Australian Transport Council. National Standard for the Administration of Marine Safety SECTION 5

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1 Australian Transport Council National Standard for the Administration of Marine Safety SECTION 5 APPROVAL AND AUDITING OF REGISTERED TRAINING ORGANISATIONS August 2008

2 First Published: August 2008 Endorsed by the Australian Transport Council October 2007 Commonwealth of Australia This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without written permission of the Chief Executive Officer, NMSC Inc. Published by The National Marine Safety Committee, Level 5, 9-13 Young Street, Sydney NSW All inquiries are to be addressed to the Chief Executive Officer, NMSC Inc. ISBN August 2008 Page 2 NSAMS Section 5 Auditing of RTOs

3 FOREWORD The National Standard for the Administration of Marine Safety (NSAMS) is being introduced to facilitate uniformity and mutual recognition between the jurisdictions. It achieves this by overcoming i) differences in opinion on administrative philosophy, objectives, desired outcomes and interpretations; and ii) any underlying lack of confidence in the practical arrangements between Marine Safety Authorities. NSAMS applies to the Marine Safety Authorities themselves. It specifies requirements for the delivery of safety outcomes by the Marine Safety Authorities, functions that include facilitating and verifying those safety outcomes. NSAMS has the following objectives a) To clearly state agreed minimum standards for the administration of marine safety. b) To provide sustainable and efficient solutions for the administration of marine safety. c) To facilitate national consistency. d) To enhance mutual recognition of functions in the administration of marine safety. e) To provide a benchmark of performance for ongoing auditing and improvement. NSAMS has been designed to address a wide range of topics relevant to the administration of marine safety in Australia. This Section should therefore be read in the knowledge that there will be other Sections upon which it will rely. The proposed table of contents for NSAMS includes the following Sections: 1. General requirements 2. Administration of marine safety 3. Regulatory compliance 4. Surveys of vessels 5. Auditing of Registered Training Organisations 6. Marine Crewing Qualifications Section 1 will establish the structure of NSAMS specifying overall objectives, definitions, required outcomes, processes and the structure for deemed-to-satisfy solutions and equivalent solutions. Section 1 of NSAMS will be similar to Part B of the National Standard for Commercial Vessels (NSCV). Section 2 will focus on issues of consistency between the Marine Safety Authorities. It will specify required outcomes and deemed to satisfy NSAMS Section 5 Auditing of RTOs Page 3 12 August 2008

4 solutions that are intended to achieve consistent and auditable levels of quality in the administration of marine safety. Section 3 will contain provisions to ensure that administrations have appropriate mechanisms in place to effectively administer marine legislation and to properly fulfil their obligations under other relevant types of legislation. Section 4 Survey of vessels is being prepared as part of the review of the Uniform Shipping Laws Code. It will replace Section 14 of the USL Code. This Standard (Section 5) deals with the Auditing of Registered Training Organisations by Marine Safety Authorities, but is not intended to duplicate audits conducted by the States and Territories VET Registering Bodies. The audits referred to are to verify compliance to the specific technical maritime content of training and assessment required under NSCV Part D; but not the Australian Quality Training Framework (AQTF) standards. This standard is to be used in conjunction with the National Marine Guidance Manual, Guidelines for Auditing Registered Training Organisations that was endorsed by the ATC in November This Standard was developed in NMSC after consultation with and guidance from a working group drawn from Maritime Safety authorities and public and private Registered Training Organisations. The draft was released for public comment on 3 July The period for public comment closed on 15 October A reference group comprising industry and government representatives reviewed the public comment on 8 November 2006, making recommendations that were subsequently accepted by NMSC. ATC approved the Standard in October August 2008 Page 4 NSAMS Section 5 Auditing of RTOs

5 TABLE OF CONTENTS FOREWORD... 3 TABLE OF CONTENTS... 5 CHAPTER 1 SCOPE AND GENERAL Introduction Scope Objectives Definitions Abbreviations References... 8 CHAPTER 2 AUDIT PROGRAM General Range of audits Audit objectives Audit criteria Approval audit Audit of specific training programs Surveillance audits Re-approval audit Special audits Suspension of approval CHAPTER 3 CONDUCTING THE AUDIT General Relationship with AQTF Document review Audit Evidence Records National register of approved RTOs CHAPTER 4 AUDITORS Audit team Audit team roles and responsibilities Auditor conduct and qualifications Auditor panel ANNEX A FLOW CHARTS OF APPROVAL PROCESS NSAMS Section 5 Auditing of RTOs Page 5 12 August 2008

