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WHS P001 Work Health and Safety Management System (WHSMS) Protocol

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Section 1 - Overview

(1) This document outlines how the University of New England will manage its health and safety obligations through a documented Work Health and Safety Management System (WHSMS).

(2) The purpose of this document is to:

  1. support the implementation of the UNE Work Health and Safety (WHS) Rule by providing a framework for the development of the WHSMS; and
  2. Establish, implement and maintain information that describes the core elements of the WHSMS and their interaction.
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Section 2 - Scope

(3) This document has been developed in accordance with:

  1. Work Health and Safety Act 2011 and Work Health and Safety Regulation 2017;
  2. AS/NZS 4801:2001 Work health and safety management systems — Specification with guidance for use; and
  3. AS/NZS 4804:2001 Occupational health and safety management systems — general guidelines on principles, systems and supporting techniques.

(4) The University is located in Armidale NSW, with an additional 'Future Campus' in Parramatta. There are several UNE owned rural properties that are used in teaching and research. These are Tulimbah, Newholme Field Laboratory, Laureldale Research Station and Kirby Research Station.

(5) The University also operates study centres based on TAFE campuses at Coonabarabran, Gunnedah, Inverell, Moree, Narrabri and Tenterfield, and other study centres at Glen Innes Guyra, Tamworth, Taree and Cooma.

(6) The UNE WHSMS applies to all locations where the University has direct control of the work environment.

(7) This Protocol applies to University Representatives, Students and visitors.

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Section 3 - Protocol

WHS Rule

(8) The Vice-Chancellor and Chief Executive Officer is responsible for approving the University's Health and Safety Rule.

(9) The University has in place a documented Health and Safety Rule which:

  1. is available for consultation and review by all University Representatives, including Senior Executive and the University's Work Health and Safety Strategic Committee, a process facilitated by Legal and Governance;
  2. includes a commitment to establish measurable objectives and targets and to ensure continual improvement;
  3. includes a commitment to comply with relevant legislation, regulations, national standards, codes of practice; and
  4. is implemented, maintained, communicated and available to all interested parties via 'Safety Hub' on the UNE web site.

Planning for Hazard Identification and Risk Management

(10) The University has procedures for the systematic approach to risk management.

(11) Hazard identification is planned via routine inspections and mandated risk assessments for specified activities. Tools are available for the reporting of ad hoc identification of hazards by University Representatives, students and visitors.

(12) Hazard registers are maintained for the University which identify activities and services (including those of contractors and suppliers) over which the University has control or influence. The hazard registers are periodically reviewed and enable logging of corrective actions to ensure effective controls are identified and actioned.

(13) Hazard identification is facilitated by:

  1. audits;
  2. inspection and monitoring;
  3. observation;
  4. analysis of hazard reports;
  5. analysis of damaging incidents and dangerous occurrence history;
  6. expert knowledge; and
  7. staff consultation.

(14) The risk assessment methodology utilised by the University is defined and applied consistently in all risk assessment tools within the WHSMS.

Planning for Legal and Other Requirements

(15) The Office of the Director Governance and University Secretary is responsible for the implementation of the documented procedures for the compliance management system. This system ensures identification and access to legal and other requirements (such as standards and codes) that are relevant to the WHSMS.

(16) The University Compliance Rule and Compliance Procedures are included in the University Policy Register System.

(17) Legal and other requirements are communicated to employees through:

  1. the induction and training process;
  2. Health and Safety Representative training; and
  3. email updates

(18) The University Policy Register and Compliance Register System (CRS) are available to all University Representatives, students and visitors via the UNE website.

(19) Changes to legal and other requirements are communicated via publication on the CRS as well as email and news bulletins addressed to staff and/or members of the University WHS consultation network. Safety Hub may also be used for this purpose.

(20) The CRS is updated whenever there is an identified change to any legal and other requirements applicable to the University's WHSMS. Significant changes to legislation are tabled with the Work Health and Safety Strategic Committee.

Planning for Objectives and Targets

(21) University-wide WHS objectives and targets are developed and communicated via Human Resource Services, in consultation with the Senior Executive, Work Health and Safety Strategic Committee and Employees through their elected Health and Safety Representative, and are documented.

(22) The identification of University WHS objectives and targets consider:

  1. legal and other requirements;
  2. identified hazards and risks (via review of risk registers and risk assessments);
  3. technological options;
  4. operational and business requirements;
  5. views of stakeholders; and
  6. shall include the imperative to continue measuring and improving upon WHS performance at the University.

