safety self assessment tool - roman catholic diocese of … · 2018-07-24 · safety self...

Safety Self Assessment Tool Doc Reference: DoMN-WHSMS Form 4.5a

Version Number: 1.4

Diocese of Maitland-Newcastle Safety Self-Assessment Tool

Issue Date: 12/2/2013 Scheduled Review Date: June 2020 Document Owner: WHS Manager

Revised: June 2018 Controlled copy – Uncontrolled on printing

This Self-Assessment Checklist is based on Australian Standard 4801:2001 – WHS Management Systems and is to be utilised at business level to gauge the level of implementation of the DoMN WHSMS and identify areas for improvement. This Self-Assessment Checklist is not intended as a full WHSMS Audit and has been developed to provide each location with a checklist to ensuring key provisions within each safety policy and procedure have been met.

Prior to conducting an audit, refer to WHSMS 4.5 WHS Auditing procedure for further information.

Location of Audit:

Audit Date:

Auditors Name:

Auditors Signature: Overall Scores

Number of “Y” responses:

Site Manager’s Name: Number of “N” responses:

Site Manager’s Signature: Number of “N/A” responses:

Persons Interviewed: Comments:

Scoring Legend

Y = YES Requirement is documented and implemented

N = NO Requirement not identified or documented

N/A Requirement not applicable


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AS4801 Criteria Evidence Required Y / N Recommendations

ELEMENT 1: SAFETY POLICY

1.1

There shall be an WHS policy authorised by the organisation’s top management that clearly states overall WHS objectives and demonstrates a commitment to improving WHS performance.

The policy shall—

a) be appropriate to the nature and scale of the organisation’s risks; b) include the commitment to establish measurable objectives and targets to

ensure continued improvement aimed at elimination of work-related injury and illness;

c) include a commitment to comply with relevant WHS legislation and with other requirements placed upon the organisation or to which the organisation subscribes;

d) be documented, implemented, maintained and communicated to all employees;

e) be available to interested parties; and f) be reviewed periodically to ensure it remains relevant and appropriate to the

organisation.

Current Safety Policy is displayed on notice boards.

Safety Policy is communicated through the induction program

Employees and Managers are aware of the policy (verify through interviews)

ELEMENT 2: PLANNING

2.2 LEGAL REQUIREMENTS AND PRACTICAL GUIDANCE

2.2.1

The organisation shall establish, implement and maintain procedures to identify and have access to all legal and other requirements that are directly applicable to the WHS issues related to its activities, products or services, including relevant relationships with contractors or suppliers and communicate relevant information on legal and other requirements to its employees.

Safe Work Procedures (SWPs) reference current legislation, codes, etc.

Access provided to current legislation, codes, standards.


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SWP’s reviewed when changes to legislation are made.

Interviews indicated employees are advised of and know how to access relevant information

Requirements for licenses and competency are identified, met and are current

Copies of registration certificates for applicable plant

2.3 OBJECTIVES AND TARGETS

2.3.1

The organisation shall establish, implement and maintain documented WHS objectives and targets at each relevant function and level within the organisation and take into consideration its legal and other requirements, its WHS hazards and risks, its technological options, its operational and business requirements and the views of interested parties. The objectives and targets shall be consistent with the WHS policy including the commitment to measuring & improving WHS performance.

Annual Business Safety Improvement Plans have been communicated to all personnel

5 Year Strategic Safety Plan has been communicated to all personnel

Annual Business Safety Improvement Plans have been established and reflect broad objectives of the 5 Year Strategic Plan

Annual Business Safety Improvement Plans are reviewed and monitored at quarterly intervals


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2.4 WHS MANAGEMENT PLANS

2.4.1

The organisation shall establish and maintain management plans for achieving its WHS objectives and targets. They shall include designation of responsibility for achievement of objectives and targets at relevant functions and levels of the organisation and outlining the means and timeframe by which objectives and targets are to be achieved.

Annual State/Region Safety Management Plans are developed and implemented that:

Reflects objectives and targets of Business Safety Improvement Plans

Specific to state/region hazards and risks

Management Plans have been communicated to all personnel

Project Specific Safety Management Plans are established for each project as required

2.4.2

Procedures shall be established to ensure that current plans are reviewed, and if necessary amended to address such changes at regular and planned intervals, and whenever there are changes to the activities, products, or services of the organisation or significant changes in operating conditions.