6 ANNEX B SAMPLE CHECK LISTS B1 Develop internal systems and procedures to manage and conduct audits B2 Conduct research B3 Conduct audit according to recognised auditing principles ANNEX C FORM OF THE REGISTER OF APPROVED MARITIME REGISTERED TRAINING ORGANISATIONS August 2008 Page 6 NSAMS Section 5 Auditing of RTOs

7 CHAPTER 1 SCOPE AND GENERAL 1.1 INTRODUCTION 1.2 SCOPE There are two aspects associated with the approval of a Registered Training Organisation (RTO) to provide training and assessment that meets the needs of a State, Territory or Commonwealth Marine Safety Authority (MSA). These aspects are: a) the administrative processes and reviews associated with application and approval of RTOs; and b) the auditing of the RTO to demonstrate compliance of the RTO s operations with the criteria established by the MSAs. The procedures contained in this standard relate to the auditing process. The approval process (Annex A) is mentioned here only as it relates to auditing. More detail about the approval process is provided in the Guidelines for Auditing Registered Training Organisations. It is a goal of the NMSC that, following a period of time when auditors from the several MSAs have conducted audits and developed an understanding of each jurisdiction s obligations, there will be mutual recognition of audits between jurisdictions. This standard specifies requirements for auditing RTOs to deliver maritime training and assessment in the competencies specified in the Maritime Training Package for the purposes of compliance with NSCV Part D, Marine Orders Part 3 or any other relevant set of marine competencies. It applies to all MSAs that audit and approve RTOs to deliver training, and to auditors who undertake audits. NOTES: 1.3 OBJECTIVES 1. The procedure in this standard is in addition to, but is not intended to duplicate, replace or take precedence over, an audit conducted by a State Registering Body. 2. Checklists that may be of assistance to MSAs are provided in Annex B. The objective of this Standard is to provide a nationally consistent procedure, binding all MSAs, for auditing RTOs. 1.4 DEFINITIONS NOTE: MSA auditors seek to confirm that RTO graduates are trained and assessed in a manner that ensures that the graduates are able to meet the relevant performance criteria of the Maritime Training Package. For the purposes of this document, the definitions contained in Part B and Part D of the National Standard for Commercial Vessels (NSCV), as well as the definitions in this clause, apply. NSAMS Section 5 Auditing of RTOs Page 7 12 August 2008

8 audit A systematic and independent examination to determine whether activities and related outcomes comply with planned arrangements and whether these arrangements are implemented effectively and are suitable to achieve objectives. Australian Quality Training Framework The set of nationally agreed standards to ensure the quality of vocational education and training services throughout Australia. The current version is known as AQTF classification society An association approved by AMSA under the Commonwealth Navigation Act as a survey authority. Marine Safety Authority (MSA) The statutory marine authority/agency of the Commonwealth of Australia, or of a State or Territory within the Commonwealth. Registered Training Organisation (RTO) - A training organisation registered by a state or territory registering body in accordance with the AQTF Standards for Registration within a defined scope of registration in order to deliver and assess nationally recognised training and issue nationally recognised qualifications of the Australian Qualifications Framework. registering body The authority responsible under the Vocational Education Training legislation and decision making framework of a particular state or territory, and in accordance with the AQTF Standards for State and Territory Registering Bodies, for registering training organisations, including all the processes relating to registration and the imposition of sanctions on RTOs. 1.5 ABBREVIATIONS NOTE: The name and contact details of each registering body are listed in the AQF Essential Standards for Registration. AMSA Australian Maritime Safety Authority AQF Australian Qualifications Framework AQTF Australian Quality Training Framework MSA Marine Safety Authority NSCV National Standard for Commercial Vessels RTO Registered Training Organisation 1.6 REFERENCES The following documents are referred to in this Section of NSAMS. 12 August 2008 Page 8 NSAMS Section 5 Auditing of RTOs

9 Any document referenced in this Section should be considered to be the latest revision of the document including amendments. AUSTRALIAN TRANSPORT COUNCIL National Standard for Commercial Vessels Part B General requirements Part D Crew competencies STANDARDS AUSTRALIA AS/NZS ISO Guidelines for quality and/or environmental management systems auditing AS ISO/IEC Requirements for bodies operating the certification of persons AUSTRALIAN QUALITY TRAINING FRAMEWORK AQTF Essential Standards for Registration AQTF Users Guide to the Essential Standards for Registration AQTF Standards for State and Territory Registering Bodies AQTF National Guideline for Industry Regulator Engagement AQTF National Guideline for Risk Management AQTF National Guideline for Audit Moderation AQTF National Guideline for Managing Non-Compliance AQTF Audit Handbook NSAMS Section 5 Auditing of RTOs Page 9 12 August 2008

