2010 ohsrm Audit Tool OHS & Injury Management Tel: 61 2 9351 4335 Fax: 61 2 9351 5868 E-mail: ohs.information@sydney.edu.au Web: www.sydney.edu.au/ohs
TABLE OF CONTENTS 1. INTRODUCTION... 4 2. AUDIT ELEMENTS... 5 2.1. The Standard Audit Elements... 5 3. AUDITOR INSTRUCTIONS... 9 3.1. Why Audit?... 9 3.2. Who Conducts the Audit?... 9 3.3. Evidence for Verification... 9 3.4. Audit Preparation... 10 4. AUDITING... 12 4.1. The ohsrm Audit Tool... 12 4.2. Audit Scoring... 13 APPENDIX A AUDIT TOOL... 14 1. MANAGEMENT LEADERSHIP AND OHS COMMUNICATION... 15 1.1. Management Knowledge... 15 1.2. General OHS Policy... 17 1.3. Management Leadership... 18 1.4. Management Meetings... 20 2. SAFETY PLANNING... 22 2.1. ohsrm Action Planning... 22 3. CONSULTATION AND INVOLVEMENT... 24 3.1. Work Group Meetings... 24 3.2. Influence on Decision-Making... 25 4. HAZARD IDENTIFICATION, RISK ASSESSMENT AND CONTROL... 27 4.1. Hazard and OHS Risk identification... 27 4.2. Risk Assessment... 28 4.3. Risk Controls... 30 5. TRAINING AND INSTRUCTION... 32 5.1. Safety Training Needs Analysis... 32 5.2. Training or Instruction in General OHS Obligations... 33 5.3. Staff & Student Inductions... 34 5.4. Specific OHS Risk Training and Instruction... 36 5.5. Maintaining Safety Training records... 37 5.6. Safe Operating Procedures... 38 5.7. Training and Support of Zone OHS Committee Members... 40 6. EMERGENCY PREPAREDNESS... 42 6.1. Emergency Planning... 42 6.2. Emergency Teams... 44 6.3. Administration and Trial Evacuation Drills... 45 6.4. Emergency Communications... 46 6.5. First Aid... 48 7. INCIDENT REPORTING AND INVESTIGATION... 50 7.1. Incident Reporting Procedure... 50 7.2. Incident Investigation System... 52 7.3. Maintenance and Facilities Improvement Requests/Reports... 53
8. PURCHASING... 55 8.1. Procurement of Goods... 55
1. INTRODUCTION The University of Sydney has established an OHS risk management (ohsrm) Program for the benefit of its staff, students and visitors. The program is designed to be both practical and compliant with NSW OHS legislation. It is underpinned by the University s OHS Policy and Guide for Staff and OHS Consultation Statement. The ohsrm Audit examines how OHS risks are managed at Unit or Departmental level in comparison with the expectations of the ohsrm Program. This document describes the audit process and includes the audit elements and questions set. Supporting information is available from the ohsrm Program website: http://www.sydney.edu.au/ohs/ohs_manual/ohsrm.shtml Page 4
2. AUDIT ELEMENTS The Audit Elements listed below examine the implementation of various aspects of the University s ohsrm Program. Each element has a description of the relevant performance standard and guidance on what is expected in terms of implementation. The audit question set is designed to assess this. 1. Management Leadership and Commitment 2. Safety Planning 3. Consultation and Involvement 4. Hazard Identification, Risk Assessment and Control 5. Training and Instruction 6. Emergency Preparedness 7. Incident Reporting and Investigation 8. Purchasing An overview of these standard audit elements and sub-elements follows. The details are put into context with applicable standards and guidance in the Audit Tool in Appendix A. There are supplementary elements to the standard ohsrm Audit that may be relevant for some University departments that deal with particular hazards and OHS risks. OHS management relating to these elements are subject to a separate high risk OHS Audit: 9. Contractors and Service Providers 10. Hazardous substances 11. Biological Hazards 12. Ionising Radiation 13. Machinery 14. Noise 15. Outdoor work 16. Fieldwork 2.1. The Standard Audit Elements 2.1.1. Management Leadership and Commitment Effective leadership and commitment from middle and senior management is vital to the success of the ohsrm Program within each Unit. The leadership shown by management provides the foundation upon which a good safety management system is built. This element is concerned with the expected standards of leadership and commitment. Management Knowledge General OHS Policy Management Leadership Management Meetings Page 5
2.1.2. Safety Planning Planning is a key feature of any safety management system. The same applies for the ohsrm Program. ohsrm Action Plans define the future direction of the Program in each Unit. ohsrm Action Plans should typically adopt the SMART principle, i.e. plans should be: specific, measurable, attainable, realistic and time-bound. 2.1.3. Consultation and Involvement The ongoing management of safety risk requires regular consultation and involvement with people that are either: a. affected by the risk, or b. have a role in managing the risk themselves. Consultation involves having a meaningful two-way discussion with the relevant risk management stakeholders. Involvement in the process and ultimately the risk-based decisions would help increase the likelihood of their support. Sub-elements for consultation and involvement include: Workgroup Meetings Influence on Decision-Making 2.1.4. Hazard or OHS Risk Identification, Risk Assessment and Control The fundamental element of the ohsrm Program involves the management of risks to health and safety. To do this effectively, a risk management process must be adopted. The essential starting block for this process is hazard identification. If the safety hazards of the Unit are not comprehensively identified, then they cannot be effectively managed. The identification and assessment of OHS risks and selection of risk controls must be done in consultation with those involved in the work. Note that the term hazard is not restricted to laboratories and workshops or construction and farming. Hazard should be interpreted as anything that may jeopardise the health, safety or welfare of staff, students or visitors. In an office environment hazards may typically include manual handling (of office equipment), overuse injury (from mouse and keyboard work), work related stress, noise, glare, trip hazards etc. A risk assessment should be performed for each activity that has been identified as presenting some risk of injury or hazard. The risk assessment reveals the factors that contribute to increased risk e.g. the environment, the people involved, the materials being used or other operational aspects. The results of the risk assessment help to choose appropriate risk controls. Risk control measures are then chosen to mitigate the risk to an acceptable level. The hierarchy of controls should be applied - these include (in order of preference): elimination, substitution, re-engineering, administrative controls or personal protective equipment. Significant risks may require several layers of control to ensure they are adequately addressed. Sub-elements for hazard identification, risk assessment and control include: Hazard or OHS Risk Identification Risk Assessment Risk Controls Page 6
