Procedure - draft

Internal Audit Procedure

1. Purpose
To provide guidance for the delivery of Health, Safety and Environment (HSE) audit programs across QUT.
The HSE audit program is designed to identify areas of best practice as well as opportunities for
improvement. The audit process is not an examination or a test so answers such as not sure, or do not
know are as valid as the standard Yes/No/Not Applicable (N/A).

2. Scope
This procedure applies to all HSE audit activity conducted at all QUT campuses and distributed sites.

3. Definitions
Refer to the Glossary for definitions of terms.

4. Audit Methodology

Image 1: Audit relationship diagram

4.1. Workplace/Hazard Inspections

Workplace/hazard inspections should be completed by the relevant person i.e. first aid inspections should
be completed by First Aid Officers, fire and evacuation inspections should be completed by members of
Emergency Control Organisation (e.g. Fire Wardens), laboratory inspections should be completed by lab
managers/technical services staff, etc.
These inspections should be completed on a regular to semi-regular basis (e.g. weekly, monthly, every
three months etc.) with specific timeframes determined by the level of risk and indicated on the relevant
inspection checklists.
Once completed, the inspection checklists should be signed and uploaded to the local Health and Safety
(H&S) committee SharePoint site under the relevant area.
Note: The term Workplace/hazard inspection is not interchangeable with auditing as they are two different processes. For information on
the difference between a workplace/hazard inspections and an audit visit the HSE internal audit FAQ page.

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4.2. Self-Assessment Review (SAR)

The SAR must be conducted by local area staff (as nominated by the Head of Discipline/School/Department
(HoD/S/D)) in consultation with local area HSAs, HSRs and technical staff (see Annex B: QUT Internal Audit
Process).
The SAR consists of nine sections. Section one is the general section and must be completed by ALL local
areas on an annual basis (see section 7: Audit Frequency). The remaining eight sections refer to specific
regulated hazards and should only be completed if relevant to the local area.
When completing the SAR staff will need to provide evidence as relevant to each answer completed. This
may take the form of providing a URL where documents are located, photographs attached to the back of
the document, or written details advising why the area meets the criteria (if assistance is required please
contact the Senior HSE Systems and Audit Officer ext. 84713).
The completed SAR is then provided to the HoD/S/D for review and signature before the signed document is
uploaded to the relevant local areas H&S Committee SharePoint site.

4.3. Risk Based Audits

Risk based audits will be conducted by H&S coordinators/managers (or DHSE where no H&S
coordinators/managers are available) and will be determined based on local area risk profiles and results
from the SAR.
The risk based audits will be used to identify how local areas have implemented and complied with processes
that relate to the commissioning, use, and decommissioning of local area regulated hazards.

4.4. Systems Audits

Systems audits will be conducted by DHSE staff.
The systems audits will be used to identify the degree of local area implementation regarding the HSE
Management System by examining QUT policies, procedures and guidelines as well as risk specific
legislation and processes.
Audits shall be scheduled in consultation with local area managers and conducted as follows:
Audit Activity
Audit Task
Responsibili
ty
Initiate the audit
Prepare for the audit

Conduct the audit

Prepare/Distribute audit report

Conduct audit follow-up

Establish initial contact with local area

Determine feasibility and scope of audit
Gather background information (i.e. SAR, desktop audit).
Prepare the audit plan.
Prepare work documents
Conduct opening meeting
Manage communication
Collect & verify information
Generate audit findings
Prepare audit conclusions
Conduct closing meeting
Prepare and distribute draft audit report for consultation.
Prepare and distribute final audit report.
Identify areas for improvement (audit report).

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HSC/M & HSE

HSC/M & HSE

HSC/M & HSE

HSC/M & HSE

Local area with
assistance from

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Identify short term solution

Investigate and identify root cause of problem
Allocate responsibility and date for implementation
Verify implementation
Identify long term solution
Verify implementation and effectiveness
Close out meeting

HSC/M & HSE

4.5. Evaluation and Management Review

It is the responsibility of the local areas to develop and maintain a Rectification Action Plan (RAP) based on the
areas for improvement identified through the audit activity that is carried out throughout the year. The local area
RAPs should be forwarded to the local H&S committees prior to each meeting for review and further discussion
where appropriate.
In December of each year the audit results will be reviewed by the Director, DHSE to determine a proposed
strategic level, whole of QUT, RAP that takes into consideration all of the major areas for improvement from the
audit activity conducted throughout the year. The status of the RAP is to be monitored at three month intervals by
DHSE in consultation with the UHSC.

5. Audit Frequency
Audit Level

Audit Type

Frequency

Level 1:
Discipline/ School/ Department

Workplace/hazard inspections

Self-assessment review (SAR)

Risk based audits

Systems audits

Local area risk profiles

ARMS reviews/audits

External audits

Level 2:
H&S Coordinators and
Managers, and HSE Department
staff

Level 3:
Independent Assurance

6. Responsibilities
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Based on risk and determined by local H&S

staff in consultation with H&S
coordinators/managers, DHSE, and local
H&S Committees.
Completed annually at the
Discipline/School/Department level. The
SAR is to be signed by the HoD/S/D then
uploaded to the local H&S committee
SharePoint site by no later than 30th June
each year.
Annually as determined by the SAR
responses and the local area risk profiles.
Annually as determined by the SAR
responses, risk based audits, and the local
area risk profiles.
Assessed annually by DHSE in consultation
with local HSAs, H&S committees and HSE
professionals.
Determined by the UHSC and will be
dependent on issues raised through the risk
based and system audits and will be
included in the ARMS auditing and review
schedule.
Scheduled by DHSE at the end of the three
year audit cycle.