(23) Individual Schools and Directorates are responsible for the development and implementation of objectives and targets that support the University-wide objectives and targets, and in response to their particular health and safety requirements.

Planning for WHS Management

(24) The setting of objectives and targets, as well as how they will be achieved is implemented according to the procedural requirements of the University. Planning and review for the management of WHS is scheduled (regularly) and documented.

(25) Management plans for the achievement of objectives and targets include:

  1. clear designation of accountability and responsibility;
  2. details on how the objectives and targets will be met;
  3. target timeframes for completion; and
  4. Are changed according to operational need and/or when there are material changes to the University environment that the WHSMS operates in.

Implementation of the WHSMS: Structure and Responsibility


(26) Senior Executive will identify and provide adequate resources required to implement, maintain and improve the University's WHSMS, including personnel with specialist skills, technology and budgetary allowance.

Responsibility and Accountability

(27) The University has defined, documented and communicated the WHS responsibilities relating to all personnel.

(28) WHS responsibilities are reinforced through induction, training, the WHS consultation network and performance review.

(29) Contractor WHS responsibility is included in tender and contract documents and in contractor inductions.

(30) The Director People and Culture has been assigned responsibility for:

  1. ensuring WHS requirements are established, implemented and maintained in accordance with AS/NZS 4801; and
  2. reporting on the performance of the WHSMS to the Senior Executive and to University Council.

Implementation of the WHSMS: Training and Competency

(31) The recruitment process of the University ensures that all staff are adequately trained in the specific requirements of the job they are employed to perform as per the specific training level descriptors and skill base specifications for professional, academic and research staff (located in the Professional Staff Enterprise Agreement and the Academic and ELC Teaching Staff Enterprise Agreement respectively) . The training level descriptors and skill base specifications are further supported by the Staff Recruitment Procedures.

(32) Additionally, all staff that perform WHS related duties are adequately trained in these functions.

(33) University staff are given the opportunity to consult on job specific training requirements as well as WHS training needs via their WHS workgroup and Health and Safety Representative (HSR).

(34) The University has procedures to ensure WHS competencies are developed and maintained through training and assessment. The procedures ensure:

  1. WHS competencies are developed and maintained via training needs analysis and regular review of training needs and provision and attendance at training;
  2. all personnel (including contractors and visitors) have undertaken Health and Safety training that is appropriate to identified needs;
  3. the training is sufficient (according to identified hazards and risks) to provide the skills required to safely and competently perform assigned tasks;
  4. staff are assessed as competent to perform assigned tasks;
  5. training accounts for the characteristics of the workforce and the WHSMS;
  6. WHS responsibilities can be executed; and
  7. Training is facilitated by persons with appropriate knowledge, skills and experience in WHS and training.

(35) In addition, University WHS training procedures ensure:

  1. any prescribed training requirements and licensing systems are known to supervisors and persons undertaking high risk work;
  2. legislated training requirements are checked prior to the purchase of new equipment or before new high risk activities are undertaken; and
  3. WHS needs are identified before new activities are commenced or new workplaces commissioned.

Implementation of the WHSMS: Consultation, Communication and Reporting


(36) The University has documented procedures, agreed to by staff, that outline the University's consultation network. These procedures and associated documents, such as terms of reference for consultative groups, are published on Safety Hub on the UNE web site.

(37) University Representatives (either directly or through their elected Health and Safety Representatives):

  1. have the opportunity to be involved in the development, implementation and review of policies and procedures for hazard identification, risk assessment and control of risks;
  2. are consulted where there are changes that affect WHS;
  3. select their Health and Safety Representatives (HSR's) via elections;
  4. Are informed as to who represents them via information published on Safety Hub.

(38) HSR's and management representatives are trained to ensure their effective contribution to the consultation network at UNE.


(39) Procedures are in place to ensure the communication of the University WHSMS to all stakeholders.

(40) Safety Hub is the online portal and part of the UNE web site that publishes the University WHSMS. Other information pertaining to the WHSMS is found in the UNE Policy Register and Compliance Register System (CSR) that is also accessible by University Representatives, students and visitors.

(41) Additionally, the following WHS communication strategies are employed by the University:

  1. WHS Committee agendas and minutes are recorded and published on the University's web page;
  2. School/Directorate meetings;
  3. notice boards; and
  4. Email correspondence to mailing lists is available for the dissemination of WHS related information.


