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LICENSEE (Attorney-General's Department)

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LICENSEE
IMPROVEMENT
PROGRAM
NATIONAL AUDIT
TOOL (CTH)
AUDIT REPORT
Commercial-in-Confidence
[Licensee Name]
[Location]
[Date]
2 | WHS 133
DOCUMENT TRACKING
Version 3
Release Date September 2014
Release Status Endorsed for use
Prepared by Comcare
Confidentiality Category Unrestricted
3 | WHS 133
CONTENTS
SCOPE OF AUDIT 4
EXECUTIVE SUMMARY 6
ELEMENT 1: HEALTH AND SAFETY POLICY 8
ELEMENT 2: PLANNING 10
ELEMENT 3: IMPLEMENTATION 18
ELEMENT 4: MEASUREMENT AND EVALUATION 59
ELEMENT 5: MANAGEMENT REVIEW 68
APPENDIX 1: SITE SPECIFIC FINDINGS 70
4 | WHS 133
SCOPE OF AUDIT
Licensee:
Scope of audit:
This audit assessed the effectiveness of [employer name] health and safety policy, health and
safety 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.
The 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 at [employer name] are an appropriate means for verifying conformance.
At the conclusion of the audit, this report is prepared identifying positive aspects of
[employer name] health and safety management systems, and any deficiencies against the
audit criteria.
Audit criteria:
This tool comprises 108 criteria combined into five elements as listed below:
Element 1. Health and Safety Policies (3 Criteria)
Element 2. Planning (11 Criteria)
Element 3. Implementation (79 Criteria)
Element 4. Measurement and evaluation (13 Criteria)
Element 5. Management review (2 Criteria)
Ratings
The findings in the audit report have been classified and marked as follows:
> Conformance: indicates that the criterion has been met.
> Non-conformance: indicates that the criterion has not been met.
> Not able to be verified: indicates that the PCBU has documented procedures in place but there
have been no cases to test that the PCBU has followed those procedures. It is expected that this
classification will only be used in limited circumstances and where applied, the reasons for the
finding will be explained by the auditor.
> Not applicable: indicates that the criterion does not apply to the licensee.
Where a criterion has been met but the auditor has identified a ‘once off’ situation or a ‘minor’
deviation from the documented management system or reference criterion, an ‘observation’ may
be made. These findings, while representing a non-fulfilment of a requirement, are recognised as
being of lower risk to the licensee. However, corrective action to address the identified deficiency
is required. An ‘observation’ can be made against a criterion which has been rated as either
Conformance or Non-conformance.
Dates and locations of
audit:
Auditor(s)/Comcare
Representative(s):
Primary licensee
contact(s):
Record of audit:
This report contains a summary of the audit outcomes. A detailed record of the documentation and
records sighted, issues observed and auditor comments are retained on the auditor’s file.
[employer name]
[list each site verification and date]
[auditor name and company]
[list licensee contact(s)]
5 | WHS 133
Acknowledgment:
The auditor(s) wish to acknowledge the cooperation and assistance provided by the management
and staff of [employer name] and thank them for their contribution to the audit process.
Conflict of interest:
The auditor(s) declare that there is no conflict of interest between them and the licensee being
audited, nor those people representing the auditee.
LIST OF PERSONS INTERVIEWED
Name Position
SCOPE OF AUDIT
Name Position
[name of site or business division]
[name of site or business division]
[name of site or business division]
6 | WHS 133
EXECUTIVE SUMMARY
NON-CONFORMANCES (NCRS)
A number of non-conformances were identified during the audit. They are:
Criterion Non-conformance
OBSERVATIONS
A number of observations were identified during the audit. They are:
Criterion Observations
NOT ABLE TO BE VERIFIED
A number of criterion were unable to be verified during the audit. They are:
Criterion Not able to be verified
7 | WHS 133
NOT APPLICABLE
A number of criterion were not applicable during the audit. They are:
Criterion Not applicable
In summary, for the 108 criteria within the NAT, the outcomes are:
Number of criteria % of assessed criteria achieved/not achieved
Conformance
Non-conformance
Observations
Not able to be verified
Not applicable
An action plan, which includes completion/review dates and responsibilities, must be developed by [employer name] to address
each of the Non-conformances and Observations identified in this report. The action plan must be provided to Comcare within the
requested timeframe.