10 CHAPTER 2 AUDIT PROGRAM 2.1 GENERAL It is the responsibility of MSAs to develop and implement an audit program to support their approval of RTOs to supply maritime training and assessment in the competencies specified in NSCV Part D. The audit program shall include a) Objectives of the program. b) Extent of the program. c) Audit criteria. d) Scope, objective, frequency and duration of audits to be conducted. e) Resources required, including personnel, standards, equipment and costs. f) Audit procedures. g) Records required. h) Procedures to monitor review and improve the audit program. NOTES: 3. The MSA may designate a specific officer as the audit program manager. 4. The audit program may include the collection of evidence from a variety of sources. 2.2 RANGE OF AUDITS There are five types of audits that can be undertaken a) Approval audits. b) Audits of specific training programs. c) Surveillance audits. d) Re-approval audits. e) Special audits. Of these, a), c) and d) are required for initial and continuing approval of an RTO. Audits b) and e) may be required in special circumstances. Specific requirements for different audits are set out in Clauses 2.5 to 2.9. In all cases the general conduct of the audit shall be in accordance with Chapter CHAPTER AUDIT OBJECTIVES The objective of all audits covered by this standard is to verify compliance by the RTO with the audit criteria and assess whether the RTO has the capability to deliver training and assessment outcomes that satisfy the legal and operational requirements of the relevant MSA. NSAMS Section 5 Auditing of RTOs Page August 2008

11 NOTES: 2.4 AUDIT CRITERIA 1. Audits can also provide the opportunity to improve the quality of teaching and assessment. Audits are expected to be a value adding process for all concerned. 2. The outcome of audits is to provide a basis for Authorities to approve and continue the approval of an RTO. In approving an RTO the MSA will consider whether the RTO can deliver training and assessment to a standard as part of the process of issuing Certificates of Competency in compliance with statutory and international obligations. The audit criteria shall be established by the MSA based on the ability of the RTO to satisfactorily train in, and assess, the relevant units of competency specified in the Maritime Training Package that relate to: i) NSCV Part D, specifically: a) Requirements for certificates of competency; and b) Prerequisites for certificates of competency; ii) Marine Orders Part 3; or iii) Other sets of marine competencies determined by the MSA. NOTE: The criteria (and hence scope) of individual audits may address a subset of the above general criteria, e.g. only a specific group of competencies, as a part of a sampling regime. The required competencies and qualifications of assessors are specified in CHAPTER APPROVAL AUDIT General The approval (or initial) audit is the most important audit. The results of this audit are used by the MSA in determining whether the RTO can be issued with a certificate as an approved maritime RTO. The audit is also used to determine the scope of the approval (i.e. the training and assessment strategy, programs and courses the RTO is approved to conduct). The applicant RTO shall have current registration with the State or Territory registering body before being audited. The issuing agency may be contacted to verify current registration if doubt exists. If the training organisation is newly established and does not have Registering Body registration the approval process, and hence the initial audit, shall be postponed until that requirement is satisfied. NOTE: The final approval should not extend beyond the registration expiry date of the RTO. This has implications for surveillance and re-validation audits. The audit shall address all grades of certificates of competency that the RTO seeks to have included in its approved RTO scope Audit Objective The objective of an approval audit shall be to determine whether an RTO can deliver outcomes that are acceptable to the MSA for the issue of NSAMS Section 5 Auditing of RTOs Page August 2008

12 2.5.3 Process Certificates of Competency, in compliance with the MSA s statutory obligations and any international obligations. The specific audit objectives shall be: a) To confirm that the RTO is a duly Recognised Training Organisation within the meaning of the AQTF. b) To assess the suitability of the specific maritime content of the teaching and learning procedures. c) To assess the suitability of the specific maritime content of the teaching and learning documents, materials and aids. d) To assess the maritime qualifications and experience of the persons delivering and assessing the specific maritime content of the teaching and learning process. e) To confirm that the RTO is able to comply with Commonwealth and State and Territory regulations that are relevant to the RTO's maritime operations and that are of concern to the MSA. f) To confirm there are sufficient resources to provide effective maritime learning and assessment opportunities. g) To confirm that the assessment strategy and tools are all of a standard acceptable to the MSA. The approval audit shall have two components a) a review of all relevant documentation; and b) one or more audit visit(s) to the establishment(s) where the maritime specific training programs are to be delivered. The documentation, including samples of procedures, teaching aids, assessment methods, assessor qualifications and training and sample records, shall be submitted with the application. The document review should normally be carried out at the MSA s establishment prior to the audit visit. Audit site visits may involve discussions with trainers and assessors, and include reviewing actual records, teaching aids, equipment and assessment instruments. The audit shall be relevant to the grades of certificates that the RTO seeks to have included in its approved RTO scope. The MSA may seek evidence with respect to each grade of certificate the RTO seeks to have included in its approved RTO scope. The initial audit shall take account of the fact that the RTO does not already have a history of operating with the Maritime Training Package and NSCV. This means certain records (e.g. assessment records, student forms, equipment maintenance) that would be used in assessing the ongoing operations of the RTO will not be available. 12 August 2008 Page 12 NSAMS Section 5 Auditing of RTOs