(42) The University has several reporting mechanisms to ensure the relevant and timely sharing of information to facilitate monitoring and improvement in WHS performance.

(43) WHS reporting occurs via the following forums/channels:

  1. incident/hazard reports and associated corrective actions;
  2. hazard registers;
  3. WHS audits (internal and external);
  4. Workgroups and HSR's;
  5. WHS Strategic Committee;
  6. WHS quarterly reports to the Vice-Chancellor and Chief Executive Officer;
  7. Statutory Notification; and
  8. The University's publication of the Annual Report, which is available on the University's webpage.

Implementation of the WHSMS: Documentation

(44) The University has established, implemented and maintains WHS information in electronic form, or in hard copy where necessary. The documented WHSMS defines the core elements for the management of WHS at the University and provides procedures and tools and other resources for its implementation.

Implementation of the WHSMS: Document and Data Control

(45) The University has established, implemented and maintains a procedure for the control of all documents and relevant data required to develop a robust WHSMS.

The procedure ensures that all documents pertaining to the WHSMS:
  1. are properly filed in TRIM and able to be readily located;
  2. periodically reviewed as necessary;
  3. approved for adequacy by competent and responsible personnel;
  4. available at all essential locations;
  5. assured against unintended use when obsolete;
  6. legible, dated and maintained in an orderly manner;
  7. created and modified according to established procedures and responsibilities;
  8. precluded from use when obsolete; and
  9. reviewed every three years or as changes are required.

Implementation of the WHSMS: Hazard Identification, Risk Assessment and Control

(46) The University will, as a minimum, comply with applicable legislation for the identification of hazards and assessing and controlling risks in the workplace.

(47) The University has in place a Risk Management Protocol to ensure that:

  1. hazards associated with work processes are identified;
  2. risk assessments are conducted;
  3. control measures are implemented and reviewed; and
  4. the risk management process is evaluated.

Hazard Identification

(48) The University has documented procedures for systematic hazard identification which take into account:

  1. work situations and activities that have the potential to cause harm;
  2. the nature of potential harm; and
  3. the University's incident, illness and injury history.

(49) The procedures for identifying hazards have been developed according to the University's specific requirements and based upon:

  1. organisational structure and management and potential changes;
  2. workplace design, work processes, materials, plant and equipment;
  3. fabrication, installation, commissioning, handling and disposal (of materials, workplaces, plant and equipment);
  4. purchasing of goods and services;
  5. asset maintenance and renewal through capital works;
  6. contracting of plant and equipment;
  7. contracted services and labour; and
  8. inspection, maintenance, testing, repair and replacement of plant and equipment.

Risk Assessment

(50) The University’s Risk Management Protocol specifies the risk assessment methodology that is applied consistently in all risk assessment tools within the WHSMS, allowing for comparison and prioritisation.

(51) This methodology includes the University risk score calculator as well as the Hierarchy of Controls that will be utilised for guidance when determining the control measures to be implemented, according to the established level of risk.

Control of Hazards and Risks

(52) The Hierarchy of Control is applied when managing the University's identified WHS risks. This requires adopting the highest ranked control measure that is reasonably practicable from the following order:

  1. elimination;
  2. substitution;
  3. isolation;
  4. engineering;
  5. administrative; then
  6. personal protective equipment; or
  7. a combination of measures.

Evaluation of the Risk Management Process (Hazard Identification, Risk Assessment and Control)

(53) Hazard identification, risk assessment and control of risk processes are subject to a documented evaluation of effectiveness and are modified as necessary. This evaluation is carried out in accordance with the University's WHS Risk Management Protocol .

(54) The Risk Management Protocol is reviewed as per WHS OP001 Document Control Procedure.

Implementation of the WHSMS: Emergency Preparedness and Response

(55) The University has endeavoured to identify all potential emergency situations and documented procedures for response to prevent and mitigate harm. The Emergency Management Plan (EMP) and associated documents has been developed and includes process for review and revision at scheduled intervals and after the occurrence of such incidents.

(56) Testing of the University EMP is included within the procedures.

Measurement and Evaluation: Monitoring and Measurement

(57) The University has in place procedures for monitoring and measuring the key characteristics of operations and activities that can cause harm. The procedure includes a process for the monitoring and measurement of the WHSMS in terms of:

  1. performance;
  2. effectiveness of operational controls;
  3. conformance with objectives and targets; and
  4. compliance with relevant legislation and other requirements.
The effectiveness of these measures will also be evaluated upon scheduled review.

