Element 1: Health and Safety Policy 18




НазваниеElement 1: Health and Safety Policy 18
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COMCARE
PUTTING YOU FIRST



National Self Insurer WHS Audit Tool

(NAT Cth)

User Guide



Version:

2.1

Release Date:

15 March 2012

Release Status:

Endorsed for use

Approval Status:

Approved by Safety, Rehabilitation and Compensation Commission (SRCC)

Prepared by:

Comcare on behalf of the SRCC

Confidentiality Category:

Unrestricted



CONTENTS

Introduction 4

Purpose of the NAT (Cth) version 2 4

Audit 4

Audit criteria 5

Explanation of criteria, and verification examples 6

Determining conformance 6

Recording 6

Audit criteria for National Self Insurer WHS Audit Tool 7

How to use this guide 16

Element 1: Health and Safety Policy 18

1.1 Health and Safety Policy 18

Element 2: Planning 21

2.1 Legal requirements and practical guidance 21

2.2 Objectives and targets 26

Element 3: Implementation 33

3.1 Structure and responsibility—Resources 33

3.2 Structure and responsibility—Responsibility and accountability 36

3.3 Structure and responsibility—Training and competency 40

3.4 Consultation, communication and reporting—Consultation 51

3.5 Consultation, communication and reporting—Communication 58

3.6 Consultation, communication and reporting—Reporting 62

3.7 Documentation 68

3.8 Document and data control 70

3.9 Health and safety risk management program 74

3.10 Hazard identification, risk assessment and control of risks 81

3.11 Emergency preparedness and response 108

Element 4: Measurement and evaluation 116

4.1 Monitoring and measurement—General 116

4.2 Monitoring and measurement—Health surveillance 122

4.3 Incident investigation, and corrective and preventive action 123

4.4 Records and records management 127

4.5 Health and safety management system audits 129

Element 5: Management review 133

APPENDIX 135

Definition of terms used in this document 135

Appendix 1: Guide to sampling of audit criteria by topic 139


Introduction

In 2005, a multi-jurisdictional working party of regulatory bodies under the Heads of Workers’ Compensation Authorities (HWCA) was formed to develop an occupational health and safety (OHS) audit program and a set of audit guidelines that were agreed at a national level. The National Self-Insurer OHS Audit Tool: User Guide and Workbook was an outcome of that process.

The content of this tool was based on Australian Standards AS/NZS 4801 (Occupational health and safety management system—Specification with guidance for use) and AS/NZS 4804 (Occupational health and safety management system—General guidelines on principles, systems and supporting techniques). Other industry-accepted audit tools, including SafetyMAP, the New South Wales Self Insurance Audit Tool, and the South Australian Performance Standards for Self-Insurers were considered during the development of the National Self-Insurer OHS Audit Tool (NAT) version 1. The views of self-insured (licensed) employers and other stakeholders were also sought and considered. The first Commonwealth jurisdiction version of the National Self Insurer OHS Audit Tool (NAT (Cth)) was developed to reflect the specific requirements of the Occupational Health and Safety Act 1991 (OHS Act). The NAT was endorsed as the standard OHS audit tool in the Commonwealth jurisdiction in September 2007.

In March 2009, at the request of HWCA, a review of the NAT was undertaken by the members of the NAT Review Working Party, taking into consideration the comments and feedback received from self-insured employers/licensees and other stakeholders. The outcome of this review is the National Self-Insurer OHS Audit Tool (NAT) version 2.

The new Work Health and Safety Act 2011 (WHS Act) came into effect on 1 January 2012; however, due to delays in implementation in some state jurisdictions, Comcare undertook a review of the NAT (Cth) to align it with the new WHS Act. Minor terminology changes resulted in the audit tool, user guide and some criteria being amended or removed to reflect the new definitions. This version of the NAT (Cth) is an interim tool until a full review can be completed by the NAT Review Working Party.

Purpose of the NAT (Cth) version 2

The purpose of this audit tool is to assess the legislative compliance and effectiveness of a licensee’s health and safety policy and procedures and its health and safety management systems. It verifies that management systems are in place and evaluates the implementation and effectiveness of those systems. It is not intended to be used for workplace inspections, nor is it designed to assess the performance of individuals.