13 Where there are concerns (both non-conformances and areas for improvement) the RTO shall be given reasonable time to correct these deficiencies before a subsequent audit is carried out. 2.6 AUDIT OF SPECIFIC TRAINING PROGRAMS General The audit of specific training programs normally forms part of the approval audit. If an RTO seeks to alter its scope of accreditation, then the MSA shall undertake an audit in relation to the specific training programs affected by the amended scope. The results of this audit shall be used by the MSA to approve, or not approve, the inclusion of the new programs Objective of audit The objective of the audit shall be to assess whether a training program, outside the currently approved scope of the RTO, can deliver outcomes that are acceptable to the MSA to allow Certificates of Competency to be issued Scope of audit NOTE: The new training program can be either completely new, a significant revision of an existing program, or a program that had not previously been approved. The scope of the audit of a specific training program shall be limited to that program. Similarly, the audit criteria shall only be those that are directly applicable to the training program. 2.7 SURVEILLANCE AUDITS Objective of audit Process The objective of a surveillance audit shall be to verify that the quality, standard and consistency of the content, delivery and assessment of approved training programs and courses are maintained, i.e. the training and assessment processes are achieving their identified outcomes. Surveillance audits shall be conducted at least annually. They may be scheduled more frequently depending on the results (areas for improvement or non-conformances) identified during the previous audit. This is in addition to special audits (see Clause 2.9), employed for checking whether satisfactory corrective action has been taken. The scope of a surveillance audit shall be a subset of the scope of approval and re-approval audits. It may concentrate on a sample of training program(s) or of the RTO s processes. The surveillance audit shall include a check of the Registering Body s registration of the training organisation as the approval lapses if the Registering Body withdraws registration. NSAMS Section 5 Auditing of RTOs Page August 2008

14 The MSA may implement a process of continuous auditing, i.e. short duration visits to monitor and suggest improvements in selected areas of the training and assessment. 2.8 RE-APPROVAL AUDIT General The re-approval audit is similar in nature to the initial audit and the results of this audit are used by the MSA in determining whether the certificate of approval as an approved maritime RTO can be re-issued. As with the initial audit, the applicant RTO shall have current Registering Body registration before being audited. The issuing MSA may be contacted to verify current registration if doubt exists. The results of this audit shall be used by the MSA to verify the scope of the training offered Objective of audit Process The objective of the re-approval audit shall be to verify that an RTO, accredited by the Registering Body, has the capability to continue to deliver outcomes that are acceptable to the MSA and hence allow the MSA to issue Certificates of Competency in compliance with their statutory obligations and any international obligations. The specific objectives for the initial audit shall also apply to the reapproval audit. The re-approval audit shall take place at an interval not exceeding five years. The re-approval audit shall have two components a) a review of all relevant documentation assessed against the results and records of previous audits (including any non-conformances and corrective action undertaken); and b) one or more visit(s) to the establishment(s) where the maritime specific training programs are being delivered. The document review should normally be carried out at the MSA s establishment. The MSA shall request from the RTO the documents required for assessment. Site visits may not be required if, following the document review, the MSA is satisfied that the RTO can deliver the outcomes required under NSCV Part D. The site audit(s) shall take into account the results and records of previous audits (including any non-conformances and corrective action). The audit shall be relevant to the grades of certificates that the RTO seeks to have included in its approved RTO scope. The MSA may seek 12 August 2008 Page 14 NSAMS Section 5 Auditing of RTOs

