete documents retained (where required) for legal purposes? eg health surveillance, hearing testing.

C

b)Senior/middle manager, staff, RHD student

NAT 3.7.2

Are safe work procedures, instructions or SOPs associated with particular products, processes, projects or sites documented and accessible, for tasks with OHS risk?

C

3.7 and 3.8 Recommended Corrective Actions (Weightings: 3 and 4)



NAT gives 3.9 heavy weighting. Suggest that attention to detail is strong and that corrective actions are high priority for 3.9.

3.9 Health and Safety Risk Management Program


a)

Senior/middle manager, staff, RHD student, WHSC, HSR.

NAT 3.9.1, 3.9.4, 3.9.5, 3.9.6, 3.9.7

Do Risk assessments, SOPs and specific instructions encompass risk management principles of elimination, substitution, engineering controls, administrative controls and PPE? Do they include emergency response where appropriate?

Are legal requirements for risk management evident in risk management documentation?

Are risk controls prioritised for implementation according to level of risk?

Is there evidence that risk assessments are reviewed when a change in work occurs or at least every five years?

If site-specific issues prevent use of UQSafe-Risk (UQ’s corporate system) is an equivalent system evident and updated with compliance requirements?

Check 2015-2017 OHS Goals compliance report (Goals 9, 10) and UQ Reportal data for risk management training completions.

Are risk assessments with a high level of risk audited?

PC

b) Senior/middle NAT 3.9.3, 3.9.4, PC

http://www.uq.edu.au/ohs/ohs-risk-management

https://ppl.app.uq.edu.au/content/2.30.01-occupational-health-and-safety-risk-management





manager staff, RHD student, WHSC, HSR.

Is the UQ OHS hazard reporting and OHS minor works system or equivalent used as needed?

Is hazard control for tasks, equipment, work environment and public areas implemented and documented, and include participation of WHSC, HSR and workers with relevant competencies?

Is there documented and site specific evidence that hazards are controlled?

A local hazard/risk register may be in place.

c) Senior/middle manager, staff, WHSC, HSR

NAT 3.9.5

Are incidents reported on the UQ Safe – Incident database and do they include effective corrective actions that eliminate or reduce the risk of incident recurrence?

C

d) Senior executive, senior/middle manager, staff, WHSC, HSR

NAT 3.9.5, 3.8.3

Is there a general awareness of potential emergency situations and the appropriate response? eg fire and emergency evacuation, critical incidents such as major chemical spill, violence, flood.

Is there awareness of the UQ PPL 7.60.01 Critical Incident Management or is it referenced in local inductions, training?

e)

Senior/middle manager, staff, WHSC,

NAT 3.9.8

Is the UQ Guide to Leading Organisational Change principles,

C



https://ppl.app.uq.edu.au/content/7.60.01-critical-incident-management

https://ppl.app.uq.edu.au/content/7.60.01-critical-incident-management

http://hr.uq.edu.au/how-to-use-guide

http://hr.uq.edu.au/how-to-use-guide


HSR procedure used to guide change and its potential impacts upon OHS? Are relevant OHS Guidelines are used for change? eg PPL 2.30.15 Laboratory Decontamination and Decommissioning

3.9 Recommended Corrective Actions (Weighting: 12)

NAT gives 3.10 heavy weighting. Suggest that attention to detail is strong and that corrective actions are high priority for 3.10.

https://ppl.app.uq.edu.au/content/2.30.15-laboratory-decontamination-and-decommissioning




3.10 Hazard Identification, Risk Assessment and Control of Risks

Function Audit Criteria Findings / Comments Score C/PC/NC

a)

Middle manager, building/facility manager, group leader, staff, RHD student, WHSC

NAT 3.10.1

Are access controls implemented according to OHS risk? eg swipe card access for laboratory/workshop/ equipment use provided when inductions, risk assessments, SOP, competency are confirmed. Public, visitors’ and contractors’ access is controlled.

C

b)

Senior/middle manager, finance, staff, WHSC

NAT 3.10.2, 3.10.6

Are OHS requirements included in all purchasing specifications for equipment?

Are OHS compliance requirements of substances and goods verified as being met by the supplier, before purchase?

What happens if items don’t meet compliance requirements when delivered?

Are purchased goods verified as meeting OHS requirements, and are non-compliances addressed before the goods are put into operational use?

C

c)

Senior/middle manager, building or facility manager, staff

NAT 3.10.3

Are Property & Facilities consultants and contractors who are OHS compliant, engaged?