Audit

Auditors will make judgements that a licensee has achieved one of the following ratings against the criteria:

> conformance

> non-conformance

> not applicable

> not able to be verified.

An audit consists of examining documentation and records to verify that systems exist and are working. There are also circumstances where observations and discussions with relevant personnel are an appropriate means for verifying conformance.

At the conclusion of the audit, a report is prepared identifying positive aspects of the licensee’s health and safety management systems, and any deficiencies against the audit criteria.

Audit criteria

This tool comprises 113 criteria combined into five elements as listed below.

Element 1—Health and Safety Policy (three criteria)

A meaningful health and safety policy depends on commitment from management and effective consultation with workers. The health and safety policy must clearly set out the intentions of the person conducting a business or undertaking (PCBU) with respect to continuous improvement of health and safety.

Element 2—Planning (12 criteria)

A health and safety management plan must outline specific strategies for managing the risks associated with all hazards identified in the workplace. Relevant health and safety legislation and information must be readily available. Criteria groups addressed by this element include:

> legal requirements and practical guidance

> objectives and targets

> health and safety management plans.

Element 3—Implementation (82 criteria)

Health and safety must be integrated into the management of all work activities. There should be a systematic process for the development of work methods that minimise health and safety risks. Hazardous operations or locations should be strictly controlled and plant and equipment should be regularly inspected and serviced. Consultation and training are key factors in the successful operation of a health and safety management system. Criteria groups addressed by this element include:

> structure and responsibility—resources, responsibility and accountability, and training and competency

> consultation, communication and reporting

> documentation

> document and data control

> health and safety risk management program

> hazard identification, risk assessment and control of risks

> emergency preparedness and response.

Element 4—Measurement and evaluation (14 criteria)

It is necessary for a PCBU to monitor the workplace to gather information about potential hazards and to have processes in place to act on the information obtained. Where hazards are identified and accidents or incidents occur, it is crucial that they are reported and a suitable investigation is carried out. Criteria groups addressed by this element include:

> monitoring and measurement—general and health surveillance

> incident investigation, corrective and preventive action

> records and records management

> health and safety management system audits.

Element 5—Management review (two criteria)

Senior management has a responsibility to ensure that the systems in place continue to meet the needs of the PCBU. This can only be successful if the management system is reviewed on an ongoing basis. Areas identified as deficient need to be actioned. The process of management review must ensure that recommendations are documented for corrective action.

Explanation of criteria, and verification examples

An explanation is provided for each criterion, followed by examples of relevant documents and records which may be sighted during worksite visits, as well as other types of evidence which may be gathered or directly observed by interviewing management and workers. Examples provided are a guide only.

Determining conformance

Determination of conformance against the assessment criteria may be done by examining documents and records that outline the relevant systems. Discussions with workers and observations by the auditor can indicate that systems have been implemented and are being followed.

Recording

When recording documentation in the corresponding NAT (Cth) Workbook, each item should be described in a way that includes the:

> name or title of the document

> revision or edition number (if any)

> date of issue

> source or location where it can be found.

A written description of the system or an explanation of how it operates should be included in the space provided. This may help clarify the way in which the procedure satisfies the criterion.

Audit criteria for National Self Insurer WHS Audit Tool

Element 1: Health and Safety Policy

1.1 Health and Safety Policy

1.1.1 Senior management, in consultation with all workers and their representatives, shall define and document its policy for, and commitment to, work health and safety (WHS). The policy shall be endorsed and supported by the most senior person within the PCBU, such as the Chief Executive Officer or Managing Director. The health and safety policy shall include a commitment to:

a) the risk management process and ensuring consistency with the nature of workplace activities and scale of health and safety risks

b) compliance with relevant health and safety legislation and other requirements placed upon the PCBU or to which the PCBU subscribes

c) establishing measurable objectives and targets for health and safety to ensure continuous improvement aimed at eliminating work-related illness and injury

d) the provision of appropriate health and safety training to all workers

e) the consultation process to ensure all workers are included in the decision-making processes impacting on workplace health and safety

f) the dissemination of health and safety information to all workers and visitors to the workplace

g) the effective implementation of the health and safety policy.