2.1.5. Training and Instruction Safety training and instruction require the communication of relevant, accurate and timely OHS information to staff, students or contractors operating within the jurisdiction of a University Unit. Sub-elements include: Safety Training Needs Analysis Training or Instruction in General OHS Obligations Staff & Student Inductions Specific OHS Risk Training Maintaining Safety Training Records Safe Operating Procedures Training and support of OHS Committee members 2.1.6. Emergency Preparedness An emergency plan should exist that is relevant to the risks associated with the Unit. It should prescribe procedures for evacuation, assign responsibilities for co-ordinating the evacuation, for notification of relevant emergency services, the means of communications and prepare people for action. Relevant sub-elements include: Emergency Planning Emergency Teams Administration and Trial Evacuation Drills Emergency Communications First Aid 2.1.7. Incident Reporting and Investigation The reporting and subsequent investigation of accidents, incidents and near misses involves a methodical review of events and conditions that contributed to the incident. Investigations are specifically undertaken to define the facts of the incident and to identify a course of remedial action to prevent the incident from recurring. Incidents are also investigated for reporting purposes to the University s OHS Committees, its insurers and Workcover. The benefits of investigating accidents are that it allows the University to learn from errors or unsafe conditions to ensure that the management system continuously improves. The most effective means of learning from incidents is to ensure that each Unit across the University investigates and reports incidents in an accurate and timely manner. These reports should not only cover accidents where an injury occurred, but also incidents that were near misses. Other sub-elements included under Incident Reporting and Investigation are: Incident Reporting Procedure Incident Investigation System Maintenance and Facilities Improvement Requests / Reports Page 7
2.1.8. Purchasing This element is designed to evaluate the systems and procedures that are in place and working to ensure that safety risks of goods purchased are controlled prior to them arriving at the University or before University-related activities occur. Page 8
3. AUDITOR INSTRUCTIONS 3.1. Why Audit? The audit tool aims to assist Units to self-monitor their management of OHS risks against the agreed standards of the University s ohsrm Program. It empowers each Unit to take responsibility for the OHS risks created by/involved with their work and seeks to audit the OHS-related activities of all people within the Unit and not just one designated OHS custodian. The audit is not a workplace safety inspection. It is an assessment of the systematic management of OHS risks within the Unit. The key objectives of the self audit function are to: provide an objective measure and quantify OHS-related activities being undertaken provide a system to record OHS performance/compliance and guide future efforts for the system s continued development encourage a systematic approach to the management of OHS across the University identify and effectively address the majority of OHS risks. The audit methodology seeks to verify claims made by each Unit and OHS & Injury Management will provide quality assurance by monitoring audit results centrally. 3.2. Who Conducts the Audit? The In-house OHS Auditor is nominated by their Head of Department and trained for familiarity with the ohsrm Program and competence in using the 2010 ohsrm Audit Tool. The audit may be conducted by an OHS Auditor from either within the Unit * or an appropriately trained Auditor from another Unit. The latter provides the advantage of being independent and reducing potential conflicts of interest. In-house OHS Auditor appointments and partner auditor arrangements are made locally by the senior manager. * For the purposes of this self-audit, a Unit is considered to be a Department or School. 3.3. Evidence for Verification The auditor should seek evidence to verify that the activities being claimed have been in existence for at least 3 months prior to the audit. The 3 methods for undertaking this are: Interviewing staff members Interview at least three levels of staff from senior management (Head of Department, Director), middle management (Executive Office, Team Leader), and operational/front line employees or researchers. Keep records of interviews and highlight items that may be confirmed with visual checking. Visual checks of the workplace Tour the workplace with a representative of the Unit and seek to validate assertions made during the interviews e.g. safety signposting, safe work practices, wearing of personal protective equipment etc. Page 9
Checking records Seek a random selection of the documented records, not only what the person being audited offers for review. The auditor should give credit only if it is evident across the Unit and not just sporadic attempts to satisfy the auditor. It should be a true reflection of the audited location. 3.4. Audit Preparation 3.4.1. Type of People to Interview The audit should seek to verify the safety-activities at different levels within the Unit and across functions. People to be audited should include the following. The codes in brackets are explained in 3.4.2. Head of Department (S) Senior administrative staff, supervisors or team leaders (M) Front line workers, operational staff, post graduate and honours students (O) Building manager or space owners (M) Purchasing/procurement manager Departmental safety officer (DSO) Chief Building / Emergency warden (CW) Nominated First Aid Officer (FA) Zone OHS Committee member (ZO) 3.4.2. Planning the Audit Interview In preparation for the audit it is important to have allocated specific sub-elements to particular staff. It makes for a very slow and time-consuming audit if the auditor does not have in advance a specific set of questions for each person they are interviewing. As such the sub-elements and questions listed in Appendix A have been designated as possible questions for: (S) Senior managers (M) Middle managers (O) Operational staff and post graduate students The question sets for each of these 3 categories are available separately from the ohsrm Audit website. Some questions are also relevant for the following officers (if appointed within the Unit). (DSO) Departmental Safety Officer (CW) Chief Building Warden or local emergency warden (FA) Nominated First Aid Officer (ZO) Zone OHS Committee member. Page 10