Are contractors outside of the

C

http://www.pf.uq.edu.au/contractors/index.html

http://www.pf.uq.edu.au/contractors/index.html


P&F system, confirmed as meeting OHS requirements specific to the site and work being conducted? eg risk assessments, safe work method statements.

d)

WHSC, middle manager, staff

NAT 3.2.4, 3.10.4

Contractors complete UQ OHS induction requirements, UQ local inductions, provide safe work plans, risk assessments including incident and emergency responses, SOPs and OHS information relevant to their work at UQ.

Suppliers provide operating manuals, SDS’s, training and participate in UQ local OHS inductions as required.

Regulatory authorities and visitors participate in local OHS inductions as required.

Appropriate supervision is provided to all categories of non UQ employees as appropriate.

Local responsibility to monitor contractor OHS performance is evident and actioned.

C

e)

Middle manager, building/facility manager, staff, WHSC, HSR

NAT 3.10.7, 3.2.5, 3.10.8

OHS compliance and risk management requirements are included in design and construction of UQ Property & Facilities projects (eg Hazardous Areas Risk Assessment).

OHS design obligations are fulfilled for modifications to UQ facilities, plant , products or

. C

http://www.pf.uq.edu.au/about/construction.html

http://www.pf.uq.edu.au/about/construction.html

http://www.uq.edu.au/ohs/COMMUNICATIONS/2016/SafetyNotice/Hazardous-Areas.pdf

http://www.uq.edu.au/ohs/COMMUNICATIONS/2016/SafetyNotice/Hazardous-Areas.pdf

http://www.worksafe.qld.gov.au/construction/laws-and-licencing/designers

http://www.uq.edu.au/ohs/plant-and-equipment-safety


processes.

OHS competencies are included in the design process.

UQ workplaces under control of another organization include OHS design requirements.

f)

WHSC, staff, facility manager, middle manager

NAT 3.10.9

Are UQ hazardous waste procedures implemented for materials and substances.

Does radiation equipment disposal comply with Radiation Safety Protection Plan and legislation?

C

g) WHSC, staff, facility manager, middle manager, staff

NAT 3.10.10

Is workspace, lighting, ventilation, drinking water, eating area, personal storage, shelter suited to work activity OHS risk? eg remote and isolated work, PC 2 laboratories, physically demanding work. (Further detailed in Managing the Work Environment and Facilities Code of Practice 2011 )

C

h) Building/facility manager, middle manager, staff, WHSC

NAT 3.10.11, 3.10.12, 3.10.13, 3.10.21, 3.10.25

Do relevant staff know where to access information about hazardous chemicals and substances? eg Chemwatch , UQ OHS Occupational Hygiene webpage , local chemical inventory, Radiation Safety Protection Plan, PC 2/3 and Quarantine manual.

Do risk assessments/SOPs and controls address hazardous

C

http://www.uq.edu.au/sustainability/recycling-and-waste

http://www.uq.edu.au/sustainability/recycling-and-waste

https://www.worksafe.qld.gov.au/laws-and-compliance/codes-of-practice

https://www.worksafe.qld.gov.au/laws-and-compliance/codes-of-practice

http://www.uq.edu.au/ohs/chemwatch-sds





materials transport, handling, storage?

Is there evidence that hazardous chemicals are safely stored and labelled in accordance with legislative requirements?

i)

Middle manager, WHSC, staff

NAT 3.10.14

Is there a procedure to confirm Permit to Work is in place when required? eg hot work, forklift driving.

C

j)

Middle manager, staff, WHSC

NAT 3.10.15

Is there evidence that provision, training, use and maintenance of personal protective equipment (PPE) is based upon risk assessment and any universal precaution requirements? eg OHS in the Laboratory (Undergraduate Students) , PPE for when providing first aid.

PC

k)

Building/facility manager,middle manager, staff, WHSC

NAT 3.10.16, 3.10.17, 3.10.19

Does the Plant and equipment register include High Risk Plant, Registerable Plant and UQ defined high risk plant with specific plant maintenance requirements and competency to operate requirements? Does the maintenance schedule (including inspections, repair, alteration and servicing detail) and CTO requirements verified as completed?

Is there evidence of unsafe plant and equipment being identified and quarantined or withdrawn from service?

Is there evidence that plant,

C

http://www.uq.edu.au/ohs/pdfs/OHYG-LabSafety-UG.pdf

http://www.uq.edu.au/ohs/pdfs/OHYG-LabSafety-UG.pdf

http://www.uq.edu.au/ohs/plant-and-equipment-registers

http://www.uq.edu.au/ohs/plant-and-equipment-registers


equipment verified as safe before being returned to service?

l)

Building/facility manager, middle manager, staff, WHSC

NAT 3.10.18

Is worker, contractor and public safety assured routinely during maintenance of plant and equipment?

C

m) Building or fire warden, WHSC

NAT 3.10.20

Do safety signs including hazards, fire and emergency information meet relevant standards and codes of practice?