1.1.2 The health and safety policy is available to other parties, including regulatory authorities, suppliers, external contractors, and those visiting the workplace.

1.1.3 The health and safety policy is maintained and reviewed periodically to ensure it remains relevant and appropriate to the PCBU’s health and safety risks.

Element 2: Planning

2.1 Legal requirements and practical guidance

2.1.1 The PCBU identifies and monitors the content of all health and safety legislation, standards, codes of practice, agreements and guidelines relevant to their operation.

2.1.2 The PCBU’s procedures, work instructions and work practices reflect the requirements of current health and safety legislation, standards, codes of practice, agreements and guidelines.

2.1.3 Relevant workers in the PCBU are advised of, and have ready access to, current relevant health and safety legislation, standards, codes of practice, agreements and guidelines.

2.1.4 The PCBU satisfies legal requirements to undertake specific activities, perform work or operate equipment, including any:

a) licence

b) certificate of competency

c) notification

d) registration

e) approval/exemption

f) other relevant requirements.

2.1.5 Changes to health and safety legislation, standards, codes of practice, agreements and guidelines generate a review of existing procedures.

2.2 Objectives and targets

2.2.1 Health and safety objectives and targets consistent with the PCBU’s health and safety policy are documented, are appropriate to the PCBU’s activities, and consider:

a) legal requirements

b) standards, codes and guidelines

c) health and safety hazards and risks

d) leadership and worker participation

e) technological developments.

2.2.2 Specific health and safety objectives and measurable targets have been established for all relevant functions and levels within the PCBU.

2.2.3 The PCBU sets health and safety performance indicators that are consistent with their objectives and targets.

2.3 Health and safety management plans

2.3.1 There is a health and safety management plan(s) that defines the means by which the PCBU will achieve their objectives and targets. The plan(s):

a) responds to legal requirements

b) is based on an analysis of information relevant to the nature of the PCBU’s activities, processes, products or services

c) takes account of identified hazards and health and safety management system failures

d) aims to eliminate or reduce workplace illness and injury

e) defines the PCBU’s priorities

f) sets timeframes

g) allocates responsibility for achieving objectives and targets to relevant functional levels

h) states how the plan will be monitored.

2.3.2 The PCBU documents their methodology to reduce health and safety risks through hazard identification, risk assessment and development of risk control measures in accordance with the ‘hierarchy of controls’ and legal requirements.

2.3.3 The PCBU monitors their progress towards meeting the objectives and targets set in the health and safety plan and takes corrective actions to ensure progress is maintained.

2.3.4 Health and safety management plans are reviewed on a regular basis to ensure they are kept up to date, and also when there are changes to the PCBU’s activities, processes, products or services.

Element 3: Implementation

3.1 Structure and responsibility—Resources

3.1.1 Financial and physical resources have been identified, allocated and are periodically reviewed, to enable the effective implementation of the PCBU’s health and safety system.

3.1.2 There are sufficient qualified and competent people to implement the PCBU’s health and safety system.

3.1.3 Those who represent workers on health and safety matters are provided with time and resources to effectively undertake this role.

3.2 Structure and responsibility—Responsibility and accountability

3.2.1 Senior management can demonstrate an understanding of the PCBU’s legal obligations for health and safety.

3.2.2 A member of senior management or the board of directors has been allocated overall responsibility for the health and safety management system and reports to that group on its performance.

3.2.3 The specific health and safety responsibilities (including legislative obligations), authority to act and reporting relationships of all levels in the PCBU have been defined, documented and communicated.

3.2.4 Workers are held accountable for health and safety performance in accordance with their defined responsibilities.

3.3 Structure and responsibility—Training and competency

3.3.1 The specific requirements of tasks are identified and applied to the recruitment and placement of workers.

3.3.2 The PCBU has established and implemented procedures for identifying and defining the health and safety training needs (including any prescribed by legislation) for all workers or visitors, where relevant. A written training plan(s) based on the outcomes of the training needs shall be developed and implemented.

3.3.3 The PCBU conducts an induction program for all workers including management, which is based on their likely risk exposure, and provides relevant instruction in the PCBU’s health and safety policy and health and safety procedures.