15 evidence with respect to each grade of certificate the RTO seeks to have included in its approved RTO scope. If there has been a substantive change to the operations of the RTO, e.g. new trainers and/or assessors delivering and assessing the training programs, new courses being offered, new locations, then the MSA shall carefully review the additional information provided to ensure the requirements of NSCV Part D are met. 2.9 SPECIAL AUDITS General Special audits shall be undertaken a) to investigate alleged deficiencies in the content of training courses, the delivery of training, or the assessment process; or b) where deficiencies (non-conformances) have been identified in previous audits and the RTO is required to correct these deficiencies. Special audits may result in the suspension or cancellation of the approved RTO status where identified deficiencies are of a serious nature. Suspension may be lifted following satisfactory corrective action by the RTO (checked by a subsequent special audit). Cancellation of approval shall require a new approval audit before the RTO can become approved again Objective of audit Process The objective of a special audit is to assess specific areas where the RTO, its training strategy, training programs or assessment processes are alleged to be deficient, or have previously been found to be deficient. The conduct of the audit, which may include a document review, shall be in accordance with CHAPTER 3. The scope of a special audit shall be confined to the identified areas of concern. The MSA shall advise the RTO of the outcome of the audit, including any recommendation for a suspension or cancellation of approved RTO status. Where corrective action is required, the MSA and RTO shall agree on the time frame for the corrective action to be completed. The MSA may undertake a further special audit to confirm that the necessary action has been completed. Alternatively, this confirmation may be part of a scheduled surveillance audit SUSPENSION OF APPROVAL The MSA shall suspend approval of the RTO if it has reasonable grounds to believe: NSAMS Section 5 Auditing of RTOs Page August 2008

16 a) The RTO is no longer in compliance with the criteria specified in NSCV Part D; or b) The RTO is no longer in compliance with AQTF standards The MSA may decline to recognise any testamurs issued by that RTO during the period over which the RTO s compliance is in question. 12 August 2008 Page 16 NSAMS Section 5 Auditing of RTOs

17 CHAPTER 3 CONDUCTING THE AUDIT 3.1 GENERAL The MSA shall initiate the audit and appoint the audit team, including the lead auditor. The audit function requires both auditing and technical skills. The prospective audit team shall be chosen on the basis of the competence and capacity to undertake the audit. The audit team may be made up of personnel from within the MSA or external to the MSA. The MSA shall determine the scope and timing of the audit in conjunction with the Lead Auditor and shall advise the RTO. The RTO may challenge the inclusion of an auditor where there are reasonable grounds to believe that the auditor does not comply with the principles of auditing set out in AS/NZS ISO The MSA shall resolve any such challenges by the RTO prior to commencing the audit. Audit reports shall be treated as confidential and shall only be made available to the MSA responsible for the audit. The RTO shall receive copies of all non-conformances (or areas for improvement) and may also receive a summary of the audit report with the agreement of the MSA. An MSA may request from the RTO copies of audit reports prepared by other organisations not being another MSA. Where during the previous audit, an RTO was audited on behalf of the relevant MSA by another MSA, or by an audit panel member appointed by the relevant MSA, the current lead auditor may request production of the immediately previous audit report. 3.2 RELATIONSHIP WITH AQTF The MSA shall recognise and cooperate with the AQTF audit process. Joint AQTF/marine safety audits should be held wherever practicable with a view to minimising disruption to the RTO. However, should a joint audit prove difficult to arrange, then the MSA may arrange separate audits. When considering separate audits the MSA shall recognise and cooperate with the RTO regarding the scheduling and scope of the audit. In the event of the MSA becoming concerned about the validity of the RTO status or the RTO's compliance with AQTF standards then the MSA should liaise with the Registering Body in accordance with: i) The AQTF National Guideline for Responding to Complaints about Vocational Education and Training Quality; and ii) The AQTF National Guideline for Managing Non Compliance. The MSA may withdraw the previously granted approved RTO status and may decline to recognise any testamurs issued by that RTO during the period in which the MSA is concerned about the proper conduct of the RTO. NSAMS Section 5 Auditing of RTOs Page August 2008

18 NOTE: An MSA has the same rights and obligations as any other party in those circumstances where it has concerns about an RTO s proper compliance with any of the standards applicable to it. Action taken can include reporting their concerns to the R/CAB and or any other relevant organisation; or such other action as the MSA sees fit. 3.3 DOCUMENT REVIEW 3.4 AUDIT Document review, shall be of sufficient rigour to assess, based on objective evidence, whether the training program conforms to the audit criteria. Documents (that relate to the maritime content) reviewed may include: a) Organisational policies. b) Written training aids and other material. c) Training and assessment procedures. d) Student records. e) Assessment instruments and evidence. The document review shall also include an assessment of the qualifications and experience of trainers and assessors. The conduct of the site audit of the establishment shall be carried out in accordance with AS/NZS ISO The following processes shall be followed when conducting the audit: a) Develop an audit plan. b) Define the audit objectives and scope. c) Appoint an audit team and assign specific tasks. d) Prepare documentation including checklists, reports and methods of transmitting and recording information. e) Establish contact with all parties concerned and arrange mutually acceptable schedules. f) Conduct an opening meeting to ensure all parties are clear on what is expected and to identify lines of communication. g) Clarify the roles and responsibilities of all those involved in the audit process. h) Apply appropriate methods for collecting and verifying information. i) Prepare audit findings, conclusions and recommendations. j) Conduct a closing meeting to present the findings and conclusions. k) Prepare and distribute the audit report including the audit findings. l) Provide appropriate feedback to the RTO. m) Conduct audit follow-up as deemed necessary. 12 August 2008 Page 18 NSAMS Section 5 Auditing of RTOs