C

n) Student placement coordinator, Senior/middle manager

NAT 3.10.23

Is OHS included UQ’s pre-placement student briefings.

Does UQ confirm that the placement organisation has OHS management systems in place including OHS induction, supervision, competency and training, PPE, incident and emergency response.

Do relevant managers, staff and student know about the 3.10.04 Placements in Coursework Programs Policy and is its use documented or referenced locally?

Is OHS information provided to students who participate in informal work experience as requisite for graduation?

PC

3.10 Recommended Corrective Actions – Weighting 12

http://ppl.app.uq.edu.au/content/3.10.04-placements-coursework-programs




3.11 Emergency preparedness and response

Function Audit Criteria Findings / Comments Score C/PC/NC

a)

Building or fire warden, WHSC, staff

NAT 3.11.1, 3.11.2, 3.11.6

Are requirements of the PPL 2.15.04 Fire Emergency Evacuation in place, displayed and reviewed for UQ controlled work areas? Are workers aware of the requirements? eg emergency evacuation plan, building and fire wardens trained and appointed, fire drills, information included in induction/refresher training such as UQ online Annual Fire Safety training.

Are UQ equivalent provisions in place for workplaces controlled by other PCBUs and occupied by UQ staff, students and volunteers?

Are site specific emergency evacuation procedures and effective communications in place for work off-campus, with emphasis upon remote or isolated* work? (WHS Reg. 48 mandates effective communications for rescue, medical assistance and emergency.

PC

b)

Building or fire warden, WHSC

NAT 3.11.4, 3.11.5

Is accessible emergency equipment suitable, well-located and accessible in accordance with requirements specified by

C

https://ppl.app.uq.edu.au/content/2.15.04-fire-emergency-evacuation




emergency responder organisations, fire safety officers, laboratory staff, WHSC/OHS adviser? eg Queensland Fire and Emergency Services specs. for fire extinguishers, exit signs, alarm systems. AS requirements for safety showers, eyewash stations.

Are inspections of emergency and fire protection equipment, exit signs and alarm systems scheduled and completed?

c) First aid officer, middle manager, staff

NAT 3.11.7

Is a suitable first aid program in place? eg first aid officers, accessible first aid kits stocked with appropriate supplies, scheduled restocking including reference to OHS guidelines such as Working Safely with Blood and Body Fluids.

C

d) Middle manager, WHSC, staff

NAT 3.11.8

Does area have a procedure to assist workers exposed to critical incidents at work (including resources such as Staff Support Services , UQ Wellness resources ) and communicate about this to staff? eg inductions, staff meetings, OHS Committee.

C

3.11 Recommended Corrective Actions - Weighting 8

http://www.uq.edu.au/ohs/occupational-health

http://www.hr.uq.edu.au/staff-support-services

http://www.uq.edu.au/wellness-program/uq-resources

http://www.uq.edu.au/wellness-program/uq-resources


Attachment 2

All interviewees consistently explained appropriate OHS management in the workshops areas; they held specific and dedicated regard for safety. This FWG safey culture is outstanding and was well supported and sufficiently resourced for potentially hazardous workshop equipment. All FWG facilities demonstrated a high standard of OHS management as is evident in the inspection reports below.

Walk-through Inspection (1)

Location: Inspection date: 15 Feb 2017

Criteria Items C / NC Comments

3.5.1 Dedicated OHS Notice Board C

3.5.1 UQ OHS Policy displayed / available NC

3.5.1 WHSC contact details displayed C

.

