• Section 1 - Governing Policy
• Section 2 - Scope
• Section 3 - University's Commitments
• Section 4 - Context of the University
• Section 5 - Leadership and Staff Participation
• Leadership and Commitment
• Work Health and Safety, and Wellbeing (WHS&W) Policy
• Organisational Roles, Responsibilities and Authorities
• 5.4 Consultation and Participation of Staff and Others
• Section 6 - Planning
• Hazard Identification and Assessment of Risks and Opportunities
• Assessing WHS Opportunities
• Determining Legal and Other Requirements
• Planning Action
• Section 7 - Support
• Resources
• Competencies
• Awareness and Communications
• Documented Information
• Section 8 - Operation
• Operation Planning and Control
• Eliminating Hazards and Reducing WHS Risks
• Managing Change
• Procurement
• Contractors
• Outsourcing
• Emergency Preparedness and Responses
• Section 9 - Performance Evaluation
• General
• Internal Audit
• Management Review
• Section 10 - Improving the WHSMS
• Incident, Non-Conformity and Treatments (Corrective Actions)
• Continual Improvement
• Section 11 - Revisions made to this Procedure
• Section 12 - Further Assistance
• Part A - Appendix A: ACU's Work Health and Safety Management System
• Section 13 - Associated Information

Section 1 - Governing Policy

(1) This Procedure is governed by the Work, Health, Safety and Wellbeing Policy.

Section 2 - Scope

(2) This Procedure applies to all staff, staff representatives, students, visitors, volunteers and contractors, and all of the working and learning activities which the University manages and influences.

Section 3 - University's Commitments

(3) The University is committed to implementing and continuously improving its Work Health and Safety Management System (WHSMS or framework) and the management of WHS risks that are associated with the working and learning activities it manages and influences.

(4) ACU prioritise aligning its WHSMS with its existing frameworks, processes, and relevant legal and other requirements.

(5) This Procedure was developed to provide guidance to staff and others about the core elements of the University’s WHSMS, which are aligned with International Standard ISO 45001: Occupational Health and Safety Management Systems. The  Procedure also describes the University’s processes for maintaining and continuously improving the framework to facilitate reductions in WHS risks and strengthening of WHS governance.

Section 4 - Context of the University

(6) The inaugural assessment of the University’s context was conducted in late 2019 and will be reviewed as part of a bi-annual review of its WHSMS. During this assessment process, People and Capability staff will support the University’s Senior Executive and Executive, including the Work Health and Safety Management Committee, to determine the external issues and internal factors that are relevant to its mission, values and vision and impact upon its capabilities to implement, maintain and continuously improve its WHSMS.

(7) The WHSMS Planning Procedure also specifies that that these factors will be assessed:

1. the key internal and external stakeholders influenced by ACU’s WHSMS and their expectations;
2. the scope of the WHSMS e.g. expectations of significant stakeholders that will inform WHSMS; and
3. compliance and the range of University activities the framework will apply to.

(8) The University implements and maintains its WHSMS in compliance with relevant standards, including ISO 45001, and its legal and other requirements.

Section 5 - Leadership and Staff Participation

Leadership and Commitment

(9) The WHSMS Roles and Responsibilities Procedure outlines that the Senior Executive and Executive staff demonstrate safety leadership, are committed to ‘zero harm’, and are accountable for preventing working- and learning-related injuries and illnesses and maintaining safe working and learning spaces by ensuring that significant WHS risks are identified and managed. They also engage Nominated Supervisors and Managers about the benefits of promoting consulting with the ACU community about contributing to the WHSMS. They also demonstrate safety commitment by:

1. ensuring WHS objectives and targets are developed and achieved, and these performance measures and the WHSMS are aligned with business processes;
2. developing, leading and promoting the WHSMS by motivating and communicating with staff and others about reporting and resolving hazards, near misses, incidents and injuries, and contributing to WHSMS improvement opportunities and to the management of WHS risk;
3. allocating adequate resources to facilitate continuous improvements to the WHSMS; and
4. ensuring local WHS Committees and other consultative forums are effective.

Work Health and Safety, and Wellbeing (WHS&W) Policy

(10) The University’s Work, Health, Safety and Wellbeing Policy is reviewed annually and informs the University’s priorities for implementing and continuously improving its WHSMS, including strengthening risk management practices and compliance. This includes an annual review, normally by the end of Quarter 2, of compliance requirements to inform any improvements in governance. The policy also communicates ACU’s commitment to zero harm, achieving its WHS objectives and targets and continuously improving its WHSMS.