Annual State/Region Safety Management Plans states date the plan was last review with Plans reviewed/developed at least annually

Management Plan is reviewed by Region/State Management in conjunction with Safety Committee/ employees (documented in meeting minutes)


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ELEMENT 3: IMPLEMENTATION

3.1 RESOURCES

3.1.1 Management shall identify and provide the resources required to implement, maintain, and improve their OHSMS. Resources include human resources and specialised skills, technology and financial resources.

Allocation of resources (both physical and financial) in minutes and Business Safety Improvement Plans

Time release for employees to complete safety activities (e.g. inspections, committee meetings)

Safety Reps/Committee participate in:

Risk assessments

Health and safety training

Workplace inspections

Committee meetings

Incident investigations

Interviews with Safety Reps/Committee confirm sufficient time and resources to undertake required activities.


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3.2 RESPONSIBILITY AND ACCOUNTABILITY

3.2.1

The organisation shall define, document and communicate the areas of accountability and responsibility (including those imposed by WHS legislation) of all personnel involved in the OHSMS’s operation.

Position descriptions include safety requirements (check sample for Management and employee positions)

Employee and Manager’s induction records on file

Training records for relevant safety training – employees and Managers

Interviews with Managers and employees confirm knowledge of Thin’s Safety Responsibility Table

3.2.2 Where contractors are involved, these areas of accountability and responsibility shall be clarified with respect to those contractors.

Contractor/Visitors Sign-in Registers available and utilised

Site induction includes safety responsibilities of Contractors

Completed contractor inductions on file


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Contractor’s SWMS’s provided

Specific personnel have been delegated responsibility for managing contractors on site (check position descriptions and knowledge)

3.3 TRAINING AND COMPETENCY

3.3.1

The organisation in consultation with employees shall identify training needs in relation to performing work activities competently, including WHS training. Procedures shall be in place to ensure that WHS competencies are developed and maintained.

Safety Competency Profiles established for employees and Managers

Training Needs Analysis conducted for employees and Managers

Training Plans established for all employees and Managers

3.3.4 The organisation shall ensure that all personnel (including contractors and visitors) have undertaken training appropriate to the identified needs.

Performance reviews include review of WHS training / developmental needs

Site induction records on file for all employees and Managers

Site induction records on file for contractors and visitors (where relevant)


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Records of specific training undertaken: e.g. construction induction (white card), manual handling, PPE, first aid etc

Training records for SWP training on file

Management training records on file (e.g. WHS for Managers, Incident Investigation etc)

3.3.5 Training shall be carried out by persons with appropriate knowledge, skills, and experience in WHS and training.

Where internal trainers are used, trainers have appropriate qualifications and/or experience to undertake the training

External trainers have appropriate qualifications and/or experience to undertake the training

3.4 CONSULTATION

3.4.1 There shall be documented procedures, agreed to by employees, for employee involvement and consultation in WHS issues. Information regarding the arrangements shall be made available to interested parties.

Agreement on the Safety Issue Resolution Flowchart is recorded in Safety Committee Meeting minutes

Safety Issue Resolution Flowchart completed with relevant names and displayed/ communicated to employees


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3.4.2

Employees shall— (a) be involved in the development, implementation and review of policies and

procedures for hazard identification, hazard/risk assessment and control of hazards/risks;

(b) be consulted where there are any changes that affect workplace OHS; (c) select those who will represent them on WHS matters; and (d) be informed as to who is/are their employee WHS representative(s) and

specified management representative(s).

Safety Committee/Representatives have been established – there are more employee reps on the committee than Management reps

Chairperson of Committee is a non-management (employee) representative

Nomination for election forms on file

Safety Committee Meeting minutes confirm appointment of Safety Committee/Reps

Safety Committee/Representative names displayed/communicated

Employees know who their Safety Representative is

Site induction advises of consultation process

3.4.3 Those representing the employees and employer shall receive appropriate training to undertake effectively their involvement in the development, implementation and review of WHS arrangements.

Safety Committee/Representatives have received the appropriate training to allow them to undertake their role

Safety Committee Meetings conducted regularly with

minutes documented and displayed as required


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3.5 COMMUNICATION

3.5.1 The organisation shall have procedures for ensuring that pertinent WHS information is communicated to and from employees and other interested parties.

Employees receive communication of safety information via appropriate forums/portals e.g. intranet, memos, emails

Safety Committee Meeting minutes show communication of safety information e.g. changes to procedures, processes etc

Interviews with employees confirm awareness of Safety Policy and Safety Committee meetings

Outcomes of incident investigations communicated to employees


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3.5.2 The organisation regularly communicates to employees the progress towards the resolution of heath and safety disputes.