[employer name] is invited to discuss any aspect of this audit report with Comcare.
Signed: Signed:
Auditor name: Auditor name:
Date: Date:
8 | WHS 133
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, WHS. The policy shall be endorsed and supported by the most senior person
within the PCBU, for example, the Chief Executive Officer or Managing Director. The health and safety policy
shall be developed consistent with relevant legislative requirements and include a commitment to:
a) the risk management process and ensure consistency with the nature of workplace activities and scale of
health and safety risks
b) comply with relevant health and safety legislation and other requirements placed upon the PCBU or to
which the PCBU subscribes
c) establish measurable objectives and targets for health and safety to ensure continuous improvement
aimed at elimination of work-related illness and injury
d) provision of appropriate health and safety training to all workers
e) the consultation process to ensure all workers are included in decision-making where there is an impact
on workplace health and safety
f) the dissemination of health and safety information to all workers and visitors to the workplace
g) effective implementation of the health and safety policy.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
[ratings are either ‘conformance’, ‘conformance (observation)’, ‘non-conformance’, ‘non-conformance (observation)’, ‘not able to be verified’ or ‘not applicable’]
[delete if no observation]
[delete if no non-conformance]
9 | WHS 133
1.1.2 The health and safety policy is available to other interested parties, including regulatory authorities, suppliers,
external contractors, and those visiting the workplace.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
10 | WHS 133
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 its operation.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
11 | WHS 133
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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
12 | WHS 133
2.1.4 The PCBU and/or individual satisfy legal requirements to undertake specific activities, perform work or operate
equipment, for example:
a) licence
b) certificate of competency
c) notification
d) registration
e) approval/exemption
f) other relevant requirements.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
13 | WHS 133
2.1.5 Changes to health and safety legislation, standards, codes of practice, agreements and guidelines generate a
review of existing procedures.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
14 | WHS 133
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) past health and safety performance (as defined by the PCBU’s system requirements)
e) technological developments
f) leadership and worker participation.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
15 | WHS 133
2.2.2 Specific health and safety objectives and measurable targets have been assigned to all relevant functions and
levels within the PCBU.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
2.2.3 The PCBU sets health and safety performance indicators that are consistent with its objectives and targets.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
16 | WHS 133
2.3 HEALTH AND SAFETY MANAGEMENT PLANS
2.3.1 In addition to defining the means by which the PCBU will achieve its objectives and targets, the health and
safety management 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 systems 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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
17 | WHS 133
2.3.2 The PCBU monitors their progress towards meeting the objectives and targets set in the health and safety
management plan and takes corrective actions to ensure progress is maintained.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
2.3.3 Health and safety management plans are reviewed on a regular basis, to ensure they are kept up to date,
and when there are changes to the PCBU’s activities, processes, products or services.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
18 | WHS 133
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 management system.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.1.2 There are sufficient qualified and competent workers to implement the PCBU’s health and safety management
system as identified through documented review.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
19 | WHS 133
3.2 STRUCTURE AND RESPONSIBILITY—RESPONSIBILITY AND
ACCOUNTABILITY
3.2.1 Senior management understands the PCBU’s legal obligations for health and safety and can demonstrate
how they fulfil them.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
20 | WHS 133
3.2.3 The specific health and safety responsibilities (including legislative obligations), authority to act and reporting
relationships in the PCBU have been defined, documented and communicated.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.2.4 Where contractors (workers) are utilised in the PCBU, the health and safety responsibilities and
accountabilities of the PCBU and the contractor(s) have been clearly defined, allocated and communicated
within the PCBU and to the contractor(s) and their workers.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
21 | WHS 133
3.2.5 Workers are held accountable for health and safety performance in accordance with their defined
responsibilities.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.3 STRUCTURE AND RESPONSIBILITY—TRAINING AND
COMPETENCY
3.3.1 The PCBU has a procedure for identifying and defining the health and safety training needs of workers.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
22 | WHS 133
3.3.2 The PCBU consults with workers to identify their training needs in relation to performing their work activities
safely.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.3.3 A documented training plan(s) based on training needs shall be developed and implemented.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
23 | WHS 133
3.3.4 The PCBU trains workers (as appropriate) to perform their work safely, and verifies their understanding of that
training.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.3.5 The PCBU has 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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
24 | WHS 133
3.3.6 Training and assessment is delivered by competent persons with appropriate knowledge, skills and
experience.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.3.7 The specific requirements of tasks are identified and applied to the recruitment and placement of workers, and
tasks are allocated according to the capability and level of training.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
25 | WHS 133
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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
26 | WHS 133
3.3.10 Refresher training (as identified by the training needs) is provided to all workers to enable them to perform
their tasks safely.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.3.11 The training program is reviewed on a regular basis and when there are changes in the workplace that