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6.1. Local H&S staff (staff who hold voluntary/designated H&S roles such as HSAs, FAOs, etc.)
Workplace/Hazard Inspections
Ensure that all workplace/hazard inspections, as relevant to the specific voluntary/designated H&S role, are
completed and uploaded to the DHSE SharePoint site.

6.2. Local area staff/H&S Advisors/Technical staff

Self-Assessment Review
Complete the SAR document for your local area (see section 7: Audit Frequency).
Ensure the completed SAR is provided to the Head of Discipline/School/Department (HoD/S/D) for review
and signature.
Provide a copy of signed SAR to HSE Department, H&S coordinators/managers if available, HSR of the local
area, and local H&S Committee.

6.3. Supervisors and Managers

Workplace/Hazard Inspections
Review and sign all workplace/hazard inspections and checklists in a timely manner.

6.4. Heads of Discipline/School/Department

Self-Assessment Review
Ensure the completion of the SAR within the local area (see section 7: Audit Frequency).
Review, approve and sign the completed SAR prior to the document being forwarded to HSE
coordinators/managers, Department of HSE (DHSE), and local H&S Committee.

6.5. H&S Coordinators and Managers

Self-Assessment Review
Review local risk profiles and outcomes of SARs to determine areas that may need further investigation.
Risk based audits
Conduct targeted risk based audits as determined by local area risk profiles and outcomes from local SARs
(see Risk Profile for QUT).
Ensure risk based audit outcomes are provided to HoD/S/D and DHSE.

6.6. Department of Health, Safety and Environment

Self-Assessment Review
Review/maintain the QUT risk profile (see section 8: risk profile).
Review SARs as relevant to specialist areas e.g. Senior Occupational Hygienist (Chemicals) will review local
SAR chemical section and determine potential need for further investigation through a risk based audit.
Risk based audits
Conduct risk based audits as per HSE Department staff specialisations, local area risk profiles and outcomes
from local SARs (see Risk Profile for QUT).
Undertake H&S coordinator/manager duties in areas that do not have access to a Faculty/Institute/Division
H&S coordinator/manager.
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Systems audits
Conduct systems audits as determined by reviewing SARs and local area risk profiles.
Ensure audit outcomes are provided to HoD/S/D and various QUT Committees for review.
Assist local areas with the development and implementation of RAPs.
ARMS reviews and audits
Provide specialist support as required.
Participate in joint audits as scheduled.
External audits
Schedule and coordinate external audits every three years to coincide with the end of the audit cycle.

6.7. Local H&S Committees

Self-Assessment Review
Review completed SARs and create RAPs from areas that have been identified as not being compliant.
Assign responsibility to ensure actions are completed.
Risk based audits
Plan for the timely completion of any rectification actions following audits.
Report findings to Faculty/Institute/Division executive meetings.
Systems audits
Plan for the timely completion of any rectification actions following audits.
Report findings to Faculty/Institute/Division executive meetings.

6.8. University H&S Committee

ARMS reviews and audits
Review HSE risk based and systems audit outcomes as reported by DHSE.
Escalate issues for ARMS to audit or review.

6.9. External Auditors

External audits
Conduct QUT wide audits every three years based on QUT risk profile and issues raised from the internal
HSE audit process.
Provide audit findings to DHSE and UHSC.

7. Risk Profile
HSE risk profiles for each Faculty/Institute/Division are developed by DHSE in consultation with the local area,
HSAs, and the H&S coordinators and managers. The risk profile provides areas with an overview of the different
levels of risk that exists in the area and provides information on control measures to ensure those risks are
managed appropriately.
The elements assessed to determine risk profiles include:
number of regulated hazards present in everyday work operations
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number of significant environmental aspects considered during normal daily work operations
number of incidents and their severity and
number of workers compensation claims and their severity.
Risk profiles are reviewed annually by local H&S committees in consultation with local HSE professionals and
DHSE to ensure the currency and effectiveness of control measures identified. They will also be reviewed in
situations where a serious incident or event occurs so that any new risks that may arise are analysed, assessed,
and treated as required.

8. Training
Guidance and training for staff will be provided both online (reference guides, audit guidelines, etc.) and face-toface (a half-day training session will be available three times a year). Attendance will not be mandatory, but may
be helpful to staff unfamiliar with auditing.

9. Records
See Records Management procedure for all related record keeping requirements.

10.

Associated Documentation

Guidance Information
HSE audit process
HSE audit framework flowchart

Templates
Audit report
Opening /closing meeting presentation
Rectification action plan (rap)

Audit Tools
Self-assessment review
Risk based audit templates
Systems based audit templates

11.

Document History

Title:
Document Number:
Author:
Document Owner:
Review Interval:
Version Number

Paragraph

Description

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Date

Approved by

Internal Audit Procedure

ANNEX A QUT Internal audit framework

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(pdf version)

Internal Audit Procedure

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Internal Audit Procedure

ANNEX B QUT internal audit process

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(pdf version)