Organisational Roles, Responsibilities and Authorities

(11) The WHSMS Roles and Responsibilities Procedure and staff Position Descriptions communicate many of the WHS responsibilities that are assigned to staff members, including their role in contributing to the WHSMS and achieving WHS objectives and targets.

(12) The following WHSMS documents define roles and responsibilities for specialist WHS positions that are mainly performed by staff members:

(13) The Senior Executive have overall responsibility and authority for the WHSMS and have assigned operational responsibility for the WHSMS to the Chief People Officer. The Director, Properties and Facilities has also been assigned responsibility for many aspects of the framework, including emergency management, permit to work processes and contractor management.

(14) Staff, staff representatives, students, visitors, volunteers and contractors are responsible for their own and other people’s safety, and confidently apply WHSMS processes and procedures. Staff and students should also report hazards, near misses, and injuries within Riskware, and visitors, volunteers and contractors engage staff members to log reports on their behalf. These reports are managed by relevant nominated supervisors and others, and documented within Riskware Action Plans.

(15) Staff and others also participate or facilitate WHS risk management and emergency management processes, including conducting formal WHS risk assessments and documenting treatments within riskware Action Plans. Staff members participate or facilitate improvement opportunities such as conducting a Job Safety Analysis, WHS Inspections and completing the WHS Workstation Ergonomics Checklist. Refer to the WHS Risk Management Procedure for more information.

5.4 Consultation and Participation of Staff and Others

(16) The University engages staff members, students, staff and student representatives – such as WHS Committees and Health and Safety Representatives (HSR), visitors, volunteers and contractors about contributing to the success of the WHSMS and the management of WHS risk.

(17) The Work, Health, Safety and Wellbeing Policy and WHS Communications and Consultation Procedure reinforces the University prioritised two-way communications and consultations about its WHSMS, performance measures, WHS risk assessments, relevant proposed changes and other issues. ACU also prioritises giving staff, students and contractors significant notice about WHS information so that informed feedback is received and help inform the WHSMS.

Section 6 - Planning

Hazard Identification and Assessment of Risks and Opportunities

(18) The WHS Risk Management Procedure specifies that every work area is required to identify and manage the significant risks that are associated with the working and learning activities they manage and influence.

(19) The University publishes or subscribes to the following WHS assessment and management tools to support work areas to conduct formal, which inform many of the treatments (controls), including Safe Work Method Statements / safe work instructions, which are selected to manage WHS risk. These treatments should be developed in collaboration with subject matter experts, impacted staff members and others, including contractors.

(20) Work areas are required to identify opportunities for improvement by conducting regular WHS Inspections, performing job safety analysis, completing ergonomic checklists, and identifying gaps in compliance and so on.

(21) A minimum of the top five WHS risks, which impact each work area, should be uploaded to organisational risk registers (CARM) by the end of March, each year. These registers should also be updated throughout the year. The Risk Management Procedure and WHS Risk Management Procedure specify that risk registers should include information about the likely impacts of risks, causes, risk rating and the treatments (risk controls) that are used to manage and minimise these identified risks.

(22) The University’s risk register is informed by the Audit and Risk Committee's determinations about which risks impact upon the whole University.

Assessing WHS Opportunities

(23) The University has established and implements a process outlined in the WHSMS Planning Procedure, to assess University wide opportunities to enhance the WHSMS, WHS performance, eliminate hazards and reduce risks, including WHS governance.

Determining Legal and Other Requirements

(24) The University publishes a WHS Register of Compliance Obligations that supports staff to easily access compliance resources and comply with the legal and other requirements that are associated with the University’s most significant hazards and associated risks, working and learning activities and its WHSMS. The register is reviewed for currency by the People and Capability Employment Relations and Safety staff in January and July, each year.

Planning Action

(25) The WHS Action Plan specifies ACU’s WHS objectives and targets and include actions for realising these performance measures. These compliance requirements support organisational units to implement the WHSMS within working and learning spaces and contribute to the realisation of the WHS objectives and targets.

(26) WHS staff, within People and Capability, conduct an annual analysis, by the end of Quarter 2, which assesses gaps in compliance with legal and other requirements. The scope of this analysis includes a review of WHSMS policies and procedures and discussions with work areas that oversee higher risk work and learning activities. Any gaps in compliance will be logged and addressed and will inform improvement to the WHS Action Plan.

WHS Action Plan

(27) The inaugural WHS Action Plan and subsequent plans detail the University’s WHS focus and includes a minimum of three WHS objectives and three WHS targets (measurable). These performance measures will be informed by hazard and incident trends, risk profiles of Faculties, organisational units, contractors and suppliers.

(28) The plan also:

1. includes actions that will support organisational units to realise the WHS objectives and targets;
2. specifies that opportunities for improvement should be identified;
3. includes actions, which are aligned with existing business processes and the WHSMS, which will support the University to achieve its WHS objectives and targets;
4. specifies key actions each organisational unit should implement to apply ACU’s WHSMS to work and learning areas and strengthen WHS risks management practices;
5. contributes to continuous improvements in the WHSMS; and
6. incorporates actions that will support ACU to respond to emergencies.

(29) The University’s progress in achieving its WHS targets and achievements is monitored through the University’s Traffic Light Report (for the WHS Action Plan).

Section 7 - Support

Resources

(30) The University identifies and allocates financial and physical resources, during its annual budget planning process, to facilitate continuous improvements in its WHSMS. These resources are allocated to People and Capability, Properties and Facilities, and other organisational units. Resource allocations, which are assigned for implementing and continuously improving the WHSMS, are reviewed during the bi-annual review of the WHSMS.

Competencies

(31) The WHS Training and Competency Procedure was informed by the Capability Development Framework (CDF), and associated processes for developing Progress Plans. The procedure and CDF support staff members, including Nominated Supervisors and Managers, to identify and develop the necessary competencies of staff to contribute to the implementation and continuous improvements of the WHSMS and perform specialist WHS roles such as First Aid Officers, Floor Wardens and Health and Safety Representatives (HSR).

(32) The identification of core WHS competencies, within position descriptions, also support the University to identify and recruit staff that have the competencies to contribute to the implementation of the WHSMS, consultation processes and manage WHS risk.

Awareness and Communications

(33) Staff and their representatives are informed of the University’s Work, Health, Safety and Wellbeing Policy and WHS objectives and targets. They are briefed about their role in contributing to the WHSMS and improving safety performance. The WHSMS Roles and Responsibilities Procedure also provides guidance to staff about how they contribute to the framework and safe campuses.

(34) The WHS Communications and Consultation Procedure also specifies that they are also made aware of:

1. the risks to health and safety of not complying with the WHSMS;
2. opportunities to improve the WHSMS;
3. expectations of internal and external stakeholders;
4. incidents and outcomes of investigations that are relevant to them;
5. how they contribute to the WHSMS and safety leadership;
6. hazards, WHS risks and opportunities, and treatments that impact upon them; and
7. the need to remove themselves from working situations that present an imminent danger.

(35) The WHS Communications and Consultation Procedure helps inform the University’s decision-making about what is communicated, the timing of this engagement and the target audience.

(36) These and other media are used to communicate with internal stakeholders:

1. WHS Website, including Quarterly WHS Reports;
2. online and face to face WHS inductions;
3. Workplace@facebook;
4. online and face to face contractor WHS inductions;
5. contacting People and Capability by visiting Service Central;
6. specialist courses that are available via the Learning and Development Calendar;
7. WHS Committee minutes; and
8. safety signage.

(37) The University should consider the diverse range of communication needs of staff members, and internal and external interested parties e.g. gender, language, culture and literacy. Documented evidence of these communications should be retained and provided during audits.

External Communications

(38) The University communicates relevant information about the WHSMS, to external audiences via the ACU website and other media.

Documented Information

(39) The University retains documentation, in alignment with ISO 45001, and maintains others documents crucial to its WHSMS. The different types of records are listed within the University’s WHSMS Records Registers and the records maintained by organisational units should be listed within their register (informed by the University’s register).

(40) Whenever documents are created and updated:

1. these documents should comply with the naming convention, outlined in the WHSMS Records and Document Management Procedure e.g. titles should be unique, meaningful and consistent;
2. the format is appropriate (e.g. software version, graphics) and medium (hard copy, digital);
3. they should be reviewed for suitability and adequacy, and authorised; and
4. they should be maintained for the periods that are specified within the WHSMS Records; and
5. register (Appendix A: ACU's Work Health and Safety Management System).

(41) The WHSMS Records and Document Management Procedure provides more detailed information about the processes for controlling, maintaining and protecting records.

Section 8 - Operation

Operation Planning and Control

(42) The WHSMS Planning Procedure describes how the University undertakes planning and implements and controls the processes associated with its WHSMS.

Eliminating Hazards and Reducing WHS Risks

(43) The University has implemented and maintains processes, which are documented in the WHS Risk Management Procedure, for eliminating hazards and reducing WHS risks. The treatments that are selected to manage risks are informed by the Hierarchy of Controls (treatments)^[1]. Significant WHS risks are uploaded to organisational unit and the University’s risk registers.

(44) The WHSMS Safety in Design Procedure and associated WHS Design Risk Register supports organisational units, in collaboration with Properties and Facilities, to identify and minimise the hazards that are associated with the design of renovations or new work and learning spaces.

(45) These documents also support staff to manage specific types of risks:

Managing Change

(46) The WHS Risk Management Procedure, the Incident and Hazard Reporting Procedure and the Complaints and Investigations Procedure specify that hazards and associated risks should be reassessed whenever planned temporary or permanent changes may impact upon the management of risk.

(47) Triggers for these reassessments:

1. changes to the University’s services and processes or the introduction of new systems and processes;
2. changes to compliance obligations;
3. new knowledge or information about hazards and WHS risks, including incident reports; and
4. developments in knowledge and technology.

(48) The consequences of these intended changes are assessed, and treatments should be developed to mitigate any adverse effects. Refer to the WHSMS Planning Procedure for more information.

Procurement

(49) The University has established, implemented and maintains processes for integrating WHS considerations into the purchase of goods and services, and prioritises the selection of suppliers that maintain Health Safety and Environment Management Systems (HSEMS) and are committed to continuously improving their HSEMS and the management of WHS risk.

(50) These requirements are outlined in the WHSMS Planning Procedure and are informed by:

1. Minimum Requirements For Suppliers of Goods and Services to ACU (Sections A.6, A.7, A.11, D.4); and
2. Minimum Requirements for Sourcing within ACU.

Contractors

(51) The University coordinates its procurement processes with its contractors so that relevant hazards and associated WHS risks, which are associated with its maintenance and construction projects, are assessed and controlled.

(52) The WHSMS Contractor Management Procedure and WHSMS Procurement Procedure articulate ACU’s commitment to ensuring that contractors comply with the requirements of the WHSMS and environmental and safety considerations inform the selection and management of contractors as they are required to address the University’s Four Pillars of Success criteria during formal tender processes. For example, contractors provide information about their governance processes, safety performance and whether they have a certified Health Safety and Environmental Management System.

(53) The WHSMS Contractor Licensing and Registration Procedure supports Properties and Facilities to verify and document maintenance contractor’s insurance and competency requirements.

(54) The WHSMS High Risk Activities Management Procedure specifies that maintenance contractors and relevant work areas, performing higher risk activities, are also required to submit Safe Work Method Statements to Facilities Management staff for review, prior to commencing work. Project Managers are assigned to new capital projects who oversee the WHS performance and incident reporting processes.

Outsourcing

(55) The University aligns outsourced functions and processes with its WHSMS. Outsourced arrangements should be compliant with legal requirements and other requirements, including safety management system standards and Minimum Requirements for Sourcing within ACU.

Emergency Preparedness and Responses

(56) The University implements and maintains a process for preparing and responding to emergency situations, including critical incidents and first aid requests. Refer to the Critical Incident Management Policy and Critical Incident Management Procedure.

(57) Some of the activities that prepare staff, students and others for emergencies, include:

1. the provision of six-monthly training sessions for building and floor wardens;
2. holding annual evacuation drills;
3. evaluating emergency responses, including evacuation drills;
4. scheduling critical incident debriefings to capture learnings;
5. conducting WHS risk assessments to inform how organisational units and the University’s respond to an emergency / reduce the risk that emergencies will occur;
6. placing emergency equipment and spill kits in laboratories; and
7. briefing staff about their responsibilities in an emergency.

(58) The University communicates and provides information to relevant staff about their emergency response roles, and provides relevant information to its tenants, contractors, volunteers, visitors, emergency services, government authorities and the local community.

(59) ACU considers the needs and capabilities of all relevant stakeholders, such as building tenants and managers, and relevant staff should engage them about these people about the development and execution of planned emergency responses.

(60) More detailed processes and requirements are outlined in the policies and procedures:

1. Emergency Management Manuals for each building;
2. In Case of an Emergency poster;
3. Critical Incident Management Policy and Critical Incident Management Procedure;
4. Reporting incidents in Riskware;
5. First Aid Policy;
6. First Aid Procedure;
7. Chemical Management Procedure; and
8. Laboratory Safety Guideline.

Section 9 - Performance Evaluation

General

(61) The WHSMS Planning Procedure and WHSMS Performance Measurement and Evaluation Procedure outlines the University’s processes for monitoring, measurement, analysing, evaluating and reporting on the performance of the framework.

(62) The components of the WHSMS that are monitored and measured, include these and other requirements:

1. an annual review of compliance, conducted by People and Capability, with legal and other requirements;
2. the measurement of a range of lag indicators, including Lost Time Injuries and workers compensation costs which are benchmarked across the University sector;
3. lead (proactive) performance indicators that measure those activities ACU initiates to reduce the risk of injuries and illnesses;
4. Health and Air Monitoring requirements, which are outlined in the WHSMS Health and Air Monitoring Procedure;
5. a review of the effectiveness of the University operational controls, including its procedures;
6. an annual review to ensure that the University has identified the significant hazards, risks and opportunities that are associated with working and learning spaces and activities the University influences;
7. an assessment of the risks that impact upon the University’s capabilities to achieve the intended outcomes for its WHSMS; and
8. progress toward achieving WHS objectives and targets.

Internal Audit

(63) The University conducts internal audits at planned intervals to assess whether the WHSMS conforms to internal requirements, including the Work, Health, Safety and Wellbeing Policy and WHS objectives and targets. The WHSMS Auditing Procedure outlines that these audits will also assess whether the WHSMS is effectively implemented and maintained by organisational units and contractors. These audits will also identify gaps in compliance and WHSMS opportunities for improvement.

Management Review

(64) The WHSMS Planning Procedure specifies that the Senior Executive and Executive, including the Work Health and Safety Management Committee, will conduct a bi-annual management review of:

1. the status of actions from previous reviews;
2. assessments and reviews of the context of the University;
3. changes in internal and external issues which will impact upon the WHSMS;
4. significant stakeholders and their expectations, including which of their needs will help inform the WHSMS;
5. the scope of the WHSMS;
6. the extent to which WHS Policy and targets and objectives have been met;
7. WHS performance data;
8. WHS risks, including the risks that could impact upon the University’s intended outcomes for the WHSMS, and opportunities;
9. the adequacy of resources for maintaining an effective WHSMS;
10. a review of the suitability, adequacy and effectiveness of the WHSMS;
11. the effectiveness of communications and consultations with interested stakeholders, including staff; and
12. opportunities for continuously improving the WHSMS.

(65) The results of the review, including any recommendations for improvement, will be documented and communicated to staff and their representatives and will help inform the WHS Action Plan.

Section 10 - Improving the WHSMS

(66) Opportunities for improving the WHSMS will be identified during annual and bi-annual reviews of the WHSMS. The framework will also be strengthened by organisational units identifying improvement opportunities^[2]; identifying and implementing corrective actions, actioning non-conformances and other actions.

Incident, Non-Conformity and Treatments (Corrective Actions)

(67) The Incident and Hazard Reporting Procedure describes the process for investigating hazards, near misses, incidents and injuries; developing treatments and reporting on actions that were taken to manage incidents, which should be documented within Riskware Action Plans. Non-conformities^[3] are also actioned and reported on.

(68) Whenever an incident and non-conformity occurs, organisational units should take timely actions to control and manage this issue and identify any contributing factors. Relevant Nominated Supervisors and Managers should evaluate the relevant risk with staff and others and consult about any proposed corrective actions.

(69) People and Capability staff will assess whether similar incidents or non-conformities are occurring on a broader scale across the University and facilitate actions to manage these risks. The logging of Riskware reports can also trigger reviews of existing assessments of risks, the application of treatments and changes to the WHSMS.

(70) The treatments, which are selected to manage reports of hazards, near misses, injuries and hazards (logged in Riskware), are assigned a risk rating (to determine their effectiveness) and documented within Riskware Action Plans. Actions taken to address WHSMS non-conformities should also be documented, within Riskware Action Plans. (logged as reports of hazards), by organisational units. Staff and their representatives, including WHS Committees, HSR and the ACU Staff Consultative Committee, are updated about the actions that are taken to manage the risks identified by incident and hazard reports, audits and other non-conformities.

Continual Improvement

(71) The WHSMS Planning Procedure outlines how the University also continuously improves the WHSMS by:

1. determining the suitability, adequacy and effectiveness of the WHSMS during bi-annual reviews;
2. enhancing the safety of working and learning spaces, and the activities which the University influences;
3. promoting a culture that supports a robust WHSMS;
4. engaging staff about implementing actions that will lead to continuous improvements in the WHSMS;
5. informing staff about improvements to the framework; and
6. documenting these continuous improvements.

Section 11 - Revisions made to this Procedure

(72) The revision table includes revisions up until this document was migrated into the current policy platform. Any later changes will show in the Status and Details tab. 

Section 12 - Further Assistance

(74) Any staff member who requires assistance in understanding this Procedure should first consult their Nominated Supervisor or Manager who is responsible for applying the University’s WHSMS within their work area. Should further information or advice be required staff should visit Service Central.

Part A - Appendix A: ACU's Work Health and Safety Management System

Section 13 - Associated Information

(75) For related legislation, policies, procedures and guidelines and any supporting resources please refer to the Associated Information tab.