impact on the health and safety of workers, to ensure that the skills and competencies of workers remain
relevant.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
27 | WHS 133
3.4 CONSULTATION, COMMUNICATION AND REPORTING—
CONSULTATION
3.4.1 There are procedures agreed to by workers outlining worker involvement and consultation in:
a) health and safety matters
b) health and safety issues
c) any proposed changes to the work environment, processes, practices or purchasing decisions that
impact on their health and safety.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
28 | WHS 133
3.4.2 The PCBU has:
a) in consultation with workers, determined the number of work groups and HSRs required to effectively
represent all workers
b) made arrangements to allow the workers to select those who will represent them on health and safety
matters
c) communicated the consultative arrangements to workers, including names of their worker and employer
representatives for health and safety matters.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
29 | WHS 133
3.4.3 Those who represent workers on health and safety matters:
a) are provided time and resources to effectively undertake this role
b) meet regularly with management about health and safety issues and the minutes of their meetings are
available to all workers.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.4.4 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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
30 | WHS 133
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 is communicated to
all workers, and consider language and standards of literacy.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.5.2 The PCBU regularly communicates to workers the progress towards the resolution of health and safety
disputes.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
31 | WHS 133
3.5.3 There are procedures for exchange of relevant health and safety information with external parties including
customers, suppliers, contractors and relevant public authorities.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.5.4 There is a procedure that encompasses health and safety issues for dealing with formal and informal
complaints received from external parties.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
32 | WHS 133
3.6 CONSULTATION, COMMUNICATION AND REPORTING—
REPORTING
3.6.1 Workplace injuries, illnesses, incidents, health and safety hazards, dangerous incidents and systems failures
are reported and recorded in accordance with relevant procedures.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.6.2 Where there is a legislative requirement, injuries, illnesses, incidents and dangerous incidents are notified to
the appropriate authorities within the stipulated timeframes.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
33 | WHS 133
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 worker representative(s) as appropriate.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.6.4 Regular, timely reports on health and safety performance—including reports against health and safety
objectives, targets and management plans—are produced and distributed within the PCBU.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
34 | WHS 133
3.6.5 Reports of audits and reviews of the health and safety management system are produced and distributed
within the PCBU.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.6.6 The PCBU’s annual report or an equivalent document includes information about health and safety
performance.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
35 | WHS 133
3.7 DOCUMENTATION
3.7.1 The PCBU’s health and safety policy, plans and procedures are documented in a planned and organised
manner.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.7.2 Specific instructions and safe work procedures associated with particular products, processes, projects or sites
have been developed where appropriate.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
36 | WHS 133
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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.8.2 Documents and data critical to health and safety shall be clearly identifiable, duly authorized prior to issue,
kept legible and include their issue status.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
37 | WHS 133
3.8.3 The PCBU provides workers with ready access to relevant health and safety documents and data and advises
them of its availability.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.8.4 Documents and data are regularly reviewed by competent persons to ensure their effectiveness, suitability,
and the currency of the information.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
38 | WHS 133
3.9 HEALTH AND SAFETY RISK MANAGEMENT PROGRAM
3.9.1 The PCBU documents its 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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.9.2 The PCBU has identified the hazards, including public safety hazards that are associated with its activities,
processes, products or services, and has assessed the risks involved and implemented suitable control
measures in accordance with the PCBU’s methodology.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
39 | WHS 133
3.9.3 The hazard identification, risk assessment and risk control process is undertaken by persons competent in the
use of the PCBU’s methodology.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.9.4 The PCBU documents all identified hazards, risk assessments and risk control plans.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
40 | WHS 133
3.9.5 Risks of identified hazards are assessed in consultation with workers having regard to the likelihood and
consequence of injury, illness or incident occurring, taking into consideration:
a) legal requirements
b) evaluation of available information
c) records of incidents, illness and disease
d) potential for emergency situations.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.9.6 The level of risk is assessed and used to prioritise the implementation of risk control measures.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
41 | WHS 133
3.9.7 Hazard management methodology and associated procedures shall be reviewed and revised where
necessary to ensure relevance, adequacy and compliance with health and safety management system
requirements.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.9.8 The PCBU has a program for identifying and managing change that may impact on health and safety.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
42 | WHS 133
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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.2 Health and safety requirements are identified, evaluated and incorporated into all purchasing specifications
for services.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
43 | WHS 133
3.10.3 The ability to meet health and safety requirements is assessed in the selection of contractors and labour hire
workers (workers).