3.3.4 The PCBU consults with workers to identify their training needs in relation to performing their work activities safely.

3.3.5 The PCBU trains workers to perform their work safely and verifies their understanding of that training.

3.3.6 Training and assessment is delivered by persons with appropriate knowledge, skills and experience.

3.3.7 Tasks are allocated according to the capability and level of training of workers.

3.3.8 Management has received training in health and safety management principles and practices appropriate to their role and responsibilities, and the relevant health and safety legislation.

3.3.9 Those representing the PCBU and the worker(s) on health and safety matters, including representatives on consultative committee(s), receive appropriate training to enable them to undertake their duties effectively.

3.3.10 Refresher training (as required) is provided to all workers to enable them to perform their tasks safely.

3.3.11 The training program is reviewed on a regular basis and when there are changes to plant or processes in the workplace, to ensure that the skills and competencies of workers remain relevant.

3.4 Consultation, communication and reporting—Consultation

3.4.1 There are documented procedures, agreed to by workers and representatives of workers, for worker involvement and consultation on health and safety matters including a procedure for dealing with health and safety issues and resolving disputes if they arise.

3.4.2 The PCBU, in consultation with workers, has determined the number of work groups and Health and Safety Representatives (HSRs) required to effectively represent all workers.

3.4.3 The consultative arrangements allow the workers to select those who will represent them on health and safety matters.

3.4.4 Details of the consultative arrangements, including the names of their management and worker representatives for health and safety matters, are communicated to workers.

3.4.5 Workers or their representatives are involved in the development, implementation and review of procedures for the identification of hazards and the assessment and control of risks.

3.4.6 Workers or their representatives are consulted regarding proposed changes to the work environment, processes or practices and purchasing decisions that could affect their health and safety.

3.4.7 Representatives of workers and management meet regularly about health and safety issues and minutes of their meetings are available to all workers.

3.5 Consultation, communication and reporting—Communication

3.5.1 The PCBU’s health and safety policy and other relevant information on health and safety are communicated to all workers and consider language and standards of literacy.

3.5.2 The PCBU regularly communicates to workers the progress towards the resolution of heath and safety disputes.

3.5.3 There are procedures for exchange of relevant health and safety information with external parties including customers, suppliers, external contractors and relevant public authorities.

3.5.4 There is a documented complaints procedure that encompasses health and safety issues for dealing with formal and informal complaints received from external parties.

3.6 Consultation, communication and reporting—Reporting

3.6.1 Workplace injuries, illnesses, incidents, health and safety hazards, dangerous occurrences and systems failures are reported and recorded in accordance with documented procedures.

3.6.2 Where there is a legislative requirement, injuries, illnesses, incidents and dangerous occurrences are notified to the appropriate authorities.

3.6.3 Reports on health and safety inspections, testing and monitoring, including recommendations for corrective action, are produced and forwarded to senior management and consultative committees as appropriate.

3.6.4 Regular, timely reports on health and safety performance are produced and distributed within the PCBU.

3.6.5 Reports of audits and reviews of the health and safety system are produced and distributed within the PCBU.

3.6.6 The PCBU’s annual report or an equivalent document includes information about health and safety performance.

3.7 Documentation

3.7.1 The PCBU’s health and safety policy, health and safety plans, and health and safety management system are documented in a planned and organised manner.

3.7.2 Specific instructions and safe work procedures associated with particular products, processes, projects or sites have been developed where appropriate.

3.8 Document and data control

3.8.1 The PCBU has a system for creating, modifying and approving health and safety documents and data and notifying relevant persons of any changes. Obsolete documents and data are identified and retained (where required) for legal and/or knowledge preservation purposes and are removed from all other access points to prevent unintended use.

3.8.2 Documents and data critical to health and safety shall be clearly identifiable, duly authorised prior to issue, kept legible and include their issue status.

3.8.3 The PCBU provides workers with ready access to relevant health and safety documents and data and advises them of its availability.

3.8.4 Documents and data are regularly reviewed by competent persons to ensure the adequacy and currency of the information.

3.9 Health and safety risk management program

3.9.1 The PCBU has identified the hazards, including public safety hazards, that are associated with its activities, processes, products or services, has assessed the risks involved and implemented suitable control measures. The risks shall be eliminated or otherwise controlled and monitored in accordance with the ‘hierarchy of controls’ and legal requirements.