19 The audit shall include, but not necessarily be limited to, assessing the following: i) The extent of compliance with applicable marine legislation, codes and standards, including the Maritime Training Package, NSCV Part D, and/or Marine Orders Part 3. ii) iii) Organisational objectives and policies relating to the provision of maritime training and assessment being applied, communicated and understood. The definition and communication of duties and responsibilities for maritime training. iv) The adequacy, currency, control and availability of documentation and information used to deliver and assess maritime training. v) The quality, completeness and method of retention of appropriate records. vi) The methods employed to plan and effectively deliver and assess the maritime training and assessment. vii) The infrastructure and physical resources available and being used to deliver and assess the maritime training programs, e.g. equipment, vessels, simulators. viii) The competence and experience of personnel available and being used to deliver or assess the maritime training programs. ix) Systems and procedures for monitoring, review, feedback and amendment. 3.5 EVIDENCE The outcome of the audit shall be to determine conformity or nonconformity with the audit criteria. The audit criteria relate to specific maritime competencies and the ability of the RTO to satisfactorily train and asses these competencies. Audit findings shall be based on objective evidence collected during the audit. Hearsay and personal views shall not be relied upon. The type of evidence shall be appropriate to the audit criteria and scope; and the extent of evidence collected shall be appropriate to the audit objective. The evidence gathered shall include at least a) Records and documents relating to operations, training and assessment. b) The results of interviews with employees and students. c) Direct observation of operations and equipment. Other evidence may include i) Internal audit reports. ii) AQTF reports. iii) Tests and measurements. iv) Inspections and surveys. NSAMS Section 5 Auditing of RTOs Page August 2008

20 3.6 RECORDS v) Client (MSA) and student feedback. Documented records of audits shall be retained in accordance with ISO These records shall include, but not necessarily be limited to a) The audit plan, including objective, scope and audit criteria. b) The audit team members and date, time and place of the audit. c) Documents, written observations and other objective evidence collected during the audit. d) The audit report, including the audit findings, summaries of compliant and noncompliant processes or functions, and any unresolved issues. e) Any non-conformances or areas for improvement identified. f) Any recommendations to the MSA. 3.7 NATIONAL REGISTER OF APPROVED RTOS Upon successful completion of an audit, the MSA concerned shall advise the NMSC Secretariat of the results for the purpose of maintaining the National Register of Approved RTOs. NOTES: 1. The NMSC will list the relevant details on the NMSC website. 2. The general form of the register is set out in Annex C. 12 August 2008 Page 20 NSAMS Section 5 Auditing of RTOs

21 CHAPTER 4 AUDITORS 4.1 AUDIT TEAM The role of the audit team is to satisfy the MSA that the training and assessing provided by the RTO meets current relevant requirements for the competencies in the Maritime Training Package and NSCV Part D and/or Marine Orders Part 3. It should be recognised that successful auditing requires specific competencies and skills that are in addition to any required marine competencies or qualifications. NOTE: Since an audit report has the potential to negatively impact on an RTO, the audit team could be called upon to adequately demonstrate their skills and experience in case it is necessary to justify their findings. If litigation was involved then the auditors could come under considerable scrutiny. Similarly, if Certificates of Competency were issued and subsequently found (possibly through an accident investigation) to be deficient, then the auditing process could be called into question. There are three classes of persons on an audit team: a) Lead auditors b) General auditors c) Technical experts The roles, responsibilities and qualifications for each class are described below. Every audit team shall include as a minimum a lead auditor and a technical expert with expertise in the relevant maritime discipline. NOTE: Technical experts may, of course, also be qualified auditors in which case they can fulfil both roles. 4.2 AUDIT TEAM ROLES AND RESPONSIBILITIES Lead auditors Lead auditors shall be responsible for a) In conjunction with the MSA, establishing the objectives, scope and extent of the audit. b) Establishing the resources required and scheduling / timetabling the audit. c) Contacting the RTO to schedule times of audits, persons to be interviewed and the topics to be covered. d) Assigning responsibilities and supervising the other auditors. e) In conjunction with the other auditors developing the work plan and ensuring other members of the audit team are aware of their roles, responsibilities and tasks. f) Conducting the opening and closing meetings. NSAMS Section 5 Auditing of RTOs Page August 2008