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.4 Temporary workers health and safety performance is monitored and reviewed to ensure continued adherence
to the PCBU’s health and safety requirements or specifications.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
44 | WHS 133
3.10.5 The PCBU determines their health and safety requirements prior to the purchase of goods and communicates
those specifications to the supplier.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.6 Procedures shall be established and implemented for verifying that purchased goods conform to health and
safety requirements and address discrepancies before the goods are put into operational use.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
45 | WHS 133
3.10.7 Hazard identification, risk assessment and the development of control measures are undertaken during the
design stage of plant, products, buildings or processes, or when the design is modified.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.8 Competent persons verify that designs and modifications meet specified health and safety requirements.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
46 | WHS 133
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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.10 Facilities and amenities in workplaces conform, as a minimum, to relevant legislation, standards and codes
of practice.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
47 | WHS 133
3.10.11 The PCBU has a program for the safe use, handling, transfer, inventory management and transport of
hazardous chemicals.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.12 Comprehensive health and safety information on all hazardous chemicals is readily accessible.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
48 | WHS 133
3.10.13 The PCBU ensures that hazardous chemicals are safely stored in accordance with legislative requirements.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.14 The PCBU permit to work procedures are available for use when required.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
49 | WHS 133
3.10.15 Where personal protective equipment is required it is appropriate for the task, its provision is accompanied by
suitable training or instruction, and it is used correctly and maintained in a serviceable condition.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.16 Plant and equipment is maintained to ensure safe operational use and a record is kept which includes (but is
not limited to) relevant details of inspections, maintenance, repair and alteration of plant.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
50 | WHS 133
3.10.17 There is a procedure for unsafe plant and equipment to be identified and quarantined or withdrawn from
service.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.18 Controls are implemented to ensure the safety of persons (including members of the public) while plant and
equipment is in the process of being cleaned, serviced, repaired or altered.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
51 | WHS 133
3.10.19 Competent persons verify that plant and equipment is safe before being returned to service after repair or
alteration.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.20 Safety signs, for example, hazard, emergency information and fire signs, meet relevant standards and codes
of practice and are displayed in accordance with legal and organisational requirements.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
52 | WHS 133
3.10.21 There are procedures to ensure that materials are transported, handled and stored in a safe manner.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.22 Workers are supervised according to their capabilities to ensure that tasks are performed safely and work
instructions and procedures are followed.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
53 | WHS 133
3.10.23 The PCBU has a program to effectively manage the safety of workers when working at workplaces not under
the control of the PCBU.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.10.24 Customer-supplied goods and services used in the PCBU’s work processes are subject to hazard identification,
risk assessment and control prior to use.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
54 | WHS 133
3.10.25 All substances in containers and transfer systems are identified and clearly labelled to avoid inadvertent or
inappropriate use.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.11 EMERGENCY PREPAREDNESS AND RESPONSE
3.11.1 Potential emergency situations have been identified and an emergency plan is:
a) developed for the PCBU and its workplace
b) in accordance with legislative requirements
c) regularly reviewed.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
55 | WHS 133
3.11.2 The PCBU has allocated overall responsibility for control of emergency situations to specified individuals and
communicated this information to all workers.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.11.3 Workers receive training and practice in emergency plans appropriate to their allocated emergency response
responsibilities.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
56 | WHS 133
3.11.4 Competent persons have periodically assessed the suitability, location and accessibility of emergency
equipment.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.11.5 Emergency and fire protection equipment, exit signs and alarm systems are inspected, tested and maintained.