3.9.2 The hazard identification, risk assessment and risk control process is undertaken by persons competent in the use of the PCBU’s methodology.

3.9.3 The PCBU documents all identified hazards, risk assessments and risk control plans.

3.9.4 Risks of identified hazards are assessed having regard to the likelihood and consequence of injury, illness or incident occurring based upon the:

a) legal requirements

b) evaluation of available information

c) records of incidents, illness and disease

d) potential for emergency situations.

3.9.5 Identified control measures shall be implemented in accordance with the assigned risk control priorities.

3.9.6 Risk management procedures shall be reviewed and revised where necessary to ensure relevance, adequacy and compliance with health and safety management system requirements.

3.9.7 The PCBU has a process for identifying and managing change that may impact on health and safety.

3.10 Hazard identification, risk assessment and control of risks

3.10.1 The PCBU determines those areas where access controls are required and ensures effective controls are implemented and maintained.

3.10.2 Health and safety requirements are identified, evaluated and incorporated into all purchasing specifications for services.

3.10.3 The ability to meet health and safety requirements is assessed in the selection of temporary workers.

3.10.4 The health and safety performance of temporary workers is monitored and reviewed to ensure continued adherence to the PCBU’s health and safety requirements or specifications.

3.10.5 The PCBU determines their health and safety requirements prior to the purchase of goods and communicates those specifications to the supplier.

3.10.6 Procedures shall be established and implemented for verifying that purchased goods conform to health and safety requirements and any non-conformances shall be addressed before the goods are put into operational use.

3.10.7 Hazard identification, risk assessment and the development of control measures are undertaken during the design stage of products, buildings, processes or when the design is modified.

3.10.8 Competent persons verify that designs and modifications meet specified health and safety requirements.

3.10.9 There are procedures to ensure that materials and substances are disposed of in a manner that minimises risk of personal injury and illness.

3.10.10 Facilities and amenities in workplaces controlled by the PCBU conform, as a minimum, to relevant legislation, standards and codes of practice.

3.10.11 The PCBU documents procedures or work instructions for the safe handling, transfer and transport of hazardous substances and dangerous goods.

3.10.12 Comprehensive health and safety information on all hazardous substances and dangerous goods is readily accessible.

3.10.13 The PCBU ensures that hazardous substances and dangerous goods are safely stored.

3.10.14 There are ‘permit to work’ procedures for high-risk tasks.

3.10.15 Where personal protective equipment (PPE) is required—it is appropriate for the task, its provision is accompanied by suitable training, and it is used correctly and maintained in a serviceable condition.

3.10.16 Plant and equipment is maintained and a record is kept which includes relevant details of inspections, maintenance, repair and alteration of plant.

3.10.17 There is a process for unsafe plant and equipment to be identified and quarantined or withdrawn from service.

3.10.18 Appropriate controls are used to ensure the safety of persons working on or near plant and equipment that is in the process of being cleaned, serviced, repaired or altered.

3.10.19 Competent persons verify that plant and equipment is safe before being returned to service after repair or alteration.

3.10.20 Safety signs (including regulatory, hazard, emergency information and fire signs) meet relevant standards and codes of practice and are displayed in accordance with legal and organisational requirements.

3.10.21 There are procedures to ensure that materials are transported, handled and stored in a safe manner.

3.10.22 Individuals are supervised according to their capabilities and the degree of risk of the task.

3.10.23 There are supervisory arrangements that ensure that tasks are performed safely and that work instructions and procedures are followed.

3.10.24 There is a documented process which requires the PCBU to identify potential health and safety hazards (including public safety hazards), assess the potential risks and determine appropriate risk control strategies when providing their goods and/or services to others whether under contract or otherwise.

3.10.25 Customer-supplied goods and services used in the PCBU’s work processes are subject to hazard identification, risk assessment and control prior to use.

3.10.26 All substances in containers and transfer systems are identified and clearly labelled to avoid inadvertent or inappropriate use.

3.11 Emergency preparedness and response

3.11.1 Potential emergency situations have been identified and emergency procedures are documented and regularly reviewed.

