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ENVIRONMENT HEALTH AND SAFETY MANUAL - NEW 16. EHS MANAGEMENT SYSTEMS AUDIT [Evaluation] |
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[? Search] [Top] [Contents]
[Prev: 15. RECORDS MANAGEMENT [Evaluation]]
[Next: 17. MANAGEMENT REVIEW [Review]]
- 16.1. New. ENVIRONMENT, HEALTH AND SAFETY MANAGEMENT SYSTEM AUDIT
- 16.1.1. New. PURPOSE
- 16.1.2. New. SCOPE
- 16.1.3. New. DEFINITIONS
- 16.1.4. New. PROCEDURE
- 16.1.5. New. RESPONSIBILITIES
- 16.1.6. New. REFERENCES
- 16.1.7. New. DOCUMENT CONTROL
To describe the requirements for the internal and external audit process of the Environment Health and Safety Management System, including:
audit scheduling
audit reporting
development of corrective action plans.
This procedure applies to all staff and students at all of the University of Melbourne's campuses and each of the University's controlled entities.
A systematic examination against defined criteria to determine whether activities and related results conform to planned arrangements. The audit will determine whether these arrangements are implemented effectively and are suitable in achieving the organization's policy and objectives.
A plan completed by the auditee to address deficiencies identified in the audit report. A corrective action plan should include the following information:
Audit criterion
Audit result
Audit finding description (from audit report)
Proposed corrective action to address adverse audit finding(s)
Timeframe or date by which planned corrective action(s) should be completed
Responsible officer for ensuring planned corrective action(s) are completed
External EHS audit is an audit conducted by a third party to the University for the purpose of:
Certification to a recognised standard
Self Insurance compliance.
External audits are normally conducted by a registered auditor or regulator.
An audit conducted by a University staff member or contractor for the purpose of:
Reviewing conformance to the EHS Management System
Reviewing compliance with legal obligations
Preparation for external EHS Audits
Identification of continuous improvement opportunities
Maintaining compliance with conditions of a self insurance license
The auditee has demonstrated:
full implementation of University procedures, and
compliance with legal requirements, and
commitment to the principle of continual improvement
Based upon the sample audited is it evident that the auditee is conformant with University and legal requirements, and is active in implementing additional measures to achieve continual improvement.
Recommendations that may assist the auditee to achieve continual improvement:
to ensure more efficient implementation of University procedures (reductions in time, cost and resources)
enhancements that may make the system more transparent to auditors, regulators and the University
The auditee is conformant with University and legal requirements and the recommendations are merely the opinion of the auditor. While failure to follow this advice will not in itself lead to Non Conformance, the recommendations are made based on the auditor's experience in reviewing the approach of areas across the entire University.
Based on the sample audited it is evident that:
the auditee has not fully, effectively or consistently implemented University procedures, and/or
there was evidence of isolated instances of apparent legal non-compliance.
Corrective Action should be undertaken as a priority to prevent the area falling into Non Conformance. The audit itself is a sampling exercise. If the sampling indicates isolated legal non-compliance, it is likely that a Regulator (WorkSafe or EPA) would reveal systematic non-compliance during more focused inspection or intervention. Further, it is likely that both internal and external auditors will focus on issues identified as RC during subsequent audits. The criterion requiring correction may be linked or interdependent on other key systems. A failure relating to this criterion may therefore lead to a significant reduction in total system effectiveness, or wider legal non-compliance.
The audit finds evidence that:
there was an absence of system elements or a part of the system, and/or
there was a failure to follow the documented systems or procedures, and/or
a lapse in the system or procedure, and/or
apparent systemic legal non-compliance.
Corrective Action must be undertaken to prevent injury, ensure continued Certification and to avoid potential prosecution by regulators. The Internal Auditor is required to report serious hazards or potentially dangerous occurrences to Budget Division (Faculty) senior management, the General Manager, EHS and the Director, Internal Audit. Non conformances are documented on Corrective Action Reports and remedial action will be confirmed by subsequent verification.
The auditor cannot confirm implementation of the system because:
the related activity has not yet occurred to provide objective evidence, or
the related activity has not yet occurred to provide objective evidence, or ' the criterion was not examined during the audit, or
evidence could not be provided due to an unforeseen circumstance
It is clear that this is no indication of conformance. The auditor may not have reviewed key documents, interviewed staff or visited key areas owing to a number of issues including; staff absence or time constraints. The criterion remains untested and should be considered for inclusion within the scope of subsequent audits.