(58) The University has equipment for monitoring and measuring WHS risks that have the potential to cause harm. The equipment is:

  1. identified;
  2. calibrated;
  3. maintained; and
  4. stored as necessary.

(59) Records of monitoring and measurement are retained according to University procedures.

Health Surveillance

(60) The University has a documented procedure that identifies situations where staff health monitoring is required (such as industrial hearing loss) and for the implementation of appropriate surveillance systems (such as audiometric screening). This procedure includes assurance that:

  1. individuals have access to their own results; and
  2. compliance with legislative requirements to ensure health of staff exposed to specific hazards are monitored and recorded.

Measurement and Evaluation: Incident Investigation and Corrective and Preventative Action

(61) The University has established, implemented and maintains a procedure for:

  1. investigating, responding to and taking action to minimise any harm caused from incidents;
  2. investigating and responding to system failures; and
  3. initiating and completing appropriate corrective and preventive action.

(62) The WHS Document Controller is responsible for updating relevant areas of the WHSMS that result from incident investigations and corrective and preventive actions.

Measurement and Evaluation: Record Management

(63) The University has an established and implemented Records Management Rule for the identification, maintenance and disposal of WHS records, including the results of audits and reviews. The procedure ensures that WHS records:

  1. are legible, identifiable and traceable to the activity or service involved;
  2. are stored electronically (where possible) and maintained to ensure they are readily retrievable and protected against damage, deterioration or loss; and
  3. Have their retention times established and recorded.

(64) All WHS records shall be filed properly in TRIM.

Measurement and Evaluation: WHSMS Audit

(65) The University has developed a WHS Audit procedure that ensures periodic (internal and external) WHS audits are conducted by a competent person. The purpose of the University WHS Audit procedure is to:

  1. provide meaningful information to management and other staff for review;
  2. determine that the University WHSMS:
    1. conforms to planned arrangements for WHS management as defined by the University WHSMS as well as legislative and other requirements.
    2. has been properly implemented and maintained; and
    3. is effective in meeting the University's WHS Rule, including objectives and targets for continual improvement.

(66) The WHS Audit procedure includes:

  1. scheduling requirements (including guidance for revised schedules should the need arise based on audit results);
  2. scope;
  3. methodologies;
  4. competencies of auditors;
  5. responsibilities for the implementation of the audit schedule; and
  6. requirements for reporting of audit results.

Management Review

(67) The Senior Executive is responsible for reviewing the WHSMS at defined intervals to:

  1. ensure its continuing suitability, adequacy and effectiveness;
  2. consider the continued relevance of the Health and Safety policies, minimum standards, procedures, objectives and targets, plans and responsibilities; and
  3. Make changes where appropriate in response to audits, changing circumstances and the commitment to continual improvement.

(68) People and Culture (HRS) is responsible for:

  1. collecting the necessary information to allow the Senior Executive to carry out the review process, including provision of audit results and information regarding changing circumstances; and
  2. Documenting the review process.

Authority and Compliance

(69) The Director People and Culture as Rule Administrator, pursuant to the University’s Work Health and Safety (WHS) Rule, is authorised to make procedures and guidelines for the operation of this University Protocol. The procedures and guidelines must be compatible with the provisions of this Protocol.

(70) University Representatives and Students must observe this Protocol in relation to University matters.

(71) This Protocol operates as and from the Effective Date.

(72) Previous Protocols relating to the University’s Work Health and Safety Management System are replaced and have no further operation from the Effective Date of this new Protocol.

(73) Notwithstanding the other provisions of this University Protocol, the Vice-Chancellor and Chief Executive Officer may approve an exception to this Protocol where the Vice-Chancellor and Chief Executive Officer determines the application of the Protocol would otherwise lead to an unfair, unreasonable or absurd outcome. Approvals by the Vice-Chancellor and Chief Executive Officer under this clause must be documented in writing and must state the reason for the exception.

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Section 4 - Definitions Specific to this Protocol

(74) Competent Person means a person who has acquired through training, qualification or experience the knowledge and skills to carry out the task.

(75) Safety Hub means the section of the UNE web site, labelled as such, where all WHS related information is published for access by University Representatives, students and visitors.