Safety Committee meeting minutes detail progress on safety issues/hazards raised by employees

3.6 DOCUMENT AND DATA CONTROL

3.6.1

The organisation shall establish, implement and maintain procedures for controlling all relevant documents and data required to ensure that— a) they can be readily located; b) they are periodically reviewed, revised as necessary and approved for

adequacy by competent and responsible personnel; c) current versions of relevant documents and data are available at all

locations where operations essential to the effective functioning of the OHSMS are performed;

d) obsolete documents and data are promptly removed from all points of issue and points of use or otherwise assured against unintended use; and

e) archival documents and data retained for legal or knowledge preservation purposes or both are suitably identified.

Documentation and data shall be legible, dated (with dates of revision) and readily identifiable and be maintained in an orderly manner for a specified period.

The organisation shall preclude the use of obsolete documents.

Current version of the Management System procedures in use across site (check ‘next review’ date on documents)

For locally developed Safe Work Procedures – document control applies to documents as per the procedure

Access to intranet site available to all employees

3.7 RISK MANAGEMENT PROGRAM

3.9.1

The organisation shall establish, implement and maintain documented procedures to ensure that hazard identification, risk assessment, control and review are conducted.

Risk control is to be based on the hierarchy of control and reasonable practicability with elimination being the first control method to be considered.

Hazards are reported via HRIS. Employees know of process for reporting hazards via HRIS


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Risk Assessment Worksheets documented for identified hazards with risk controls identified

Safety Inspections are completed and documented with risk controls identified

Incidents/Near misses are reported via HRIS with corrective actions identified and implemented

Current Safety Risk Registers completed with all known site-specific hazards recorded and associated risk assessments completed and recorded

Interviewed employees know risk management process i.e. reporting hazards and incidents via HRIS, risk assessment and control

Safety Committee meetings show discussion of corrective actions and risk controls from hazards identified, risk assessments, workplace inspections, incident reports and investigations etc.


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3.9.2 The risk management process shall also include consideration of—

(a) the way work is organized, managed, carried out and any changes that occur in this;

Signage and physical barriers present on restricted areas

Ergonomic Self-Assessment Checklists completed and retained on file for individual employees and workstations

Observations of workstations indicate adequate control of ergonomic risks (e.g. desk heights, adjustable chairs, lighting, glare, posture etc)

3.9.2 (b) the contracting and subcontracting of plant, equipment, services and labour

including contract specification and responsibilities to and by contractors; and

Where contractors are engaged by the site:

Contractor Safety Evaluation Forms completed and on file

Register of Approved Contractors implemented and is up-to-date

Copies of relevant insurances obtained and retained on file (e.g. workers compensation, public liability etc)


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Contractor/Visitor Sign-in Registers available and completed

Contractor SWMSs and relevant licenses, certificates of competency obtained prior to commencement of services

Selection of contractors from Register of Approved Contractors

Contractor Corrective Action Reports (CARs) completed and on file where relevant


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3.9.2

(c) the design of workplaces, work processes, materials, plant and equipment; (d) the purchasing of goods and services;

Safety Pre-Purchase Checklists completed for new plant, equipment or materials prior to purchase

Risk assessments of new plant, equipment or materials conducted PRIOR to purchase (documented on Risk Assessment Worksheet)

SWPs developed for new plant, equipment, materials

3.9.2

(e) the fabrication, installation and commissioning and handling and disposal (of materials, workplaces, plant and equipment);

Chemical containers at site correctly labelled

Hazardous Substances /Dangerous Goods Register completed and is current for the site

MSDS available on site and are current (within 5 years of issue date)

Records of issue of and training in PPE to employees provided as applicable

Manual Handling Risk Assessment Form completed and retained on file for activities involving manual handling

Employees trained in manual handling and ergonomics as relevant


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Appropriate and sufficient manual handling equipment available (e.g. trolleys)

Stock and materials stored to minimise manual handling risks

3.9.2 f) the inspection, maintenance, testing repair and replacement (of plant and

equipment).

Observed plant/equipment in good condition e.g. ladders, trolleys

Unsafe plant/equipment quarantined and tagged-out

Plant Risk Assessments completed for relevant items of plant/equipment

Electrical equipment and leads have been tested and tagged

3.10 EMERGENCY PREPAREDNESS AND RESPONSE

3.10.1 All potential emergency situations shall be identified and emergency procedures documented for preventing and mitigating the associated illness and injury, including exposures to the public.