The auditee is not required to implement systems to satisfy the specified criterion.
Documents the reason for the non conformance and determines the date for the corrective actions to be reviewed.
The Director, Internal Audit in consultation with General Manager EHS, Deans and Vice Principals shall develop an annual internal EHS audit schedule.
The General Manager EHS shall publish the internal audit schedule on the EHS website.
The Director, Internal Audit shall ensure:
the annual internal EHS audit schedule is based on previous audit results, the level of EHS risk associated with the activities and operations of the Budget Division (Faculty) or local area to be audited.
each Budget Division (Faculty) and controlled entity is audited at least once per calendar year.
internal auditors are sufficiently qualified, competent and experienced to perform EHS audits or that the internal auditors are supported by other experts to enable them to perform audits competently.
internal auditors are independent of the direct management control of the Budget Division (Faculty) or controlled entity that they are auditing.
The University of Melbourne shall audit its Environment Health and Safety Management System to the requirements of SafetyMAP (4th Edition) - initial level and ISO 14001:2004.
The Director, Internal Audit in consultation with the General Manager EHS shall develop and maintain the University of Melbourne Internal EHS Audit Methodology.
The audit methodology shall include:
scope of Internal EHS Audits
opening meeting requirements
audit process requirements
closing meeting requirements
audit report requirements
The Director, Internal Audit shall publish the University of Melbourne Internal EHS Audit Methodology on the EHS website.
The Director, Internal Audit should ensure that internal audit reports consistent with the University of Melbourne EHS Audit Methodology are provided to the Dean (Vice Principal) of the Faculty (Budget Division) 4 weeks from the Internal Audit closing meeting. The Internal Audit report shall include Corrective Action Report for each Non Conformance and Requires Correction finding.
The Dean (Vice Principal) shall within 4 weeks of receiving the internal audit report ensure that documented Corrective Action Plans are developed and provided to the Director, Internal Audit, for each:
Non Conformance finding
Requires Correction finding
The Dean (Vice Principal) shall ensure that the Faculty (Budget Division) EHS Audit reports are tabled at Faculty EHS committee meetings.
The Director, Internal Audit shall report Internal EHS audit results according to the following schedule.
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The Director, Internal Audit shall select competent and qualified external auditors for the certification of the University's Environment Health and Safety Management System to
SafetyMAP (4th Edition) initial level
ISO 14001:2004
The Director, Internal Audit and General Manager, EHS shall provide advice to Certification Auditors in the planning of external certification audits.
Scheduling
Scope
The Director, Internal Audit shall, upon confirmation by the Certification Auditors, advise Deans (Vice Principals) of the Certification Auditor's proposed audit schedule.
The General Manager, EHS and Director, Internal Audit shall distribute relevant sections from Certification Audit Reports to Deans (Vice Principals) of Budget Division (Faculties) subjected to Certification Audits.
The Dean (Vice Principal) shall ensure that the Faculty (Budget Division) EHS Audit reports are tabled at Faculty EHS committee meetings.
The Director, Internal Audit shall report External EHS audit results according to the following schedule.
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Dean (Vice-Principal)
Director, Internal Audit
General Manager, Environment Health and Safety
Internal EHS Auditor
AS/NZS 4801:2001. Occupational Health and Safety: Management Systems. Guidance for use.
SafetyMAP (4th Edition)
ISO 14001:2004 Environmental Management Systems- requirements with guidance for use.
SafetyMAP, Audit Standards.
AS/NZS ISO: 19011:2003 Guidelines for Quality and or Environmental Management Systems Auditing.
PBC EHS Budget Incentives 2007
University of Melbourne Internal EHS Audit Methodology
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[? Search] [Top] [Contents]
[Prev: 15. RECORDS MANAGEMENT [Evaluation]]
[Next: 17. MANAGEMENT REVIEW [Review]]
Created: January 2000
Last Modified: 13 August 2009
Authorised by: General Manager, Environment Health and Safety Unit.
Maintained by: EHSM Maintainer ehsm-webmaster@unimelb.edu.au
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