3.4.3. Understand the Interviewee s Job When conducting interviews and before commencing the official audit questions, the Auditor should allow the person being interviewed to briefly describe their job. This will assist the auditor to contextualise the questions and provide some of the necessary background to ensure questions are relevant. 3.4.4. Relevant Documentation The following documents relating to the Unit may be sighted during the audit or sought to validate assertions made by the interviewees about local OHS risk management: OHS Policy and Guide for Staff ohsrm Action Plans showing short-term and long-term OHS goals Incident reports, notification forms and procedures OHS-related policies and guidelines Safe work method statements and standard operating procedures Organisational charts Management and staff job descriptions and appraisals OHS training records, including attendance records, course material, lesson plans and trainer details General orientation and induction outline Specific task orientation, including checklists and records System for communication with staff, students and contractors Bulletins or newsletters published and distributed Group meeting records where safety issues have been discussed Filed OHS documents Inspection checklists and reports Emergency response plans Emergency team training and meeting records Records of emergency drills held and debriefing afterwards First aid training records Page 11
4. AUDITING 4.1. The ohsrm Audit Tool An audit template has been developed to allow the auditor to have easy access to the relevant information for each ohsrm element and sub-element. The template contains: Standard A description of the activity and the expected level, value or quantity of that activity. Guideline Some useful background information about the standard or tips on where to look for evidence of the standard. Links Many of the sub-elements are linked to other OHS documents or indeed to other audit questions. These links have been included to assist the auditor to locate related information. Score Guide These describe the typical levels of compliance with the standard. The ratings range from A - E. A is indicative of full implementation and focus on continued improvement, whereas E indicates that there has been no effort made. Question The question(s) to be asked by the auditor to assess the standard. Comments notes may be made where appropriate to record answers to each audit question. General comments relating to each sub-element may also be recorded to qualify this information. Rating A rating of A - E will be assigned for each sub-element based on the responses to the associated questions and evidence presented. Half point scores are allowed where the score does not align well with the associated Score Guide increments e.g. B+ would rate more highly than B, but less than A. See Appendix A for the ohsrm Audit Tool. Page 12
4.2. Audit Scoring The OHS Audit applies a five point ranking system on each sub-element. Auditors should enter a rating of A E with reference to the relevant Score Guide for the respective subelement. The corresponding score will be used by the audit software to calculate a percentage. Description Rating Score Exemplary performance A 4 Very good implementation of most aspects B 3 Substantial evidence of implementation C 2 Minimum effort D 1 No score E 0 Half point scores are allowed where the score does not align well with the associated Score Guide increments e.g. B+ would rate more highly than B, but less than A. B+ would score 3.5. Each sub-element score is tallied to allow benchmarking. The overall score will be expressed as a percentage i.e. score out of 100. The final audit score for each sub-element should account for all of the interview responses and evidence checked. Where there is wide discrepancy between interviewee responses, additional information should be sought and variables noted as comments. Using Not Applicable The 8 standard audit elements are relevant for all Departments. The sub-element most likely to be non-applicable is 5.7 Training of OHS Committee Members. Units that do not have or have not had a member of staff on the local Zone OHS Committee may mark related questions as not applicable. Where a question or sub-element is not relevant, the score should be marked N/A. This shall indicate that a no score applies in that field and that it will not contribute to the overall percentage. Page 13
APPENDIX A AUDIT TOOL Page 14
1. MANAGEMENT LEADERSHIP AND OHS COMMUNICATION 1.1. Management Knowledge Standard Guideline Links Managers should be able to demonstrate knowledge of the OHS issues that pertain to their Unit. They must also understand how to systematically manage these OHS risks in accordance with the University s ohsrm Program. For the ohsrm Program to be successful in each Unit, managers need to demonstrate that they properly understand the Program and its requirements. Each manager must have knowledge of the OHS issues that relate to the Unit and how the ohsrm Program is applied to address these i.e. inclusion in management meetings, development of ohsrm Action Plans, active identification and management of OHS risks. Score Guide A All managers demonstrate a thorough knowledge of the health and safety issues within their work teams. Managers understand and apply the University s ohsrm Program to manage these risks e.g. OHS is included on management meeting agendas and an ohsrm Action Plan has been developed. The ohsrm Program is well understood and is an intrinsic part of managing local OHS risks. B All managers know about the key OHS issues in their Unit. The ohsrm Program is widely understood and is generally applied throughout the Unit to manage key OHS risks. C Managers demonstrate a basic awareness of some health and safety issues within their work area. Managers are aware of OHS management requirements, but elements are applied irregularly within the Unit. D Only some managers have basic knowledge about OHS issues in the Unit. Some managers have heard of the OHS management requirements, but have only taken basic steps in applying the Program within the Unit. E No managers are aware of health and safety issues within their work area. Managers do not know about the requirements for managing OHS risks as per the ohsrm Program. Sub-element Category Question Can managers describe the health and safety issues within their Unit? What are the main OHS issues? S, M Notes Page 15