Emergency Wardens have been nominated

Current Emergency Response Procedure Manuals available and implemented at site

Names of wardens displayed and communicated to employees

Evacuation drills conducted at prescribed intervals and recorded with records retained


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Training provided to Wardens in emergency response responsibilities and records retained

Employees provided with sufficient opportunity to participate in evacuation drills

First Aid risk assessment conducted and documented to determine first aid needs of site

First aid kits provided and checked regularly – First Aid Kit Checklist completed

Qualified First Aid Attendants available and names displayed/communicated (meeting minutes/noticeboards)

Copies of First Aid Officer’s training certificates obtained and retained on file

First aid treatment recorded in First Aid Treatment Register (or similar)

Interviews with employees confirm knowledge of who First Aid attendants and Emergency Wardens are


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ELEMENT 4: MEASUREMENT AND EVALUATION

4.1 MONITORING AND MEASUREMENT

4.1.1

The organisation shall establish, implement and maintain documented procedures to monitor and measure on a regular basis the key characteristics of its operations and activities that can cause illness and injury. Where specified by legislation, the health of employees exposed to specific hazards shall be monitored and recorded.

Safety Inspection Program established with inspections scheduled

Safety Inspection Checklists conducted at 1-3 monthly intervals and documented with records retained on file

Employees/Safety Reps are involved in conducting Safety Inspections

Corrective actions arising from inspections are documented on Inspection Checklists

Risk assessments of corrective actions requiring further investigation are conducted and recorded on the Risk Assessment Worksheet


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Corrective actions arising from inspections are discussed at Safety Committee meetings and recorded in minutes with responsibilities allocated for implementation

Service tags on equipment confirm testing conducted at 6-monthly intervals

Exit and emergency signs appear to be in good/working condition


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4.3 INCIDENT INVESTIGATION, CORRECTIVE AND PREVENTIVE ACTION

4.3.1

The organisation shall establish, implement and maintain procedures for— (a) investigating, responding to, and taking action to minimise any harm caused

from incidents; (b) investigating and responding to system failures; and (c) initiating and completing appropriate corrective and preventive action.

The organisation shall implement and record any changes in the OHSMS procedures resulting from incident investigations and corrective and preventive action.

All incidents and near misses are reported and recorded via the HRIS – employees can confirm knowledge of this process

Incident Investigation Reports are completed for high and extreme risk incidents and are retained on file

Evidence of corrective actions generated and implemented following incident investigations

Training provided to relevant employees and Managers in Incident Investigation and records retained on file

Low-Medium risk incidents reported via HRIS outline appropriate contributing factors

Low-Medium risk incidents reported via HRIS have appropriate corrective actions identified and implemented


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High-Extreme risk incident investigations are:

undertaken by a competent person(s)

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

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

recommend appropriate control measures in line with the hierarchy of controls

Key findings and corrective actions from incidents and investigations are communicated in Safety Committee Meetings

4.4 RECORD MANAGEMENT

4.4.1

The organisation shall establish, implement and maintain procedures for the identification, maintenance and disposition of WHS records, as well as the results of audits and reviews.

WHS records shall be legible, identifiable and traceable to the activity, product or service involved.

WHS records shall be stored and maintained in such a way that they are readily retrievable and protected against damage, deterioration or loss. Their retention times shall be established and recorded.

Health and safety records filed at site

Intranet access for records available

Appropriate access to and confidentiality of records at site

Records of archived files in accordance with the Safety Records Register


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4.5 WHS MANAGEMENT SYSTEM AUDITS

4.5.2

The organisation shall establish, implement and maintain an audit program and procedures for periodic OHSMS audits to be carried out by a competent person, in order to:

a. Determine whether the OHSMS:

(i) Conforms to planned arrangements for the WHS management including the requirements of this Standard

(ii) Has been properly implemented and maintained; and

(iii) Is effectively in meeting the organisation’s policy as well as objectives and targets for continual WHS improvement; and

b. Provide information on the results of audits to management and employees. The audit program, including any schedule, shall be based on the WHS importance of the activity concerned, and the results of previous audits. The audit procedures shall cover the scope, frequency, methodologies and competencies, as well as the responsibilities and requirements for conducting audits and reporting results.

Outcomes of formal Safety Audits in which the site/location has been involved in have been communicated to all relevant employees

An internal Self-Assessment has been undertaken (using this Checklist) with a Corrective Action Plan documented

Corrective Action Plans from self assessments are discussed in Safety Committee meetings with close out of actions monitored and recorded


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CORRECTIVE ACTION PLAN

Criteria No.: Corrective Action Required Responsibility for Implementation

Due Date Date Implemented

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