Suitability, location and accessibility are reviewed if there has been a change in the workplace.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
57 | WHS 133
3.11.6 The PCBU ensures that a system is in place to inform emergency authorities of all relevant hazards (including
hazardous chemicals) and on attendance during an emergency.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
3.11.7 The PCBU has assessed its first aid requirements and the first aid program is in place.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
58 | WHS 133
3.11.8 The PCBU has procedures in place to assist workers who are exposed to critical incidents at work.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
59 | WHS 133
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 incorporates timely and effective
corrective action processes.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
4.1.2 Inspections seek input and involvement from the workers who are required to undertake the tasks being
inspected.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
60 | WHS 133
4.1.3 Engineering controls including safety devices are regularly inspected and tested (where appropriate) to ensure
their integrity.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
4.1.4 Monitoring of the workplace environment (general and personal) is conducted where appropriate and records
of the results are maintained.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
61 | WHS 133
4.1.5 Inspection, measuring and test equipment related to health and safety monitoring is appropriately identified,
calibrated, maintained and stored.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
4.2 MONITORING AND MEASUREMENT—HEALTH SURVEILLANCE
4.2.1 The PCBU has identified those situations where worker health surveillance should occur and has procedures
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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
62 | WHS 133
4.3 INCIDENT INVESTIGATION, AND CORRECTIVE AND PREVENTIVE
ACTION
4.3.1 There are procedures (incorporating appropriate methodologies) for investigating and implementing
corrective action following injuries, illnesses, incidents and other systems failures impacting on health and
safety.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
63 | WHS 133
4.3.2 Investigations shall:
a) be undertaken by a competent persons 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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
64 | WHS 133
4.3.3 Corrective actions are:
a) implemented in a timely manner
b) undertaken in consultation with affected workers
c) assessed for their effectiveness by assigned workers.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
65 | WHS 133
4.4 RECORDS AND RECORDS MANAGEMENT
4.4.1 The PCBU has a program 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.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
66 | WHS 133
4.5 HEALTH AND SAFETY MANAGEMENT SYSTEM AUDITS
4.5.1 There is a health and safety management system audit program to verify the effectiveness of the PCBU’s
health and safety management system requirements. The audit program takes into consideration the
significance of health and safety risks and the results of previous audits.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
4.5.2 The PCBU conducts scheduled audits to verify that:
a) workplace activities comply with health and safety procedures
b) procedures are properly implemented and maintained and
c) procedures are effectively implemented across the PCBU.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
67 | WHS 133
4.5.3 Deficiencies highlighted by the audits are prioritised and progress is monitored to ensure corrective action is
implemented.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
68 | WHS 133
ELEMENT 5: MANAGEMENT REVIEW
5.1 MANAGEMENT REVIEW
5.1.1 The PCBU has a health and safety management system review program to ensure the continuing suitability
and effectiveness of the system. The review program is undertaken with senior management and officers and
takes into account:
a) health and safety management system audit results
b) objectives, targets and performance indicators
c) changing circumstances
d) opportunities for continuous improvements.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
69 | WHS 133
5.1.2 Recommendations arising from health and safety management system reviews generate actions to improve
performance and those actions are implemented.
Finding:
Evidence:
Comment:
Observation:
Non-conformance:
70 | WHS 133
APPENDIX 1: SITE SPECIFIC FINDINGS
SUMMARY OF NCRS AND OBSERVATIONS BY SITE/BUSINESS
DIVISION
[completion of this Appendix is optional. To assist in the development of specific site/business division corrective action plans, it
is recommended that it be completed in instances where a large number of sites have been audited and/or there are significant
differences between a licensee’s various business divisions or business activities]
Criterion Rating (NCR and/or
Observation)
Reason for NCR and/or Observation
[site/business division]
[site/business division]
[site/business division]
[site/business division]
[site/business division]
[site/business division]
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Completed 7 February 2021

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