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ENVIRONMENT HEALTH AND SAFETY MANUAL - NEW

16. EHS MANAGEMENT SYSTEMS AUDIT [Evaluation]

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Contents:
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

16.1. New. ENVIRONMENT, HEALTH AND SAFETY MANAGEMENT SYSTEM AUDIT

16.1.1. New. PURPOSE

To describe the requirements for the internal and external audit process of the Environment Health and Safety Management System, including:

16.1.2. New. SCOPE

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.

16.1.3. New. DEFINITIONS

Audit:

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.

Corrective Action Plan:

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:

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.

Internal EHS Audit:

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

Conformance [Internal EHS Audit]:

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.

Area for Improvement (AFI) [Internal EHS Audit]:

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.

Requires Correction [Internal EHS Audit]:

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.

Non Conformance [Internal EHS Audit]:

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.

Not Verified [Internal EHS Audit]:

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.

Not Applicable [Internal EHS Audit]:

The auditee is not required to implement systems to satisfy the specified criterion.

Corrective Action Report (CAR):

Documents the reason for the non conformance and determines the date for the corrective actions to be reviewed.

16.1.4. New. PROCEDURE

16.1.4.1. New. Internal Audit Schedule

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:

16.1.4.2. New. Internal Audit Methodology

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:

The Director, Internal Audit shall publish the University of Melbourne Internal EHS Audit Methodology on the EHS website.

16.1.4.3. New. Internal Audit reports, Corrective Action Reports (CAR) and corrective action plans.

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:

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.

 Table 71: Internal EHS Audit Results Reporting Schedule

Committee Audience 

Audit Results to be Reported 

Frequency 

Environment Advisory Committee 

ISO 14001:2004 Audit Results 

Annually 

Occupational Health and Safety Committee 

SafetyMAP Audit Results 

Annually 

Risk Management Committee 

ISO 14001:2004 Audit Results 

SafetyMAP Audit Results 

Annually 

Audit and Risk Committee 

ISO 14001:2004 Audit Results 

SafetyMAP Audit Results 

Annually 

Planning and Budget Committee 

ISO 14001:2004 Audit Results 

SafetyMAP Audit Results 

Annually 

16.1.4.4. External Environment Health and Safety Management System AuditNew.

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

The Director, Internal Audit and General Manager, EHS shall provide advice to Certification Auditors in the planning of external certification audits.

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.

 Table 72: External EHS Audit Results Reporting Schedule

Committee Audience 

Audit Results to be Reported 

Frequency 

Environment Advisory Committee 

ISO 14001:2004 Audit Results 

Annually 

Occupational health and Safety Committee 

SafetyMAP Audit Results 

Annually 

Risk Management Committee 

ISO 14001:2004 Audit Results 

SafetyMAP Audit Results 

Annually 

Audit and Risk Committee 

ISO 14001:2004 Audit Results 

SafetyMAP Audit Results 

Annually 

Planning and Budget Committee 

ISO 14001:2004 Audit Results 

SafetyMAP Audit Results 

Annually 

16.1.5. New. RESPONSIBILITIES

Dean (Vice-Principal)

Director, Internal Audit

General Manager, Environment Health and Safety

Internal EHS Auditor

16.1.6. New. REFERENCES

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

16.1.7. New. DOCUMENT CONTROL

 Table 73: Document Control 16.1.New. EHSMS Audit

Date: 6 March 2007 

Authorised by: OHSC 23 January 2007, RMC 6 March 2007 

Version: 1.0 

Next Review: 6 March 2010 

© The University of Melbourne - Uncontrolled when printed 


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