Are ohsrm forms or other ohsrm guidance material used by managers to assist them to address OHS issues? Comments Score Page 16
1.2. General OHS Policy Standard Guideline Links Staff should be aware of the University s OHS Policy and Guide for Staff and its intent. They should also be able describe a location where it can be found. The University OHS Policy reflects the positive attitude and commitment toward OHS by University management. Effective leadership is vital to the success of the ohsrm Program. The OHS responsibilities of all staff are described in the OHS Policy Guide for Staff. The senior manager of the Unit should ensure that OHS expectations and responsibilities are communicated to all staff members regularly. University of Sydney OHS Policy and Guide for Staff. http://www.sydney.edu.au/ohs/ohs_manual/index.shtml (follow links) Score Guide A All staff are familiar with the University s OHS Policy and Guide for Staff and can describe the content in some detail. The OHS Policy is readily available in a prominent place in the Unit and can be easily viewed there in hard copy by staff and via direct links on the intranet. Sub-element Category Question B All staff are familiar with the University s OHS Policy and Guide for Staff and can describe how the content applies to their own position. The University s OHS policy is available, but not in a prominent position. It can, however, be found quickly and viewed in hard copy or via direct links on the intranet. C Only some staff members are familiar with the University s OHS Policy and Guide for Staff. Staff interviewed can describe its intent, but not in detail. The intranet or hard copy document can be found with some searching. D Staff are only vaguely aware of the OHS Policy and Guide for Staff, but cannot readily locate the document. The version of the OHS Policy and Guide held is out-of-date. E Staff have not heard of the University s OHS Policy and Guide for Staff. The OHS Policy and Guide for Staff is not available anywhere within the Unit. Are staff familiar with the University s OHS Policy and Guide to staff? Can they describe it in detail or at minimum its intent? Can the current OHS Policy and Guide for Staff be readily located? S, M, O Notes Page 17
Comments Score 1.3. Management Leadership Standard Senior managers must demonstrate active involvement in leading OHS risk management within their Unit. Guideline Links Senior managers should demonstrate their commitment by promoting and participating in OHS activities. They should actively seek out OHS issues concerning staff and students under their direction (via reports from their line managers/supervisors) and act on these, or forward those beyond their control to the relevant line of management for resolution. Staff should be allowed time for OHS activities and the manager should allocate appropriate resources for resolution of OHS issues. ohsrm Meeting Guide http://www.sydney.edu.au/ohs/ohs_manual/ohsrm.shtml OHS Policy and Guide for Staff http://www.sydney.edu.au/ohs/ohs_manual/index.shtml Score Guide A The senior managers openly articulate their ultimate responsibility for managing OHS risks across the entire Faculty/Division/School/ Department. Senior managers lead by example and their decision-making and behaviours reflect a positive OHS attitude. They require other staff and students to do likewise. The senior manager actively seeks-out and addresses OHS issues, seeing them through to resolution. The senior manager requires quarterly reports on OHS risk management from each of their line managers. Senior managers willingly allow staff time to attend to OHS activities. Sufficient resources are allocated to address OHS issues. B Senior managers promote and require staff to follow OHS rules etc. but without leading by example. The senior manager actively addresses OHS issues brought to their attention, seeing them through to resolution. The senior manager requires 6 monthly reports on OHS risk management from each of their line managers. Staff are allowed time to attend to OHS activities. Sufficient resources are allocated to address OHS issues. Page 18
C The senior manager sets a good example by following OHS rules etc. without promoting the requirement for other staff and students to do likewise. They initially address OHS issues brought to their attention, but without seeing them through to resolution. The senior manager requires annual reports on OHS risk management from each of their line managers. Staff are allowed time to attend to OHS activities. Some resources are allocated to address OHS issues. D The senior manager expects direct reports/middle managers and supervisors, or designated safety personnel, to promote and address OHS risk management. The senior manager only occasionally reports on OHS risk management from their line managers. The senior manager sometimes acts on OHS issues brought to their attention, but primarily for critical issues. E There is no specific evidence of senior management leadership in OHS risk management. The senior manager takes no ownership of OHS issues and does not enquire about OHS risk management, nor allow staff time or resources for addressing OHS issues. Sub-element Category Question Do senior managers actively seek out OHS issues in their management area? If so, how have they done this? Does the senior manager require that each of their line managers/supervisors report regularly on the management of OHS risks in their respective portfolios? If so, how frequently and in what form are these reports required? What is the response of senior managers when OHS issues are brought to their attention? Does their decision-making and behaviour reflect a positive Unit health and safety attitude? Are the OHS issues addressed by senior managers seen through to resolution? Are sufficient time and resources allocated to address OHS issues? Comments S, M Notes Score Page 19
1.4. Management Meetings Standard Guideline Senior and middle managers should participate in regular e.g. monthly meetings to discuss ohsrm issues in the work area. OHS risk management should be a standing item on the Agenda of relevant management meetings. This is a useful forum for addressing ohsrm performance targets, new projects and refurbishments, recent incidents that may have occurred etc. Links 2. Safety Planning ohsrm Guidelines ohsrm Meeting Guide ohsrm Consultation Statement http://www.sydney.edu.au/ohs/ohs_manual/ohsrm.shtml Score Guide A ohsrm is a standing agenda item at all relevant management meetings. Management meetings that address ohsrm are held monthly. There is active interest and dialogue about OHS issues, as per the ohsrm Meeting Guide. Sub-element Category Question B ohsrm is a standing agenda item at all relevant management meetings. Management meetings that address ohsrm are held quarterly. There is interest and dialogue about OHS issues, generally aligned with the ohsrm Meeting Guide. C ohsrm is a standing agenda item at all relevant management meetings. Management meetings that address ohsrm are held 6 monthly. There is some dialogue about OHS issues, but only selected items from the ohsrm Meeting Guide. D ohsrm is a standing agenda item at all relevant management meetings. However the management meetings that address ohsrm are held annually, or less frequently. There is some dialogue about OHS issues, but no reference to the ohsrm Meeting Guide. E Meetings with ohsrm as an agenda item are not held regularly. There is no recognition that ohsrm should be regularly addressed, nor reference to the ohsrm Meeting Guide. Is ohsrm a standing agenda item at management meetings? S, M Notes Page 20
Is there structured and useful discussion of ohsrm at the relevant stage of the Agenda (as outlined in the ohsrm Meeting Guide)? Do OHS issues and workplace incidents and injuries get discussed at management meetings? Are meeting records kept and made available to those who attend? Comments Score Page 21
2. SAFETY PLANNING 2.1. ohsrm Action Planning Standard Guideline Links Score Guide ohsrm Action Plans should be established in each Unit to set clear goals to incrementally, but continually improve OHS risk management. Long term OHS planning i.e. 12 months into the future and beyond, encourages a strategic focus to continuous improvement in the implementation of the ohsrm Program. The long-term plan may be combined with the Unit s strategic plan, or as a separate document. Longterm plans for improving OHS may include refurbishment and accommodation issues, acquisition of new equipment, modification of research or teaching methods etc. Short-term ohsrm Action Plans set goals for the year ahead. The ohsrm Action Plan Form lists numerous goals that should be addressed by each Unit at least in the short term i.e. annually. Units may establish performance targets for arranging OHS training sessions, conducting in-house inspections, publishing information etc. Plans should be practical and achievable. They should also be documented and communicated to all relevant staff and students. 1.2 Management Leadership and OHS Communication 4.1, 4.2, 4.3 Hazard Identification, Risk Assessment and Risk Control 6.2 Training and Instruction 7.1 Emergency Preparedness ohsrm Action Plan Form http://www.sydney.edu.au/ohs/ohs_manual/ohsrm.shtml A Long term and short term Action Plans have been formally set for the Unit. All of the objectives listed on the ohsrm Action Plan form have been formally addressed with clear time frames and responsibilities allocated. OHS performance targets are practical and achievable. These are communicated to all relevant staff and students. B Short term Action Plans have been formally set for the Unit. All of the objectives from the ohsrm Action Plan form have been embraced. These are clear and achievable. C ohsrm Action Plans for the Unit are shorter than one year. Only selected objectives from the ohsrm Action Plan form have been embraced. Inappropriate or unclear goals are set. D The Unit has a modest goal to improve OHS performance, but this is informal i.e. not documented and no reference has been made to the ohsrm Action Plan form. Page 22
E The Unit has no health and safety performance targets established. Sub-element Category Question Are there formal ohsrm Action Plans in place with measurable targets and objectives? Are these plans documented? How far into the future do ohsrm Action Plans go one year, more? How regularly is the Action Plan re-visited? Have each of the objectives listed in the ohsrm Action Plan Form been addressed? Comments S, M Notes Score Page 23
3. CONSULTATION AND INVOLVEMENT 3.1. Work Group Meetings Standard Guideline Regular workgroup meetings should be held to allow for consultation on OHS issues. These are additional to management meetings. The Unit must be able to demonstrate that staff are regularly consulted on OHS issues relating to their work. Consultation is a key feature of the OHS Act (NSW) 2000. The University s OHS Consultation Statement also requires consultation to occur at workgroup and management meetings. This consultation must be meaningful and effective. Staff and P/G students should have ready opportunity to raise OHS concerns and have their suggestions for improving workplace OHS taken seriously. Meetings that deal with OHS issues should be held on a regular basis and include all relevant staff and post-graduate students. If the meeting is not exclusively devoted to OHS, then a significant part of the agenda should address OHS issues. Records of these meetings/this consultation should be kept and made available to relevant staff and students. Links Score Guide ohsrm Meeting Guide OHS Consultation Statement http://www.sydney.edu.au/ohs/ohs_manual/ohsrm.shtml A A formal workgroup has been established and there is routine consultation within the workgroup on OHS matters monthly. All staff and P/G students have the opportunity to raise OHS issues at any time. Clear and consistent records of OHS consultation are kept readily accessible. B A formal workgroup has been established and there is periodic e.g. quarterly consultation on OHS matters affecting the workgroup. Most staff and P/G students can raise OHS issues of concern at certain times. Records of this OHS consultation are kept and can be located quickly. C There is an informal workgroup. Sometimes there is consultation with relevant staff on OHS issues. Records are patchy. D A token effort is made towards consultation, but it is not meaningful or effective. Records are not kept. E Decisions are made without appropriate consultation. Staff and students have no opportunity to raise OHS concerns. Page 24
Sub-element Category Question Has a workgroup been identified? Has the Unit adopted an OHS consultation arrangement to assist with meeting its duty to consult? What is the arrangement for consultation? Are group meetings held with employees to discuss current topics related to OHS issues? Do staff and P/G students actively raise concerns about workplace OHS issues? Is there open discussion of OHS issues? Comments M, O Notes Score 3.2. Influence on Decision-Making Standard Guideline Links OHS objectives should influence decisions. Managers should ensure that decisions are not based purely on financial outcomes. OHS objectives should be considered during decision-making above financial, academic and commercial objectives. Decisions may relate to equipment purchases, project work methods, shift staffing levels etc. OHS Consultation Statement http://www.sydney.edu.au/ohs/ohs_manual/ohsrm.shtml Score Guide A OHS implications are always considered and where appropriate these influence decision making. The input of staff and P/G students in the workgroup positively influences decision-making. B OHS implications are usually considered and where appropriate these may influence decision-making. The input of staff and P/G students in the workgroup usually has a positive influence on decision-making. C OHS implications are sometimes considered and where appropriate these may influence decision-making. The input of staff and P/G students is usually taken seriously, but not always acted upon. Page 25
Sub-element Category Question D OHS implications are sometimes recognised, but these have a low priority and little influence during decision making. The input of staff and P/G students is given token acceptance, but seldom influences decisionmaking. E There is no evidence that safety objectives are taken into consideration when decisions are made. Decision makers generally ignore the input of staff and P/G students. Have decisions been influenced by safety objectives? Can you give an example of where consultation with workers influenced a decision in favour of improved OHS? Is there evidence that a consultative process has been undertaken when decisions are made that are OHS-related? Comments M, O Notes Score Page 26
4. HAZARD IDENTIFICATION, RISK ASSESSMENT AND CONTROL 4.1. Hazard and OHS Risk identification # The term hazard is not restricted to high risk areas such as laboratories and workshops or construction and farming. Hazard should be interpreted as anything that may jeopardise the health, safety or welfare of staff, students or visitors. In an office environment, hazards may typically include manual handling (of office equipment), overuse injury (from mouse and keyboard use), work related stress, noise, glare, trip hazards etc. Standard Guideline Links There must be an active process for identifying hazards in the workplace and hazardous jobs undertaken by staff and students. A hazard register should be maintained for the work area and updated at least once per year. The OHS Act 2000 requires that each work area has identified the hazards # that may affect people in their place of work. The process of identification should be active (rather than passively waiting for incidents) and be systematic i.e. part of regular processes in the workplaces The ohsrm Part A Form may be used to register these hazards, although alternative methods of record keeping are acceptable. The Part A Form also provides a matrix to assist in prioritising the hazards in order of importance by considering the likelihood of occurrence and severity of outcome. ohsrm Guidelines ohsrm Part A Form http://www.sydney.edu.au/ohs/ohs_manual/ohsrm.shtml Score Guide A A systematic process has been used to identify all hazards and hazardous jobs in the Unit. A variety of hazard identification methods are used, including formal/informal work discussions, independent review, hazard/incident reporting system, and job analysis/observation. The Unit conducts its own regular inspections to identify and monitor OHS risks. All identified hazards have been recorded in a risk register and given a priority ranking in accordance with the likelihood of occurrence and severity of outcome. B A register of all hazards and hazardous jobs has been compiled, but these have not been prioritised in order of importance. Review of hazard/incident reports, workgroup discussions and job observations are the only methods used to regularly identify OHS risks. C The workgroup has identified some hazards and hazardous jobs through an initial risk identification process, however it is incomplete. The Unit has considered past and current incident information to identify potential hazards. Page 27
D Some hazards and hazardous jobs have been casually identified, but these are not recorded. The Unit relies solely upon occasional Zone OHS Committee inspections to identify OHS risks. Sub-element Category Question E No effort has been made to identify OHS risks. Have hazards # and hazardous jobs/ohs risks been identified? Is there a register of these hazards and hazardous jobs? Have the hazards and hazardous jobs/ohs risks been given a priority order for attention in accordance with the likelihood of occurrence and severity of outcome matrix? Does the Unit use past and current incident information to identify potential risks? Does the Unit use any of the following to identify risks and hazards: formal/informal work discussions, independent review, hazard reporting system, job analysis/observation or other? Are there regular inspections to identify OHS risks? If so, by whom? Comments M, O Notes Score 4.2. Risk Assessment Standard Managers and supervisors should ensure that risk assessments are conducted for hazardous jobs or tasks that present OHS risks to staff, students and contractors working under their direction. Guideline The risk assessment process may use a qualitative, semi-quantitative or quantitative methodology depending upon the technical nature of the risks being assessed. The ohsrm Part B Form (Step 3) should be used to perform a qualitative risk assessment for hazardous jobs or tasks that present OHS risks. This simple form also allows the results of the risk assessment to be recorded. Those hazardous jobs and tasks that were assigned a higher priority at the time of their identification have a high priority for risk assessment and control i.e. assessment should be done of high priority issues before low priority ones. The risk assessment aims to reveal numerous risk factors associated with the job/task. It should be done in consultation with those who are directly involved with the job/task. Page 28
Links Score Guide ohsrm Guidelines ohsrm Part B Form (Step 3) http://www.sydney.edu.au/ohs/ohs_manual/ohsrm.shtml A OHS risks are routinely assessed in order of priority. The ohsrm Part B Form or equivalent is used to guide and record each risk assessment. Risk assessments are always done in consultation with the staff affected by/involved with the hazardous job/task that presents an OHS risk. The risk factors associated with the job/task are clearly derived from the process. Risk assessment records are readily accessible. B Risk assessments are conducted, but not in any priority order. The ohsrm Part B Form or equivalent is usually used to guide and document the risk assessment. There is usually consultation with relevant staff when conducting a risk assessment. C Risk assessments are done occasionally. There is no consultation during the risk assessment. The risk factors are not routinely ascertained. Risk assessments are documented inconsistently or incompletely. The ohsrm Part B Form or equivalent is sometimes used. D Risk assessments are conducted informally. There is no consistent format to the risk assessments conducted and no records kept. Sub-element Category Question E OHS risks are not assessed. Have risk assessments been done on hazardous jobs/tasks that present OHS risks? Have risk assessments been done in accordance with risk priorities? Are staff involved with the hazardous job/task routinely consulted during the risk assessment? Is the ohsrm Part B Form or equivalent used to guide and record the risk assessment? Are risk assessment records readily available? Comments M, O Notes Score Page 29
4.3. Risk Controls Standard Guideline Links Score Guide Risk controls should be derived from the risk assessment process and be clearly linked to the risk factors for hazardous jobs/tasks that present OHS risks in the workplace. A combination of risk control measures will usually be required. Risk controls should be chosen with reference to the hierarchy of hazard control. The choice and provision of adequate controls is a direct outcome of the risk assessment process. The risk controls should be directly related to the risk factors found during the risk assessment. The following hierarchy of controls should routinely be referred to when choosing risk controls. These are listed in hierarchical order from the most effective (top) to the least effective. It is usual for several risk controls to be applied concurrently. Elimination (e.g. clear obstructions from access areas) Substitution (e.g. use less hazardous chemical that does the same job) Isolation (e.g. consider vibration isolation mountings on machinery) Engineering (e.g. use mechanical lifting device to lift heavy items) Administrative (e.g. establish safe work procedures, provide training and supervision) Personal Protective Equipment (e.g. protective eyewear, respirators) Staff who are potentially affected by the workplace hazards or involved with tasks that present OHS risks should be consulted when choosing the risk controls. Responsibilities and time frames should be assigned for the implementation of agreed risk controls. This should be documented e.g. using the ohsrm Part B Form (Step 4) and kept accessible for ready reference. Implementation of the agreed risk controls should be monitored via inclusion on the agenda of workgroup meetings and ohsrm Action Plans. ohsrm Guidelines ohsrm Part B Form (Step 4) 2.1 Safety Planning ohsrm Action Plan form http://www.sydney.edu.au/ohs/ohs_manual/ohsrm.shtml University Occupational Health and Safety Manual (on-line) http://www.sydney.edu.au/ohs/policies/ohs/index.shtml A There is always consultation with relevant staff when choosing risk control measures. Risk controls are always chosen with consideration for the risk factors found during the risk assessment and the hierarchy of hazard control. Responsibility is always assigned for the implementation of risk controls, with time frames set and met. Decisions on agreed risk controls, responsibilities and time frames are consistently well documented e.g. using the ohsrm Part B Form (Step 4) and kept in an accessible location. Page 30
B There is usually consultation with relevant staff when choosing risk control measures. Risk controls are usually chosen with consideration for the risk factors found during the risk assessment and the hierarchy of control. Responsibility is usually assigned for the implementation of risk controls, with time frames set and met. Decisions on agreed risk controls are not consistently documented, or not readily accessible. C Sometimes there is consultation with relevant staff when choosing risk control measures. Risk controls are sometimes chosen with consideration for the risk factors found during the risk assessment and the hierarchy of control. Responsibility for the implementation of risk controls is only sometimes assigned, with time frames not always set or met. Documentation is patchy. D There is no effective consultation when deciding on risk controls. The risk controls do not align with the risk factors present or preferred options in the hierarchy of control. Responsibilities and/or time frames have not been set for implementation. Personal protective equipment is provided and considered to be the only form of protection. Records of decisions on risk controls are not kept. E No effort has been made to control OHS risks identified/assessed. Sub-element Category Question Is the hierarchy of hazard controls applied when choosing risk controls? Are staff and students who are directly involved with a hazardous jobs routinely consulted about the choice of risk controls? Do risk controls directly address the risk factors found during the risk assessment? Are responsibilities and time frames clearly set and documented for implementation of risk controls? Are records of risk controls readily available? Is the implementation of agreed risk controls monitored formally via inclusion in workgroup meetings and/or ohsrm Action Plans? M, O Notes Comments Score Page 31