3.11.2 The PCBU has allocated overall responsibility for control of emergency situations to specified individuals and communicated this information to all workers.

3.11.3 Workers receive training and practice in emergency procedures appropriate to their allocated emergency response responsibilities and the degree of risk.

3.11.4 Competent persons have assessed the suitability, location and accessibility of emergency equipment.

3.11.5 Emergency and fire protection equipment, exit signs and alarm systems are inspected, tested and maintained at regular intervals.

3.11.6 A dangerous goods and/or hazardous substances manifest or inventory system is in place and in accordance with legal requirements.

3.11.7 The PCBU has assessed their first aid requirements, and the first aid system in place is appropriate to the organisational risks.

3.11.8 The PCBU has systems in place to assist workers who are exposed to critical incidents at work.

Element 4: Measurement and evaluation

4.1 Monitoring and measurement—General

4.1.1 There is a health and safety inspection, testing and monitoring program that is documented and implemented that:

a) meets legal requirements

b) defines intervals based on identified risk

c) incorporates a reporting and corrective action process

d) uses workplace-specific checklist(s)

e) monitors conformance to the PCBU’s safe working procedures

f) monitors the effectiveness of control measures.

4.1.2 Inspections seek input and involvement from the workers who are required to undertake the tasks being inspected.

4.1.3 Engineering controls, including safety devices, are regularly inspected and tested to ensure their integrity.

4.1.4 Monitoring of the workplace environment (general and personal) is conducted where appropriate, and records of the results are maintained.

4.1.5 Inspection, measuring and test equipment related to health and safety monitoring is appropriately identified, calibrated, maintained and stored.

4.2 Monitoring and measurement—Health surveillance

4.2.1 The PCBU has identified those situations where worker health surveillance should occur and has implemented systems to conduct this surveillance. The health of workers exposed to specific hazards is monitored, recorded, and reported, and action is taken to address any adverse effects.

4.3 Incident investigation, and corrective and preventive action

4.3.1 There is a procedure, which involves operational line management, for the investigation of injuries, illnesses, incidents and other systems failures impacting on health and safety.

4.3.2 Investigations shall:

a) be undertaken by a competent person or persons in accordance with the PCBU’s procedure

b) identify the factor(s) that led to the injury, illness, incident or other system failure

c) review the identified hazards, assessed risks and effectiveness of the control measures

d) recommend appropriate control measures and corrective actions.

4.3.3 Responsibility is assigned to identified persons for implementing and reviewing the effectiveness of corrective actions arising from investigations.

4.3.4 Corrective actions are discussed with affected workers prior to implementation.

4.4 Records and records management

4.4.1 There are effective systems for the management of health and safety records, including their:

a) identification and traceability

b) collection, indexing, and filing

c) access and confidentiality

d) retention and maintenance

e) protection against damage, deterioration or loss

f) retrieval

g) disposal.

4.5 Health and safety management system audits

4.5.1 There is a health and safety management systems audit procedure that covers:

a) audit scope

b) audit frequency

c) audit methodologies

d) auditor selection, independence, competencies and responsibilities

e) input from a representative sample of workers

f) reporting of results.

4.5.2 Scheduled audits are conducted to verify whether the health and safety management systems:

a) comply with planned arrangements

b) have been properly implemented and maintained

c) are effectively implemented across the PCBU.

The audit program takes into consideration the significance of health and safety risks and the results of previous audits.

4.5.3 Deficiencies highlighted by the audits are prioritised and progress is monitored to ensure corrective action is implemented.

Element 5: Management review

5.1.1 Senior management oversee a comprehensive documented review of the health and safety management system at defined intervals to ensure its continuing suitability and effectiveness in satisfying the PCBU’s stated health and safety objectives and targets. The reviews take into account health and safety management system audit results, performance indicators, resources, business continuity, changing circumstances and a commitment to continuous improvement.

5.1.2 Recommendations arising from health and safety management system reviews generate actions to improve performance.

How to use this guide

This user guide is designed to be printed double-sided.

User guide

The guidance is set out as in the example below.

1.1.2 The health and safety policy is available to other parties, including regulatory authorities, suppliers, contractors, customers and those visiting the workplace.
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