22 g) Approving the audit report and any non-conformances issued to the RTO. h) Providing a recommendation to the MSA General auditors General auditors shall be responsible for a) Participating in the pre-audit discussions. b) Participating in the opening and closing meetings. c) Conducting the allocated auditing tasks including document review, observation and interview. d) Assist in preparation of the audit report. General auditors may operate independently, including at sites separate from the site of the main audit Technical experts Technical experts shall a) Work directly under the responsibility of an auditor. b) Provide technical advice when requested. 4.3 AUDITOR CONDUCT AND QUALIFICATIONS General All auditors shall comply with the principles of auditing described in AS/NZS ISO These principles include a) Ethical conduct. b) Fair presentation. c) Professional care. d) Independence. e) Evidence-based approach. Auditors should also have personal qualities that assist in meeting the principles and ensuring the audit is conducted effectively and with minimum antagonism. These qualities include a) Open-mindedness. b) Diplomatic. c) Observant. d) Versatile. e) Tenacious. f) Decisive. 12 August 2008 Page 22 NSAMS Section 5 Auditing of RTOs

23 Audit team members shall have relevant industry experience to the satisfaction of the MSA. The MSA shall ensure that any auditors used by them have the qualifications and experience specified below, and have the necessary skills to carry out the audits in an appropriate manner as set out in Clause Lead auditors Lead auditors shall have a) successfully completed lead auditor training from a recognised auditor training organisation; and b) been certified, or have the qualifications and experience to be certified, as an auditor by an AMSA recognised Classification Society, or by a body accredited in accordance with AS ISO/IEC General auditors General auditors shall have the qualifications and experience to be certified as an auditor by an AMSA recognised Classification Society, or by a body accredited in accordance with AS ISO/IEC Technical experts Technical experts shall have technical knowledge and skills in the subject area required. This shall include appropriate qualifications and extensive practical experience. NOTE: Technical experts may also be qualified auditors in which case they can fulfil both roles. Technical experts shall hold a relevant Certificate of Competency at least to the level being assessed, provided that the minimum level shall be a Master Class 5 or MED II or demonstrated equivalent industry experience that is satisfactory to the MSA. 4.4 AUDITOR PANEL In order to simplify the allocation of appropriate personnel to auditing teams, the NMSC operates a registration scheme for Maritime Auditors including a National Panel of Maritime Auditors. This register contains the names, contact details, qualifications, experience and technical expertise of auditors available to conduct audits of RTOs. An example of the format of the register is shown in Table 1. NOTE: The NMSC registration scheme consists of procedures for nominating auditors, verifying their qualifications and experience, assessing that they can perform the tasks required in the relevant areas, running a web based register, implementing procedures for periodic review of performance and re-registration, and a complaints handling process (i.e. NMSC runs a Personnel Certification scheme for marine auditors). Each MSA shall list their auditors on this register. These auditors may then, by agreement, conduct audits in other jurisdictions and thus broaden their experience base and contribute towards the NMSC s goal of national NSAMS Section 5 Auditing of RTOs Page August 2008

24 consistency. Independent auditors may also be listed and be available for contract auditing. NOTE: The panel of auditors is intended to provide efficiencies to Authorities conducting audits. For example, where a particular MSA experiences temporary overload or other difficulty in meeting audit service requirements that MSA could use the register to identify suitable individuals who could provide short term services. There is also the situation, typically involving a State or Territory Authority and the Commonwealth Authority where each MSA might issue a certificate of competency based on the same training package course and each MSA involved accepts an obligation to audit the subject RTOs involved. In those circumstances the Authorities concerned can use the panel to manage their auditing services with the aim of conducting joint audits and minimising disruption to the RTOs. Auditor s Name Table 1 Format of Register for National Panel of Maritime Auditors Organisation Contact Details Auditing Qualification Maritime Qualification Auditing Scope Key Name: Name of individual auditor Organisation: the name of the Authority or business employing or contracting the auditor. Contact Details: the business address, , telephone and facsimile and mobile telephone details of the auditor. Auditing Qualification: the name of the issuing body and the date and grade of auditing certificate held. Maritime Qualifications: the maritime qualifications held and the issuing body and the date of issue or last revalidation. Auditing Scope: The list of courses and certificates that the auditor is approved to audit. 12 August 2008 Page 24 NSAMS Section 5 Auditing of RTOs