5. TRAINING AND INSTRUCTION 5.1. Safety Training Needs Analysis Standard Guideline Links Score Guide A training needs analysis is to identify the training necessary to do a job safely. It should be specific to the individual roles and the activities to be implemented. The training needs analysis (TNA) should be a documented examination of the skills, knowledge and abilities required for each job. A prioritised TNA will first examine high-risk jobs. It should not be generic, but ideally targeted to various levels of responsibility, occupational groups and/or work locations. For instance, a supervisor or team leader will typically require training which differs from that required by subordinate staff. The training requirements for individuals should be considered during the PM&D (Performance Management and Development) review of staff. ohsrm Action Plan form http://www.sydney.edu.au/ohs/ohs_manual/ohsrm.shtml PM&D Website - training http://intranet.sydney.edu.au/pmd/training/index.shtml A OHS training needs are assessed at least annually. There is a clear link between the training undertaken and the OHS risks identified in the workplace. The training needs are documented and included in ohsrm Action Plans. Sub-element Category Question B OHS training needs are systematically reviewed once every two years. There is a link between the training undertaken and workplace risks. The training needs are documented and included in ohsrm Action Plans. C OHS training needs are periodically reviewed, but this is not regular or systematic. The training generally relates to workplace risks. That link may be documented, but not as part of the ohsrm Action Plan. D The OHS training needs of only some individuals are considered e.g. new staff and P/G students. E There is no system used for identifying safety training needs. Is there a system used for identifying safety training needs? If so, what is the system? How often are OHS training needs assessed? Are training needs documented in the ohsrm Action Plan and/or the PM&D process? M Notes Page 32
Comments Score 5.2. Training or Instruction in General OHS Obligations Standard Guideline Links Score Guide All staff, including managers, should have received some briefing or training in OHS obligations. Managers and supervisors have particular responsibilities to ensure the health, safety and welfare of all staff and students working under their direction. All staff and students also have OHS responsibilities that include following safe work practices, using safety equipment correctly, reporting incidents and raising OHS issues of concern etc. Minimum compliance standards are prescribed under the NSW OHS Act 2000, OHS Regulation 2001 and University Policies and Guidelines. Information should be provided that includes an understanding of OHS obligations pertinent to each persons delegated authority. The information may be disseminated in the form of formal training, in-house seminars and/or distribution of informative materials. This level of understanding may be tested via some form of assessment. OHS Guide for Staff http://www.sydney.edu.au/ohs/policies/ohs/guide.shtml University Occupational Health and Safety Manual (on-line) http://www.sydney.edu.au/ohs/policies/ohs/index.shtml ohsrm Guidelines http://www.sydney.edu.au/ohs/docs/ohsrm/guidelines.pdf A Training in OHS responsibilities is provided for all staff, including managers and supervisors. Trainees are required to demonstrate a particular level of understanding. Staff are acutely aware of their own OHS responsibilities and those of other staff and can readily recite these. B Training in OHS responsibilities is provided for staff, except for managers and supervisors. Trainees are required to demonstrate a particular level of understanding. Staff are aware of their OHS responsibilities and can recite the main points with relative ease. C Training in OHS responsibilities is not required for all staff, but information about OHS responsibilities is regularly made available. Staff are able to describe their OHS responsibilities in general terms. Page 33
Sub-element Category Question D Training in OHS responsibilities is not provided for staff, but information about OHS responsibilities has been made available at some stage. Staff can only vaguely describe their OHS responsibilities. E There is no training or introduction to OHS responsibilities and staff are unaware of these responsibilities. Is training provided to staff, including supervisors, to ensure that they understand their OHS responsibilities and how to discharge these? Are training participants required to achieve a particular level of competency? M, O Notes Comments Score 5.3. Staff & Student Inductions Standard Guideline Links Score Guide Staff and students should receive a structured induction to the space within which they will work or study. This should include: Fire exit locations Emergency procedures Hazards of the workplace Mechanism for reporting OHS issues of concern, incidents etc. Local inductions should be a systematic aspect of starting new staff or students in the workplace. This is additional to the general induction provided centrally by the University. Local inductions should be given within the first week of employment/commencement. A certain standard or level of understanding should be confirmed via set questions and answers. A record should be kept of this training and the demonstration of competence. 5.5 Maintaining Safety Training Records. http://www.sydney.edu.au/learningsolutions/orientation/index.shtml A All new staff and students are systematically inducted during their first week in the workplace. The induction is well documented with a lesson plan and other supporting documentation. Those who attend the training are required to demonstrate their understanding of the content by answering set questions. Records of this training are retained. Page 34