3.5.1 HSR contact details displayed C .

3.5.1 First Aid Officer name displayed near first aid kit C

3.7.2 SOPs displayed (if required, relevant to the level of risk)

3.8.1 Displayed OHS information is up-to-date C

3.8.2 Local OHS documents include date and version number C

3.8.4 Local OHS documents reviewed at least every 3 years C

3.10.1 Facility security appropriate to the level of risk C .

3.10.1 Laboratories have UQ “CAUTION” sign on door C

3.10.1 Hazardous and/or specialised areas and rooms signed C

3.10.9 UQ “Guide to Laboratory Waste Disposal” displayed N/A



3.10.9 Waste stored safely prior to appropriate disposal N/A

3.10.10 Good housekeeping – facilities / equipment maintained C

3.10.12 SDS’s readily accessible (in event of emergency) C

3.10.13 Sufficient chemical storage cabinets N/A

3.10.13 Hazardous chemicals and DGs stored safely / correctly N/A

3.10.13 Chemical substances in appropriate containers N/A

3.10.13 Chemical containers in good condition N/A

3.10.15 PPE available and maintained in good condition C

3.10.16 Equipment appropriately guarded C

3.10.16 Equipment maintained and records kept C

3.10.16 e.g. Plant / Equipment Register available and up-to-date C

3.10.16 Electrical items safety tested (where applicable) C

3.10.16 Power boards compliant (e.g. individually switched) N/A

3.10.17 Appropriate use of “Out-Of-Service” tags C

3.10.25 Chemicals labelled correctly e.g. Chemwatch labels C

3.11.1 UQ Emergency Procedures Cards (EPC) displayed C

3.11.2 EPC filled out with current information C

3.11.2 Building / Emergency / Floor Warden names displayed C

3.11.5 Emergency Evacuation Plan displayed C

3.11.5 Emergency exits clear (check stairwell) C



3.11.5 Emergency equipment tagged and inspected – ‘in-date’? C

3.11.5 Safety showers / eyewash stations – tested? Records? N/A

3.11.5 Chemical Spill Kits – fully stocked C

3.11.5 Chemical Spill Kits – contents ‘in-date’ C

3.11.6 Chemical Register/Manifest available and up-to-date C

3.11.7 First Aid Kits – signed / labelled C

3.11.7 First Aid Kits – fully stocked C

3.11.7 First Aid Kits – contents ‘in-date’ C

3.11.8 EAP brochures displayed C

Comments / General Housekeeping? Overall good standard



Location: Precision Workshop Inspection date: 15 Feb 2017



3.5.1 UQ OHS Policy displayed / available NC


3.5.1 HSR contact details displayed C


3.7.2 SOPs displayed (if required, relevant to the level of risk) C




3.10.1 Facility security appropriate to the level of risk C






3.10.12 SDS’s readily accessible (in event of emergency) C











3.10.16 Power boards compliant (e.g. individually switched) C


3.10.25 Chemicals labelled correctly e.g. Chemwatch labels N/A








3.11.5 Chemical Spill Kits – fully stocked C

3.11.5 Chemical Spill Kits – contents ‘in-date’ C




3.11.7 First Aid Kits – contents ‘in-date’ C Yes


3.11.8 EAP brochures displayed NC

Comments / General Housekeeping?

.



Location: Architecture Workshop Inspection date: 15 Feb 2017



3.5.1 UQ OHS Policy displayed / available PC


3.5.1 HSR contact details displayed C


3.7.2 SOPs displayed (if required, relevant to the level of risk) C




3.10.1 Facility security appropriate to the level of risk C






3.10.12 SDS’s readily accessible (in event of emergency) N/A












3.10.16 Power boards compliant (e.g. individually switched) C .


3.10.25 Chemicals labelled correctly e.g. Chemwatch labels N/A








3.11.5 Chemical Spill Kits – fully stocked N/A

3.11.5 Chemical Spill Kits – contents ‘in-date’ N/A






3.11.7 First Aid Kits – contents ‘in-date’ C

3.11.8 EAP brochures displayed PC

Comments / General Housekeeping? Overall good standard


Attachment 3

Audit Conformance Rating Definitions

Rating Outcome Achieved

C Conformance. A judgment made by an auditor that the activities undertaken and the results achieved fulfil the specified requirements of the audit criteria. While further improvements may still be possible, the minimum requirements are being met.

PC Partial Conformance. A judgment made by an auditor that the activities undertaken and the results achieved partially fulfil the specified requirements of the audit criteria. Minor improvements are required to ensure the minimum requirements are being met.

NC Non-conformance. A judgment made by an auditor that the activities undertaken and the results achieved do not fulfil the specified requirements of the audit criterion. This may be caused by the absence or inadequate implementation of a system or part of a system, documented systems or procedures not being followed or a minor or isolated lapse in a system or procedure.

NA Not Applicable. A judgement made by an auditor that the requirements of a particular audit criterion do not need to be met, because of the nature of the client organization’s operations.

NV Not able to be verified. A situation where a relevant system procedure has been developed, but because of the infrequent need to use the system procedure there are no recent records or other form of verification available.

Corrective Actions Priority Definitions

:

Priority Ranking – Corrective actions

High Matters that are fundamental to the OHS management system of control. The partial or non-conformances observed can seriously compromise the OHS management system of control or success of the business activity, and should be addressed as a matter of urgency.

Medium Matters that are important to the OHS management system of control or success of the business activity, and should be addressed as soon as possible.

Low Matters which are unlikely to have a significant impact on the OHS management system of control or success of the project, but should be addressed as part of continuous improvement.

Value Added Recommendations that would, if implemented, enhance the OHS management system of control or efficiency of the system. These recommendations are considered as best practice as opposed to OHS management system weaknesses.

Documents

OHS Management Systems Audit Report - uq.edu.au · PDF fileAudit Scope ... Occupational Health and Safety Division UQ Internal OHS Audit Program 3 April 2017, v1 Audit Week start: