Corrective actions instruction

Instruction statement

This instruction is designed to assist a School / Department develop their Corrective Actions Registers in order to ensure that all health and safety risks are identified for University or off-campus University-related operations and controlled.

Instruction steps and actions

1. Responsibility

Head of School/Department

  • Ensure compliance with the Corrective actions instruction within their area of authority
  • Ensure every corrective action is fully implemented by an action sequence within an agreed timeframe

Stakeholders

  • Participate in the consultation process for all relevant self- assessments being conducted. Stakeholders are not responsible for ensuring that an action is undertaken.

2. New action identified

The list below may be utilised to identify health and safety hazards that will require corrective action:

  • Hazard and incident reporting
  • Incident investigations or Hazard assessments
  • OHS Audits
  • Emergency preparedness
  • Risk assessments
  • OHS committees
  • OHS management system implementation
  • Workplace inspections

3. Consultation of corrective actions

When an issue has been identified that requires action, the consultation process must be initiated.

The resolution of an issue must be assigned to a responsible party who has management authority. In a situation where multiple responsible parties are identified (e.g. multiple organisational units involved), agreement must be reached on whom the most appropriate party is.

Consultation with key stakeholders must occur for all corrective actions. Stakeholders must include, where applicable; Head of School or Department or approved delegate, relevant supervisors, the designated work group’s HSR and/or any staff, students, contractors or visitors undertaking work or located near work area. OHS chairpersons, safety officers and any other specialty safety roles, Health Safety and Wellbeing Team and/or external consultants may be included in consultation if requested or required.

Stakeholders must agree upon:

  • what is the problem
  • what potential solutions are available and which of these is the preferred option
  • what time frame for this action is reasonable
  • who is responsible for resolving the matter

If agreement on any of these elements cannot be reached, escalation of the responsible party must follow the RMIT University Health and Safety Issue Resolution process.

Once agreement has been reached, the Corrective Actions Register must be completed which contains information including:

  • Source of issue
  • Date issue identified
  • Title of issue
  • Portfolio/College
  • School/Department
  • Description of issue
  • Risk Ranking
  • Corrective Action
  • Due Date
  • Responsible person
  • Status (open/closed)

4. Implementation of corrective actions

By using the Hierarchy of control instruction, it will help to identify the most appropriate action to be taken consistent with the level of risk. Corrective actions must be discussed with people affected prior to implementation.

In situations where many corrective actions are identified at once (e.g. following a health and safety workplace inspection), the corrective actions should be assigned a priority rating according to identified risk so that those posing the highest risk are addressed first.

There should be a record of corrective actions implemented using the Corrective actions register template (XLSX 16KB).

5. Assigning responsibility

Responsibility, authority and accountability for corrective actions are designated as follows:

  • When assigning corrective actions, the competency of the person to whom the action is assigned must be taken into account. Advice should be sought from personnel with specific expertise as appropriate.
  • Property Services is responsible for corrective action relating to building and grounds infrastructure.
  • Property Services is responsible for corrective action relating to plant and equipment associated with building infrastructure and grounds.
  • The Managers of Schools and Departments are responsible for corrective action relating to plant, equipment, hazardous substances, dangerous goods, work procedures (including training), in their day-to-day operations.
  • Supervisors or nominated responsible persons are responsible for ensuring corrective actions from hazard and incident reports are completed.
  • Nominated responsible persons for corrective actions from workplace inspections are responsible for ensuring the corrective actions assigned to them are completed by the date recommended.
  • Corrective actions not completed in a timely manner shall be reported to the Head of School or Department. The Head of School or Department will then contact the person(s) responsible for the corrective action to ensure completion.
  • Any corrective action that cannot be fixed by the local area needs to be escalated to the College/Portfolio office or the Health Safety and Wellbeing Team.

6. Monitoring of corrective actions

Corrective actions are reviewed and monitored by school or work area unit by monitoring the corrective action status report.

  • All new hazards should be documented in the school or work area unit risk register.
  • Colleges and Portfolios review and monitor corrective actions beyond the scope of schools/ work areas.
  • The Health Safety and Wellbeing Team reviews and monitors corrective actions beyond the scope of Colleges/Portfolios, schools, and work areas.

Effectiveness of implemented corrective actions are assessed as being appropriate by re-inspections, audit follow-up, re-testing of plant and equipment, consulting with workers and reviewing hazard, incident and workers compensation statistics.

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