25 ANNEX A FLOW CHARTS OF APPROVAL PROCESS This informative Annex provides a general outline of the approval and reapproval process for Registered Training Organisations. This Annex is referenced in Clause 1.1. PROCESS FOR APPROVING AN RTO Initial Application Application Form to Authority Acknowledgement to RTO Required Documents Revise or supply extra documents Document Rev iew Audit Point NO OK? YES Site Visit Site Audit Audit Point NO Audit Report Correctiv e action to be taken NO OK? YES NO Recommendation to Authority Authority Approv es YES Certificate to RTO Approved RTO Continual Compliance NSAMS Section 5 Auditing of RTOs Page August 2008

26 CONTINUING RTO APPROVAL Continual Compliance Authority adv ises RTO of Audit schedule Site Visit Prev ious Nonconf ormances NO Site Audit Audit Report Audit Point Change to Scope (New Course) Staff Change NO Application Form to Authority Serious? NO OK? YES Recommendation to Authority NO Required Documents Audit Point Fatal? NO OK? OK? YES Approv al terminated Approved RTO NO YES Site v isit required? NO Re-Approval Application YES Site Visit Audit Point Authority adv ises RTO Re-approv al requirements YES Site Audit NO Required Documents Audit Report Document Rev iew Audit Point OK? Site v isit required? YES No Site Visit Audit Site Report Audit Audit Point OK? YES Authority Approv es Certificate to RTO 12 August 2008 Page 26 NSAMS Section 5 Auditing of RTOs

27 ANNEX B SAMPLE CHECK LISTS This informative Annex provides a suggested check list of activities to manage and conduct audits. This Annex is referenced in Clause 1.2. B1 B2 B3 DEVELOP INTERNAL SYSTEMS AND PROCEDURES TO MANAGE AND CONDUCT AUDITS. Record purpose of audit; Conduct initial internal desktop audit; Assemble audit team; Check validity of auditors. Check client file: Identify key personnel, sites and activities. Check RTO scope and AQTF audit status Collect documents: AQTF Standards. Maritime Training Package. NSCV Part D. Marine Orders Part 3. Guidelines for auditing Registered Training Organisations. National Standard for Approval and Audit of Registered Training Organisations. CONDUCT RESEARCH. Prepare Working Papers. Establish time line with RTO, STA and Auditors: Contact STA. Contact target RTO. Advise RTO as appropriate. Schedule interviews. CONDUCT AUDIT ACCORDING TO RECOGNISED AUDITING PRINCIPLES. Prepare audit reports. Advise stakeholders of audit outcome. Issue letter of approval as appropriate to RTO. Advise client RTO and draw attention to corrective actions required. Advise NMSC Registrar of Approved RTOs. Advise other MSAs as appropriate. Follow up. Review audit Review internal systems and procedures Follow up on corrective actions. Attend to appeals process. Note next due date for next audit activity. NSAMS Section 5 Auditing of RTOs Page August 2008

28 ANNEX C FORM OF THE REGISTER OF APPROVED MARITIME REGISTERED TRAINING ORGANISATIONS This informative Annex provides information about the National Register of Approved Registered Training Organisations (RTOs) maintained by the National Marine Safety Committee (NMSC) Secretariat, including the format of information contained in the Register. The Register of Approved RTO s will be maintained by the NMSC Secretariat and will be posted on the NMSC website for reference by Maritime Safety Authorities (MSA) and clients of the RTO s The Register will allow the Marine Safety Authority (MSA) to know which RTO s credentials will be recognised in all MSA jurisdictions as valid to support the issue of a Certificate of Competency. An MSA, in nominating an RTO to be recorded in this register after audit, is confirming that full mutual recognition should be accorded to the RTO and its credentials. Candidates for Certificate of Competency may also access the register to confirm that their chosen RTO is authorized by the MSA s to issue credentials that will be recognised in all States and Territories and the Commonwealth for the award of Certificates of Competency in compliance with NSCV Part D and Marine Orders Part 3, in Australia. The format of the information contained in the Register is illustrated in Figure C.1. Figure C.1 Register of Approved Maritime Registered Training Organisations Ref Port Jurisdiction (MSA) Name& Address of RTO (incl. Contact Person) Scope (list of AQF Certificates Approved) Period of Validity of Approval. (Commencement and end dates) Approving MSA (incl. Contact Person) NSAMS Section 5 Auditing of RTOs Page August 2008

29 This page is intentionally left blank. NSAMS Section 5 Auditing of RTOs Page August 2008

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